710 results on '"Robert W. Yeh"'
Search Results
2. Optimized Risk Score to Predict Mortality in Patients With Cardiogenic Shock in the Cardiac Intensive Care Unit
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Eric Yamga, Sreekar Mantena, Darin Rosen, Emily M. Bucholz, Robert W. Yeh, Leo A. Celi, Berk Ustun, and Neel M. Butala
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cardiogenic shock ,CICU ,machine learning ,mortality ,risk score ,SCAI shock ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Mortality prediction in critically ill patients with cardiogenic shock can guide triage and selection of potentially high‐risk treatment options. Methods and Results We developed and externally validated a checklist risk score to predict in‐hospital mortality among adults admitted to the cardiac intensive care unit with Society for Cardiovascular Angiography & Interventions Shock Stage C or greater cardiogenic shock using 2 real‐world data sets and Risk‐Calibrated Super‐sparse Linear Integer Modeling (RiskSLIM). We compared this model to those developed using conventional penalized logistic regression and published cardiogenic shock and intensive care unit mortality prediction models. There were 8815 patients in our training cohort (in‐hospital mortality 13.4%) and 2237 patients in our validation cohort (in‐hospital mortality 22.8%), and there were 39 candidate predictor variables. The final risk score (termed BOS,MA2) included maximum blood urea nitrogen ≥25 mg/dL, minimum oxygen saturation
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- 2023
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3. Trends in Spending and Claims for P2Y12 Inhibitors by Medicare and Medicaid From 2015 to 2020
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Mohammed Essa, Joseph S. Ross, Sanket S. Dhruva, Nihar R. Desai, Robert W. Yeh, and Kamil F. Faridi
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clopidogrel ,medication costs ,prasugrel ,ticagrelor ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Published
- 2023
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4. Clinical Characteristics and Outcomes Among People Living With HIV Undergoing Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program
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Rushi V. Parikh, Annika Hebbe, Anna E. Barón, Gary K. Grunwald, Mary E. Plomondon, Jonathan Gordin, Robert W. Yeh, Hani Jneid, Rajesh V. Swaminathan, Stephen W. Waldo, Alexander Monto, Eric Secemsky, and Priscilla Y. Hsue
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coronary artery disease ,HIV ,mortality ,percutaneous coronary intervention ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Clinical characteristics and outcomes in people living with HIV (PLWH) undergoing percutaneous coronary intervention (PCI) remain poorly described. We sought to compare real‐world treatment of coronary artery disease, as well as patient and procedural factors and outcomes after PCI between PLWH and uninfected controls. Methods and Results We utilized procedural registry data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program between January 1, 2009 and December 31, 2019 to analyze patients with obstructive coronary artery disease on angiography. In the PCI subgroup, we used inverse probability of treatment weighting and applied Cox proportional hazards to evaluate the association of HIV serostatus with outcomes, including all‐cause mortality at 5 years. Among 184 310 patients with obstructive coronary artery disease, treatment strategy was similar between PLWH and controls—35.7% versus 34.2% PCI, 13.6% versus 15% coronary artery bypass grafting, and 50.7% versus 50.8% medical therapy. The PCI cohort consisted of 546 (0.9%) PLWH and 56 811 (99.1%) controls. PLWH undergoing PCI had well‐controlled HIV disease, and compared with controls, were younger, more likely to be Black, had fewer traditional risk factors, more acute coronary syndrome, less extensive coronary artery disease, and similar types of stents and P2Y12 therapy. However, PLWH experienced worse survival as early as 6 months post‐PCI, which persisted over time and amounted to a 21% increased mortality risk by 5 years (hazard ratio, 1.21 [95% CI, 1.03–1.42; P=0.02]). Conclusions Despite well‐controlled HIV disease, a more favorable overall cardiovascular risk profile, and similar PCI procedural metrics, PLWH still have significantly worse long‐term survival following PCI than controls.
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- 2023
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5. Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis
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Rahul Aggarwal, Robert W. Yeh, Issa J. Dahabreh, Sarah E. Robertson, and Rishi K. Wadhera
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Medicine - Abstract
Background US policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US. Methods and findings We used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor’s degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p < 0.001) and higher-income groups (8.0% versus 85.9%, p < 0.001). Medicare eligibility at 65 years was associated with a decreases in the percentage of low-income adults who delayed (14.7% to 6.2%; −8.5% [95% CI, −14.7%, −2.4%], P = 0.007) or avoided medical care (15.5% to 5.9%; −9.6% [−15.9%, −3.2%], P = 0.003) due to costs, and a larger decrease in the percentage who were worried about (66.5% to 51.1%; −15.4% [−25.4%, −5.4%], P = 0.003) or had problems (33.9% to 20.6%; −13.3% [−23.0%, −3.6%], P = 0.007) paying medical bills. In contrast, there were no significant associations between Medicare eligibility and measures of cost-related barriers to medication use. For higher-income adults, there was a large decrease in worrying about paying medical bills (40.5% to 27.5%; −13.0% [−21.4%, −4.5%], P = 0.003), a more modest decrease in avoiding medical care due to cost (3.5% to 0.6%; −2.9% [−5.3%, −0.5%], P = 0.02), and no significant association between eligibility and other measures of healthcare access and affordability. All estimates were stronger when examining the association of Medicare enrollment with outcomes for low and higher-income adults. Additional analyses that adjusted for clinical comorbidities and employment status were largely consistent with the main findings, as were analyses stratified by levels of educational attainment. Study limitations include the assumption adults age 64 and 66 would have similar outcomes if both groups were eligible for Medicare or if eligibility were withheld from both. Conclusions Medicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US. Rahul Aggarwal and colleagues explore the association of Medicare eligibility and enrollment with health care access, affordability, and financial strain from medical bills in low- and higher-income adults in the US. Author summary Why was this study done? In the United States, low-income adults are more likely to lack health insurance coverage, face barriers accessing healthcare, and disproportionately experience financial strain due to healthcare expenditures compared with higher-income adults. Policymakers are increasingly debating whether to expand the Medicare program by lowering the age of eligibility. We determine if Medicare eligibility and enrollment at age 65 years is associated with changes in healthcare access, affordability, and financial strain for low-income and higher-income adults. What did the researchers do and find? In this cross-sectional study, Medicare eligibility and enrollment were associated with decreases in the percentage of low-income adults who delayed or avoided medical care due to costs, as well as in the percentage whom were worried about or had problems paying medical bills. These findings were more modest and less consistent in higher-income adults. Medicare was not associated with changes in the percentage of low-income or higher-income adults who experienced cost-related barriers to medication use. What do these findings mean? As the debate on lowering the age of Medicare eligibility continues, policymakers should consider the potential implications of doing so on healthcare access and affordability for low-income adults and, more broadly, health equity in the US.
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- 2022
6. Enriching the American Heart Association COVID‐19 Cardiovascular Disease Registry Through Linkage With External Data Sources: Rationale and Design
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Andrew S. Oseran, Tianyu Sun, Rishi K. Wadhera, Issa J. Dahabreh, James A. de Lemos, Sandeep R. Das, Christine Rutan, Aarti H. Asnani, Robert W. Yeh, and Dhruv S. Kazi
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cardiovascular diseases ,COVID‐19 ,medicare ,fee‐for‐service ,mortality ,readmissions ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background The AHA Registry (American Heart Association COVID‐19 Cardiovascular Disease Registry) captures detailed information on hospitalized patients with COVID‐19. The registry, however, does not capture information on social determinants of health or long‐term outcomes. Here we describe the linkage of the AHA Registry with external data sources, including fee‐for‐service (FFS) Medicare claims, to fill these gaps and assess the representativeness of linked registry patients to the broader Medicare FFS population hospitalized with COVID‐19. Methods and Results We linked AHA Registry records of adults ≥65 years from March 2020 to September 2021 with Medicare FFS claims using a deterministic linkage algorithm and with the American Hospital Association Annual Survey, Rural Urban Commuting Area codes, and the Social Vulnerability Index using hospital and geographic identifiers. We compared linked individuals with unlinked FFS beneficiaries hospitalized with COVID‐19 to assess the representativeness of the AHA Registry. A total of 10 010 (47.0%) records in the AHA Registry were successfully linked to FFS Medicare claims. Linked and unlinked FFS beneficiaries were similar with respect to mean age (78.1 versus 77.9, absolute standardized difference [ASD] 0.03); female sex (48.3% versus 50.2%, ASD 0.04); Black race (15.1% versus 12.0%, ASD 0.09); dual‐eligibility status (26.1% versus 23.2%, ASD 0.07); and comorbidity burden. Linked patients were more likely to live in the northeastern United States (35.7% versus 18.2%, ASD 0.40) and urban/metropolitan areas (83.9% versus 76.8%, ASD 0.18). There were also differences in hospital‐level characteristics between cohorts. However, in‐hospital outcomes were similar (mortality, 23.3% versus 20.1%, ASD 0.08; home discharge, 45.5% versus 50.7%, ASD 0.10; skilled nursing facility discharge, 24.4% versus 22.2%, ASD 0.05). Conclusions Linkage of the AHA Registry with external data sources such as Medicare FFS claims creates a unique and generalizable resource to evaluate long‐term health outcomes after COVID‐19 hospitalization.
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- 2022
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7. Predicting Residual Angina After Chronic Total Occlusion Percutaneous Coronary Intervention: Insights from the OPEN‐CTO Registry
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Neel M. Butala, Hector Tamez, Eric A. Secemsky, J. Aaron Grantham, John A. Spertus, David J. Cohen, Philip Jones, Adam C. Salisbury, Suzanne V. Arnold, Frank Harrell, William Lombardi, Dimitrios Karmpaliotis, Jeffrey Moses, James Sapontis, and Robert W. Yeh
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angina ,angina frequency ,chronic total occlusion ,patient selection ,percutaneous coronary intervention ,prediction ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Given that percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is indicated primarily for symptom relief, identifying patients most likely to benefit is critically important for patient selection and shared decision‐making. Therefore, we identified factors associated with residual angina frequency after CTO PCI and developed a model to predict postprocedure anginal burden. Methods and Results Among patients in the OPEN‐CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion Hybrid Procedures) registry, we evaluated the association between patient characteristics and residual angina frequency at 6 months, as assessed by the Seattle Angina Questionnaire Angina Frequency Scale. We then constructed a prediction model for angina status after CTO PCI using ordinal regression. Among 901 patients undergoing CTO PCI, 28% had no angina, 31% had monthly angina, 30% had weekly angina, and 12% had daily angina at baseline. Six months later, 53% of patients had a ≥20‐point increase in Seattle Angina Questionnaire Angina Frequency Scale score. The final model to predict residual angina after CTO PCI included baseline angina frequency, baseline nitroglycerin use frequency, dyspnea symptoms, depressive symptoms, number of antianginal medications, PCI indication, and presence of multiple CTO lesions and had a C index of 0.78. Baseline angina frequency and nitroglycerin use frequency explained 71% of the predictive power of the model, and the relationship between model components and angina improvement at 6 months varied by baseline angina status. Conclusions A 7‐component OPEN‐AP (OPEN‐CTO Angina Prediction) score can predict angina improvement and residual angina after CTO PCI using variables commonly available before intervention. These findings have implications for appropriate patient selection and counseling for CTO PCI.
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- 2022
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8. Trends and predictors of early ablation for Atrial Fibrillation in a Nationwide population under age 65: a retrospective observational study
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Robert N. D’Angelo, Rahul Khanna, Robert W. Yeh, Laura Goldstein, Iftekhar Kalsekar, Stephen Marcello, Patricia Tung, and Peter J. Zimetbaum
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Atrial fibrillation ,Catheter ablation ,Rhythm control ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Abstract Background Catheter ablation (CA) has emerged as an effective treatment for symptomatic atrial fibrillation (AF). However practice patterns and patient factors associated with referral for CA within the first 12 months after diagnosis are poorly characterized. This study examined overall procedural trends and factors predictive of catheter ablation for newly-diagnosed atrial fibrillation in a young, commercially-insured population. Methods A large nationally-representative sample of patients age 20 to 64 from years 2010 to 2016 was studied using the IBM MarketScan® Commercial Database. Patients were included with a new diagnosis of AF in the inpatient or outpatient setting with continuous enrollment for at least 1 year pre and post index visit. Patients were excluded if they had prior history of AF or had filled an anti-arrhythmic drug (AAD) in the pre-index period. Results Early CA increased from 5.0% in 2010 to 10.5% in 2016. Patients were less likely to undergo CA if they were located in the Northeast (OR: 0.80, CI: 0.73–0.88) or North Central (OR: 0.91, CI: 0.83–0.99) regions (compared with the West), had higher CHA2DS2-VASc scores, or had Charlson Comorbidity Index (CCI) score of 3 or greater (OR: 0.61; CI: 0.51–0.72). Conclusions CA within 12 months for new-diagnosed AF increased significantly from 2010 to 2016, with most patients still trialed on an AAD prior to CA. Patients are less likely to be referred for early CA if they are located in the Northeast and North Central regions, have more comorbidities, or higher CHA2DS2-VASc scores.
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- 2020
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9. Cholesterol Efflux Capacity and Its Association With Adverse Cardiovascular Events: A Systematic Review and Meta-Analysis
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Jane J. Lee, Gerald Chi, Clara Fitzgerald, Syed Hassan A. Kazmi, Arzu Kalayci, Serge Korjian, Danielle Duffy, Alka Shaunik, Bronwyn Kingwell, Robert W. Yeh, Deepak L. Bhatt, and C. Michael Gibson
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acute coronary syndrome ,atherosclerosis ,acute myocardial infarction ,cholesterol ,cholesterol efflux capacity (CEC) ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background: Serum high-density lipoprotein cholesterol (HDL-C) levels are inversely associated with cardiovascular disease events. Yet, emerging evidence suggests that it is the functional properties of HDL, in particular, reverse cholesterol transport, which is a key protective mechanism mediating cholesterol removal from macrophage cells and reducing plaque lipid content. Cholesterol efflux capacity (CEC) measures the capacity of HDL to perform this function. A systematic review and meta-analysis were conducted to explore the association of CEC and adverse cardiovascular events.Methods: A comprehensive literature review of Embase, PubMed, and Web of Science Core Collection from inception to September 2019 was performed for all studies that examined the association between CEC and cardiovascular outcomes. The primary outcome was adverse cardiovascular events, which were inclusive of atherosclerotic cardiovascular disease (ASCVD) or mortality.Results: A total of 20 trials were included. Compared with low CEC levels, high CEC levels were associated with a 37% lower risk of adverse cardiovascular events (crude RR = 0.63; 95% CI, 0.52–0.76; P < 0.00001). Every SD increase of CEC was associated with a 20% lower risk of adverse cardiovascular events (HR = 0.80; 95% CI, 0.66–0.97; P = 0.02). The association remained significant after adjusting for cardiovascular risk factors, medications, and HDL-C levels (HR = 0.76; 95% CI, 0.63–0.91; P = 0.004). A significant CEC-endpoint relationship was observed (P = 0.024) such that for every 0.1 unit increase in CEC, there was a 5% reduced risk for adverse cardiovascular events (RR = 0.95; 95% CI, 0.91–0.99).Conclusions: Higher CEC is associated with lower adverse cardiovascular outcomes. These findings warrant further research on whether CEC is merely a biomarker or a mechanism that could be targeted as a pharmacologic intervention for improving clinical outcomes.PROSPERO Registration Number: CRD42020146681; https://www.crd.york.ac.uk/prospero/.
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- 2021
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10. Association of Frailty With Treatment Selection and Long‐Term Outcomes Among Patients With Chronic Limb‐Threatening Ischemia
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Neel M. Butala, Aishwarya Raja, Jiaman Xu, Jordan B. Strom, Marc Schermerhorn, Joshua A. Beckman, Mehdi H. Shishehbor, Changyu Shen, Robert W. Yeh, and Eric A. Secemsky
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chronic limb‐threatening ischemia ,frailty ,outcomes ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background The optimal treatment strategy for patients with chronic limb‐threatening ischemia (CLTI) is often unclear. Frailty has emerged as an important factor that can identify patients at greater risk of poor outcomes and guide treatment selection, but few studies have explored its utility among the CLTI population. We examine the association of a health record‐based frailty measure with treatment choice and long‐term outcomes among patients hospitalized with CLTI. Methods and Results We included patients aged >65 years hospitalized with CLTI in the Medicare Provider Analysis and Review data set between October 1, 2009 and September 30, 2015. The primary exposure was frailty, defined by the Claims‐based Frailty Indicator. Baseline frailty status and revascularization choice were examined using logistic regression. Cox proportional hazards regression was used to determine the association between frailty and death or amputation, stratifying by treatment strategy. Of 85 060 patients, 35 484 (42%) were classified as frail. Frail patients had lower likelihood of revascularization (adjusted odds ratio [OR], 0.78; 95% CI, 0.75‒0.82). Among those revascularized, frailty was associated with lower likelihood of surgical versus endovascular treatment (adjusted OR, 0.76; CI, 0.72‒0.81). Frail patients experienced increased risk of amputation or death, regardless of revascularization status (revascularized: adjusted hazard ratio [HR], 1.34; CI, 1.30‒1.38; non‐revascularized: adjusted HR, 1.22; CI, 1.17‒1.27). Among those revascularized, frailty was independently associated with amputation or death irrespective of revascularization strategy (surgical: adjusted HR, 1.36; CI, 1.31‒1.42; endovascular: aHR, 1.29; CI, 1.243‒1.35). Conclusions Among patients hospitalized with CLTI, frailty is an important independent predictor of revascularization strategy and longitudinal adverse outcomes.
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- 2021
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11. Identification of Frailty Using a Claims‐Based Frailty Index in the CoreValve Studies: Findings from the EXTEND‐FRAILTY Study
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Jordan B. Strom, Jiaman Xu, Ariela R. Orkaby, Changyu Shen, Brian R. Charest, Dae H. Kim, David J. Cohen, Daniel B. Kramer, John A. Spertus, Robert E. Gerszten, and Robert W. Yeh
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aortic valve disease ,claims ,frailty ,SAVR ,TAVR ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background In aortic valve disease, the relationship between claims‐based frailty indices (CFIs) and validated measures of frailty constructed from in‐person assessments is unclear but may be relevant for retrospective ascertainment of frailty status when otherwise unmeasured. Methods and Results We linked adults aged ≥65 years in the US CoreValve Studies (linkage rate, 67%; mean age, 82.7±6.2 years, 43.1% women), to Medicare inpatient claims, 2011 to 2015. The Johns Hopkins CFI, validated on the basis of the Fried index, was generated for each study participant, and the association between CFI tertile and trial outcomes was evaluated as part of the EXTEND‐FRAILTY substudy. Among 2357 participants (64.9% frail), higher CFI tertile was associated with greater impairments in nutrition, disability, cognition, and self‐rated health. The primary outcome of all‐cause mortality at 1 year occurred in 19.3%, 23.1%, and 31.3% of those in tertiles 1 to 3, respectively (tertile 2 versus 1: hazard ratio, 1.22; 95% CI, 0.98–1.51; P=0.07; tertile 3 versus 1: hazard ratio, 1.73; 95% CI, 1.41–2.12; P
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- 2021
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12. Association Between Diagnosis Code Expansion and Changes in 30‐Day Risk‐Adjusted Outcomes for Cardiovascular Diseases
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Lauren Gilstrap, Rishi K. Wadhera, Andrea M. Austin, Stephen Kearing, Karen E. Joynt Maddox, and Robert W. Yeh
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acute myocardial infarction ,heart failure ,medicare ,outcomes ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BACKGROUND In January 2011, Centers for Medicare and Medicaid Services expanded the number of inpatient diagnosis codes from 9 to 25, which may influence comorbidity counts and risk‐adjusted outcome rates for studies spanning January 2011. This study examines the association between (1) limiting versus not limiting diagnosis codes after 2011, (2) using inpatient‐only versus inpatient and outpatient data, and (3) using logistic regression versus the Centers for Medicare and Medicaid Services risk‐standardized methodology and changes in risk‐adjusted outcomes. METHODS AND RESULTS Using 100% Medicare inpatient and outpatient files between January 2009 and December 2013, we created 2 cohorts of fee‐for‐service beneficiaries aged ≥65 years. The acute myocardial infarction cohort and the heart failure cohort had 578 728 and 1 595 069 hospitalizations, respectively. We calculate comorbidities using (1) inpatient‐only limited diagnoses, (2) inpatient‐only unlimited diagnoses, (3) inpatient and outpatient limited diagnoses, and (4) inpatient and outpatient unlimited diagnoses. Across both cohorts, International Classification of Diseases, Ninth Revision (ICD‐9) diagnoses and hierarchical condition categories increased after 2011. When outpatient data were included, there were no significant differences in risk‐adjusted readmission rates using logistic regression or the Centers for Medicare and Medicaid Services risk standardization. A difference‐in‐differences analysis of risk‐adjusted readmission trends before versus after 2011 found that no significant differences between limited and unlimited models for either cohort. CONCLUSIONS For studies that span 2011, researchers should consider limiting the number of inpatient diagnosis codes to 9 and/or including outpatient data to minimize the impact of the code expansion on comorbidity counts. However, the 2011 code expansion does not appear to significantly affect risk‐adjusted readmission rate estimates using either logistic or risk‐standardization models or when using or excluding outpatient data.
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- 2021
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13. Association of Socioeconomic Disadvantage With Mortality and Readmissions Among Older Adults Hospitalized for Pulmonary Embolism in the United States
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Rishi K. Wadhera, Eric A. Secemsky, Yun Wang, Robert W. Yeh, and Samuel Z. Goldhaber
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healthcare disparities ,mortality ,pulmonary embolism ,readmissions ,socioeconomic disadvantage ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background In the United States, hospitalizations for pulmonary embolism (PE) are increasing among older adults insured by Medicare. Although efforts to reduce health disparities have intensified, it remains unclear whether clinical outcomes differ between socioeconomically disadvantaged and nondisadvantaged Medicare beneficiaries hospitalized with PE. Methods and Results In this study, there were 53 386 Medicare fee‐for‐service beneficiaries age ≥65 years hospitalized for PE between October 2015 and January 2017. Of these, 5494 (10.3%) were socioeconomically disadvantaged and 47 892 (89.7%) were nondisadvantaged. Socioeconomically disadvantaged adults were of similar age as nondisadvantaged adults (77.1 versus 77.0), more likely to be female (68.5% versus 54.2%), and less likely to receive advanced therapies (11.0% versus 12.1%). After adjustment for demographics, 90‐day all‐cause mortality rates were similar between disadvantaged and nondisadvantaged adults. In contrast, 1‐year mortality rates were higher among socioeconomically disadvantaged adults (hazard ratio [HR], 1.16; 95% CI, 1.10–1.22), although these differences were partially attenuated after additional adjustments for comorbidities and PE severity (HR, 1.09; 95% CI, 1.02–1.16). Risk‐adjusted 30‐day and 90‐day all‐cause readmission rates were substantially higher among socioeconomically disadvantaged patients (30‐day HR, 1.14 [95% CI, 1.06–1.22]; 90‐day HR, 1.18 [95% CI, 1.12–1.25]). In addition, 90‐day readmissions attributed to PE, deep vein thrombosis, and/or bleeding were higher among socioeconomically disadvantaged patients (HR, 1.16; 95% CI, 1.02–1.32). Conclusions Socioeconomically disadvantaged older adults hospitalized with PE have higher 1‐year mortality rates compared with their nondisadvantaged counterparts. Nearly 1 in 3 socioeconomically disadvantaged older adults was readmitted within 90 days of a hospitalization for PE. Targeted strategies are needed to improve transitional and ambulatory care for this vulnerable population.
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- 2021
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14. Prognosis of Claims‐ Versus Trial‐Based Ischemic and Bleeding Events Beyond 1 Year After Coronary Stenting
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Neel M. Butala, Kamil F. Faridi, Eric A. Secemsky, Yang Song, Jeptha Curtis, Charles Michael Gibson, Dhruv Kazi, Changyu Shen, and Robert W. Yeh
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claims ,clinical trials ,DAPT ,end points ,prognosis ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background It is unknown whether clinical events identified with administrative claims have similar prognosis compared with trial‐adjudicated events in cardiovascular clinical trials. We compared the prognostic significance of claims‐based end points in context of trial‐adjudicated end points in the DAPT (Dual Antiplatelet Therapy) study. Methods and Results We matched 1336 patients aged ≥65 years who received percutaneous coronary intervention in the DAPT study with the CathPCI registry linked to Medicare claims. We compared death at 21 months post‐randomization using Cox proportional hazards models among patients with ischemic events (myocardial infarction or stroke) and bleeding events identified by: (1) both trial adjudication and claims; (2) trial adjudication only; and (3) claims only. A total of 47 patients (3.5%) had ischemic events identified by both trial adjudication and claims, 24 (1.8%) in trial adjudication only, 15 (1.1%) in claims only, and 1250 (93.6%) had no ischemic events, with annualized unadjusted mortality rates of 12.8, 5.5, 14.9, and 1.26 per 100 person‐years, respectively. A total of 44 patients (3.3%) had bleeding events identified with both trial adjudication and claims, 13 (1.0%) in trial adjudication only, 65 (4.9%) in claims only, and 1214 (90.9%) had no bleeding events, with annualized unadjusted mortality rates of 11.0, 16.8, 10.7, and 0.95 per 100 person‐years, respectively. Among patients with no trial‐adjudicated events, patients with events in claims only had a high subsequent adjusted mortality risk (hazard ratio (HR) ischemic events: 31.5; 95% CI, 8.9‒111.9; HR bleeding events 23.9; 95% CI, 10.7‒53.2). Conclusions In addition to trial‐adjudicated events, claims identified additional clinically meaningful ischemic and bleeding events that were prognostically significant for death.
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- 2021
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15. Comparison of Reperfusion Strategies for ST‐Segment–Elevation Myocardial Infarction: A Multivariate Network Meta‐analysis
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Reza Fazel, Timothy I. Joseph, Mullasari A. Sankardas, Duane S. Pinto, Robert W. Yeh, Dharam J. Kumbhani, and Brahmajee K. Nallamothu
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facilitated percutaneous coronary intervention ,fibrinolytic therapy ,pharmacoinvasive approach ,primary percutaneous coronary intervention ,ST‐segment–elevation myocardial infarction ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background We systematically reviewed trials comparing different reperfusion strategies for ST‐segment–elevation myocardial infarction and used multivariate network meta‐analysis to compare outcomes across these strategies. Methods and Results We identified 31 contemporary trials in which patients with ST‐segment–elevation myocardial infarction were randomized to ≥2 of the following strategies: fibrinolytic therapy (n=4212), primary percutaneous coronary intervention (PCI) (n=6139), or fibrinolysis followed by routine early PCI (n=5006). We categorized the last approach as “facilitated PCI” when the median time interval between fibrinolysis to PCI was
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- 2020
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16. Mitral Valve Surgical Volume and Transcatheter Mitral Valve Repair Outcomes: Impact of a Proposed Volume Requirement on Geographic Access
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Sreekanth Vemulapalli, Julie Prillinger, Vinod Thourani, and Robert W. Yeh
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mitral regurgitation ,mitral valve repair ,mitral valve replacement ,valvular disease ,volume‐outcomes ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background There is an open Centers for Medicare and Medicaid Services National Coverage Decision for Transcatheter Mitral Valve Repair (TMVr) and a recent multisociety consensus document suggesting that TMVr centers should achieve prespecified mitral valve replacement or repair (MVRr). Yet, little is known about the MVRr volume–TMVr outcome relationship. Methods and Results Using Centers for Medicare and Medicaid Services administrative claims from January 1, 2016 to December 31, 2018, we computed the Pearson correlation coefficient and performed multivariable hierarchical modeling to estimate the MVRr volume to TMVr outcome relationship for mortality and heart failure hospitalization. Additionally, we assessed the impact of the consensus recommendations on geographic access to care by hospital referral region. Total annualized MVRr volume was
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- 2020
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17. Multidisciplinary Heart Team Approach for Complex Coronary Artery Disease: Single Center Clinical Presentation
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Michael N. Young, Dhaval Kolte, Mary E. Cadigan, Elizabeth Laikhter, Kevin Sinclair, Eugene Pomerantsev, Michael A. Fifer, Thoralf M. Sundt, Robert W. Yeh, and Farouc A. Jaffer
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cardiac surgery ,percutaneous coronary intervention ,quality improvement ,revascularization ,team‐based care ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background The Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision‐making and outcomes of patients based on this strategy. Methods and Results One hundred sixty‐six high‐risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery (STS‐PROM/SYNTAX) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end‐stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty‐seven (52.4%) patients had New York Heart Association III‐IV and 112 (67.5%) had Canadian Cardiovascular Society III‐IV symptomatology. Sixty‐seven (40.4%) patients had left main and 118 (71.1%) had 3‐vessel coronary artery disease. The median STS‐PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy‐nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS‐PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In‐hospital and 30‐day mortality was 3.9% and 4.8%, respectively. Conclusions Integrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence‐based management within this team‐based construct.
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- 2020
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18. Attribution of Adverse Events Following Coronary Stent Placement Identified Using Administrative Claims Data
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Sanket S. Dhruva, Craig S. Parzynski, Ginger M. Gamble, Jeptha P. Curtis, Nihar R. Desai, Robert W. Yeh, Frederick A. Masoudi, Richard Kuntz, Richard E. Shaw, Danica Marinac‐Dabic, Art Sedrakyan, Sharon‐Lise T. Normand, Harlan M. Krumholz, and Joseph S. Ross
- Subjects
drug‐eluting stent ,percutaneous coronary intervention ,real‐world data ,registry ,surveillance ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background More than 600 000 coronary stents are implanted during percutaneous coronary interventions (PCIs) annually in the United States. Because no real‐world surveillance system exists to monitor their long‐term safety, claims data are often used for this purpose. The extent to which adverse events identified with claims data can be reasonably attributed to a specific medical device is uncertain. Methods and Results We used deterministic matching to link the NCDR (National Cardiovascular Data Registry) CathPCI Registry to Medicare fee‐for‐service claims for patients aged ≥65 years who underwent PCI with drug‐eluting stents (DESs) between July 1, 2009 and December 31, 2013. We identified subsequent PCIs within 1 year of the index procedure in Medicare claims as potential safety events. We linked these subsequent PCIs back to the NCDR CathPCI Registry to ascertain how often the revascularization could be reasonably attributed to the same coronary artery as the index PCI (ie, target vessel revascularization). Of 415 306 DES placements in 368 194 patients, 33 174 repeat PCIs were identified in Medicare claims within 1 year. Of these, 28 632 (86.3%) could be linked back to the NCDR CathPCI Registry; 16 942 (51.1% of repeat PCIs) were target vessel revascularizations. Of these, 8544 (50.4%) were within a previously placed DES: 7652 for in‐stent restenosis and 1341 for stent thrombosis. Of 16 176 patients with a claim for acute myocardial infarction in the follow‐up period, 4446 (27.5%) were attributed to the same coronary artery in which the DES was implanted during the index PCI (ie, target vessel myocardial infarction). Of 24 288 patients whose death was identified in claims data, 278 (1.1%) were attributed to the same coronary artery in which the DES was implanted during the index PCI. Conclusions Most repeat PCIs following DES stent implantation identified in longitudinal claims data could be linked to real‐world registry data, but only half could be reasonably attributed to the same coronary artery as the index procedure. Attribution among those with acute myocardial infarction or who died was even less frequent. Safety signals identified using claims data alone will require more in‐depth examination to accurately assess stent safety.
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- 2020
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19. Landscape of Cardiovascular Device Registries in the United States
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Prashant V. Rajan, Jessica N. Holtzman, Aaron S. Kesselheim, Robert W. Yeh, and Daniel B. Kramer
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post‐market surveillance ,registry ,systematic review ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Regulators increasingly rely on registries for decision making related to high‐risk medical devices in the United States. However, the limited uniform standards for registries may create substantial variability in registry implementation and utility to regulators. We surveyed the current landscape of US cardiovascular device registries and chart the extent of inconsistency in goals, administration, enrollment procedures, and approach to data access. Methods and Results A systematic review using Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines identified studies (1995–2017) referencing cardiovascular device registries with a US‐based institution. Registries were then evaluated by reviewing associated articles and websites. Extracted data included device type, primary scientific aim(s), funding, stewardship (eg, administration of registry procedures), enrollment procedures, informed consent process, and mechanisms to access data for research. The 138 cardiovascular device registries in the cohort covered devices addressing interventional cardiology (65.9%), arrhythmias (15.2%), heart failure (10.1%), and valvular disease (10.1%). While the majority (55.8%) were industry‐funded, stewardship was predominantly overseen by academic centers (74.0%). Most registry participation was voluntary (77.5%), but a substantial minority (19.7%) were required as a condition of device implantation. Informed consent requirements varied widely, with written consent required in only 55.1% of registries. Registry data were primarily accessible only to stewards (84.1%), with 13.8% providing pathways for external applications. Conclusions The majority of cardiovascular device registries were funded privately under the auspices of academic institutions, which set the rules for data access. The substantial variation between cardiovascular device registries suggests a role for regulators to further strengthen guidelines to improve quality, consistency, and ethical standards.
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- 2019
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20. Treating Symptomatic Aortic Stenosis With Transcatheter Aortic Valve Replacement: Is There Time to Wait?
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Kamil F. Faridi, Robert W. Yeh, and Marie‐France Poulin
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Editorials ,aortic stenosis ,aortic valve replacement ,quality of care ,transcatheter aortic valve replacement ,wait times ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Published
- 2019
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21. High Burden of 30‐Day Readmissions After Acute Venous Thromboembolism in the United States
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Eric A. Secemsky, Kenneth Rosenfield, Kevin F. Kennedy, Michael Jaff, and Robert W. Yeh
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deep vein thrombosis ,pulmonary embolism ,readmission ,venous thromboembolism ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Venous thromboembolism (VTE) is the third leading cause of vascular disease and accounts for $10 billion in annual US healthcare costs. The nationwide burden of 30‐day readmissions after such events has not been comprehensively assessed. Methods and Results We analyzed adults ≥18 years of age with hospitalizations associated with acute VTE between January 1, 2010, and December 31, 2014, in the Nationwide Readmissions Database. International Classification of Disease, Ninth Revision, Clinical Modification (ICD‐9‐CM) codes were used to identify hospitalizations associated with acute pulmonary embolism or deep vein thrombosis. The primary outcome was the rate of unplanned 30‐day readmission. Hierarchical logistic regression was used to calculate hospital‐specific 30‐day risk‐standardized readmission rates, a marker of healthcare quality. Among 1 176 335 hospitalizations with acute VTE, in‐hospital death occurred in 6.2%. VTE was associated with malignancy in 19.7%, recent surgery in 19.3%, recent trauma in 4.6%, hypercoagulability in 3.3%, and pregnancy in 1.0%. Among survivors to discharge, the 30‐day readmission rate was 17.5%, with no significant difference in rates across study years (17.4%–17.7%; P=0.10 for trend). Major predictors of readmission were malignancy (relative risk, 1.49, 95% confidence interval 1.47‐1.50), Medicaid insurance (relative risk, 1.48, 95% confidence interval 1.46‐1.50), and nonelective index admission (relative risk, 1.31, 95% confidence interval 1.29‐1.33). Top causes of readmission included sepsis (9.6%) and procedural complications (8.1%). Median rehospitalization costs were $9781.7 (interquartile range, $5430.7–$18 784.1), and 8.1% died during readmission. The interquartile range in risk‐standardized readmission rates was 16.6% to 18.3%, suggesting modest interhospital heterogeneity in readmission risk. Conclusions Nearly 1 in 5 patients with acute VTE were readmitted within 30 days. Predictors and causes of readmission were primarily related to patient characteristics and complications from comorbid conditions, whereas healthcare quality had a moderate impact on readmission risk.
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- 2018
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22. Acute Myocardial Infarction Mortality During Dates of National Interventional Cardiology Meetings
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Anupam B. Jena, Andrew Olenski, Daniel M. Blumenthal, Robert W. Yeh, Dana P. Goldman, and John Romley
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acute coronary syndrome ,acute myocardial infarction ,Cardiology meetings ,health services research ,Mortality ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BackgroundPrevious research has found that patients with acute cardiovascular conditions treated in teaching hospitals have lower 30‐day mortality during dates of national cardiology meetings. Methods and ResultsWe analyzed 30‐day mortality among Medicare beneficiaries hospitalized with acute myocardial infarction (overall, ST‐segment–elevation myocardial infarction, and non–ST‐segment–elevation myocardial infarction) from January 1, 2007, to November 31, 2012, in major teaching hospitals during dates of a major annual interventional cardiology meeting (Transcatheter Cardiovascular Therapeutics) compared with identical nonmeeting days in the ±5 weeks. Treatment differences were assessed. We used a database of US physicians to compare interventional cardiologists who practiced and did not practice during meeting dates (“stayers” and “attendees,” respectively) in terms of demographic characteristics and clinical and research productivity. Unadjusted and adjusted 30‐day mortality rates were lower among patients admitted during meeting versus nonmeeting dates (unadjusted, 15.3% [482/3153] versus 16.7% [5208/31 556] [P=0.04]; adjusted, 15.4% versus 16.7%; difference −1.3% [95% confidence interval, −2.7% to −0.1%] [P=0.05]). Rates of interventional cardiologist involvement were similar between dates (59.5% versus 59.8% of hospitalizations; P=0.88), as were percutaneous coronary intervention rates (30.2% versus 29.1%; P=0.20). Mortality reductions were largest among patients with non–ST‐segment–elevation myocardial infarction not receiving percutaneous coronary intervention (16.9% versus 19.5% adjusted 30‐day mortality; P=0.008). Compared with stayers, attendees were of similar age and sex, but had greater publications (18.9 versus 6.3; P
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- 2018
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23. Successful treatment of flecainide overdose with sustained mechanical circulatory support
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Anant Mandawat, MD, Stephen A. McCullough, MD, Lauren G. Gilstrap, MD, and Robert W. Yeh, MD, MBA
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Flecainide ,Overdose ,Arrhythmia ,Extracorporeal membrane oxygenation ,Mechanical circulatory support ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Published
- 2015
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24. Shockwave Lithoplasty Compared to Cutting Balloon Treatment in Calcified Coronary Disease - A Randomized Controlled Trial (Short-Cut)
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Robert W. Yeh, MD, Ajay Kirtane, MD, C. Michael Gibson, MS, MD, Kathleen Kearney, MD, Akiko Maehara, MD, and Suzanne Baron, MD
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- 2023
25. Use of Chronic Oral Anticoagulation and Associated Outcomes Among Patients Undergoing Percutaneous Coronary Intervention
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Eric A. Secemsky, Neel M. Butala, Uri Kartoun, Sadiqa Mahmood, Jason H. Wasfy, Kevin F. Kennedy, Stanley Y. Shaw, and Robert W. Yeh
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anticoagulant ,bleeding ,mortality ,percutaneous coronary intervention ,readmission ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BackgroundContemporary rates of oral anticoagulant (OAC) therapy and associated outcomes among patients undergoing percutaneous coronary intervention (PCI) have been poorly described. Methods and ResultsUsing data from an integrated health care system from 2009 to 2014, we identified patients on OACs within 30 days of PCI. Outcomes included in‐hospital bleeding and mortality. Of 9566 PCIs, 837 patients (8.8%) were on OACs, and of these, 7.9% used non–vitamin K antagonist agents. OAC use remained stable during the study (8.1% in 2009, 9.0% in 2014; P=0.11), whereas use of non–vitamin K antagonist agents in those on OACs increased (0% in 2009, 16% in 2014; P
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- 2016
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26. Development and Validation of a Scoring System for Predicting Periprocedural Complications During Percutaneous Coronary Interventions of Chronic Total Occlusions: The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) Complications Score
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Barbara Anna Danek, Aris Karatasakis, Dimitri Karmpaliotis, Khaldoon Alaswad, Robert W. Yeh, Farouc A. Jaffer, Mitul P. Patel, Ehtisham Mahmud, William L. Lombardi, Michael R. Wyman, J. Aaron Grantham, Anthony Doing, David E. Kandzari, Nicholas J. Lembo, Santiago Garcia, Catalin Toma, Jeffrey W. Moses, Ajay J. Kirtane, Manish A. Parikh, Ziad A. Ali, Judit Karacsonyi, Bavana V. Rangan, Craig A. Thompson, Subhash Banerjee, and Emmanouil S. Brilakis
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chronic total occlusion ,complication ,outcome ,percutaneous coronary intervention ,risk stratification ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BackgroundHigh success rates are achievable for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid approach, but periprocedural complications remain of concern. Although scores estimating success and efficiency in CTO PCI have been developed, there is currently no available score for estimation of the risk for periprocedural complications. We sought to develop a scoring tool for prediction of periprocedural complications during CTO PCI. Methods and ResultsWe analyzed data from 1569 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS CTO) using a derivation and validation sampling ratio of 2:1. Variables independently associated with periprocedural complications in multivariable analysis in the derivation set were assigned points based on their respective odds ratios. Forty‐four (2.8%) patients experienced complications. Three factors were independent predictors of complications and were included in the score: patient age >65 years, +3 points (odds ratio, OR=4.85, CI 1.82‐16.77); lesion length ≥23 mm, +2 points (OR=3.22, CI 1.08‐13.89); and use of the retrograde approach +1 point (OR=2.41, CI 1.04‐6.05). The resulting score showed good calibration and discriminatory capacity in the derivation (Hosmer‐Lemeshow χ2 6.271, P=0.281, receiver‐operating characteristic [ROC] area=0.758) and validation (Hosmer‐Lemeshow χ2 4.551, P=0.473, ROC area=0.793) sets. Score values of 0 to 2, 3 to 4, and ≥5 were defined as low, intermediate, and high risk of complications (derivation cohort 0.4%, 1.8%, 6.5%, P
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- 2016
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27. Use of Intravascular Imaging During Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From a Contemporary Multicenter Registry
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Judit Karacsonyi, Khaldoon Alaswad, Farouc A. Jaffer, Robert W. Yeh, Mitul Patel, John Bahadorani, Aris Karatasakis, Barbara A. Danek, Anthony Doing, J. Aaron Grantham, Dimitri Karmpaliotis, Jeffrey W. Moses, Ajay Kirtane, Manish Parikh, Ziad Ali, William L. Lombardi, David E. Kandzari, Nicholas Lembo, Santiago Garcia, Michael R. Wyman, Aya Alame, Phuong‐Khanh J. Nguyen‐Trong, Erica Resendes, Pratik Kalsaria, Bavana V. Rangan, Imre Ungi, Craig A. Thompson, Subhash Banerjee, and Emmanouil S. Brilakis
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chronic total occlusion ,intravascular ultrasound ,optical coherence tomography ,percutaneous coronary intervention ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
BackgroundIntravascular imaging can facilitate chronic total occlusion (CTO) percutaneous coronary intervention. Methods and ResultsWe examined the frequency of use and outcomes of intravascular imaging among 619 CTO percutaneous coronary interventions performed between 2012 and 2015 at 7 US centers. Mean age was 65.4±10 years and 85% of the patients were men. Intravascular imaging was used in 38%: intravascular ultrasound in 36%, optical coherence tomography in 3%, and both in 1.45%. Intravascular imaging was used for stent sizing (26.3%), stent optimization (38.0%), and CTO crossing (35.7%, antegrade in 27.9%, and retrograde in 7.8%). Intravascular imaging to facilitate crossing was used more frequently in lesions with proximal cap ambiguity (49% versus 26%, P
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- 2016
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28. Comparison of Unibody and Non-Unibody Endografts for Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries: The SAFE-AAA Study
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Eric A. Secemsky, Yang Song, Tianyu Sun, Carmen Gacchina Johnson, Megan Gatski, Li Wang, Andrew Farb, Robert E. Lee, Aurko Shaw, Jiaman Xu, and Robert W. Yeh
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Physiology (medical) ,Cardiology and Cardiovascular Medicine - Abstract
Background: Concerns have been raised about the long-term performance of aortic stent grafts for the treatment of abdominal aortic aneurysms, in particular, unibody stent grafts (eg, Endologix AFX AAA stent grafts). Only limited data sets are available to evaluate the long-term risks related to these devices. The SAFE-AAA Study (Comparison of Unibody and Non-Unibody Endografts for Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries Study) was designed with the Food and Drug Administration to provide a longitudinal assessment of the safety of unibody aortic stent grafts among Medicare beneficiaries. Methods: The SAFE-AAA Study was a prespecified, retrospective cohort study evaluating whether unibody aortic stent grafts are noninferior to non-unibody aortic stent grafts with respect to the composite primary outcome of aortic reintervention, rupture, and mortality. Procedures were evaluated from August 1, 2011, through December 31, 2017. The primary end point was evaluated through December 31, 2019. Inverse probability weighting was used to account for imbalances in observed characteristics. Sensitivity analyses were used to evaluate the effect of unmeasured confounding, including assessment of the falsification end points heart failure, stroke, and pneumonia. A prespecified subgroup included patients treated from February 22, 2016, through December 31, 2017, corresponding to the market release of the most contemporary unibody aortic stent grafts (Endologix AFX2 AAA stent graft). Results: Of 87 163 patients who underwent aortic stent grafting at 2146 US hospitals, 11 903 (13.7%) received a unibody device. The average age of the total cohort was 77.0±6.7 years, 21.1% were female, 93.5% were White, 90.8% had hypertension, and 35.8% used tobacco. The primary end point occurred in 73.4% of unibody device-treated patients versus 65.0% of non-unibody device–treated patients (hazard ratio, 1.19 [95% CI, 1.15–1.22]; noninferior P value of 1.00; median follow-up, 3.4 years). Falsification end points were negligibly different between groups. In the subgroup treated with contemporary unibody aortic stent grafts, the cumulative incidence of the primary end point occurred in 37.5% of unibody device–treated patients and 32.7% of non-unibody device–treated patients (hazard ratio, 1.06 [95% CI, 0.98–1.14]). Conclusions: In the SAFE-AAA Study, unibody aortic stent grafts failed to meet noninferiority compared with non-unibody aortic stent grafts with respect to aortic reintervention, rupture, and mortality. These data support the urgency of instituting a prospective longitudinal surveillance program for monitoring safety events related to aortic stent grafts.
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- 2023
29. Out-of-Pocket Drug Costs for Medicare Beneficiaries With Cardiovascular Risk Factors Under the Inflation Reduction Act
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Prihatha R. Narasimmaraj, Andrew Oseran, Archana Tale, Jiaman Xu, Utibe R. Essien, Dhruv S. Kazi, Robert W. Yeh, and Rishi K. Wadhera
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Cardiology and Cardiovascular Medicine - Published
- 2023
30. Characterizing the Accuracy of
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Jordan B, Strom, Jiaman, Xu, Tianyu, Sun, Yang, Song, Jonathan, Sevilla-Cazes, Zaid I, Almarzooq, Lawrence J, Markson, Rishi K, Wadhera, and Robert W, Yeh
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Aged, 80 and over ,Male ,Transcatheter Aortic Valve Replacement ,International Classification of Diseases ,Aortic Valve ,Aortic Valve Insufficiency ,Humans ,Female ,Aortic Valve Stenosis ,Middle Aged ,Medicare ,United States ,Aged - Abstract
Administrative claims for aortic stenosis (AS) regurgitation may be useful, but their accuracy and ability to identify individuals at risk for valve-related outcomes have not been well characterized.Using echocardiographic (transthoracic echocardiogram [TTE]) reports linked to US Medicare claims, 2017 to 2018, the performance of candidateOf those included in the derivation (N=5497, mean age 74.4±11.0 years, 49.7% female), any AS or aortic regurgitation was present in 24% and 38.8%, respectively. The sensitivity and specificity ofAmong US Medicare beneficiaries receiving a TTE
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- 2023
31. Outcomes of Medical Therapy Plus PCI for Multivessel or Left Main CAD Ineligible for Surgery
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Adam C. Salisbury, J. Aaron Grantham, W. Morris Brown, William L. Ballard, Keith B. Allen, Ajay J. Kirtane, Michael Argenziano, Robert W. Yeh, Kamal Khabbaz, John Lasala, Puja Kachroo, Dimitri Karmpaliotis, Jeffrey Moses, William L. Lombardi, Karen Nugent, Ziad Ali, Kensey L. Gosch, John A. Spertus, and David E. Kandzari
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Cardiology and Cardiovascular Medicine - Published
- 2023
32. Use of Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention
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Judit, Karacsonyi, Karen, Deffenbacher, Keith H, Benzuly, James D, Flaherty, Khaldoon, Alaswad, Mir, Basir, Michael S, Megaly, Farouc, Jaffer, Darshan, Doshi, Paul, Poommipanit, Jaikirshan, Khatri, Mitul, Patel, Robert, Riley, Abdul, Sheikh, Jason R, Wollmuth, Ethan, Korngold, Barry F, Uretsky, Robert W, Yeh, Raj H, Chandwaney, Ahmed M, Elguindy, Khalid, Tammam, Nidal, AbiRafeh, Christian W, Schmidt, Brynn, Okeson, Spyridon, Kostantinis, Bahadir, Simsek, Bavana V, Rangan, Emmanouil S, Brilakis, and Daniel R, Schimmel
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Cardiology and Cardiovascular Medicine - Abstract
The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p0.001) and procedural (39% vs 86%, p0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates.
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- 2023
33. Days at home after transcatheter or surgical aortic valve replacement in high-risk patients
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Mabel Chung, Neel M. Butala, Kamil F. Faridi, Zaid I. Almarzooq, Dingning Liu, Jiaman Xu, Yang Song, Suzanne J. Baron, Changyu Shen, Dhruv S. Kazi, and Robert W. Yeh
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Transcatheter Aortic Valve Replacement ,Heart Valve Prosthesis Implantation ,Treatment Outcome ,Time Factors ,Risk Factors ,Aortic Valve ,Humans ,Aortic Valve Stenosis ,Medicare ,Cardiology and Cardiovascular Medicine ,United States ,Aged - Abstract
Days at home (DAH) quantifies time spent at home after a medical event but has not been fully evaluated for TAVR. We sought to compare 1- and 5-year DAH (DAHWe linked data from the U.S. CoreValve High Risk Trial to Medicare Fee-for-Service claims in 456 patients with 450 (234 TAVR/216 SAVR) and 427 (222 TAVR/205 SAVR) analyzed at 1 and 5 years. DAH was calculated as the number of days alive and spent outside of a hospital, skilled nursing facility, rehabilitation, long-term acute care hospital, emergency department, or observation stay.Mean DAHIn the U.S. CoreValve High Risk Trial linked to Medicare, high-risk patients undergoing TAVR spend an average of 27 additional DAH compared with SAVR in the first year after the procedure due to a shorter index LOS and the additive effect of fewer but nonsignificantly different mortality and total facility days after discharge from the index hospitalization compared with SAVR. After the first year, both groups spend a similar number of DAH. These results describe the postprocedural course of high-risk patients from a patient-centered perspective, which may guide expectations regarding longitudinal health care needs and inform shared decision-making.
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- 2023
34. Assessment of the Social Security Administration Death Master File for Comparative Analysis Studies of Peripheral Vascular Devices
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Eric A, Secemsky, Eric, Barrette, Lindsay, Bockstedt, and Robert W, Yeh
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Health Policy ,Public Health, Environmental and Occupational Health - Abstract
The objective of this study was to assess the reliability the Social Security Administration Death Master File (SSADMF) for evaluating mortality in comparative peripheral vascular device studies.We leveraged 2 versions of an administrative claims data set that were identical except for the source of mortality data. The SSADMF was the primary source of mortality records in one version. The SSADMF was combined with mortality from Medicare beneficiary records in the other. Our study was set in the context of a comparative effectiveness analysis of recent Food and Drug Administration interest involving peripheral paclitaxel-coated devices. Mortality of patients with Medicare Advantage insurance coverage from 2015 to 2018 who underwent femoropopliteal artery revascularization with a drug-coated device (DCD) or non-DCD was assessed through 2019. Covariate differences between treatment groups were adjusted by inverse propensity treatment weighting. The hazard ratio of DCD to non-DCD mortality was estimated using Cox regression.The cumulative incidences of mortality differed substantially between versions of the data. Nevertheless, we could not reject the null hypothesis that the hazard ratios of the SSADMF (1.05; 95% confidence interval 0.95-1.17) and the Master Beneficiary Summary File/SSADMF (1.03; 95% confidence interval 0.96-1.11) were the same (P = .63).The SSADMF is a common source of mortality records in the United States that can be linked to real-world data sources but is known to underreport mortality rates. We find that the SSADMF provides a reliable source of all-cause mortality for a comparative study assessing the safety of peripheral vascular devices.
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- 2023
35. Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease
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Andrew S. Oseran, Tianyu Sun, Rahul Aggarwal, Ashley Kyalwazi, Robert W. Yeh, and Rishi K. Wadhera
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Cross-Sectional Studies ,Cardiovascular Diseases ,Costs and Cost Analysis ,Humans ,Medicare Part C ,Cardiology and Cardiovascular Medicine ,Health Services Accessibility ,United States ,Aged - Abstract
Background: Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown. Methods: We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability. Results: The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P =0.01) and to be college educated (24.2% versus 19.0%; P =0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33–2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17–2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07–1.76]) compared with those enrolled in traditional Medicare. Conclusions: Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.
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- 2023
36. Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019
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Ashley N. Kyalwazi, Eméfah C. Loccoh, LaPrincess C. Brewer, Elizabeth O. Ofili, Jiaman Xu, Yang Song, Karen E. Joynt Maddox, Robert W. Yeh, and Rishi K. Wadhera
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Adult ,Male ,Social Segregation ,Black People ,United States ,White People ,Race Factors ,Black or African American ,Cardiovascular Diseases ,Residence Characteristics ,Physiology (medical) ,Humans ,Female ,Cardiology and Cardiovascular Medicine ,Aged - Abstract
Background: Black adults experience a disproportionately higher burden of cardiovascular risk factors and disease in comparison with White adults in the United States. Less is known about how sex-based disparities in cardiovascular mortality between these groups have changed on a national scale over the past 20 years, particularly across geographic determinants of health and residential racial segregation. Methods: We used CDC WONDER (Centers for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiologic Research) to identify Black and White adults age ≥25 years in the United States from 1999 to 2019. We calculated annual age-adjusted cardiovascular mortality rates (per 100 000) for Black and White women and men, as well as absolute rate differences and rate ratios to compare the mortality gap between these groups. We also examined patterns by US census region, rural versus urban residence, and degree of neighborhood segregation. Results: From 1999 to 2019, age-adjusted mortality rates declined overall for both Black and White adults. There was a decline in age-adjusted cardiovascular mortality among Black (602.1 to 351.8 per 100 000 population) and White women (447.0 to 267.5), and the absolute rate difference (ARD) between these groups decreased over time (1999: ARD, 155.1 [95% CI, 149.9–160.3]; 2019: ARD, 84.3 [95% CI, 81.2–87.4]). These patterns were similar for Black (824.1 to 526.3 per 100 000) and White men (637.5 to 396.0; 1999: ARD, 186.6 [95% CI, 178.6–194.6]; 2019: ARD, 130.3 [95% CI, 125.6–135.0]). Despite this progress, cardiovascular mortality in 2019 was higher for Black women (rate ratio, 1.32 [95% CI, 1.30–1.33])— especially in the younger (age Conclusions: During the past 2 decades, age-adjusted cardiovascular mortality declined significantly for Black and White adults in the United States, as did the absolute difference in death rates between these groups. Despite this progress, Black women and men continue to experience higher cardiovascular mortality rates than their White counterparts.
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- 2023
37. Assessment of Prices for Cardiovascular Tests and Procedures at Top-Ranked US Hospitals
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Andrew S. Oseran, Shylie Ati, William B. Feldman, Suhas Gondi, Robert W. Yeh, and Rishi K. Wadhera
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Internal Medicine ,Humans ,Hospital Mortality ,Hospitals ,United States - Published
- 2023
38. The Outcomes of Percutaneous RevascularizaTIon for Management of SUrgically Ineligible Patients With Multivessel or Left Main Coronary Artery Disease (OPTIMUM) Registry: Rationale and Design
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Adam C, Salisbury, Ajay J, Kirtane, Ziad A, Ali, J Aaron, Grantham, William L, Lombardi, Robert W, Yeh, Philippe, Genereux, Keith B, Allen, W Morris, Brown, Karen, Nugent, Kensey L, Gosch, Dimitri, Karmpaliotis, John A, Spertus, and David E, Kandzari
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Percutaneous Coronary Intervention ,Treatment Outcome ,Risk Factors ,Humans ,Coronary Artery Disease ,Registries ,General Medicine ,Coronary Artery Bypass ,Cardiology and Cardiovascular Medicine - Abstract
Guidelines endorse coronary artery bypass as the preferred revascularization strategy for patients with left main and/or multivessel coronary artery disease (CAD). However, many patients are deemed excessively high risk for surgery after Heart Team evaluation. No prospective studies have examined contemporary treatment patterns, rationale for surgical decision-making, completeness of revascularization with percutaneous coronary intervention (PCI), and outcomes in this high-risk population with advanced CAD.We designed the Outcomes of Percutaneous RevascularizaTIon for Management of SUrgically Ineligible Patients with Multivessel or Left Main Coronary Artery Disease (OPTIMUM) registry, a prospective, multicenter study of patients with "surgical anatomy" determined to be at prohibitive risk for bypass surgery. The primary outcome is comparison of observed to predicted 30-day mortality, with secondary outcomes of patient-reported health status and the association between completeness of revascularization and clinical outcomes. Patient characteristics driving surgical risk determinations will be reported, and peri-operative risk will be assessed using validated scoring methods. Angiograms will be assessed by an independent core laboratory, and clinical events will be adjudicated.Clinical outcomes assessments will include 30-day and 1-year cardiovascular events, health status at 1, 6 and 12-months, and 5-year mortality.OPTIMUM is the first prospective, multicenter study to examine treatment strategies and outcomes among multivessel CAD patients deemed ineligible for surgical revascularization after Heart Team assessment. This registry will provide unique insights into the clinical decision-making, revascularization practices, safety, effectiveness, and health status outcomes in this high-risk population.
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- 2022
39. Differences in Comorbidities Explain Black–White Disparities in Outcomes After Femoropopliteal Endovascular Intervention
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Anna K. Krawisz, Sahana Natesan, Rishi K. Wadhera, Siyan Chen, Yang Song, Robert W. Yeh, Michael R. Jaff, Jay Giri, Howard Julien, and Eric A. Secemsky
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Adult ,Male ,Endovascular Procedures ,Limb Salvage ,Medicare ,Amputation, Surgical ,United States ,Peripheral Arterial Disease ,Treatment Outcome ,Risk Factors ,Physiology (medical) ,Humans ,Female ,Healthcare Disparities ,Cardiology and Cardiovascular Medicine ,Aged ,Retrospective Studies - Abstract
Background: Black adults have a higher incidence of peripheral artery disease and limb amputations than White adults in the United States. Given that peripheral endovascular intervention (PVI) is now the primary revascularization strategy for peripheral artery disease, it is important to understand whether racial differences exist in PVI incidence and outcomes. Methods: Data from fee-for-service Medicare beneficiaries ≥66 years of age from 2016 to 2018 were evaluated to determine age- and sex-standardized population-level incidences of femoropopliteal PVI among Black and White adults over the 3-year study period. Patients’ first inpatient or outpatient PVIs were identified through claims codes. Age- and sex-standardized risks of the composite outcome of death and major amputation within 1 year of PVI were examined by race. Results: Black adults underwent 928 PVIs per 100 000 Black beneficiaries compared with 530 PVIs per 100 000 White beneficiaries (risk ratio, 1.75 [95% CI, 1.73–1.77]; P P P< 0.01), and had a higher burden of diabetes (70.6% versus 56.0%; P P< 0.01), and heart failure (47.4% versus 41.7%; P< 0.01) than White adults. When analyzed by indication for revascularization, Black adults were more likely to undergo PVI for chronic limb-threatening ischemia than White adults (13 023 per 21 352 [61.0%] versus 59 956 per 120 049 [49.9%]; P< 0.01). There was a strong association between Black race and the composite outcome at 1 year (odds ratio, 1.21 [95% CI, 1.16–1.25]). This association persisted after adjustment for socioeconomic status (odds ratio, 1.08 [95% CI, 1.03–1.13]) but was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92–1.01]). Conclusions: Among fee-for-service Medicare beneficiaries, Black adults had substantially higher population-level PVI incidence and were significantly more likely to experience adverse events after PVI than White adults. The association between Black race and adverse outcomes appears to be driven by a higher burden of comorbidities. This analysis emphasizes the critical need for early identification and aggressive management of peripheral artery disease risk factors and comorbidities to reduce Black–White disparities in the development and progression of peripheral artery disease and the risk of adverse events after PVI.
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- 2022
40. Predicting Periprocedural Complications in Chronic Total Occlusion Percutaneous Coronary Intervention
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Bahadir Simsek, Spyridon Kostantinis, Judit Karacsonyi, Khaldoon Alaswad, Oleg Krestyaninov, Dmitrii Khelimskii, Rhian Davies, Jeremy Rier, Omer Goktekin, Sevket Gorgulu, Ahmed ElGuindy, Raj H. Chandwaney, Mitul Patel, Nidal Abi Rafeh, Dimitrios Karmpaliotis, Amirali Masoumi, Jaikirshan J. Khatri, Farouc A. Jaffer, Darshan Doshi, Paul B. Poommipanit, Bavana V. Rangan, Yader Sandoval, James W. Choi, Basem Elbarouni, William Nicholson, Wissam A. Jaber, Stephane Rinfret, Michael Koutouzis, Ioannis Tsiafoutis, Robert W. Yeh, M. Nicholas Burke, Salman Allana, Olga C. Mastrodemos, and Emmanouil S. Brilakis
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Cardiology and Cardiovascular Medicine - Published
- 2022
41. Outcomes of stroke events during transcatheter aortic valve implantation
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Zaid I, Almarzooq, Dhruv S, Kazi, Yun, Wang, Mabel, Chung, Wei, Tian, Jordan B, Strom, Suzanne J, Baron, and Robert W, Yeh
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Heart Valve Prosthesis Implantation ,Male ,Aortic Valve Stenosis ,Medicare ,United States ,Brain Ischemia ,Stroke ,Transcatheter Aortic Valve Replacement ,Treatment Outcome ,Risk Factors ,Aortic Valve ,Humans ,Female ,Cardiology and Cardiovascular Medicine ,Aged ,Ischemic Stroke - Abstract
Despite improvements in the safety of transcatheter aortic valve implantation (TAVI), ~4% of patients experience a procedure-related stroke. Understanding long-term health and healthcare implications of these events may motivate the development and adoption of preventative strategies. Aims: We aimed to assess the association of TAVI-related ischaemic stroke with subsequent clinical outcomes and healthcare utilisation.We used Medicare fee-for-service claims to identify patients who underwent their first TAVI between January 2012 and December 2017. Previously used ICD-9-CM and ICD-10-CM codes were used to identify TAVI-related ischaemic stroke. Among those with and without TAVI-related ischaemic stroke, we compared the risk of a composite endpoint that included all-cause mortality, acute myocardial infarction, and subsequent stroke using inverse probability treatment weighted Cox regression. We also performed a difference-in-difference analysis to compare 1-year Medicare expenditures and days spent at home during the first year after TAVI. Among 129,628 primary TAVI patients, 5,549 (4.3%) had a procedure-related stroke. These patients were more likely to be female and have had prior stroke, peripheral vascular disease, ischaemic heart disease, or renal failure. After adjustment, TAVI-related ischaemic stroke was associated with a higher risk of the 1-year composite outcome (HR 1.67, 95% CI: 1.56-1.78), higher 1-year Medicare expenditures (difference $9,245 [standard error 790], p0.001), and fewer days at home during the first year (difference 16 days [standard error 1], p0.001).Among Medicare beneficiaries undergoing TAVI, procedure-related ischaemic stroke was associated with worse outcomes, increased Medicare expenditures, and less time spent at home. Procedure-related ischaemic stroke during TAVI remains a critically important and potentially preventable source of patient mortality, morbidity and healthcare utilisation.
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- 2022
42. Availability and Use of In-Person and Virtual Cardiac Rehabilitation Among US Medicare Beneficiaries: A Post-Pandemic Update
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Merilyn S. Varghese, Yang Song, Jiaman Xu, Issa Dahabreh, Alexis L. Beatty, Laurence S. Sperling, Gregg C. Fonarow, Steven J. Keteyian, Robert W. Yeh, Wen-Chih Wu, and Dhruv S. Kazi
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Pulmonary and Respiratory Medicine ,Rehabilitation ,Cardiology and Cardiovascular Medicine - Published
- 2023
43. Incidence, Treatment, and Outcomes of Symptomatic Device Lead-Related Venous Obstruction
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Enrico G. Ferro, Daniel B. Kramer, Siling Li, Andrew H. Locke, Shantum Misra, Alec A. Schmaier, Brett J. Carroll, Yang Song, Andre A. D’Avila, Robert W. Yeh, Peter J. Zimetbaum, and Eric A. Secemsky
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Cardiology and Cardiovascular Medicine - Published
- 2023
44. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults
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Jamie Diamond, Iyanuoluwa Ayodele, Gregg C. Fonarow, Karen E. Joynt-Maddox, Robert W. Yeh, Gmerice Hammond, Larry A. Allen, Stephen J. Greene, Karen Chiswell, Adam D. DeVore, Clyde Yancy, and Rishi K. Wadhera
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Cardiology and Cardiovascular Medicine - Abstract
ImportanceBlack adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown.ObjectiveTo compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals.Design, Setting, and ParticipantsPatients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022.ExposuresHospitals caring for high proportions of Black patients.Main Outcomes and MeasuresQuality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients.ResultsThis study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02).Conclusions and RelevanceQuality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.
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- 2023
45. Ischemic Risk Prediction Scores
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Serge Korjian, Robert W. Yeh, and Donald E. Cutlip
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Cardiology and Cardiovascular Medicine - Published
- 2022
46. Expansion of Insurance Under the Affordable Care Act and Invasive Management of Acute Myocardial Infarction
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Jason H. Wasfy, Robert W. Yeh, Timothy G. Ferris, John Hsu, Jinghan Cui, and Julian S. Haimovich
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Care process ,medicine.medical_specialty ,medicine.medical_treatment ,Myocardial Infarction ,Medicare ,Insurance Coverage ,Percutaneous Coronary Intervention ,Health care ,medicine ,Health insurance ,Humans ,Myocardial infarction ,Healthcare Cost and Utilization Project ,health care economics and organizations ,Aged ,Insurance, Health ,Medicaid ,business.industry ,Patient Protection and Affordable Care Act ,Percutaneous coronary intervention ,General Medicine ,medicine.disease ,United States ,Health Care Reform ,Emergency medicine ,Conventional PCI ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background The Affordable Care Act of 2010 extended health insurance through expansion of Medicaid and subsidies for commercial insurance. Prior work has produced differing results in associating expanded insurance with improvements in health care processes and outcomes. Evaluating specific mechanisms of care processes and their association with insurance expansion may help reconcile those results. Methods and results We used inpatient hospitalization data in the Nationwide Inpatient Sample (NIS) Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 1/1/2008 to 9/30/2015. We included all hospitalizations for acute myocardial infarction (AMI). As a primary outcome, we defined percent rate of AMI hospitalizations receiving percutaneous coronary intervention (PCI) per month. In the non-Medicare (intervention) group, there was a relative decrease of 0.2% of the monthly trend before and after expansion (95% CI [-0.3%, -0.1%]). In the Medicare group, there was a relative decrease of 0.1% of the monthly trend before and after expansion (95% CI [-0.2%, 0%]). Conclusions We did not detect a relative difference in PCI for AMI associated with insurance expansion under health reform.
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- 2022
47. Days out of Institution after Tracheostomy and Gastrostomy Placement in Critically Ill Older Adults
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Eunhee Choi, Changyu Shen, Jennifer P. Stevens, Anuj B. Mehta, Allan J. Walkey, Anica C. Law, and Robert W. Yeh
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Critical Illness ,MEDLINE ,Medicare ,law.invention ,Tracheostomy ,law ,Hospital discharge ,Medicine ,Humans ,Aged ,Retrospective Studies ,Original Research ,Gastrostomy ,business.industry ,Critically ill ,Medicare beneficiary ,Retrospective cohort study ,Length of Stay ,medicine.disease ,Intensive care unit ,Comorbidity ,United States ,Intensive Care Units ,Emergency medicine ,business - Abstract
Rationale Tracheostomy and gastrostomy tubes are frequently placed during critical illness for long-term life-support, with the majority placed in older adults. Large knowledge gaps exist regarding outcomes expressed as most important to patients. Objectives To determine days alive and out of institution and mortality after tracheostomy and gastrostomy placement during critical illness; to evaluate associations between health states prior to critical illness and outcomes. Methods In this retrospective cohort study of Medicare beneficiaries admitted to an intensive care unit (ICU) who received a tracheostomy, gastrostomy, or both, we determined number of days alive and out of institution (DAOI) following procedure date; 90-day, 6-month, and 1-year mortality; hospital discharge destination; and hospital length of stay. We used claims from the year prior to admission to define eight mutually exclusive pre-ICU health states (permutations of one or more of: Cancer, Chronic Organ Failure, Frail, Robust) and assessed their association with DAOI in 90 days and 1-year mortality. Results Among 3,365 patients who received a tracheostomy, 6,709 patients who received a gastrostomy tube, and 3,540 patients who received both procedures, the median DAOI in the first 90 days after placement was 3 (IQR 0-46), 12 (0-61), and 0 (0-37), respectively. Over half died within 180 days. 1-year mortality was 62%, 60%, and 64%, respectively. When compared to the Robust state, all other pre-ICU health states were associated with loss of DAOI and increased 1-year mortality; however, between the seven non-Robust pre-ICU health states, there were no differences in outcomes. Conclusions Medicare beneficiaries with prior comorbidity who received tracheostomy, gastrostomy tube, or both during critical illness spent few days alive and out of institution and had high short- and long-term mortality.
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- 2023
48. Development of a Novel Score to Predict Urgent Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention
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Judit Karacsonyi, Larissa Stanberry, Bahadir Simsek, Spyridon Kostantinis, Salman S. Allana, Athanasios Rempakos, Brynn Okeson, Khaldoon Alaswad, Mir B. Basir, Farouc Jaffer, Paul Poommipanit, Jaikirshan Khatri, Mitul Patel, Ehtisham Mahmud, Abdul Sheikh, Jason R. Wollmuth, Robert W Yeh, Raj H. Chandwaney, Ahmed M ElGuindy, Nidal AbiRafeh, Daniel R. Schimmel, Keith Benzuly, M. Nicholas Burke, Bavana V. Rangan, Olga C. Mastrodemos, Yader Sandoval, Imre Ungi, and Emmanouil S. Brilakis
- Abstract
BackgroundEstimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).MethodsWe analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample as well as on 2411 out-of-sample procedures who did not require urgent MCS.ResultsUrgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63, 77] vs. 66 [58, 73] years, p=0.003) compared with those who did not require urgent MCS. Technical (68% vs. 87%, pConclusionThe PROGRESS CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI.What Is Known?Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI).What the Study Adds?We developed a risk model for urgent MCS use during CTO PCI using retrograde crossing strategy, left ventricular ejection fraction, and lesion length.Use of the PROGRESS CTO urgent MCS score may facilitate patient selection for prophylactic hemodynamic support optimizing the risk benefit ratio of the procedure.
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- 2023
49. List of contributors
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Nidal Abi Rafeh, Pierfrancesco Agostoni, Sukru Akyuz, Khaldoon Alaswad, Ziad A. Ali, Salman S. Allana, Chadi Alraies, Mario Araya, Alexandre Avran, Lorenzo Azzalini, Avtandil Babunashvili, Subhash Banerjee, Sripal Bangalore, Baktash Bayani, Michael Behnes, Ravinay Bhindi, Nicolas Boudou, Nenad Ž. Božinović, Leszek Bryniarski, Alexander Bufe, Christopher E. Buller, M. Nicholas Burke, Pedro Pinto Cardoso, Mauro Carlino, Joao L. Cavalcante, Tarek Chami, Raj H. Chandwaney, Konstantinos Charitakis, Victor Y. Cheng, James W. Choi, Evald Høj Christiansen, Yashasvi Chugh, Antonio Colombo, Claudia Cosgrove, Kevin Croce, Ramesh Daggubati, Félix Damas de los Santos, Rustem Dautov, Rhian E. Davies, Tony de Martini, Ali E. Denktas, Joseph Dens, Carlo di Mario, Roberto Diletti, Zisis Dimitriadis, Darshan Doshi, Parag Doshi, Kefei Dou, Mohaned Egred, Basem Elbarouni, Ahmed M. ElGuindy, Amr Elhadidy, Stephen Ellis, Javier Escaned, Panayotis Fasseas, Farshad Forouzandeh, Sergey Furkalo, Andrea Gagnor, Alfredo R. Galassi, Robert Gallino, Roberto Garbo, Santiago Garcia, Gabriele Gasparini, Junbo Ge, Lei Ge, Pravin Kumar Goel, Omer Goktekin, Nieves Gonzalo, Sevket Gorgulu, Luca Grancini, J. Aaron Grantham, Raviteja Guddeti, Elias V. Haddad, Allison B. Hall, Jack J. Hall, Sean Halligan, Franklin Leonardo Hanna Quesada, Colm Hanratty, Stefan Harb, Scott A. Harding, Raja Hatem, David Hildick-Smith, Jonathan M. Hill, Taishi Hirai, Mario Iannaccone, Wissam Jaber, Farouc A. Jaffer, Yangsoo Jang, Brian K. Jefferson, Allen Jeremias, Risto Jussila, Nikolaos Kakouros, Artis Kalnins, Sanjog Kalra, Arun Kalyanasundaram, David E. Kandzari, Hsien-Li Kao, Judit Karacsonyi, Dimitri Karmpaliotis, Hussien Heshmat Kassem, Kathleen Kearney, Jimmy Kerrigan, Jaikirshan Khatri, Dmitrii Khelimskii, Ajay J. Kirtane, Paul Knaapen, Spyridon Kostantinis, Michalis Koutouzis, Mihajlo Kovacic, Oleg Krestyaninov, A.V. Ganesh Kumar, Prathap Kumar N., Katherine J. Kunkel, Pablo Manuel Lamelas, Seung-Whan Lee, Thierry Lefevre, Gregor Leibundgut, Nicholas J. Lembo, Martin Leon, John R. Lesser, Raymond Leung, Soo-Teik Lim, Sidney Tsz Ho Lo, William Lombardi, Michael Luna, Ehtisham Mahmud, Madeline K. Mahowald, Anbukarasi Maran, Konstantinos Marmagkiolis, Evandro Martins Filho, Kambis Mashayekhi, Margaret B. McEntegart, Michael Megaly, Perwaiz Meraj, Lampros Michalis, Anastasios N. Milkas, Owen Mogabgab, Jeffrey Moses, Muhammad Munawar, Bilal Murad, Alexander Nap, Andres Navarro, William J. Nicholson, Anja Øksnes, Göran Olivecrona, Mohamed A. Omer, Jacopo Andrea Oreglia, Lucio Padilla, Mitul P. Patel, Rajan A.G. Patel, Taral Patel, Ashish Pershad, Duane Pinto, Paul Poommipanit, Marin Postu, Srini Potluri, Stylianos Pyxaras, Alexandre Schaan de Quadros, Michael Ragosta, Sunil V. Rao, Vithala Surya Prakasa Rao, Sudhir Rathore, Joerg Reifart, Athanasios Rempakos, Jeremy Rier, Robert Riley, Stéphane Rinfret, Juan J. Russo, Meruzhan Saghatelyan, Gurpreet S. Sandhu, Yader Sandoval, Ricardo Santiago, James Sapontis, Alpesh Shah, Evan Shlofmitz, Kendrick A. Shunk, George Sianos, Bahadir Simsek, Elliot J. Smith, Anthony Spaedy, James Spratt, Julian W. Strange, Bradley Strauss, Péter Tajti, Hector Tamez, Khalid O. Tammam, Craig A. Thompson, Aurel Toma, Catalin Toma, Ioannis Tsiafoutis, Etsuo Tsuchikane, Imre Ungi, Barry F. Uretsky, Georgios J. Vlachojannis, Minh Nhat Vo, Hoang Vu Vu, Simon Walsh, Daniel Weilenmann, Gerald Werner, Jarosław Wójcik, Jason Wollmuth, Eugene B. Wu, R. Michael Wyman, Iosif Xenogiannis, Bo Xu, Masahisa Yamane, Luiz F. Ybarra, and Robert W. Yeh
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- 2023
50. Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States
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Aishwarya Raja, Rishi K. Wadhera, Eunhee Choi, Siyan Chen, Changyu Shen, Jose F. Figueroa, Robert W. Yeh, and Eric A. Secemsky
- Subjects
Cardiology and Cardiovascular Medicine - Abstract
Background: After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers. Methods: In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up. Results: Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531–1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89–0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90–0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79–0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84–0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings. Conclusions: In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.
- Published
- 2023
Catalog
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