80 results on '"Murugiah K"'
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2. CATHOLIC EDUCATION IN TIRUNELVELI AND TUTICORIN DISTRICTS OF TAMIL NADU FROM 1947 TO 1992
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Murugiah, K.
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- 1999
3. Development of Scaffolds from Bio-Based Natural Materials for Tissue Regeneration Applications: A Review
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Murugiah Krishani, Wong Yen Shin, Hazwani Suhaimi, and Nonni Soraya Sambudi
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tissue engineering ,scaffold ,fabrication techniques ,tissue regeneration ,Science ,Chemistry ,QD1-999 ,Inorganic chemistry ,QD146-197 ,General. Including alchemy ,QD1-65 - Abstract
Tissue damage and organ failure are major problems that many people face worldwide. Most of them benefit from treatment related to modern technology’s tissue regeneration process. Tissue engineering is one of the booming fields widely used to replace damaged tissue. Scaffold is a base material in which cells and growth factors are embedded to construct a substitute tissue. Various materials have been used to develop scaffolds. Bio-based natural materials are biocompatible, safe, and do not release toxic compounds during biodegradation. Therefore, it is highly recommendable to fabricate scaffolds using such materials. To date, there have been no singular materials that fulfill all the features of the scaffold. Hence, combining two or more materials is encouraged to obtain the desired characteristics. To design a reliable scaffold by combining different materials, there is a need to choose a good fabrication technique. In this review article, the bio-based natural materials and fine fabrication techniques that are currently used in developing scaffolds for tissue regeneration applications, along with the number of articles published on each material, are briefly discussed. It is envisaged to gain explicit knowledge of developing scaffolds from bio-based natural materials for tissue regeneration applications.
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- 2023
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4. Prevalence of Takotsubo cardiomyopathy in the United States.
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Deshmukh A, Kumar G, Pant S, Rihal C, Murugiah K, and Mehta JL
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- 2012
5. Association of door-to-balloon time and one-year outcomes in hospital survivors of ST-elevation myocardial infarction.
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Sawano M, Kohsaka S, Murugiah K, Ishii H, Yamaji K, Takahashi J, Ozaki K, Amano T, and Kozuma K
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In this study of 19,824 ST-elevated myocardial infarction (STEMI) patients from the J-PCI OUTCOME registry (January 1, 2017, to December 31, 2018), we investigated the association between door-to-balloon time (DTB) and 1-year post-discharge cardiovascular outcomes. Patients with DTB >90 min were older and had higher comorbidities. The incidence of 1-year major adverse cardiovascular events (MACE) showed an incremental increase: 3.7 %, 4.8 %, and 7.7 % for DTB ≤60, DTB 60-90, and DTB >90 groups, respectively. Adjusted hazard ratios (aHR) compared to the DTB 60-90 group were 0.83 (DTB ≤60, p = 0.03) and 1.25 (DTB >90, p = 0.005). Subgroup analysis revealed higher risk for MACE in DTB >90 group for patients aged <70, men, no history of coronary revascularization, and those with cardiac arrest or cardiogenic shock. Conversely, DTB ≤60 group without previous history had a lower MACE risk (aHR 0.80, p = 0.02). This study, the largest of its kind, demonstrates that a DTB below 90 min is associated with lower 1-year MACE risk, supporting current guidelines, and indicating additional benefits for specific patient subgroups, especially those experiencing their first acute coronary event. The findings suggest the importance of early intervention in primary prevention and emphasize the need for prompt detection of vulnerable plaque., (Copyright © 2024 Elsevier Ltd. All rights reserved.)
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- 2024
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6. Heterogeneity in the Prognosis of Acute Kidney Injury Following Percutaneous Coronary Intervention.
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Hu JR, Murugiah K, Xin X, Sawano M, Lu Y, Wilson FP, Masoudi FA, Messenger JC, Krumholz HM, and Huang C
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- Humans, Prognosis, Contrast Media, Risk Factors, Creatinine, Acute Kidney Injury diagnosis, Acute Kidney Injury therapy, Percutaneous Coronary Intervention adverse effects
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- 2024
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7. Patterns of Digoxin Prescribing for Medicare Beneficiaries in the United States 2013-2019.
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See C, Wheelock KM, Caraballo C, Khera R, Annapureddy A, Mahajan S, Lu Y, Krumholz HM, and Murugiah K
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Background: Studies show that digoxin use is declining but is still prevalent. Recent data on digoxin prescription and characteristics of digoxin prescribers are unknown, which can help understand its contemporary use., Methods: Using Medicare Part D data from 2013 to 2019, we studied the change in number and proportion of digoxin prescriptions and digoxin prescribers, overall and by specialty. Using logistic regression, we identified prescriber characteristics associated with digoxin prescription., Results: From 2013 to 2019, total digoxin prescriptions (4.6 to 1.8 million) and proportion of digoxin prescribers decreased (9.1% to 4.3% overall; 26.6% to 11.8% among General Medicine prescribers and 65.4% to 48.9% among Cardiology). Of digoxin prescribers from 2013 practicing in 2019 (91.2% remained active), 59.1% did not prescribe digoxin at all, 31.7% reduced, and 9.2% maintained or increased prescriptions. The proportion of all digoxin prescriptions that were prescribed by General Medicine prescribers declined from 59.7% to 48.2% and increased for Cardiology (29% to 38.5%). Among new prescribers in 2019 ( N = 85,508), only 1.9% prescribed digoxin. Digoxin prescribers when compared to non-digoxin prescribers were more likely male, graduated from medical school earlier, were located in the Midwest or South, and belonged to Cardiology (all P < .001)., Conclusions: Digoxin prescriptions continue to decline with over half of 2013 prescribers no longer prescribing digoxin in 2019. This may be a result of the increasing availability of newer heart failure therapies. The decline in digoxin prescription was greater among general medicine physicians than cardiologists, suggesting a change in digoxin use to a medication prescribed increasingly by specialists., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rohan Khera reports a relationship with NEJM Journal Watch that includes: consulting or advisory. Rohan Khera reports a relationship with Evidence2Health that includes: employment. Rohan Khera has pending Provisional Patent Application No. 63/177,177. Harlan Krumholz reports a relationship with UnitedHealth, Element Science, Aetna, Reality Labs, Tesseract/4Catalyst, F-Prime, the Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, and Martin/Baughman Law Firm that includes: consulting or advisory. Harlan Krumholz reports a relationship with Refactor Health and HugoHealth that includes: employment. Harlan Krumholz reports a relationship with the Centers for Medicare & Medicaid Services and Johnson & Johnson that includes: employment. Yuan Lu reports a relationship with National Heart Lung and Blood Institute that includes: funding grants. Karthik Murugiah reports a relationship with National Heart Lung and Blood Institute that includes: funding grants.
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- 2023
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8. Intravascular Imaging Use by Intermediate to High-Volume US Operators - A Medicare Data Analysis.
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See C, Sawano M, Nagpal S, Chamie D, Curtis JP, and Murugiah K
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- 2023
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9. Wireless pulmonary artery sensor implantation in a unilateral lung transplant recipient.
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Kelly R, Bae JY, Mansour AY, Nagpal S, Hahn S, and Murugiah K
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Patients with lung transplantation can have concomitant left ventricular failure which can either precede the lung transplantation or develop after. Implantable wireless pulmonary artery (PA) pressure monitors to guide hemodynamic management in heart failure such as the CardioMEMS device (Abbott, Sylmar, CA, USA) have been shown to improve outcomes. However, in a lung transplant recipient there are unique physiological and practical considerations when contemplating to implant a PA pressure sensor such as safety of implanting the device, choice of site of implantation, accuracy of wedge tracings to calibrate, and exclusion of vascular stenoses post transplantation. We discuss these considerations in the context of a man in his early 60s with a known left lung transplant two years previously who developed worsening heart failure needing invasive monitoring. Right lung PA sensor placement was considered, but on selective pulmonary angiography the right PA was found to be of small caliber and with significant tortuosity. After careful hemodynamic assessment, the PA sensor was implanted in the PA of the transplanted lung which is the first such case to our knowledge., Learning Objective: We report the first documented case of an implantable wireless pulmonary artery pressure monitor (CardioMEMs) into a transplanted lung. Device-related complications, such as pulmonary artery injury, infection, and hemoptysis, must be assessed after placement. Given the changes in pulmonary artery pressures after lung transplantation, recalibration of the CardioMEMs device may need to be considered if placed within first year of transplant., Competing Interests: The authors declare that there is no conflict of interest., (© 2023 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)
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- 2023
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10. Invasive Pulmonary Angiogram Performance and Interpretation in the Diagnosis of Pulmonary Thromboembolic Disease.
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Bae JY and Murugiah K
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- Humans, Pulmonary Artery diagnostic imaging, Angiography, Hypertension, Pulmonary diagnosis, Pulmonary Embolism diagnostic imaging, Thromboembolism diagnostic imaging
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Invasive or selective pulmonary angiography has historically been used as the gold standard diagnostic test for the evaluation of a wide array of pulmonary arterial conditions, most commonly pulmonary thromboembolic diseases. With the emergence of various noninvasive imaging modalities, the role of invasive pulmonary angiography is shifting to the assistance of advanced pharmacomechanical therapies for such conditions. Components of invasive pulmonary angiography methodology include optimal patient positioning, vascular access, catheter selections, angiographic positioning, contrast settings, and recognition of angiographic patterns of common thromboembolic and nonthromboembolic conditions. We review the pulmonary vascular anatomy, step-by-step performance, and interpretation of invasive pulmonary angiography., (Copyright © 2023 Elsevier Inc. All rights reserved.)
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- 2023
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11. Sex Difference in Outcomes of Acute Myocardial Infarction in Young Patients.
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Sawano M, Lu Y, Caraballo C, Mahajan S, Dreyer R, Lichtman JH, D'Onofrio G, Spatz E, Khera R, Onuma O, Murugiah K, Spertus JA, and Krumholz HM
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- Humans, Male, Female, Risk Factors, Sex Factors, Health Status, Hospitalization, Sex Characteristics, Myocardial Infarction epidemiology, Myocardial Infarction therapy
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Background: Younger women experience worse health status than men after their index episode of acute myocardial infarction (AMI). However, whether women have a higher risk for cardiovascular and noncardiovascular hospitalizations in the year after discharge is unknown., Objectives: The aim of this study was to determine sex differences in causes and timing of 1-year outcomes after AMI in people aged 18 to 55 years., Methods: Data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which enrolled young patients with AMI across 103 U.S. hospitals, were used. Sex differences in all-cause and cause-specific hospitalizations were compared by calculating incidence rates ([IRs] per 1,000 person-years) and IR ratios with 95% CIs. We then performed sequential modeling to evaluate the sex difference by calculating subdistribution HRs (SHRs) accounting for deaths., Results: Among 2,979 patients, at least 1 hospitalization occurred among 905 patients (30.4%) in the year after discharge. The leading causes of hospitalization were coronary related (IR: 171.8 [95% CI: 153.6-192.2] among women vs 117.8 [95% CI: 97.3-142.6] among men), followed by noncardiac hospitalization (IR: 145.8 [95% CI: 129.2-164.5] among women vs 69.6 [95% CI: 54.5-88.9] among men). Furthermore, a sex difference was present for coronary-related hospitalizations (SHR: 1.33; 95% CI: 1.04-1.70; P = 0.02) and noncardiac hospitalizations (SHR: 1.51; 95% CI: 1.13-2.07; P = 0.01)., Conclusions: Young women with AMI experience more adverse outcomes than men in the year after discharge. Coronary-related hospitalizations were most common, but noncardiac hospitalizations showed the most significant sex disparity., Competing Interests: Funding Support and Author Disclosures The VIRGO study (NCT00597922) was supported by grant R01 HL081153 from the National Heart, Lung, and Blood Institute. In the past 3 years, Dr Krumholz has received expenses and/or personal fees from UnitedHealth, Element Science, Eyedentifeye, and F-Prime; is a co-founder of Refactor Health and HugoHealth; and is associated with contracts, through Yale New Haven Hospital, from the Centers for Medicare & Medicaid Services and through Yale University from the U.S. Food and Drug Administration, Johnson & Johnson, Google, and Pfizer. Dr. Murugiah has received support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award K08HL157727). Dr. Khera has received support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award K23HL153775) and the Doris Duke Charitable Foundation (under award, 2022060); receives research support, through Yale, from Bristol Myers Squibb and Novo Nordisk; is a coinventor of U.S. Provisional Patent Applications 63/177,117, 63/428,569, and 63/346,610, unrelated to current work; and is a founder of Evidence2Health, a precision health platform to improve evidence-based cardiovascular care. All other 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.)
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- 2023
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12. Effect of the New Glomerular Filtration Rate Estimation Equation on Risk Predicting Models for Acute Kidney Injury After Percutaneous Coronary Intervention.
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Huang C, Murugiah K, Li X, Masoudi FA, Messenger JC, Williams KA Sr, Mortazavi BJ, and Krumholz HM
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- Humans, Glomerular Filtration Rate, Treatment Outcome, Kidney, Creatinine, Contrast Media, Risk Factors, Acute Kidney Injury diagnosis, Acute Kidney Injury etiology, Percutaneous Coronary Intervention adverse effects
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- 2023
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13. Timing of Blood Draws Among Patients Hospitalized in a Large Academic Medical Center.
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Caraballo C, Mahajan S, Murugiah K, Mortazavi BJ, Lu Y, Khera R, and Krumholz HM
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- Humans, Hospitalization, Time Factors, Academic Medical Centers, Phlebotomy
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- 2023
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14. Depression and Perceived Stress After Spontaneous Coronary Artery Dissection and Comparison With Other Acute Myocardial Infarction (the VIRGO Experience).
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Murugiah K, Chen L, Dreyer RP, Bouras G, Safdar B, Lu Y, Spatz ES, Gupta A, Khera R, Ng VG, Bueno H, Tweet MS, Spertus JA, Hayes SN, Lansky A, and Krumholz HM
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- Coronary Angiography adverse effects, Coronary Vessels, Depression diagnosis, Depression epidemiology, Female, Humans, Risk Factors, Stress, Psychological epidemiology, Coronary Vessel Anomalies complications, Coronary Vessel Anomalies diagnosis, Coronary Vessel Anomalies epidemiology, Myocardial Infarction diagnosis, Vascular Diseases congenital, Vascular Diseases diagnosis
- Abstract
Data on depression and stress among patients with spontaneous coronary artery dissection (SCAD) are limited. Using data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study, which prospectively enrolled 3,572 acute myocardial infarction (AMI) patients between 18 and 55 years of age, we identified 67 SCAD cases. We compared Patient Health Questionnaire-9 (PHQ-9) and 14-item Perceived Stress Scale (PSS-14) scores obtained at baseline, 1 month, and 12 months between SCAD and AMI of all other causes. Using longitudinal linear mixed-effects analysis, we compared depression and stress scores between SCAD and other AMI, adjusting for time and selected covariates. Patients with SCAD had lower baseline PHQ-9 scores (6.1 ± 6.0 vs 7.7 ± 6.4 for other patients with AMI, p = 0.03), similar 1-month scores, and lower 12-month scores (3.2 ± 4.3 vs 4.9 ± 5.5, p = 0.004). At baseline and 1 month, patients with SCAD had similar PSS-14 scores to those of other patients with AMI. At 12 months, patients with SCAD had lower scores (18.4 ± 8.8 vs 21.5 ± 9.3 for other patients with AMI, p = 0.009). After adjustment for cardiovascular risk factors, co-morbidities, and clinical acuity, no differences in PHQ-9 or PSS-14 scores remained between SCAD and other AMI. Similar results were obtained in a subgroup analysis of only women with SCAD and other AMI. In conclusion, patients with SCAD had a relatively lower burden of depression and perceived stress than other patients with AMI, potentially because of fewer co-morbidities and favorable socioeconomic factors. However, given high depression and stress burden in both SCAD and other patients with AMI, routine screening can help identify and treat these patients., Competing Interests: Disclosures Dr. Bueno receives research funding from the Instituto de Salud Carlos III, Spain (PIE16/00021 and PI17/01799), Sociedad Española de Cardiología, Astra-Zeneca, Bayer, PhaseBio, and Novartis; has received consulting fees from Astra-Zeneca, Novartis, and Organon; speaking fees from Novartis, and is a scientific advisor for MEDSCAPE-the heart.org. In the past 3 years, Dr. Krumholz received expenses and/or personal fees from UnitedHealth, Element Science, Aetna, Reality Labs, Tesseract/4Catalyst, F-Prime, the Siegfried and Jensen Law Firm, Arnold and Porter Law Firm, and Martin/Baughman Law Firm. He is a co-founder of Refactor Health and HugoHealth, and is associated with contracts, through Yale New Haven Hospital, with the Centers for Medicare & Medicaid Services and through Yale University with Johnson & Johnson. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2022
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15. Sex-Specific Risk Factors Associated With First Acute Myocardial Infarction in Young Adults.
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Lu Y, Li SX, Liu Y, Rodriguez F, Watson KE, Dreyer RP, Khera R, Murugiah K, D'Onofrio G, Spatz ES, Nasir K, Masoudi FA, and Krumholz HM
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- Case-Control Studies, Female, Humans, Male, Nutrition Surveys, Risk Factors, Young Adult, Diabetes Mellitus epidemiology, Hypercholesterolemia, Hypertension complications, Myocardial Infarction diagnosis
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Importance: An increasing proportion of people in the US hospitalized for acute myocardial infarction (AMI) are younger than 55 years, with the largest increase in young women. Effective prevention requires an understanding of risk factors associated with risk of AMI in young women compared with men., Objectives: To assess the sex-specific associations of demographic, clinical, and psychosocial risk factors with first AMI among adults younger than 55 years, overall, and by AMI subtype., Design, Setting, and Participants: This study used a case-control design with 2264 patients with AMI, aged 18 to 55 years, from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study and 2264 population-based controls matched for age, sex, and race and ethnicity from the National Health and Nutrition Examination Survey from 2008 to 2012. Data were analyzed from April 2020 to November 2021., Exposures: A wide range of demographic, clinical, and psychosocial risk factors., Main Outcomes and Measures: Odds ratios (ORs) and population attributable fractions (PAF) for first AMI associated with demographic, clinical, and psychosocial risk factors., Results: Of the 4528 case patients and matched controls, 3122 (68.9%) were women, and the median (IQR) age was 48 (44-52) years. Seven risk factors (diabetes [OR, 3.59 (95% CI, 2.72-4.74) in women vs 1.76 (1.19-2.60) in men], depression [OR, 3.09 (95% CI, 2.37-4.04) in women vs 1.77 (1.15-2.73) in men], hypertension [OR, 2.87 (95% CI, 2.31-3.57) in women vs 2.19 (1.65-2.90) in men], current smoking [OR, 3.28 (95% CI, 2.65-4.07) in women vs 3.28 (2.65-4.07) in men], family history of premature myocardial infarction [OR, 1.48 (95% CI, 1.17-1.88) in women vs 2.42 (1.71-3.41) in men], low household income [OR, 1.79 (95% CI, 1.28-2.50) in women vs 1.35 (0.82-2.23) in men], hypercholesterolemia [OR, 1.02 (95% CI, 0.81-1.29) in women vs 2.16 (1.49-3.15) in men]) collectively accounted for the majority of the total risk of AMI in women (83.9%) and men (85.1%). There were significant sex differences in risk factor associations: hypertension, depression, diabetes, current smoking, and family history of diabetes had stronger associations with AMI in young women, whereas hypercholesterolemia had a stronger association in young men. Risk factor profiles varied by AMI subtype, and traditional cardiovascular risk factors had higher prevalence and stronger ORs for type 1 AMI compared with other AMI subtypes., Conclusions and Relevance: In this case-control study, 7 risk factors, many potentially modifiable, accounted for 85% of the risk of first AMI in young women and men. Significant differences in risk factor profiles and risk factor associations existed by sex and by AMI subtype. These findings suggest the need for sex-specific strategies in risk factor modification and prevention of AMI in young adults. Further research is needed to improve risk assessment of AMI subtypes.
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- 2022
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16. Evaluation of Temporal Trends in Racial and Ethnic Disparities in Sleep Duration Among US Adults, 2004-2018.
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Caraballo C, Mahajan S, Valero-Elizondo J, Massey D, Lu Y, Roy B, Riley C, Annapureddy AR, Murugiah K, Elumn J, Nasir K, Nunez-Smith M, Forman HP, Jackson CL, Herrin J, and Krumholz HM
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- Adult, Black People, Cross-Sectional Studies, Female, Humans, Male, Middle Aged, Sleep, Ethnicity, Hispanic or Latino
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Importance: Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years., Objective: To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US., Design, Setting, and Participants: This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022., Exposures: Self-reported race, ethnicity, household income, and sex., Main Outcomes and Measures: Temporal trends and racial and ethnic differences in short (<7 hours in 24 hours) and long (>9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age., Results: The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P < .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P < .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age., Conclusions and Relevance: The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.
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- 2022
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17. Health status outcomes after spontaneous coronary artery dissection and comparison with other acute myocardial infarction: The VIRGO experience.
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Murugiah K, Chen L, Dreyer RP, Bouras G, Safdar B, Khera R, Lu Y, Spatz ES, Ng VG, Gupta A, Bueno H, Tweet MS, Spertus JA, Hayes SN, Lansky A, and Krumholz HM
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- Coronary Vessel Anomalies, Coronary Vessels, Female, Health Status, Humans, Middle Aged, Vascular Diseases congenital, Myocardial Infarction epidemiology, Quality of Life
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Background: Data on health status outcomes after spontaneous coronary artery dissection (SCAD) are limited., Methods and Findings: Using the Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study we compared patients with SCAD and other acute myocardial infarction (AMI) at presentation (baseline), 1-month, and-12 months using standardized health status instruments. Among 3572 AMI patients ≤ 55 years, 67 had SCAD. SCAD patients were younger (median age (IQR) 45 (40.5-51) years vs. 48 (44-52) in other AMI, p = 0.003), more often female (92.5% vs. 66.6%), have college education (73.1% vs. 51.7%) and household income >$100,000 (43.3% vs. 17.7% (All p<0.001). SCAD patients at baseline had higher mean ± SD Short Form-12 [SF-12] physical component scores [PCS] (48.7±10.2 vs. 43.8±12.1, p<0.001) and mental component scores [MCS] (49.6±12.4 vs. 45.4±12.5, p = 0.008), and at 12-months [PCS (50.1±9.0 vs. 44.3±12.3, p<0.001) and MCS (53±10.1 vs 50.2±11.0, p = 0.045)]. The Euro-Quality of Life Scale [EQ-5D] VAS and EQ-5D index scores were similar at baseline, but higher at 12-months for SCAD (EQ-5D VAS: 82.2±10.2 vs. 72.3±21.0, p<0.001; EQ-5D index scores; 90.2±15.3 vs. 83.7±19.8, p = 0.012). SCAD patients had better baseline Seattle Angina Questionnaire [SAQ] physical limitation (88.8±20.1 vs. 81.2±25.4, p = 0.017). At 12-months SCAD patients had better physical limitation (98.0±8.5 vs. 91.4±18.8, p = 0.007), angina frequency (96.4±8.8 vs. 91.3±16.8, p = 0.018) and quality of life scores (80.7±14.7 vs 72.2±23.2, p = 0.005). Magnitude of change in health status from baseline to 12-months was not statistically different between the groups. After adjustment for time and comorbidities there remained no difference in most health status outcomes., Conclusions: SCAD patients fare marginally better than other AMI patients on most health status instruments and have similar 12-month health status recovery. Better pre-event health status suggests a need to modify exercise prescriptions and cardiac rehabilitation protocols to better assist this physically active population to recover., Competing Interests: The authors have declared that no competing interests exist.
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- 2022
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18. Physical Activity Among Patients With Intracardiac Remote Monitoring Devices Before, During, and After COVID-19-Related Restrictions.
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Lu Y, Jones PW, Murugiah K, Caraballo C, Massey DS, Mahajan S, Ahmed R, Bader EM, and Krumholz HM
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- Aged, Aged, 80 and over, COVID-19 complications, COVID-19 physiopathology, Female, Heart Diseases etiology, Heart Diseases physiopathology, Humans, Male, Retrospective Studies, SARS-CoV-2, COVID-19 epidemiology, Exercise physiology, Heart Diseases diagnosis, Monitoring, Physiologic methods, Pandemics, Quarantine, Telemetry methods
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- 2022
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19. Clinician Trends in Prescribing Direct Oral Anticoagulants for US Medicare Beneficiaries.
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Wheelock KM, Ross JS, Murugiah K, Lin Z, Krumholz HM, and Khera R
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- Administration, Oral, Humans, Retrospective Studies, Time Factors, United States, Atrial Fibrillation drug therapy, Factor Xa Inhibitors therapeutic use, Medicare, Practice Patterns, Physicians' trends, Warfarin therapeutic use
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Importance: Contemporary national clinical practice guidelines recommend direct-acting oral anticoagulants (DOACs) as the first-line anticoagulant strategy over warfarin for most indications, especially among older individuals with an elevated bleeding risk., Objective: To evaluate anticoagulant prescribing and DOAC uptake by US clinicians in the Medicare population., Design, Setting, and Participants: This retrospective cohort study included all US clinicians with more than 10 Medicare oral anticoagulant prescription claims, who were included in the national Medicare Provider Utilization and Payment Data (2013-2018). Data analyses were conducted between October 2020 and October 2021., Exposures: DOAC prescription in 2013., Main Outcomes and Measures: Clinicians were categorized based on 2013 prescribing as solely prescribing warfarin, DOAC, or both, and their temporal trajectories of proportionate DOAC use were examined., Results: The analysis included 325 666 unique clinicians with more than 10 oral anticoagulant prescriptions between 2013 and 2018 (26 620 [8.2%] cardiologists, 85 563 [26.3%] internal medicine physicians, 84 369 [25.9%] family medicine physicians, and 81 161 [24.9%] advanced practice clinicians, including nurse practitioners and physician assistants). In 2013, among 91 837 prescribers, 54 501 (59.3%) prescribed only warfarin, 1918 (2.1%) prescribed only a DOAC, and 35 418 (38.6%) prescribed both. During the study period, the number of clinicians prescribing DOACs increased, but 19% continued to prescribe only warfarin in 2018. While 359 cardiologists prescribing anticoagulants (1.6%) were warfarin-only prescribers, 10 414 (20.0%) and 6296 (12.6%) of family and internal medicine physicians also prescribed only warfarin, respectively. Clinicians prescribing only warfarin in 2013 had lower proportionate DOAC use throughout the study compared with 2013 DOAC prescribers, which represents a median (IQR) of 41.9% (20.3%-61.9%) of their anticoagulant prescriptions in 2018 vs 67.0% (49.9%-82.8%) for DOAC prescribers., Conclusions and Relevance: Despite the increase in DOAC use among Medicare beneficiaries, many clinicians in this study continued to use warfarin as their predominant or only anticoagulant instead of DOACs. There is a need to address barriers to the uptake of these medications to realize their potential benefits for patients.
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- 2021
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20. Scope of Practice of US Interventional Cardiologists from an Analysis of Medicare Billing Data.
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Murugiah K, Chen L, Castro-Dominguez Y, Khera R, and Krumholz HM
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- Echocardiography trends, Exercise Test, Female, Health Facility Size, Humans, Male, Medicare, Physician's Role, Radionuclide Imaging trends, United States, Cardiac Imaging Techniques trends, Cardiologists trends, Cardiology trends, Coronary Disease surgery, Percutaneous Coronary Intervention trends, Peripheral Vascular Diseases surgery, Scope of Practice trends
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The contemporary scope of practice of interventional cardiologists (ICs) in the United States and recent trends are unknown. Using Medicare claims from 2013 to 2017, we categorized ICs into 4 practice categories (only percutaneous coronary intervention [PCI], PCI with noninvasive imaging, PCI with specialized interventions [peripheral/structural], and all 3 services) and evaluated associations with region, hospital bed size and teaching status, gender, and graduation year. Of 6,083 ICs in 2017, 10.9% performed only PCI, 68.3% PCI with noninvasive imaging, 5.7% PCI with specialized interventions, and 15.1% all 3 services. A higher proportion of Northeast ICs (vs South ICs) were performing only PCI (24.8% vs 7.3%) and PCI with specialized interventions (12% vs 3.4%), but lower PCI and noninvasive imaging (53.8% vs 71.7%) and all 3 services (9.3% and 17.6%). Regarding ICs at larger hospitals (bed size >575 vs <218), a higher proportion was performing only PCI (23.8% vs 5.2%) or PCI with specialized interventions (13.5% vs 1.7%) and lower proportion was performing PCI with noninvasive imaging (48.8% vs 78%), similar to teaching hospitals. Female ICs (vs male ICs) more frequently performed only PCI (18.9% vs 10.6%) and less frequently all 3 services (8.3% vs 15.4%). A lower proportion of recent graduates (2001 to 2016) performed only PCI (9.8% vs 13.8%) and PCI with noninvasive imaging (66.3% vs 72.6%) but a higher proportion performed all 3 services (18% vs 8.4%) than earlier graduates (1959 to 1984). From 2013 to 2017, only PCI and PCI with noninvasive imaging decreased, whereas PCI and specialized interventions and all 3 services increased (all p <0.001). In conclusion, there is marked heterogeneity in practice responsibilities among ICs, which has implications for training and competency assessments., Competing Interests: Disclosures Dr. Krumholz reported that he has contracts through Yale New Haven Hospital with the Centers for Medicare & Medicaid Services to support quality measurement programs and through Yale with UnitedHealth Group to engage in collaborative research. He was a recipient of a research grant, through Yale, from Medtronic for data sharing; from the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices; from Johnson & Johnson to support data sharing; and from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion. He is an advisor to the National Center for Cardiovascular Diseases in Beijing, was an expert witness for the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation, and is an expert witness for the Martin/Baughman Law Firm for work related to the Cook Celect IVC filter litigation and to the C.R. Bard Recovery IVC filter litigation and for the Siegfried and Jensen Law Firm for work related to the Vioxx litigation. He chairs a cardiac scientific advisory board for UnitedHealth; was a member of the IBM Watson Health Life Sciences Board; and is a member of the advisory board for Element Science, the healthcare advisory board for Facebook, and the physician advisory board for Aetna. He is the cofounder of HugoHealth, a personal health information platform, and cofounder of Refactor Health, an enterprise health care artificial intelligence–augmented data management company. He is a venture partner at F-Prime. Dr. Murugiah is supported by contracts through Yale New Haven Hospital with the Centers for Medicare & Medicaid Services to support quality measurement programs. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)
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- 2021
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21. Haemophilus Parainfluenzae mural endocarditis with large atrial septal defect and peripheral embolization.
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Bae JY, Murugiah K, McLeod GX, Anwer M, and Howes CJ
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Mural endocarditis is a rare subclass of infective endocarditis (IE) associated with intra-cardiac tumors, prosthesis, valvular vegetation's, or structural abnormalities such as ventricular septal defects. Bacteria classified as HACEK ( Haemophilus species, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens , and Kingella kingae ) are rare causes of IE found in only 1.3% to 10% of cases. We describe the second reported case of mural endocarditis involving the left ventricle (LV) caused by a Haemophilus species. A young male with no prior intravenous drug use, valvular heart disease, or recent dental work presented with splenic infarcts. H. para-influenza was identified on blood cultures. Cardiac imaging revealed a 1.5 cm LV mass underneath the posterior leaflet of the mitral valve and a large Atrial Septal Defect (ASD). Awaiting surgery, the patient sustained embolic and hemorrhagic cerebral events. The patient underwent debulking of LV mass, ASD closure, and mitral valve repair complicated by post-pericardiotomy syndrome, and he completed six weeks of ceftriaxone therapy. The patient met modified Duke Criteria, but the diagnosis was challenging due to absence of risk factors, sub-acute symptom onset, delayed blood culture growth, and ambiguous characterization of the mass on imaging. < Learning objective: To recognize mural endocarditis as a distinct subset of infective endocarditis and understand its risk factors. To appreciate the unique diagnostic and prognostic considerations of HACEK endocarditis. To understand the indications for urgent surgical intervention in treatment of infective endocarditis>., Competing Interests: The authors declare that there is no conflict of interest, (© 2021 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)
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- 2021
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22. Changes in ST segment elevation myocardial infarction hospitalisations in China from 2011 to 2015.
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Zhou T, Li X, Lu Y, Murugiah K, Bai X, Hu S, Gao Y, Masoudi FA, Krumholz HM, and Li J
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- Aged, China epidemiology, Female, Follow-Up Studies, Hospital Mortality trends, Humans, Incidence, Male, Middle Aged, Retrospective Studies, ST Elevation Myocardial Infarction epidemiology, Time Factors, Hospitalization statistics & numerical data, Hospitals statistics & numerical data, Registries, ST Elevation Myocardial Infarction therapy
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Objective: Access to acute cardiovascular care has improved and health services capacity has increased over the past decades. We assessed national changes in (1) patient characteristics, (2) in-hospital management and (3) patient outcomes among patients presenting with ST segment elevation myocardial infarction (STEMI) in 2011-2015 in China., Methods: In a nationally representative sample of hospitals in China, we created two random cohorts of patients in 2011 and 2015 separately. We weighted our findings to estimate nationally representative numbers and assessed changes from 2011 to 2015. Data were abstracted from medical charts centrally using standardised definitions., Results: While the proportion of patients with STEMI among all patients with acute myocardial infarction decreased over time from 82.5% (95% CI 81.7 to 83.3) in 2011 to 68.5% (95% CI 67.7 to 69.3) in 2015 (p<0.0001), the weighted national estimate of patients with STEMI increased from 210 000 to 380 000. The rate of reperfusion eligibility among patients with STEMI decreased from 49.3% (95% CI 48.1 to 50.5) to 42.2% (95% CI 41.1 to 43.4) in 2015 (p<0.0001); ineligibility was principally driven by larger proportions with prehospital delay exceeding 12 hours (67.4%-76.7%, p<0.0001). Among eligible patients, the proportion receiving reperfusion therapies increased from 54% (95% CI 52.3 to 55.7) to 59.7% (95% CI 57.9 to 61.4) (p<0.0001). Crude and risk-adjusted rates of in-hospital death did not differ significantly between 2011 and 2015., Conclusions: In this most recent nationally representative study of STEMI in China, the use of acute reperfusion increased, but no significant improvement occurred in outcomes. There is a need to continue efforts to prevent cardiovascular diseases, to monitor changes in in-hospital treatments and outcomes, and to reduce prehospital delay., Competing Interests: Competing interests: JL reported receiving research grants, through Fuwai Hospital, from the People’s Republic of China for work to improve the management of hypertension and blood lipids and to improve care quality and patient outcomes of cardiovascular disease; receiving research agreements, through the National Center for Cardiovascular Diseases and Fuwai Hospital, from Amgen for a multicentre clinical trial assessing the efficacy and safety of omecamtiv mecarbil and for dyslipidaemic patient registration; receiving a research agreement, through Fuwai Hospital, from Sanofi for a multicentre clinical trial on the effects of sotagliflozin; receiving a research agreement, through Fuwai Hospital, with the University of Oxford for a multicentre clinical trial of empagliflozin; receiving a research agreement, through the National Center for Cardiovascular Diseases, from AstraZeneca for clinical research methods training, outside the submitted work; and receiving a research agreement, through the National Center for Cardiovascular Diseases, from Lilly for physician training, outside the submitted work. HK works under contract with the Centers for Medicare & Medicaid Services to support quality measurement programmes; was a recipient of a research grant, through Yale, from Medtronic and the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices; was a recipient of a research grant with Medtronic and is the recipient of a research grant from Johnson & Johnson, through Yale University, to support clinical trial data sharing; was a recipient of a research agreement, through Yale University, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion; collaborates with the National Center for Cardiovascular Diseases in Beijing; receives payment from the Arnold & Porter law firm for work related to the Sanofi clopidogrel litigation, from the Martin/Baughman law firm for work related to the Cook IVC filter litigation, and from the Siegfried and Jensen law firm for work related to Vioxx litigation; chairs a Cardiac Scientific Advisory Board for UnitedHealth; was a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science, the Advisory Board for Facebook and the Physician Advisory Board for Aetna; and is the founder of Hugo Health, a personal health information platform, and cofounder of Refactor Health, an enterprise healthcare AI-augmented data management company. FM has a contract with the American College of Cardiology as the Chief Scientific Advisor for the NCDR and has received travel expenses from the Fuwai Hospital. YL is supported by the National Heart, Lung, and Blood Institute (K12HL138037) and was a recipient of a research agreement, through Yale, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion., (© 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.)
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- 2021
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23. Quality of Cardiovascular Registries: Turning the Mirror Around.
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Murugiah K and Masoudi FA
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- Humans, Registries, Percutaneous Coronary Intervention
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- 2021
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24. Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018.
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Mahajan S, Caraballo C, Lu Y, Valero-Elizondo J, Massey D, Annapureddy AR, Roy B, Riley C, Murugiah K, Onuma O, Nunez-Smith M, Forman HP, Nasir K, Herrin J, and Krumholz HM
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- Adolescent, Adult, Aged, Costs and Cost Analysis, Cross-Sectional Studies, Delivery of Health Care trends, Female, Health Status Disparities, Health Surveys, Healthcare Disparities ethnology, Humans, Income, Male, Middle Aged, United States, Young Adult, Delivery of Health Care ethnology, Health Services Accessibility trends, Health Status, Healthcare Disparities trends
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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 < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification., Conclusions and Relevance: In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.
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- 2021
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25. Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers With the Risk of Hospitalization and Death in Hypertensive Patients With COVID-19.
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Khera R, Clark C, Lu Y, Guo Y, Ren S, Truax B, Spatz ES, Murugiah K, Lin Z, Omer SB, Vojta D, and Krumholz HM
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- Adolescent, Adult, Aged, Aged, 80 and over, COVID-19 complications, COVID-19 therapy, Cohort Studies, Female, Hospital Mortality, Humans, Hypertension drug therapy, Male, Middle Aged, Propensity Score, Young Adult, Angiotensin Receptor Antagonists therapeutic use, Angiotensin-Converting Enzyme Inhibitors therapeutic use, COVID-19 mortality, Hospitalization, Hypertension complications, Hypertension mortality
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Background Despite its clinical significance, the risk of severe infection requiring hospitalization among outpatients with severe acute respiratory syndrome coronavirus 2 infection who receive angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) remains uncertain. Methods and Results In a propensity score-matched outpatient cohort (January-May 2020) of 2263 Medicare Advantage and commercially insured individuals with hypertension and a positive outpatient SARS-CoV-2, we determined the association of ACE inhibitors and ARBs with COVID-19 hospitalization. In a concurrent inpatient cohort of 7933 hospitalized with COVID-19, we tested their association with in-hospital mortality. The robustness of the observations was assessed in a contemporary cohort (May-August). In the outpatient study, neither ACE inhibitors (hazard ratio [HR], 0.77; 0.53-1.13, P =0.18) nor ARBs (HR, 0.88; 0.61-1.26, P =0.48) were associated with hospitalization risk. ACE inhibitors were associated with lower hospitalization risk in the older Medicare group (HR, 0.61; 0.41-0.93, P =0.02), but not the younger commercially insured group (HR, 2.14; 0.82-5.60, P =0.12; P -interaction 0.09). Neither ACE inhibitors nor ARBs were associated with lower hospitalization risk in either population in the validation cohort. In the primary inpatient study cohort, neither ACE inhibitors (HR, 0.97; 0.81-1.16; P =0.74) nor ARBs (HR, 1.15; 0.95-1.38, P =0.15) were associated with in-hospital mortality. These observations were consistent in the validation cohort. Conclusions ACE inhibitors and ARBs were not associated with COVID-19 hospitalization or mortality. Despite early evidence for a potential association between ACE inhibitors and severe COVID-19 prevention in older individuals, the inconsistency of this observation in recent data argues against a role for prophylaxis.
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- 2021
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26. Characteristics of cardiac catheterization laboratory directors at the 2017 U.S. News & World Report top 100 U.S. cardiovascular hospitals.
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Murugiah K, Annapureddy AR, Khera R, Lansky A, and Curtis JP
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- Aged, Female, Hospitals, Humans, Leadership, Male, Medicare, Middle Aged, Treatment Outcome, United States, Cardiac Catheterization, Faculty, Medical, Laboratories
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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., (© 2021 Wiley Periodicals LLC.)
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27. Physical Activity Patterns Among Patients with Intracardiac Remote Monitoring Devices Before, During, and After COVID-19-related Public Health Restrictions.
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Lu Y, Murugiah K, Jones PW, Massey DS, Mahajan S, Caraballo C, Ahmed R, Bader EM, and Krumholz HM
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Nationwide public health restrictions due to the coronavirus disease 2019 (COVID-19) pandemic have disrupted people's routine physical activities, yet little objective information is available on the extent to which physical activity has changed among patients with pre-existing cardiac diseases. Using remote monitoring data of 9,924 patients with pacemakers and implantable cardiac defibrillators (ICDs) living in New York City and Minneapolis/Saint Paul, we assessed physical activity patterns among these patients in 2019 and 2020 from January through October. We found marked declines in physical activity among patients with implantable cardiac devices during COVID-19-related restrictions and the reduction was consistent across age and sex subgroups. Moreover, physical activity among these vulnerable patients did not return to pre-restrictions levels several months after COVID-19 restrictions were eased. Our findings highlight the need to consider the unintended consequences of mitigation strategies and develop approaches to encourage safe physical activity during the pandemic.
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- 2021
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28. Trends in Thoracic Impedance and Arrhythmia Burden Among Patients with Implanted Cardiac Defibrillators During the COVID-19 Pandemic.
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Lu Y, Murugiah K, Jones PW, Caraballo C, Mahajan S, Massey DS, Ahmed R, Bader EM, and Krumholz HM
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Hospitalizations for acute cardiac conditions have markedly declined during the coronavirus disease 2019 (COVID-19) pandemic, yet the cause of this decline is not clear. Using remote monitoring data of 4,029 patients with implantable cardiac defibrillators (ICDs) living in New York City and Minneapolis/Saint Paul, we assessed changes in markers of cardiac status among these patients and compared thoracic impedance and arrhythmia burden in 2019 and 2020 from January through August. We found no change in several key disease decompensation markers among patients with implanted ICD devices during the first phase of COVID-19 pandemic, suggesting that the decrease in cardiovascular hospitalizations in this period is not reflective of a true population-level improvement in cardiovascular health.
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- 2021
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29. Time to Reperfusion in ST-Segment Elevation Acute Myocardial Infarction: When Does the Clock Start?
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Murugiah K, Gupta A, and Krumholz HM
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- Humans, Myocardial Reperfusion adverse effects, ST Elevation Myocardial Infarction diagnostic imaging, ST Elevation Myocardial Infarction therapy
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- 2021
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30. Assessment of Prevalence, Awareness, and Characteristics of Isolated Systolic Hypertension Among Younger and Middle-Aged Adults in China.
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Mahajan S, Feng F, Hu S, Lu Y, Gupta A, Murugiah K, Gao Y, Lu J, Liu J, Zheng X, Spatz ES, Zhang H, Krumholz HM, and Li J
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- Adult, Blood Pressure, China epidemiology, Cross-Sectional Studies, Female, Humans, Hypertension etiology, Male, Middle Aged, Obesity complications, Prevalence, Age Factors, Hypertension epidemiology
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Importance: Isolated systolic hypertension (ISH) is increasing in prevalence among young and middle-aged adults. However, most studies of ISH are limited to older individuals, and a substantial knowledge gap exists regarding younger adults with ISH., Objective: To assess the prevalence, awareness, and characteristics of ISH among younger and middle-aged adults in China., Design, Setting, and Participants: This cross-sectional study was performed as part of the China Patient-Centered Evaluative Assessment of Cardiac Events Million Persons Project, which enrolled 3.1 million community residents aged 35 to 75 years from all of the 31 provinces in China between December 15, 2014, and May 15, 2019. The present analysis included only participants younger than 50 years. Data were analyzed from May to November 2019., Main Outcomes and Measures: Prevalence and awareness of ISH (defined as systolic blood pressure of 140 mm Hg or higher and diastolic blood pressure of less than 90 mm Hg) and individual characteristics of participants with ISH., Results: Among 898 929 participants aged 35 to 49 years, the mean (SD) age was 43.8 (3.9) years; 548 657 participants (61.0%) were women, and 235 138 participants (26.2%) had hypertension. Of those with hypertension, 62 819 participants (26.7%; 95% CI, 26.5%-26.9%) had ISH (mean [SD] age, 45.0 [3.5] years; 41 417 women [65.9%]), and 54 463 of those with ISH (86.7%; 95% CI, 86.4%-87.0%) had not received treatment. The prevalence of ISH was higher among individuals who were older, were female, were farmers, resided in the eastern region of China, and had an educational level of primary school or lower. Women and older individuals were more likely to have ISH than to be normotensive or to have other hypertension subtypes. Participants who were obese, currently used alcohol, had diabetes, and experienced previous cardiovascular events were more likely to have other types of hypertension and less likely to have normotension than to have ISH. Among the 54 463 participants with ISH who had not received treatment, only 3682 individuals (6.8%; 95% CI, 6.6%-7.0%) were aware of having hypertension, and awareness rates remained low even among those with systolic blood pressure of 160 mm Hg or higher (7135 individuals [13.1%; 95% CI, 12.4%-13.9%])., Conclusions and Relevance: In this study, ISH was identified in 1 of 4 young and middle-aged adults with hypertension in China, most of whom remained unaware of having hypertension. These results highlight the increasing need for better guidance regarding the management of ISH in this population.
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- 2020
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31. Intussusception after Rotavirus Vaccine Introduction in India.
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Reddy SN, Nair NP, Tate JE, Thiyagarajan V, Giri S, Praharaj I, Mohan VR, Babji S, Gupte MD, Arora R, Bidari S, Senthamizh S, Mekala S, Goru KB, Reddy B, Pamu P, Gorthi RP, Badur M, Mohan V, Sathpathy S, Mohanty H, Dash M, Mohakud NK, Ray RK, Mohanty P, Gathwala G, Chawla S, Gupta M, Gupta R, Goyal S, Sharma P, Mathew MA, Jacob TJK, Sundaram B, Purushothaman GKC, Dorairaj P, Jagannatham M, Murugiah K, Boopathy H, Maniam R, Gurusamy R, Kumaravel S, Shenoy A, Jain H, Goswami JK, Wakhlu A, Gupta V, Vinayagamurthy G, Parashar UD, and Kang G
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- Administration, Oral, Case-Control Studies, Female, Humans, Immunization, Secondary adverse effects, Incidence, India epidemiology, Infant, Intussusception epidemiology, Male, Product Surveillance, Postmarketing, Risk, Rotavirus Infections prevention & control, Vaccination, Vaccines, Attenuated adverse effects, Intussusception etiology, Rotavirus Vaccines adverse effects
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Background: A three-dose, oral rotavirus vaccine (Rotavac) was introduced in the universal immunization program in India in 2016. A prelicensure trial involving 6799 infants was not large enough to detect a small increased risk of intussusception. Postmarketing surveillance data would be useful in assessing whether the risk of intussusception would be similar to the risk seen with different rotavirus vaccines used in other countries., Methods: We conducted a multicenter, hospital-based, active surveillance study at 27 hospitals in India. Infants meeting the Brighton level 1 criteria of radiologic or surgical confirmation of intussusception were enrolled, and rotavirus vaccination was ascertained by means of vaccination records. The relative incidence (incidence during the risk window vs. all other times) of intussusception among infants 28 to 365 days of age within risk windows of 1 to 7 days, 8 to 21 days, and 1 to 21 days after vaccination was evaluated by means of a self-controlled case-series analysis. For a subgroup of patients, a matched case-control analysis was performed, with matching for age, sex, and location., Results: From April 2016 through June 2019, a total of 970 infants with intussusception were enrolled, and 589 infants who were 28 to 365 days of age were included in the self-controlled case-series analysis. The relative incidence of intussusception after the first dose was 0.83 (95% confidence interval [CI], 0.00 to 3.00) in the 1-to-7-day risk window and 0.35 (95% CI, 0.00 to 1.09) in the 8-to-21-day risk window. Similar results were observed after the second dose (relative incidence, 0.86 [95% CI, 0.20 to 2.15] and 1.23 [95% CI, 0.60 to 2.10] in the respective risk windows) and after the third dose (relative incidence, 1.65 [95% CI, 0.82 to 2.64] and 1.08 [95% CI, 0.69 to 1.73], respectively). No increase in intussusception risk was found in the case-control analysis., Conclusions: The rotavirus vaccine produced in India that we evaluated was not associated with intussusception in Indian infants. (Funded by the Bill and Melinda Gates Foundation and others.)., (Copyright © 2020 Massachusetts Medical Society.)
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- 2020
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32. Racial and Ethnic Disparities in Health of Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.
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Mahajan S, Caraballo C, Lu Y, Massey D, Murugiah K, Annapureddy AR, Roy B, Riley C, Onuma O, Nunez-Smith M, Valero-Elizondo J, Forman HP, Nasir K, Herrin J, and Krumholz HM
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Importance: Thirty-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., Objectives: To evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades., Design: Cross-sectional., Setting: National Health Interview Survey data, years 1999-2018., Participants: Adults aged 18-85 years., Exposure: Race/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic)., Main Outcome and Measures: Proportion 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., Results: We 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 Relevance: The 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.
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- 2020
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33. Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.
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Caraballo C, Massey D, Mahajan S, Lu Y, Annapureddy AR, Roy B, Riley C, Murugiah K, Valero-Elizondo J, Onuma O, Nunez-Smith M, Forman HP, Nasir K, Herrin J, and Krumholz HM
- Abstract
Importance: Racial 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., Objectives: To determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades., Design: Cross-sectional., Setting: Data from the National Health Interview Survey, 1999-2018., Participants: Individuals >18 years old., Exposure: Race and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic., Main Outcome and Measures: Rates 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., Results: We 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 Relevance: Insurance 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 Points: Question: In the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities? Findings: Using 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. Meaning: Despite 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.
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- 2020
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34. Trends in Reoperative Coronary Artery Bypass Graft Surgery for Older Adults in the United States, 1998 to 2017.
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Mori M, Wang Y, Murugiah K, Khera R, Gupta A, Vallabhajosyula P, Masoudi FA, Geirsson A, and Krumholz HM
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- Aged, Ethnicity statistics & numerical data, Female, Heart Disease Risk Factors, Humans, Likelihood Functions, Male, Medicare statistics & numerical data, Prognosis, United States epidemiology, Coronary Artery Bypass methods, Coronary Artery Bypass statistics & numerical data, Coronary Artery Disease epidemiology, Coronary Artery Disease surgery, Hospitalization statistics & numerical data, Long Term Adverse Effects epidemiology, Long Term Adverse Effects surgery, Reoperation methods, Reoperation trends
- Abstract
Background The likelihood of undergoing reoperative coronary artery bypass graft surgery (CABG) is important for older patients who are considering first-time CABG. Trends in the reoperative CABG for these patients are unknown. Methods and Results We used the Medicare fee-for-service inpatient claims data of adults undergoing isolated first-time CABG between 1998 and 2017. The primary outcome was time to first reoperative CABG within 5 years of discharge from the index surgery, treating death as a competing risk. We fitted a Cox regression to model the likelihood of reoperative CABG as a function of patient baseline characteristics. There were 1 666 875 unique patients undergoing first-time isolated CABG and surviving to hospital discharge. The median (interquartile range) age of patients did not change significantly over time (from 74 [69-78] in 1998 to 73 [69-78] in 2017); the proportion of women decreased from 34.8% to 26.1%. The 5-year rate of reoperative CABG declined from 0.77% (95% CI, 0.72%-0.82%) in 1998 to 0.23% (95% CI, 0.19%-0.28%) in 2013. The annual proportional decline in the 5-year rate of reoperative CABG overall was 6.6% (95% CI, 6.0%-7.1%) nationwide, which did not differ across subgroups, except the non-white non-black race group that had an annual decline of 8.5% (95% CI, 6.2%-10.7%). Conclusions Over a recent 20-year period, the Medicare fee-for-service patients experienced a significant decline in the rate of reoperative CABG. In this cohort of older adults, the rate of declining differed across demographic subgroups.
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- 2020
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35. Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction in China.
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Song J, Murugiah K, Hu S, Gao Y, Li X, Krumholz HM, and Zheng X
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Background: Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction (AMI) after initial AMI remain poorly understood. Data on recurrent AMI in China is unknown., Methods: Using the China Patient-centred Evaluative Assessment of Cardiac Events (PEACE)-Prospective AMI Study, we studied 3387 patients admitted to 53 hospitals for AMI and discharged alive. The association of recurrent AMI with 1-year mortality was evaluated using time-dependent Cox regression. Recurrent AMI events were classified as early (1-30 days), late (31-180 days), and very late (181-365 days). Their impacts on 1-year mortality were estimated by Kaplan-Meier methodology and compared by the log-rank test. Multivariable modelling was used to identify factors associated with recurrent AMI., Results: The mean (SD) age was 60.7 (11.9) years and 783 (23.1%) were women. The observed 1-year recurrent AMI rate was 2.5% (95% CI 2.00 to 3.07) with 35.7% events occurring within the first 30 days. Recurrent AMI was associated with 1-year mortality with an adjusted HR of 25.42 (95% CI 15.27 to 42.34). Early recurrent AMI was associated with the highest 1-year mortality rate of 53.3% (log-rank p<0.001). Predictors of recurrent AMI included age 75-84, in-hospital percutaneous coronary intervention, heart rate >90 min/beats at initial admission, renal dysfunction, and not being prescribed any of guideline-based medications at discharge., Conclusions: One-third of recurrent AMI events occurred early. Recurrent AMI is strongly associated with 1-year mortality, particularly if early. Heightened surveillance during this early period and improving prescription of recommended discharge medications may reduce recurrent AMI in China., Competing Interests: Competing interests: HMK is the recipient of a research grant from Medtronic and Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing; chairs a cardiac scientific advisory board for United Health; works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. HMK and KM work under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported, (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
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- 2020
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36. Association of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers with the Risk of Hospitalization and Death in Hypertensive Patients with Coronavirus Disease-19.
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Khera R, Clark C, Lu Y, Guo Y, Ren S, Truax B, Spatz ES, Murugiah K, Lin Z, Omer SB, Vojta D, and Krumholz HM
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Background: Whether angiotensin-converting enzyme (ACE) Inhibitors and angiotensin receptor blockers (ARBs) mitigate or exacerbate SARS-CoV-2 infection remains uncertain. In a national study, we evaluated the association of ACE inhibitors and ARB with coronavirus disease-19 (COVID-19) hospitalization and mortality among individuals with hypertension., Methods: Among Medicare Advantage and commercially insured individuals, we identified 2,263 people with hypertension, receiving ≥1 antihypertensive agents, and who had a positive outpatient SARS-CoV-2 test (outpatient cohort). In a propensity score-matched analysis, we determined the association of ACE inhibitors and ARBs with the risk of hospitalization for COVID-19. In a second study of 7,933 individuals with hypertension who were hospitalized with COVID-19 (inpatient cohort), we tested the association of these medications with in-hospital mortality. We stratified all our assessments by insurance groups., Results: Among individuals in the outpatient and inpatient cohorts, 31.9% and 29.8%, respectively, used ACE inhibitors and 32.3% and 28.1% used ARBs. In the outpatient study, over a median 30.0 (19.0 - 40.0) days after testing positive, 12.7% were hospitalized for COVID-19. In propensity score-matched analyses, neither ACE inhibitors (HR, 0.77 [0.53, 1.13], P = 0.18), nor ARBs (HR, 0.88 [0.61, 1.26], P = 0.48), were significantly associated with risk of hospitalization. In analyses stratified by insurance group, ACE inhibitors, but not ARBs, were associated with a significant lower risk of hospitalization in the Medicare group (HR, 0.61 [0.41, 0.93], P = 0.02), but not the commercially insured group (HR: 2.14 [0.82, 5.60], P = 0.12; P-interaction 0.09). In the inpatient study, 14.2% died, 59.5% survived to discharge, and 26.3% had an ongoing hospitalization. In propensity score-matched analyses, neither use of ACE inhibitor (0.97 [0.81, 1.16]; P = 0.74) nor ARB (1.15 [0.95, 1.38]; P = 0.15) was associated with risk of in-hospital mortality, in total or in the stratified analyses., Conclusions: The use of ACE inhibitors and ARBs was not associated with the risk of hospitalization or mortality among those infected with SARS-CoV-2. However, there was a nearly 40% lower risk of hospitalization with the use of ACE inhibitors in the Medicare population. This finding merits a clinical trial to evaluate the potential role of ACE inhibitors in reducing the risk of hospitalization among older individuals, who are at an elevated risk of adverse outcomes with the infection.
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- 2020
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37. Database Inaccuracies and Disparities in Care Among Homeless Adults Hospitalized for Cardiovascular Conditions.
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Murugiah K, Wang Y, and Krumholz HM
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- Adult, Humans, Data Management, Ill-Housed Persons
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- 2020
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38. Digoxin Use and Associated Adverse Events Among Older Adults.
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Angraal S, Nuti SV, Masoudi FA, Freeman JV, Murugiah K, Shah ND, Desai NR, Ranasinghe I, Wang Y, and Krumholz HM
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- Aged, Aged, 80 and over, Cohort Studies, Female, Humans, Male, Practice Patterns, Physicians', Retrospective Studies, United States, Digoxin adverse effects, Digoxin therapeutic use, Heart Failure drug therapy
- Abstract
Background: Over the past 2 decades, guidelines for digoxin use have changed significantly. However, little is known about the national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over this time period., Methods: To describe digoxin prescription trends, we conducted a population-level, cohort study using data from IQVIA, Inc.'s National Prescription Audit (2007-2014) for patients aged ≥65 years. Further, in a national cohort of Medicare fee-for-service beneficiaries aged ≥65 years in the United States, we assessed temporal trends of hospitalizations associated with digoxin toxicity and the outcomes of these hospitalizations between 1999 and 2013., Results: From 2007 through 2014, the number of digoxin prescriptions dispensed decreased by 46.4%; from 8,099,856 to 4,343,735. From 1999 through 2013, the rate of hospitalizations with a principal or secondary diagnosis of digoxin toxicity decreased from 15 to 2 per 100,000 person-years among Medicare fee-for-service beneficiaries. In-hospital and 30-day mortality rates associated with hospitalization for digoxin toxicity decreased significantly among Medicare fee-for-service beneficiaries; from 6.0% (95% confidence interval [CI], 5.2-6.8) to 3.7% (95% CI, 2.2-5.7) and from 14.0% (95% CI, 13.0-15.2) to 10.1% (95% CI, 7.6-13.0), respectively. Rates of 30-day readmission for digoxin toxicity decreased from 23.5% (95% CI, 22.1-24.9) in 1999 to 21.7% (95% CI, 18.0-25.4) in 2013 (P < .05)., Conclusion: While digoxin prescriptions have decreased, it is still widely prescribed. However, the rate of hospitalizations for digoxin toxicity and adverse outcomes associated with these hospitalizations have decreased. These findings reflect the changing clinical practice of digoxin use, aligned with the changes in clinical guidelines., (Copyright © 2019 Elsevier Inc. All rights reserved.)
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- 2019
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39. Distribution of Industry Payments Among Medical Directors of Catheterization and Electrophysiology Laboratories From the Top 100 US Hospitals.
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Annapureddy A, Sengodan P, Mahajan S, Annapureddy T, Murugiah K, Desai NR, and Curtis JP
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- 2019
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40. Association of in-hospital resource utilization with post-acute spending in Medicare beneficiaries hospitalized for acute myocardial infarction: a cross-sectional study.
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Nuti SV, Li SX, Xu X, Ott LS, Lagu T, Desai NR, Murugiah K, Duan M, Martin J, Kim N, and Krumholz HM
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- Aged, Cross-Sectional Studies, Fee-for-Service Plans, Health Resources statistics & numerical data, Humans, Myocardial Infarction economics, Patient Readmission economics, Patient Readmission statistics & numerical data, United States, Economics, Hospital statistics & numerical data, Health Expenditures statistics & numerical data, Hospitalization economics, Medicare economics, Myocardial Infarction therapy, Patient Acceptance of Health Care statistics & numerical data
- Abstract
Background: Efforts to decrease hospitalization costs could increase post-acute care costs. This effect could undermine initiatives to reduce overall episode costs and have implications for the design of health care under alternative payment models., Methods: Among Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with acute myocardial infarction (AMI) between July 2010 and June 2013 in the Premier Healthcare Database, we studied the association of in-hospital and post-acute care resource utilization and outcomes by in-hospital cost tertiles., Results: Among patients with AMI at 326 hospitals, the median (range) of each hospital's mean per-patient in-hospital risk-standardized cost (RSC) for the low, medium, and high cost tertiles were $16,257 ($13,097-$17,648), $18,544 ($17,663-$19,875), and $21,831 ($19,923-$31,296), respectively. There was no difference in the median (IQR) of risk-standardized post-acute payments across cost-tertiles: $5014 (4295-6051), $4980 (4349-5931) and $4922 (4056-5457) for the low (n = 90), medium (n = 98), and high (n = 86) in-hospital RSC tertiles (p = 0.21), respectively. In-hospital and 30-day mortality rates did not differ significantly across the in-hospital RSC tertiles; however, 30-day readmission rates were higher at hospitals with higher in-hospital RSCs: median = 17.5, 17.8, and 18.0% at low, medium, and high in-hospital RSC tertiles, respectively (p = 0.005 for test of trend across tertiles)., Conclusions: In our study of patients hospitalized with AMI, greater resource utilization during the hospitalization was not associated with meaningful differences in costs or mortality during the post-acute period. These findings suggest that it may be possible for higher cost hospitals to improve efficiency in care without increasing post-acute care utilization or worsening outcomes.
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- 2019
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41. Industry Payments to Cardiologists.
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Annapureddy A, Murugiah K, Minges KE, Chui PW, Desai N, and Curtis JP
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- Cardiologists ethics, Cardiologists trends, Cross-Sectional Studies, Health Care Sector ethics, Health Care Sector trends, Humans, Time Factors, Truth Disclosure, Cardiologists economics, Compensation and Redress ethics, Conflict of Interest economics, Health Care Sector economics
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- 2018
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42. Enhancing the prediction of acute kidney injury risk after percutaneous coronary intervention using machine learning techniques: A retrospective cohort study.
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Huang C, Murugiah K, Mahajan S, Li SX, Dhruva SS, Haimovich JS, Wang Y, Schulz WL, Testani JM, Wilson FP, Mena CI, Masoudi FA, Rumsfeld JS, Spertus JA, Mortazavi BJ, and Krumholz HM
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- Acute Kidney Injury diagnosis, Acute Kidney Injury prevention & control, Aged, Clinical Decision-Making, Female, Humans, Male, Middle Aged, Protective Factors, Registries, Reproducibility of Results, Retrospective Studies, Risk Assessment, Risk Factors, Time Factors, Treatment Outcome, Acute Kidney Injury etiology, Data Mining methods, Decision Support Techniques, Machine Learning, Percutaneous Coronary Intervention adverse effects
- Abstract
Background: The current acute kidney injury (AKI) risk prediction model for patients undergoing percutaneous coronary intervention (PCI) from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) employed regression techniques. This study aimed to evaluate whether models using machine learning techniques could significantly improve AKI risk prediction after PCI., Methods and Findings: We used the same cohort and candidate variables used to develop the current NCDR CathPCI Registry AKI model, including 947,091 patients who underwent PCI procedures between June 1, 2009, and June 30, 2011. The mean age of these patients was 64.8 years, and 32.8% were women, with a total of 69,826 (7.4%) AKI events. We replicated the current AKI model as the baseline model and compared it with a series of new models. Temporal validation was performed using data from 970,869 patients undergoing PCIs between July 1, 2016, and March 31, 2017, with a mean age of 65.7 years; 31.9% were women, and 72,954 (7.5%) had AKI events. Each model was derived by implementing one of two strategies for preprocessing candidate variables (preselecting and transforming candidate variables or using all candidate variables in their original forms), one of three variable-selection methods (stepwise backward selection, lasso regularization, or permutation-based selection), and one of two methods to model the relationship between variables and outcome (logistic regression or gradient descent boosting). The cohort was divided into different training (70%) and test (30%) sets using 100 different random splits, and the performance of the models was evaluated internally in the test sets. The best model, according to the internal evaluation, was derived by using all available candidate variables in their original form, permutation-based variable selection, and gradient descent boosting. Compared with the baseline model that uses 11 variables, the best model used 13 variables and achieved a significantly better area under the receiver operating characteristic curve (AUC) of 0.752 (95% confidence interval [CI] 0.749-0.754) versus 0.711 (95% CI 0.708-0.714), a significantly better Brier score of 0.0617 (95% CI 0.0615-0.0618) versus 0.0636 (95% CI 0.0634-0.0638), and a better calibration slope of observed versus predicted rate of 1.008 (95% CI 0.988-1.028) versus 1.036 (95% CI 1.015-1.056). The best model also had a significantly wider predictive range (25.3% versus 21.6%, p < 0.001) and was more accurate in stratifying AKI risk for patients. Evaluated on a more contemporary CathPCI cohort (July 1, 2015-March 31, 2017), the best model consistently achieved significantly better performance than the baseline model in AUC (0.785 versus 0.753), Brier score (0.0610 versus 0.0627), calibration slope (1.003 versus 1.062), and predictive range (29.4% versus 26.2%). The current study does not address implementation for risk calculation at the point of care, and potential challenges include the availability and accessibility of the predictors., Conclusions: Machine learning techniques and data-driven approaches resulted in improved prediction of AKI risk after PCI. The results support the potential of these techniques for improving risk prediction models and identification of patients who may benefit from risk-mitigation strategies., Competing Interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: SSD is supported by the Department of Veterans Affairs. WLS is a consultant for Hugo, a personal health information platform. CIM is a consultant for Cook, Bard, Medtronic, Abbott and Cardinal Health. FPW is supported by the National Science Foundation grant R01DK113191. JSR is the Chief Innovation Officer for the American College of Cardiology. HMK is a recipient of research agreements from Medtronic and from Johnson & Johnson (Janssen), through Yale University, to develop methods of clinical trial data sharing; was the recipient of a grant from the Food and Drug Administration and Medtronic to develop methods for postmarket surveillance of medical devices; works under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures; chairs a cardiac scientific advisory board for UnitedHealth; is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; is a participant/participant representative of the IBM Watson Health Life Sciences Board; and is the founder of Hugo, a personal health information platform. JAS is supported by grants from Gilead, Genentech, Lilly, Amorcyte, and EvaHeart and has a patent for the Seattle Angina Questionnaire with royalties paid. He also owns the copyright to the Seattle Angina Questionnaire. He is the PI of an Analytic Center for the American College of Cardiology Foundation and has an equity interest in Health Outcomes Sciences. FAM has a contract (through his primary institution) for his role as Chief Science Officer of the NCDR. BJM is an associate editor for PLOS ONE, which is involved in this special issue. He has a relationship with the American College of Cardiology in selecting and pursuing innovative research based upon their registry data (unrelated to this paper). He has a pending patent application for an EHR-based prediction tool in Yale New Haven Health, as well as two funded studies, one by the DoD-Advanced Research Projects Agency and one with the NSF to support student travel to conferences in the body sensor networks field. American College of Cardiology may incorporate this work, or future iterations, into its registry. No other organisation named above has a competing interest in relation to this work. The other authors report no potential competing interests.
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- 2018
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43. Accurate estimation of cardiovascular risk in a non-diabetic adult: detecting and correcting the error in the reported Framingham Risk Score for the Systolic Blood Pressure Intervention Trial population.
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Warner F, Dhruva SS, Ross JS, Dey P, Murugiah K, and Krumholz HM
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- Cardiovascular Diseases physiopathology, Cardiovascular Diseases prevention & control, Humans, Hypertension drug therapy, Hypertension physiopathology, Randomized Controlled Trials as Topic, Systole, Antihypertensive Agents therapeutic use, Blood Pressure Determination methods, Cardiovascular Diseases diagnosis, Hypertension diagnosis
- Abstract
Objectives: To understand the discrepancy between the published 10-year cardiovascular risk and 10-year cardiovascular risk generated from raw data using the Framingham Risk Score for participants in the Systolic Blood Pressure Intervention Trial (SPRINT)., Design: Secondary analysis of SPRINT data published in The New England Journal of Medicine ( NEJM ) and made available to researchers in late 2016., Setting: SPRINT clinical trial sites., Participants: Study participants enrolled into SPRINT., Results: The number of SPRINT study participants identified as having ≥15% 10-year cardiovascular risk was not consistent with what was reported in the original publication. Using the data from the trial, the Framingham Risk Score indicated ≥15% 10-year cardiovascular risk for 7089 participants compared with 5737 reported in the paper, a change from 61% to 76% of the total study population., Conclusions: The analysis of the clinical trial data by independent investigators identified an error in the reporting of the risk of the study population. The SPRINT trial enrolled a higher risk population than was reported in the initial publication, which was brought to light by data sharing., Competing Interests: Competing interests: Drs HMK and JSR are recipients of research agreements from Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing and of a grant from Medtronic and the Food and Drug Administration, through Yale, to develop methods for postmarket surveillance of medical devices and work under contract with the Centers for Medicare and Medicaid Services to develop and maintain performance measures that are publicly reported. Dr HMK chairs a cardiac scientific advisory board for United Health, is a participant/participant representative of the IBM Watson Health Life Sciences Board, is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna and is the founder of Hugo, a personal health information platform. Dr JSR has received research support from the Blue Cross Blue Shield Association to better understand medical technology evidence generation. The other co-authors report no potential competing interests., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
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- 2018
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44. Urban-Rural Comparisons in Hospital Admission, Treatments, and Outcomes for ST-Segment-Elevation Myocardial Infarction in China From 2001 to 2011: A Retrospective Analysis From the China PEACE Study (Patient-Centered Evaluative Assessment of Cardiac Events).
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Li X, Murugiah K, Li J, Masoudi FA, Chan PS, Hu S, Spertus JA, Wang Y, Downing NS, Krumholz HM, and Jiang L
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- Aged, Aged, 80 and over, China epidemiology, Female, Hospital Mortality trends, Humans, Male, Middle Aged, Odds Ratio, Retrospective Studies, Rural Population statistics & numerical data, ST Elevation Myocardial Infarction mortality, Survival Rate trends, Time Factors, Urban Population statistics & numerical data, Disease Management, Healthcare Disparities, Hospitalization trends, Hospitals, Rural statistics & numerical data, Hospitals, Urban statistics & numerical data, Quality Improvement, ST Elevation Myocardial Infarction therapy
- Abstract
Background: In response to urban-rural disparities in healthcare resources, China recently launched a healthcare reform with a focus on improving rural care during the past decade. However, nationally representative studies comparing medical care and patient outcomes between urban and rural areas in China during this period are not available., Methods and Results: We created a nationally representative sample of patients in China admitted for ST-segment-elevation myocardial infarction in 2001, 2006, and 2011, using a 2-stage random sampling design in 2 urban and 3 rural strata. In China, evidence-based treatments were provided less often in 2001 in rural hospitals, which had lower volume and less availability of advanced cardiac facilities. However, these differences diminished by 2011 for reperfusion therapy (54% in urban versus 57% in rural; P =0.1) and reversed for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (66% versus 68%; P =0.04) and early β-blockers (56% versus 60%; P =0.01). The risk-adjusted rate of in-hospital death or withdrawal from treatment was not significantly different between urban and rural hospitals in any study year, with an adjusted odds ratio of 1.13 (0.77-1.65) in 2001, 0.99 (0.77-1.27) in 2006, and 0.94 (0.74-1.19) in 2011., Conclusions: Although urban-rural disparities in evidence-based treatment for myocardial infarction in China have largely been eliminated, substantial gaps in quality of care persist in both settings. In addition, urban hospitals providing more resource-intensive care did not achieve better outcomes., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883., (© 2017 American Heart Association, Inc.)
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- 2017
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45. Quality of Care in the United States Territories, 1999-2012.
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Nuti SV, Wang Y, Masoudi FA, Nunez-Smith M, Normand ST, Murugiah K, Rodríguez-Vilá O, Ross JS, and Krumholz HM
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- Aged, Aged, 80 and over, Female, Health Expenditures statistics & numerical data, Hospitalization statistics & numerical data, Humans, Insurance, Health, Reimbursement statistics & numerical data, Male, Public Health Surveillance methods, Racial Groups, United States, Heart Failure mortality, Medicare statistics & numerical data, Myocardial Infarction mortality, Pneumonia mortality, Quality of Health Care statistics & numerical data
- Abstract
Background: Millions of Americans live in the US territories, but health outcomes and payments among Medicare beneficiaries in these territories are not well characterized., Methods: Among Fee-for-Service Medicare beneficiaries aged 65 years and older hospitalized between 1999 and 2012 for acute myocardial infarction (AMI), heart failure (HF), and pneumonia, we compared hospitalization rates, patient outcomes, and inpatient payments in the territories and states., Results: Over 14 years, there were 4,350,813 unique beneficiaries in the territories and 402,902,615 in the states. Hospitalization rates for AMI, HF, and pneumonia declined overall and did not differ significantly. However, 30-day mortality rates were higher in the territories for all 3 conditions: in the most recent time period (2008-2012), the adjusted odds of 30-day mortality were 1.34 [95% confidence interval (CI), 1.21-1.48], 1.24 (95% CI, 1.12-1.37), and 1.85 (95% CI, 1.71-2.00) for AMI, HF, and pneumonia, respectively; adjusted odds of 1-year mortality were also higher. In the most recent study period, inflation-adjusted Medicare in-patient payments, in 2012 dollars, were lower in the territories than the states, at $9234 less (61% lower than states), $4479 less (50% lower), and $4403 less (39% lower) for AMI, HF, and pneumonia hospitalizations, respectively (P<0.001 for all)., Conclusions and Relevance: Among Medicare Fee-for-Service beneficiaries, in 2008-2012 mortality rates were higher, or not significantly different, and hospital reimbursements were lower for patients hospitalized with AMI, HF, and pneumonia in the territories. Improvement of health care and policies in the territories is critical to ensure health equity for all Americans.
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- 2017
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46. Are non-ST-segment elevation myocardial infarctions missing in China?
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Murugiah K, Wang Y, Nuti SV, Li X, Li J, Zheng X, Downing NS, Desai NR, Masoudi FA, Spertus JA, Jiang L, and Krumholz HM
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- Aged, Arabidopsis Proteins, Biomarkers blood, China epidemiology, Female, Follow-Up Studies, Hospital Mortality trends, Humans, Male, Middle Aged, Morbidity trends, Non-ST Elevated Myocardial Infarction blood, Nuclear Proteins, Retrospective Studies, Survival Rate trends, Creatine Kinase, MB Form blood, Hospitalization statistics & numerical data, Non-ST Elevated Myocardial Infarction epidemiology, Troponin blood
- Abstract
Aims: ST-segment elevation myocardial infarctions (STEMI) in China and other low- and middle-income countries outnumber non-ST-segment elevation myocardial infarctions (NSTEMI). We hypothesized that the STEMI predominance was associated with lower biomarker use and would vary with hospital characteristics., Methods and Results: We hypothesized that the STEMI predominance was associated with lower biomarker use and would vary with hospital characteristics. Using data from the nationally representative China PEACE-Retrospective AMI Study during 2001, 2006, and 2011, we compared hospital NSTEMI proportion across categories of use of any cardiac biomarker (CK, CK-MB, or troponin) and troponin, as well as across region, location, level, and teaching status. Among 15 416 acute myocardial infarction (AMI) patients, 14% had NSTEMI. NSTEMI patients were older, more likely female, and to have comorbidities. Median hospital NSTEMI proportion in each study year was similar across categories of any cardiac biomarker use, troponin, region, location, level, and teaching status. For instance, in 2011 the NSTEMI proportion at hospitals without troponin testing was 11.2% [inter quartile range (IQR) 4.4-16.7%], similar to those with ≥ 75% troponin use (13.0% [IQR 8.7-23.7%]) (P-value for difference 0.77). Analysed as continuous variables there was no relationship between hospital NSTEMI proportion and proportion biomarker use. With troponin use there was no relationship in 2001 and 2006, but a modest correlation in 2011 (R = 0.16, P = 0.043). Admissions for NSTEMI increased from 0.3/100 000 people in 2001 to 3.3/100 000 people in 2011 (P-value for trend < 0.001)., Conclusion: STEMI is the dominant presentation of AMI in China, but the proportion of NSTEMI is increasing. Biomarker use and hospital characteristics did not account for the low NSTEMI rate., Clinical Trial Registration: www.clinicaltrials.gov (NCT01624883)., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: journals.permissions@oup.com.)
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- 2017
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47. Quality of Care in Chinese Hospitals: Processes and Outcomes After ST-segment Elevation Myocardial Infarction.
- Author
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Downing NS, Wang Y, Dharmarajan K, Nuti SV, Murugiah K, Du X, Zheng X, Li X, Li J, Masoudi FA, Spertus JA, Jiang L, and Krumholz HM
- Subjects
- China, Guideline Adherence standards, Humans, Practice Guidelines as Topic standards, Practice Patterns, Physicians' standards, Quality Improvement standards, Retrospective Studies, ST Elevation Myocardial Infarction diagnosis, Time Factors, Treatment Outcome, Healthcare Disparities standards, Hospitals standards, Process Assessment, Health Care standards, Quality Indicators, Health Care standards, ST Elevation Myocardial Infarction therapy
- Abstract
Background: China has gaps in the quality of care provided to patients with ST-elevation myocardial infarction, but little is known about how quality varies between hospitals., Methods and Results: Using nationally representative data from the China PEACE-Retrospective AMI Study, we characterized the quality of care for ST-elevation myocardial infarction at the hospital level and examined variation between hospitals. Two summary measures were used to describe the overall quality of care at each hospital and to characterize variations in quality between hospitals in 2001, 2006, and 2011. The composite rate measured the proportion of opportunities a hospital had to deliver 6 guideline-recommended treatments for ST-elevation myocardial infarction that were successfully met, while the defect-free rate measured the proportion of patients at each hospital receiving all guideline-recommended treatments for which they were eligible. Risk-standardized mortality rates were calculated. Our analysis included 12 108 patients treated for ST-elevation myocardial infarction at 162 hospitals. The median composite rate increased from 56.8% (interquartile range [IQR], 45.9-72.0) in 2001 to 80.5% (IQR, 74.7-84.8) in 2011; however, substantial variation remained in 2011 with defect-free rates ranging from 0.0% to 76.9%. The median risk-standardized mortality rate increased from 9.9% (IQR, 9.1-11.7) in 2001 to 12.6% (IQR, 10.9-14.6) in 2006 before falling to 10.4% (IQR, 9.1-12.4) in 2011., Conclusions: Higher rates of guideline-recommended care and a decline in variation between hospitals are indicative of an improvement in quality. Although some variation persisted in 2011, very top-performing hospitals missed few opportunities to provide guideline-recommended care. Quality improvement initiatives should focus on eliminating residual variation as well as measuring and improving outcomes., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01624883., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)
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- 2017
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48. Admission Glucose and In-hospital Mortality after Acute Myocardial Infarction in Patients with or without Diabetes: A Cross-sectional Study.
- Author
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Zhao S, Murugiah K, Li N, Li X, Xu ZH, Li J, Cheng C, Mao H, Downing NS, Krumholz HM, and Jiang LX
- Subjects
- Aged, Cross-Sectional Studies, Female, Hospitalization, Humans, Male, Middle Aged, Risk Assessment, Blood Glucose analysis, Diabetes Mellitus blood, Diabetes Mellitus mortality, Hospital Mortality, Myocardial Infarction blood, Myocardial Infarction mortality
- Abstract
Background: Hyperglycemia on admission has been found to elevate risk for mortality and adverse clinical events after acute myocardial infarction (AMI), but there are evidences that the relationship of blood glucose and mortality may differ between diabetic and nondiabetic patients. Prior studies in China have provided mixed results and are limited by statistical power. Here, we used data from a large, nationally representative sample of patients hospitalized with AMI in China in 2001, 2006, and 2011 to assess if admission glucose is of prognostic value in China and if this relationship differs depending on the presence or absence of diabetes., Methods: Using a nationally representative sample of patients with AMI in China in 2001, 2006, and 2011, we categorized patients according to their glucose levels at admission (Results: Compared to patients with euglycemia (5.8%), patients with moderate hyperglycemia (13.1%, odds ratio [OR] = 2.44, 95% confidence interval [CI, 2.08-2.86]), severe hyperglycemia (21.5%, OR = 4.42, 95% CI [3.78-5.18]), and hypoglycemia (13.8%, OR = 2.59, 95% CI [1.68-4.00]), all had higher crude in-hospital mortality after AMI regardless of the presence of recognized diabetes mellitus. After adjustment for patients' characteristics and clinical status, however, the relationship between admission glucose and in-hospital mortality was different for diabetic and nondiabetic patients (P for interaction = 0.045). Among diabetic patients, hypoglycemia (OR = 3.02, 95% CI [1.20-7.63]), moderate hyperglycemia (OR = 1.75, 95% CI [1.04-2.92]), and severe hyperglycemia (OR = 2.97, 95% CI [1.87-4.71]) remained associated with elevated risk for mortality, but among nondiabetic patients, only patients with moderate hyperglycemia (OR = 2.34, 95% CI [1.93-2.84]) and severe hyperglycemia (OR = 3.92, 95% CI [3.04-5.04]) were at elevated mortality risk and not hypoglycemia (OR = 1.12, 95% CI [0.60-2.08]). This relationship was consistent across different study years (P for interaction = 0.900)., Conclusions: The relationship between admission glucose and in-hospital mortality differs for diabetic and nondiabetic patients. Hypoglycemia was a bad prognostic marker among diabetic patients alone. The study results could be used to guide risk assessment among AMI patients using admission glucose., Trial Registration: www.clinicaltrials.gov, NCT01624883; https://clinicaltrials.gov/ct2/show/NCT01624883.
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- 2017
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49. Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study.
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Dreyer RP, Dharmarajan K, Kennedy KF, Jones PG, Vaccarino V, Murugiah K, Nuti SV, Smolderen KG, Buchanan DM, Spertus JA, and Krumholz HM
- Subjects
- Acute Disease, Female, Humans, Male, Middle Aged, Patient Readmission, Prospective Studies, Sex Factors, Myocardial Infarction epidemiology
- Abstract
Background: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI., Methods: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction., Results: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women., Conclusions: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference., (© 2017 American Heart Association, Inc.)
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- 2017
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50. Community Level Association between Home Health and Nursing Home Performance on Quality and Hospital 30-day Readmissions for Medicare Patients.
- Author
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Wang Y, Pandolfi MM, Fine J, Metersky ML, Wang C, Ho SY, Galusha D, Nuti SV, Murugiah K, Spenard A, Elwell T, and Krumholz HM
- Abstract
We evaluated whether community-level home health agencies and nursing home performance is associated with community-level hospital 30-day all-cause risk-standardized readmission rates for Medicare patients used data from the Centers for Medicare & Medicaid Service from 2010 to 2012. Our final sample included 2,855 communities that covered 4,140 hospitals with 6,751,713 patients, 13,060 nursing homes with 1,250,648 residents, and 7,613 home health agencies providing services to 35,660 zipcodes. Based on a mixed effect model, we found that increasing nursing home performance by one star for all of its 4 measures and home health performance by 10 points for all of its 6 measures is associated with decreases of 0.25% (95% CI 0.17-0.34) and 0.60% (95% CI 0.33-0.83), respectively, in community-level risk-standardized readmission rates., Competing Interests: Financial Disclosures: The other authors report no conflicts of interest.
- Published
- 2016
- Full Text
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