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Background: Extreme-heat events are increasing as a result of climate change. Prior studies, typically limited to urban settings, suggest an association between extreme heat and cardiovascular mortality. However, the extent of the burden of cardiovascular deaths associated with extreme heat across the United States and in different age, sex, or race and ethnicity subgroups is unclear. Methods: County-level daily maximum heat index levels for all counties in the contiguous United States in summer months (May–September) and monthly cardiovascular mortality rates for adults ≥20 years of age were obtained. For each county, an extreme-heat day was identified if the maximum heat index was ≥90 °F (32.2 °C) and in the 99th percentile of the maximum heat index in the baseline period (1979–2007) for that day. Spatial empirical Bayes smoothed monthly cardiovascular mortality rates from 2008 to 2017 were the primary outcome. A Poisson fixed-effects regression model was estimated with the monthly number of extreme-heat days as the independent variable of interest. The model included time-fixed effects and time-varying environmental, economic, demographic, and health care–related variables. Results: Across 3108 counties, from 2008 to 2017, each additional extreme-heat day was associated with a 0.12% (95% CI, 0.04%–0.21%; P =0.004) higher monthly cardiovascular mortality rate. Extreme heat was associated with an estimated 5958 (95% CI, 1847–10 069) additional deaths resulting from cardiovascular disease over the study period. In subgroup analyses, extreme heat was associated with a greater relative increase in mortality rates among men compared with women (0.20% [95% CI, 0.07%–0.33%]) and non-Hispanic Black compared with non-Hispanic White adults (0.19% [95% CI, 0.01%–0.37%]). There was a greater absolute increase among elderly adults compared with nonelderly adults (16.6 [95% CI, 14.6–31.8] additional deaths per 10 million individuals per month). Conclusions: Extreme-heat days were associated with higher adult cardiovascular mortality rates in the contiguous United States between 2008 and 2017. This association was heterogeneous among age, sex, race, and ethnicity subgroups. As extreme-heat events increase, the burden of cardiovascular mortality may continue to increase, and the disparities between demographic subgroups may widen.

Background & Aims There is significant variability in county-level rates of liver disease–related mortality. Although this variability is explained partly by demographics, risk factors for liver disease, and access to specialty liver care, little is known about temporal changes in mortality, and its association with economic prosperity. Therefore, we sought to explore the association between changes in county-level economic prosperity and liver disease–related mortality. Methods We performed a retrospective cohort study using county-level mortality data from the Centers for Disease Control and Prevention, economic prosperity measures from the Distressed Communities Index, and county-level markers of demographics, risk factors for liver disease, and access to health care. Primary analyses focused on adults aged 20 to 64 years of age. We used generalized linear mixed models (outcome = annual percentage change in age-adjusted liver disease–related mortality), with the primary exposure being an interaction between year and change in economic prosperity. Results There was an inverse relationship between county-level changes in economic prosperity and changes in county-level age-adjusted liver disease–related mortality rates (eg, counties with the smallest increase in economic prosperity had the biggest annual increase in liver disease–related mortality). In generalized linear mixed models accounting for county-level covariates, there was a significant association between economic prosperity and liver disease–related mortality, that is, for every 10-point higher mean rank for change in economic prosperity, there was an additional 0.65% decrease (95% CI, 0.19%–1.10%; P = .006) in mortality per year. Conclusions County-level changes in economic prosperity, independent of other county-level clinical, demographic, and access-to-care variables, may play a role in population-level trends in liver disease–related deaths among the working age population.

BACKGROUND: Individuals experiencing homelessness have higher hospitalization and mortality rates compared with the housed. Whether they also experience higher readmission rates, and if readmissions vary by region or cause of hospitalization is unknown. OBJECTIVE: Evaluate the association of homelessness with readmission rates across multiple US states. DESIGN: Retrospective analysis of administrative claims PATIENTS: All inpatient hospitalizations in Florida, Massachusetts, and New York from January 2010 to October 2015 MAIN MEASURES: Thirty- and 90-day readmission rates KEY RESULTS: Out of a total of 23,103,125 index hospitalizations, 515,737 were for patients who were identified as homeless at the time of discharge. After adjusting for cause of index hospitalization, state, demographics, and clinical comorbidities, 30-day and 90-day readmission rates were higher for index hospitalizations in the homeless compared with those in the housed group. The difference in 30-day readmission rates between homeless and housed groups was the largest in Florida (30.4% vs. 19.3%; p < 0.001), followed by Massachusetts (23.5% vs. 15.2%; p < 0.001) and New York (15.7% vs. 13.4%; p < 0.001) (combined 17.3% vs. 14.0%; p < 0.001). Among the most common causes of hospitalization, 30-day readmission rates were 4.1 percentage points higher for the homeless group for mental illness, 4.9 percentage points higher for diseases of the circulatory system, and 2.4 percentage points higher for diseases of the digestive system. CONCLUSIONS: After adjusting for demographic and clinical characteristics, homelessness is associated with significantly higher 30- and 90-day readmission rates, with a significant variation across the three states. Interventions to reduce the burden of readmissions among individuals experiencing homelessness are urgently needed. Differences across states point to the potential of certain public policies to impact health outcomes for individuals experiencing homelessness. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-020-05946-4) contains supplementary material, which is available to authorized users.

IMPORTANCE: Despite the benefits of high-technology therapeutics, inequitable access to these technologies may generate disparities in care. OBJECTIVE: To examine the association between zip code–level racial, ethnic, and socioeconomic composition and rates of transcatheter aortic valve replacement (TAVR) among Medicare patients living within large metropolitan areas with TAVR programs. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, nationwide cross-sectional analysis of Medicare claims data between January 1, 2012, and December 31, 2018, included beneficiaries of fee-for-service Medicare who were 66 years or older living in the 25 largest metropolitan core-based statistical areas. EXPOSURE: Receipt of TAVR. MAIN OUTCOMES AND MEASURES: The association between zip code–level racial, ethnic, and socioeconomic composition and rates of TAVR per 100 000 Medicare beneficiaries. RESULTS: Within the studied metropolitan areas, there were 7590 individual zip codes. The mean (SD) age of Medicare beneficiaries within these areas was 71.4 (2.0) years, a mean (SD) of 47.6% (5.8%) of beneficiaries were men, and a mean (SD) of 4.0% (7.0%) were Asian, 11.1% (18.9%) were Black, 8.0% (12.9%) were Hispanic, and 73.8% (24.9%) were White. The mean number of TAVRs per 100 000 Medicare beneficiaries by zip code was 249 (IQR, 0-429). For each $1000 decrease in median household income, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 0.2% (95% CI, 0.1%-0.4%) lower (P = .002). For each 1% increase in the proportion of patients who were dually eligible for Medicaid services, the number of TAVR procedures performed per 100 000 Medicare beneficiaries was 2.1% (95% CI, 1.3%-2.9%) lower (P

Objective: Food insecurity is associated with diabetes. The Supplemental Nutrition Assistance Program (SNAP) is the largest US government food assistance program. Whether such programs impact diabetes trends is unclear. The objective of this study is to evaluate the association between changes in state-level policies affecting SNAP participation and county-level diabetes prevalence. Research Design and Methods: We evaluated the association between change in county-level diabetes prevalence and changes in the US Department of Agriculture SNAP policy index – a measure of adoption of state-level policies associated with increased SNAP participation (higher value indicating adoption of more policies associated with increased SNAP participation; range: 1 to 10) – from 2004 to 2014 using g-computation – a robust causal inference methodology. The study includes all US counties with diabetes prevalence data available from the Center for Disease Control’s US Diabetes Surveillance System. Results: A total of 3,135 (out of 3,143) US counties were included. Mean diabetes prevalence increased from 7.3% (SD=1.3) in 2004 to 9.1% (SD=1.8) in 2014. The mean SNAP policy index increased from 6.4 (SD=0.9) to 8.2 (SD=0.6) in 2014. After accounting for changes in demographic, economic and healthcare related variables and baseline SNAP policy index, a 1-point absolute increase in the SNAP policy index between 2004 to 2014 was associated with 0.050 (95% CI 0.042 to 0.057) percentage point lower diabetes prevalence per year. Conclusion: State policies aimed at increasing SNAP participation were independently associated with a lower rise in diabetes prevalence between 2004 and 2014.

Background Rates of major lower extremity amputation in patients with peripheral artery disease are higher in rural communities with markers of low socioeconomic status, but most Americans live in metropolitan areas. Whether amputation rates vary within US metropolitan areas is unclear, as are characteristics of high amputation rate urban communities. Methods and Results We estimated rates of major lower extremity amputation per 100 000 Medicare beneficiaries between 2010 and 2018 at the ZIP code level among ZIP codes with ≥100 beneficiaries. We described demographic characteristics of high and low amputation ZIP codes, and the association between major amputation rate and 3 ZIP code–level markers of socioeconomic status—the proportion of patients with dual eligibility for Medicaid, median household income, and Distressed Communities Index score—for metropolitan, micropolitan, and rural ZIP code cohorts. Between 2010 and 2018, 188 995 Medicare fee‐for‐service patients living in 31 391 ZIP codes with ≥100 beneficiaries had a major lower extremity amputation. The median (interquartile range) ZIP code–level number of amputations per 100 000 beneficiaries was 262 (75–469). Though nonmetropolitan ZIP codes had higher rates of major amputation than metropolitan areas, 78.2% of patients undergoing major amputation lived in metropolitan areas. Compared with ZIP codes with lower amputation rates, top quartile amputation rate ZIP codes had a greater proportion of Black residents (4.4% versus 17.5%, P Conclusions In metropolitan areas, where most individuals undergoing lower extremity amputation live, markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation. Development of community‐based tools for peripheral artery disease diagnosis and management targeted to communities with high amputation rates in urban areas may help reduce inequities in peripheral artery disease outcomes.

Key Points Question Are there inequities in glucagon-like peptide-1 receptor agonist (GLP-1 RA) use based on race, ethnicity, sex, and socioeconomic status among patients with diabetes in the US? Findings This 5-year cohort study of 1 180 260 commercially insured patients with diabetes in the US found that GLP-1 RA use increased but use remained low. Lower rates of GLP-1 RA use were found among Asian, Black, and Hispanic individuals and among those with lower household income; results were similar among patients with diabetes who also had cardiovascular disease. Meaning The findings of this cohort study suggest that racial, ethnic, and socioeconomic inequities are present in access to GLP-1 RA, a medication with established benefits for improved cardiovascular outcomes in patients with diabetes., Importance Randomized clinical trials have shown that glucagon-like peptide-1 receptor agonists (GLP-1 RAs) cause significant weight loss and reduce cardiovascular events in patients with type 2 diabetes (T2D). Black patients have a disproportionate burden of obesity and cardiovascular disease and have a higher rate of cardiovascular-related mortality. Racial and ethnic disparities in health outcomes are largely attributable to the pervasiveness of structural racism, and patients who are marginalized by racism have less access to novel therapeutics. Objectives To evaluate GLP-1 RA uptake among a commercially insured population of patients with T2D; identify associations of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use; and specifically examine its use among the subgroup of patients with atherosclerotic cardiovascular disease (ASCVD) because of the known benefit of GLP-1 RA use for this population. Design, Setting, and Participants This was a retrospective cohort analysis using data from OptumInsight Clinformatics Data Mart of commercially insured adult patients with T2D (with or without ASCVD) in the US. Data from October 1, 2015, to June 31, 2019, were included, and the analyses were performed in July 2020. We estimated multivariable logistic regression models to identify the association of race, ethnicity, sex, and socioeconomic status with GLP-1 RA use. Main Outcome and Measure A prescription for a GLP-1 RA. Results Of the 1 180 260 patients with T2D (median [IQR] age, 69 [59-76] years; 50.3% female; 57.7% White), 90 934 (7.7%) were treated with GLP-1 RA during the study period. From 2015 to 2019, the percentage of T2D patients treated with an GLP-1 RA increased from 3.2% to 10.7%. Among patients with T2D and ASCVD, use also increased but remained low (2.8%-9.4%). In multivariable analyses, lower rates of GLP-1 RA use were found among Asian (aOR, 0.59; 95% CI, 0.56-0.62), Black (adjusted odds ratio [aOR] 0.81; 95% CI, 0.79-0.83), and Hispanic (aOR, 0.91; 95% CI, 0.88-0.93) patients with T2D. Female sex (aOR, 1.22; 95% CI, 1.20-1.24) and higher zip code–linked median household incomes (>$100 000 [OR, 1.13; 95% CI, 1.11-1.16] and $50 000-$99 999 [OR, 1.07; 95% CI, 1.05-1.09] vs, This cohort study examines the racial, ethnic, sex, and socioeconomic inequities associated with use of glucagon-like peptide-1 receptor agonists in US patients with type 2 diabetes.

Telemedicine utilization increased significantly in the United States during the COVID-19 pandemic. However, there is concern that disadvantaged groups face barriers to access based on single-center studies. Whether there has been equitable access to telemedicine services across the US and during later parts of the pandemic is unclear. This study retrospectively analyzes outpatient medical encounters for patients 18 years of age and older using Healthjump–a national electronic medical record database–from March 1 to December 31, 2020. A mixed effects multivariable logistic regression model was used to assess the association between telemedicine utilization and patient and area-level factors and the odds of having at least one telemedicine encounter during the study period. Among 1,999,534 unique patients 21.6% had a telemedicine encounter during the study period. In the multivariable model, age [OR = 0.995 (95% CI 0.993, 0.997); p

Background: Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation. Methods: Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes. Results: Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75–1.34], P =0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84–1.41], P =0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78–0.99], P =0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03–1.30], P =0.011) of adverse event episodes compared with commercially insured patients. Conclusions: All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.

Background PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors represent a promising class of lipid‐lowering therapy, although their use has been limited by cost concerns. Methods and Results A retrospective cohort study was conducted using a nationwide commercial claims database comprising patients with atherosclerotic cardiovascular disease (ASCVD), aged 18 to 64 years. We identified the number of patients with ASCVD started on a PCSK9 inhibitor from the dates of US Food and Drug Administration approval in quarter 3 2015 through quarter 2 2019. Secondary objectives identified the proportions of patients started on a PCSK9 inhibitor in various ASCVD risk groups based on statin use and baseline low‐density lipoprotein cholesterol. We identified 126 419 patients with ASCVD on either PCSK9 inhibitor or statin therapy. Among these patients, 1168 (0.9%) filled a prescription for a PCSK9 inhibitor. The number of patients initiating a PCSK9 inhibitor increased from 2 patients in quarter 3 2015 to 119 patients in quarter 2 2019, corresponding to an increase from 0.05% to 2.5% of patients with ASCVD already on statins who started PCSK9 inhibitor therapy. Of patients with ASCVD with high adherence to a high‐intensity statin, 13 643 had low‐density lipoprotein cholesterol ≥70 mg/dL, and in this subgroup, 119 (0.9%) patients initiated a PCSK9 inhibitor. Conclusions Few patients started PCSK9 inhibitors from 2015 through mid‐2019, despite increasing trial evidence of efficacy, guidelines recommending PCSK9 inhibitors in high‐risk patients with ASCVD, and price reductions during this period. The magnitude of price reductions may not yet be sufficient to influence use management strategies aimed to limit PCSK9 inhibitor use.

Background: In 2009, the American College of Cardiology and American Heart Association published Appropriate Use Criteria for Coronary Revascularization (AUC) to aid patient selection for percutaneous coronary intervention (PCI). The subsequent decline in inappropriate PCIs was interpreted as a success of AUC. However, there are concerns clinicians reclassify nonacute PCIs to acute indications to fulfill AUC. Methods: A longitudinal, observational difference-in-differences analysis was performed using administrative claims from US Department of Veterans Affairs (VA) beneficiaries coenrolled in Medicare and from a national random sample of Medicare beneficiaries, undergoing PCI from September 30, 2009, to December 31, 2013. Non-VA hospitals participating in the American College of Cardiology CathPCI registry began receiving AUC reports in 2011, while VA hospitals did not receive reports, serving as quasiexperimental and control cohorts, respectively. We measured the proportion of PCIs coded for acute myocardial infarction, unstable angina, and nonacute coronary syndrome indications by quarter. Results: There were 87 464 and 30 251 PCIs performed in the Medicare and VA cohorts, respectively. In Medicare, proportion of PCIs coded for acute myocardial infarction and unstable angina changed from 31.9% and 12.6% in quarter 4 2009 to 41.0% and 10.5% in quarter 4 2013, an associated 2.00% (95% CI, 1.56%–2.44%; P P =0.001) increase per year in PCIs coded for acute coronary syndrome indications. Difference-in-differences modeling found no statistically significant change in PCI coded for acute indications between Medicare and VA, pre- and post-AUC reporting. Conclusions: After introduction of AUC assessments and reporting, we observed comparable increases in coding for acute myocardial infarction and corresponding decreases in coding for unstable angina and nonacute coronary syndrome indications among national cohorts of Medicare and VA enrollees. The provision of appropriate use reporting did not appear to have a substantial impact on the proportion of PCIs coded for acute indications during this study period.

Importance After a decline in cardiovascular mortality for nonelderly US adults, recent stagnation has occurred alongside rising income inequality. Whether this is associated with underlying economic trends is unclear. Objective To assess the association between changes in economic prosperity and trends in cardiovascular mortality in middle-aged US adults. Design, Setting, and Participants Retrospective analysis of the association between change in 7 markers of economic prosperity in 3123 US counties and county-level cardiovascular mortality among 40- to 64-year-old adults (102 660 852 individuals in 2010). Exposures Mean rank for change in 7 markers of economic prosperity between 2 time periods (baseline: 2007-2011 and follow-up: 2012-2016). A higher mean rank indicates a greater relative increase or lower relative decrease in prosperity (range, 5 to 92; mean [SD], 50 [14]). Main Outcomes and Measures Mean annual percentage change (APC) in age-adjusted cardiovascular mortality rates. Generalized linear mixed-effects models were used to estimate the additional APC associated with a change in prosperity. Results Among 102 660 852 residents aged 40 to 64 years living in these counties in 2010 (51% women), 979 228 cardiovascular deaths occurred between 2010 and 2017. Age-adjusted cardiovascular mortality rates did not change significantly between 2010 and 2017 in counties in the lowest tertile for change in economic prosperity (mean [SD], 114.1 [47.9] to 116.1 [52.7] deaths per 100 000 individuals; APC, 0.2% [95% CI, −0.3% to 0.7%]). Mortality decreased significantly in the intermediate tertile (mean [SD], 104.7 [38.8] to 101.9 [41.5] deaths per 100 000 individuals; APC, −0.4% [95% CI, −0.8% to −0.1%]) and highest tertile for change in prosperity (100.0 [37.9] to 95.1 [39.1] deaths per 100 000 individuals; APC, −0.5% [95% CI, −0.9% to −0.1%]). After accounting for baseline prosperity and demographic and health care–related variables, a 10-point higher mean rank for change in economic prosperity was associated with 0.4% (95% CI, 0.2% to 0.6%) additional decrease in mortality per year. Conclusions and Relevance In this retrospective study of US county-level mortality data from 2010 to 2017, a relative increase in county-level economic prosperity was significantly associated with a small relative decrease in cardiovascular mortality among middle-aged adults. Individual-level inferences are limited by the ecological nature of the study.

This study investigates variation in site-specific risk-adjusted mortality rates of percutaneous coronary intervention for physicians practicing at multiple sites within New York State.

Background & Aims The Affordable Care Act provided the opportunity for states to expand Medicaid for low-income individuals. Not all states adopted Medicaid expansion, and the timing of adoption among expansion states varied. Prior studies have shown that Medicaid expansion improved mortality rates for several chronic conditions. Although there are data on the association between Medicaid expansion on insurance type among patients waitlisted for a liver transplant, there are no published data to date on its impact on liver disease-related mortality in the broader population. We therefore sought to evaluate the association between Medicaid expansion and state-level liver disease–related mortality using a quasi-experimental study design. Methods We evaluated age-adjusted, state-level, liver disease–related mortality rates using the Centers for Disease Control and Prevention data. We fit multivariable linear regression models that accounted for sociodemographic, clinical, and access-to-care variables at the state level, and a difference-in-difference estimator to evaluate the association between Medicaid expansion and liver disease–related mortality. Results In multivariable linear regression models, there was a significant association between Medicaid expansion and liver disease–related mortality (P = .02). Medicaid expansion was associated with 8.3 (95% CI, 1.6–15.1) fewer deaths from liver disease per 1,000,000 adult residents per year after Medicaid expansion compared with what would have been expected to occur if those states followed the same trajectory as nonexpansion states. The impact of Medicaid expansion translated to 870 fewer liver-related deaths per year in expansion states (4350 in the postexpansion study period from 2014 to 2018). Conclusions These data support the contention that Medicaid expansion has been associated with significantly decreased liver disease–related mortality. Universal Medicaid expansion could further decrease liver disease–related mortality in the United States.

Introduction: Prior analyses suggest a link between food insecurity and cardiovascular (CV) health but are limited by cross-sectional designs. We investigated whether longitudinal changes in food insecurity are independently associated with CV mortality. Methods: Using National Center for Health Statistics data, we determined annual U.S. county-level age-adjusted CV mortality rates for non-elderly (20-64 years old) and elderly (65 years and older) adults. County-level food insecurity rates were obtained from the Map the Meal Gap project. We examined CV mortality trends by quartiles of average annual percent change (APC) in food insecurity. Using a Poisson fixed effects estimator, we assessed the association between longitudinal changes in food insecurity and CV mortality rates after accounting for time-varying demographic (proportion of residents who were male, black, Hispanic), economic (median household income, unemployment, poverty, education attainment, and housing vacancy rates), and healthcare access (insurance coverage, density of healthcare providers and hospital beds) variables. Results: Between 2011 and 2017, mean food insecurity rates decreased from 14.7% to 13.3%. In counties in the highest quartile of APC for absolute value change in food insecurity, non-elderly CV mortality increased from 82.2(SD=33.9) to 87.4(SD=37.3) per 100,000 individuals (p Conclusion: From 2011 to 2017, an increase in food insecurity was independently associated with an increase in CV mortality rates for non-elderly adults in the U.S. Interventions targeting food insecurity may play a role in improving community CV health.

Introduction: New York State (NYS) publicly reports physician-level post-percutaneous coronary intervention (PCI) mortality at each individual site they practice, to empower patients to make informed decisions. Given that mortality is a rare event and some sites have low case volumes, we hypothesized that the reported data at each site for physicians practicing at multiple sites is highly unstable and thus misleading for patients. In this study, we examined variation in site-specific risk-adjusted mortality rates (RAMR) for physicians practicing at multiple sites in NYS. Methods: This study uses publicly reported 30-day physician-level RAMR for all PCI performed in NYS between 2014 and 2016. We obtained the site-specific RAMR (ssRAMR) at each hospital where the physician performed PCI, and overall mean RAMR (mRAMR) for the physician. We excluded physicians who performed PCI at only one hospital. We identified outliers for mRAMR and maximum ssRAMR if values were greater than the 95 th percentile for each measure and plotted the outliers. Results: Between 2014 and 2016, 142,853 PCI procedures were performed by 373 physicians at 61 hospitals. Among 207 (55.5%) physicians practicing at multiple sites who performed 82,075 PCI (57.5%), the median mRAMR was 1.11% (IQR 0.66-1.60%, range 0-5.33%) and the median ssRAMR was 0.52% (IQR 0-1.53%, range 0-47.69%). Among the 11 physicians classified as ssRAMR outliers, only 3 (27.2%) physicians were also classified as an mRAMR outlier. Conclusion: We found that the individual ssRAMRs reported for a physician practicing at multiple hospitals is highly variable, and that mRAMR and ssRAMR outlier status are not consistent with each other. Thus, we believe public reporting of ssRAMR in NYS does not adequately reflect the quality of care delivered by physicians performing PCI. Figure: mRAMR and ssRAMR among maximum ssRAMR outliers. Each letter (A-K) represents a separate outlier physician.

The Coronavirus Disease 2019 (COVID-19) pandemic has taken an unprecedented toll on the American healthcare system and economy. While numerous COVID-19 clinical trials have been initiated in hopes of curtailing its impact, most pre-existing clinical trials have been forced to suspend or limit activity, which itself can have significant consequences. Missed or postponed trial-related assessments may hinder data quality, and heterogeneity in data collection both across the country and over time introduces bias. In addition, COVID-19 may lower specific event rates due to patients avoiding the healthcare system that could result in underpowered outcome analyses, or conversely, some endpoints (mortality) may be inflated.

Background: For patients presenting with ST-segment–elevation myocardial infarction, national quality initiatives monitor hospitals’ proportion of cases with door-to-balloon (D2B) time under 90 minutes. Hospitals are allowed to exclude patients from reporting and may modify behavior to improve performance. We sought to identify whether there is a discontinuity in the number of cases included in the D2B time metric at 90 minutes and whether operators were increasingly likely to pursue femoral access in patients with less time to meet the 90-minute quality metric. Methods: Adult patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention from 2011 to 2018 were identified from the Cardiac Care Outcomes Assessment Program, a quality improvement registry in Washington state. We used the regression discontinuity framework to test for discontinuity at 90 minutes among the included cases. We defined a novel variable, remaining D2B as 90 minutes minus the time between hospital arrival and catheterization laboratory arrival. We estimated multivariable logistic regression models to assess the relationship between remaining D2B time and access site. Results: A total of 19 348 patients underwent primary percutaneous coronary intervention and were included in the analysis. Overall, 7436 (38.4%) were excluded from the metric. There appeared to be a visual discontinuity in included cases around 90 minutes; however, local quadratic regression around the 90-minute cutoff did not reveal evidence of a significant discontinuity ( P =0.66). Multivariable analysis showed no significant relationship between remaining D2B time and the odds of undergoing femoral access ( P =0.73). Conclusions: Among patients undergoing percutaneous coronary intervention for ST-segment–elevation myocardial infarction, we did not find evidence of a statistically significant discontinuity in the frequency of included cases around 90 minutes or an increased preference for femoral access correlated with decreasing time to meet the 90-minute D2B time quality metric. Together, these findings indicate no evidence of widespread inappropriate methods to improve performance on D2B time metrics.

BACKGROUND: Patients with atrial fibrillation (AF) who have undergone mitral valve repair are at risk for thromboembolic strokes. Prior to 2019, only vitamin K antagonists were recommended for patients with AF who had undergone mitral valve repair despite the introduction of direct oral anticoagulants (DOAC) in 2010. OBJECTIVE: To characterize the use of anticoagulants in patients with AF who underwent surgical mitral valve repair (sMVR) or transcatheter mitral valve repair (tMVR). METHODS: We performed a retrospective cohort analysis of patients with AF undergoing sMVR or tMVR between 04/2014 and 12/2018 using Optum’s de-identified Clinformatics® Data Mart Database. We identified anticoagulants prescribed within 90 days of discharge from hospitalization. RESULTS: Overall, 1997 patients with AF underwent valve repair: 1,560 underwent sMVR, and 437 underwent tMVR. The mean CHA(2)DS(2)-VASc score among all patients was 4.1 (SD 1.9). The overall use of anticoagulation was unchanged between 2014 (72.2%) and 2018 (70.0%) (p=0.49). Among patients who underwent sMVR or tMVR between April 2014 and December 2018, the use of VKA therapy decreased from 62.9% to 32.1% (p

Purpose: Public reporting of surgical outcomes can promote quality improvement. However, this could also incentivize surgeons to avoid high-risk patients. Senior surgeons, with established referral networks, may select lower-risk cases than their junior colleagues. This study aimed to assess the relationship between surgeon experience and expected mortality rate of cases performed. Methods: Publicly available data on coronary artery bypass graft (CABG) surgeries between 2011-2013 were obtained from the New York State Department of Health. The 30-day expected mortality rate (EMR) for each CABG was calculated from validated models. Additionally, we obtained data on each surgeon’s medical school gradation year and board certification status from Internet sources, such as Doximity. Surgeon experience was calculated by subtracting the medical school graduation year from 2011, the start of the study period. A multivariable linear regression model was used to estimate the association between EMR and surgeon experience, adjusting for case volume and board certification status. Results: Between 2011-2013, there were 132 cardiac surgeons that performed CABG at 39 hospitals across New York State. The mean surgeon experience was 25.1 years (SD 9.1 years) and the overall mean EMR of CABG surgeries was 1.46% (SD 0.38%). The unadjusted analysis showed a 0.005% increase in EMR per additional year of surgeon experience. However, this was not statistically significant (p=0.25, 95% CI -0.0036 to 0.0013). Through the multivariable linear regression model, we did not find evidence of a significant association between operator experience and the EMR of cases performed (0.0040% per year, p=0.35, 95% CI -0.0044 to 0.012%). There was a significant association between the number of cases performed during the study period and the EMR, with an increase in EMR by 0.0005% per additional case performed (p=0.04, 95% CI 0.00004 to 0.001). There was no significant association between board certification status and EMR (p=0.10). Conclusion: Despite public reporting of CABG outcomes, our findings suggest that more experienced surgeons may not be exhibiting risk-avoidant behavior. Future research could focus on supplementing publicly reported physician-level data with patient-level datasets to better understand the association between surgeon experience and expected mortality rate of cases performed.

IMPORTANCE: Quality of percutaneous coronary intervention (PCI) is commonly assessed by risk-adjusted mortality. However, this metric may result in procedural risk aversion, especially for high-risk patients. OBJECTIVE: To determine correlation and reclassification between hospital-level disease-specific mortality and PCI procedural mortality among patients with acute myocardial infarction (AMI). DESIGN, SETTING, AND PARTICIPANTS: This hospital-level observational cross-sectional multicenter analysis included hospitals participating in the Chest Pain–MI Registry, which enrolled consecutive adult patients admitted with a diagnosis of type I non–ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI), and hospitals in the CathPCI Registry, which enrolled consecutive adult patients treated with PCI with an indication of NSTEMI or STEMI, between April 1, 2011, and December 31, 2017. EXPOSURES: Inclusion into the National Cardiovascular Data Registry Chest Pain–MI and CathPCI registries. MAIN OUTCOMES AND MEASURES: For each hospital in each registry, a disease-based excess mortality ratio (EMR-D) for AMI was calculated, which represents a risk-adjusted observed to expected rate of mortality for AMI as a disease using the Chest Pain–MI Registry, and a procedure-based excess mortality ratio (EMR-P) for PCI was calculated using the CathPCI Registry. RESULTS: A subset of 625 sites participated in both registries, with a final count of 776 890 patients from the Chest Pain–MI Registry (509 576 men [65.6%]; 620 981 white [80.0%]; and median age, 64 years [interquartile range, 55-74 years]) and 853 386 patients from the CathPCI Registry (582 701 men [68.3%]; 691 236 white [81.0%]; and median age, 63 years [interquartile range, 54-73 years]). Among the 625 linked hospitals, the Spearman rank correlation coefficient between EMR-D and EMR-P produced a ρ of 0.53 (95% CI, 0.47-0.58), suggesting moderate correlation. Among the highest-performing tertile for disease-based risk-adjusted mortality, 90 of 208 sites (43.3%) were classified into a lower category for procedural risk-adjusted mortality. Among the lowest-performing tertile for disease-based risk-adjusted mortality, 92 of 208 sites (44.2%) were classified into a higher category for procedural risk-adjusted mortality. Bland-Altman plots for the overall linked cohort demonstrate a mean difference between EMR-P and EMR-D of 0.49% (95% CI, –1.61% to 2.58%; P

The number of extreme heat events is increasing because of climate change. Previous studies showing an association between extreme heat and higher mortality rates generally have been limited to urban areas, and whether there is heterogeneity across different populations is not well studied; understanding whether this association varies across different communities, particularly minoritized racial and ethnic groups, may allow for more targeted mitigation efforts.To the assess the association between extreme heat and all-cause mortality rates in the US.This cross-sectional study involved a longitudinal analysis of the association between the number of extreme heat days in summer months from 2008 to 2017 (obtained from the Centers for Disease Control and Prevention's Environmental Public Health Tracking Program) and county-level all-cause mortality rates (obtained from the National Center for Health Statistics), using a linear fixed-effects model across all counties in the contiguous US among adults aged 20 years and older. Data analysis was performed from September 2021 to March 2022.The number of extreme heat days per month. Extreme heat was identified if the maximum heat index was greater than or equal to 90 °F (32.2 °C) and in the 99th percentile of the maximum heat index in the baseline period (1979 to 2007).County-level, age-adjusted, all-cause mortality rates.There were 219 495 240 adults aged 20 years and older residing in the contiguous US in 2008, of whom 113 294 043 (51.6%) were female and 38 542 838 (17.6%) were older than 65 years. From 2008 to 2017, the median (IQR) number of extreme heat days during summer months in all 3108 counties in the contiguous US was 89 (61-122) days. After accounting for time-invariant confounding, secular time trends, and time-varying environmental and economic measures, each additional extreme heat day in a month was associated with 0.07 additional death per 100 000 adults (95% CI, 0.03-0.10 death per 100 000 adults; P = .001). In subgroup analyses, greater increases in mortality rates were found for older vs younger adults (0.19 death per 100 000 individuals; 95% CI, 0.04-0.34 death per 100 000 individuals), male vs female adults (0.12 death per 100 000 individuals; 95% CI, 0.05-0.18 death per 100 000 individuals), and non-Hispanic Black vs non-Hispanic White adults (0.11 death per 100 000 individuals; 95% CI, 0.02-0.20 death per 100 000 individuals).These findings suggest that from 2008 to 2017, extreme heat was associated with higher all-cause mortality in the contiguous US, with a greater increase noted among older adults, men, and non-Hispanic Black individuals. Without mitigation, the projected increase in extreme heat due to climate change may widen health disparities between groups.

Durable ventricular assist device (VAD) therapy improves survival in patients with refractory heart failure with reduced ejection fraction, but is inaccessible to uninsured patients due to high cost. Medicaid expansion under the Affordable Care Act increased health insurance coverage for low-income

Background: Beginning in 2012, direct oral anticoagulants (DOACs) were approved for treatment and prevention of venous thromboembolism. Prior investigations have demonstrated slow rates of adoption of novel therapeutics for black patients. We assessed the association of racial/ethnic and socioeconomic factors with DOAC use among commercially insured venous thromboembolism patients. Methods and Results: We performed a retrospective cohort analysis of adult patients with an incident diagnosis of venous thromboembolism between January 2010 and December 2016 using OptumInsight’s Clinformatics Data Mart. We identified the first filled oral anticoagulant prescription within 30 days of discharge of an inpatient admission. We performed a multivariable logistic regression, adjusting for age, sex, race/ethnicity, region, zip code–linked household income, and clinical covariates to identify factors associated with the use of DOACs. Race and ethnicity were determined in this database through a combination of public records, self-report, and proprietary ethnicity code tables. There were 14 140 patients included in the analysis. Treatment with DOACs increased from P =0.02). There were no differences in DOAC utilization among Asian (odds ratio, 1.06; 95% CI, 0.75–1.49; P =0.74) or Hispanic patients (odds ratio, 1.04; 95% CI, 0.88–1.22; P =0.66) compared with whites. Patients with a household income over $100 000 per year were more likely to receive DOAC therapy compared with patients with a household income of P Conclusions: Although DOAC adoption has increased steadily since 2012, among a commercially insured population, black race and low household income were associated with lower use of DOACs for incident venous thromboembolism despite controlling for other clinical and socioeconomic factors. These findings suggest the possibility of both racial and socioeconomic inequity in access to this novel pharmacotherapy.

Background: Public reporting of cardiovascular outcomes has been associated with risk aversion for potentially lifesaving procedures and may have spillover effects on nonreported but related procedures. Methods and Results: A cross-sectional analysis of the utilization of coronary angiography among patients presenting with out-of-hospital cardiac arrest between 2005 and 2011 in states with public reporting of percutaneous coronary intervention outcomes (New York and Massachusetts) versus neighboring states without public reporting of percutaneous coronary intervention outcomes (Delaware, Connecticut, Maine, Vermont, Maryland, and Rhode Island) was performed using the Nationwide Inpatient Sample. We analyzed 50 125 admission records with out-of-hospital cardiac arrest between 2005 and 2011. The unadjusted rate of coronary angiography for patients presenting with out-of-hospital cardiac arrest in states with public reporting versus without public reporting was not different (20.8% versus 22.8%, P =0.35). We found no statistically significant difference in the adjusted likelihood of coronary angiography in states with public reporting, though the point estimate suggested decreased utilization (odds ratio, 0.84; 95% CI, 0.66–1.06; P =0.14). There was no difference in the adjusted likelihood of in-hospital mortality for patients presenting with out-of-hospital cardiac arrest in states with public reporting compared to states without public reporting (odds ratio, 0.98; 95% CI, 0.78–1.23; P =0.88). Conclusions: Public reporting of percutaneous coronary intervention outcomes was associated with a nonstatistically significant reduction in the utilization of diagnostic coronary angiography, a nonreported but related procedure, for patients with out-of-hospital cardiac arrest.

Background: Venous thromboembolism (VTE) occurs in approximately 100 persons per 100,000 each year in the United States, and for decades warfarin had been the mainstay of therapy. However, beginning in 2012 direct oral anticoagulants (DOAC) were approved for treatment and prevention of VTE, and are now recommended as first-line therapy. We assessed the factors associated with direct oral anticoagulant use among commercially-insured VTE patients. Methods: We performed a retrospective cohort analysis of adult patients with an incident diagnosis of VTE between 01/01/2010 and 12/01/2016 using OptumInsight’s Clinformatics Data Mart, a large US health care claims database. We identified the first filled anticoagulant prescription within 30 days of discharge, as well as baseline demographic and socioeconomic characteristics for all VTE patients with available prescription data. We then performed a multivariate logistic regression, adjusting for age, sex, race/ethnicity, region of residence, household net worth, prescribing provider specialty, and clinical covariates to identify factors associated with the use of direct oral anticoagulants. Results: There were 12,390 patients included in the analysis. In adjusted multivariate analyses, there was no difference in the use of DOAC among men and women (OR 0.99, 95% CI 0.91 - 1.08, p=0.80). Black patients were less likely to receive a DOAC compared to white patients (OR 0.86, 95% CI 0.76 - 0.98, p=0.020). There were no differences in the utilization among Asian patients (OR 1.21, 95% CI 0.83 - 1.75, p=0.324) or Hispanic patients (OR 1.04, 95% CI 0.88 - 1.23, p=0.66) as compared to white patients. Conclusion: Although DOAC adoption has increased steadily, among a commercially-insured population, black race was independently associated with the use of warfarin as compared to DOAC for incident VTE despite controlling for other socioeconomic factors. This finding was not present among Asian or Hispanic patients. This suggests the possibility of a racial disparity in access to this new pharmacotherapy.

Background: Medicaid expansion under the Affordable Care Act (ACA) led to one of the largest gains in health insurance coverage for non-elderly adults in the US. However, its impact on health outcomes is unclear. We aimed to study whether trends in cardiovascular mortality for middle-aged adults differed between states that did and did not expand Medicaid. Methods: Using the CDC Wide-ranging Online Data for Epidemiologic Research mortality database, we obtained county-level, age-adjusted, cardiovascular mortality rates for all individuals 45 to 64 years of age from 2010 to 2016 for all states except Massachusetts and Wisconsin (due to non-ACA related Medicaid expansion in these two states). We used a differences-in-differences (DID) approach to measure differences in cardiovascular morality rates between states, based on Medicaid expansion status, before and after expansion. The DID estimator was adjusted for percentage of residents who were female, African-American, Hispanic, percentage of residents living in poverty, county unemployment rate, median household income, number of primary care providers per 100,000 residents, number of cardiologists per 100,000 residents, metropolitan vs. non-metropolitan county classification, and percentage of low-income residents with health insurance in 2010. Results: A total of 1960 counties were included. As of 2016, 29 states and DC had expanded Medicaid eligibility, while 19 states had not. Compared with counties in non-expansion states, counties in expansion states had a greater increase in health insurance coverage for low-income residents [19.8% (SD = 5.5) vs. 13.5% (SD = 3.9); p th percentile for residents living in poverty. Conclusion: Counties in Medicaid expansion states had a significantly smaller increase in cardiovascular mortality rates among non-elderly adults compared with counties in non-expansion states. Our findings suggest that Medicaid expansion was associated with a beneficial effect on cardiovascular mortality and may be an important consideration for states debating expansion of Medicaid eligibility.

This cohort study evaluates whether inequities in race/ethnicity, gender, and socioeconomic status exist in sodium-glucose cotransporter 2 (SGLT2) inhibitor use among US patients with type 2 diabetes., Key Points Question Are race/ethnicity, gender, and socioeconomic status associated with use of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients with type 2 diabetes in the US? Findings In a 5-year cohort study of 934 737 commercially insured US patients with type 2 diabetes, the frequency of SGLT2 inhibitor use increased, but use remained low even among patients with heart failure, kidney disease, and cardiovascular disease. Black race, female gender, and lower household income were associated with lower rates of SGLT2 inhibitor use. Meaning In this study, racial/ethnic, gender, and socioeconomic inequities were present in access to SGLT2 inhibitor treatment, which if unaddressed, may widen disparities in kidney and cardiovascular outcomes in the US., Importance Sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. Black individuals have a disproportionate burden of cardiovascular and chronic kidney disease (CKD). Adoption of novel therapeutics has been slower among Black and female patients and among patients with low socioeconomic status than among White or male patients or patients with higher socioeconomic status. Objective To assess whether inequities based on race/ethnicity, gender, and socioeconomic status exist in SGLT2 inhibitor use among patients with type 2 diabetes in the US. Design, Setting, and Participants This retrospective cohort study of commercially insured patients in the US was performed from October 1, 2015, to June 30, 2019, using the Optum Clinformatics Data Mart. Adult patients with a diagnosis of type 2 diabetes, including those with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or CKD, were evaluated in the analysis. Main Outcomes and Measures Prescription of an SGLT2 inhibitor. Multivariable logistic regression models were used to assess the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use. Results Of 934 737 patients with type 2 diabetes (mean [SD] age, 65.4 [12.9] years; 50.7% female; 57.6% White), 81 007 (8.7%) were treated with an SGLT2 inhibitor during the study period. Between 2015 and 2019, the percentage of patients with type 2 diabetes treated with an SGLT2 inhibitor increased from 3.8% to 11.9%. Among patients with type 2 diabetes and cardiovascular or kidney disease, the rate of SGLT2 inhibitor use increased but was lower than that among all patients with type 2 diabetes (HFrEF: 1.9% to 7.6%; ASCVD: 3.0% to 9.8%; CKD: 2.1% to 7.5%). In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85), Asian race (aOR, 0.94; 95% CI, 0.90-0.98), and female gender (aOR, 0.84; 95% CI, 0.82-0.85) were associated with lower rates of SGLT2 inhibitor use, whereas higher median household income (≥$100 000: aOR, 1.08 [95% CI, 1.05-1.10]; $50 000-$99 999: aOR, 1.05 [95% CI, 1.03-1.07] vs

Key Points Question Where do US veterans who are enrolled in both the Veterans Affairs (VA) health care system and Medicare Advantage undergo coronary revascularization, and what are the associated charges? Findings In a national cohort study, among the 18 874 dually enrolled veterans who underwent coronary revascularization from 2010 to 2013, 4115 underwent a procedure through the VA system only, and 478 did so through both the VA and Medicare Advantage. These coronary revascularizations cost the VA $214.7 million, reflecting duplicative spending, because the federal government prepays private Medicare Advantage plans to cover veterans. Meaning These findings suggest that US government officials should consider policy solutions to mitigate duplicative federal spending, given the financial pressures facing both Medicare and the VA., This cohort study examines where US veterans who are enrolled in both the Veterans Affairs (VA) health care system and Medicare Advantage undergo coronary revascularization and the associated costs., Importance More than 1 million US veterans are dually enrolled in a Medicare Advantage (MA) plan and in the Veterans Affairs (VA) health care system. The federal government prepays private MA plans to cover veterans; if a dually enrolled veteran receives an MA-covered service at the VA, the government is making 2 payments for the same service. It is not clear what proportion of veterans dually enrolled in VA and MA are undergoing coronary revascularization at VA vs non-VA hospitals. Objective To describe where veterans who are enrolled in both VA and MA undergo coronary revascularization and the associated costs. Design, Settings, and Participants This is a cohort study consisting of US veterans dually enrolled in VA and MA from January 1, 2010, to December 31, 2013, who had at least 1 VA encounter and underwent coronary revascularization during the study period. Data were analyzed from April 2019 to September 2019. Main Outcomes and Measures Number of coronary artery bypass graft (CABG) operations and percutaneous coronary interventions (PCIs) performed through the VA and through MA during years 2010 to 2013, and the associated VA costs of coronary revascularization. In addition, multivariable logistic regression was performed to assess patient factors associated with receiving care through the VA. Results A total of 18 874 VA users with concurrent MA enrollment who underwent coronary revascularization during 2010 to 2013 were identified (mean [SD] age, 75.3 [8.8] years; 18 739 men [99.0%]). Enrollees were predominantly white (17 457 patients [92.0%]). Among patients, 4115 (22.0%) underwent either CABG or PCI through the VA only, 14 281 (75.0%) did so through MA only, and 478 (2.5%) underwent coronary revascularization procedures through both payers. From 2010 to 2013, these veterans underwent 4764 coronary revascularization procedures (721 CABGs and 3043 PCIs) that cost the VA $214.7 million ($115.8 million for CABGs and $99.0 million for PCIs). In multivariable analysis, nonwhite patients were more likely than white patients to undergo coronary revascularization through the VA (odds ratio, 1.73; 95% CI, 1.52-1.96; P

IMPORTANCE: Cardiovascular disease is a major cause of death among homeless adults, with mortality rates that are substantially higher than in the general population. It is unknown whether differences in hospitalization-related care contribute to these disparities in cardiovascular outcomes. OBJECTIVE: To evaluate differences in intensity of care and mortality between homeless and nonhomeless individuals hospitalized for cardiovascular conditions (ie, acute myocardial infarction, stroke, cardiac arrest, or heart failure). DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study included all hospitalizations for cardiovascular conditions among homeless adults (n = 24 890) and nonhomeless adults (n = 1 827 900) 18 years or older in New York, Massachusetts, and Florida from January 1, 2010, to September 30, 2015. Statistical analysis was performed from February 6 to July 16, 2019. MAIN OUTCOMES AND MEASURES: Risk-standardized diagnostic and therapeutic procedure rates and in-hospital mortality rates. RESULTS: Of the 1 852 790 total hospitalizations for cardiovascular conditions across 525 hospitals, 24 890 occurred among patients who were homeless (11 452 women and 13 438 men; mean [SD] age, 65.1 [14.8] years) and 1 827 900 occurred among patients who were not homeless (850 660 women and 977 240 men; mean [SD] age, 72.1 [14.6] years). Most hospitalizations among homeless individuals were primarily concentrated among 11 hospitals. Homeless adults were more likely than nonhomeless adults to be black (38.6% vs 15.6%) and insured by Medicaid (49.3% vs 8.5%). After accounting for differences in demographics (age, sex, and race/ethnicity), insurance payer, and clinical comorbidities, homeless adults hospitalized for acute myocardial infarction were less likely to undergo coronary angiography compared with nonhomeless adults (39.5% vs 70.9%; P

Background: Patients and other providers have access to few publicly available physician attributes that identify interventional cardiologists with better postprocedural outcomes, particularly in states without public reporting of outcomes. Interventional cardiology board certification, maintenance of certification, graduation from a US medical school, medical school ranking, and length of practice represent such publicly available attributes. Previous studies on these measures have shown mixed results. Methods and Results: We included interventional cardiologists practicing in New York State in the years 2011 to 2013. The primary outcome was 30-day risk-standardized mortality rate (RSMR) after percutaneous coronary intervention. Hierarchical regression modeling was used to analyze the physician attributes and was adjusted for provider caseload. A total of 356 providers were studied. The average 30-day RSMR was 1.1 (SD=0.1) deaths per 100 cases for all percutaneous coronary interventions and 0.7 (SD=0.1) deaths per 100 cases for nonemergent procedures. The primary outcome was slightly lower among providers with interventional cardiology board certification compared with noncertified providers (1.06 [SD=0.14] versus 1.14 [SD=0.14] deaths per 100 cases; P Conclusions: Interventional cardiology board-certified providers had a modestly lower 30-day RSMR before accounting for caseload. However, after adjusting for provider caseload, none of the examined publicly available physician attributes, including interventional cardiology board certification, were independently associated with 30-day RSMR.

Percutaneous coronary intervention (PCI) is the treatment of choice for acute myocardial infarction (AMI). In an effort to improve care delivery, public reporting of PCI outcomes has been adopted in several states, including New York. Until recently, cardiovascular programs were ranked according to

Objectives: Patients have few objective predictors of quality in their choice of physician. We studied whether physician education variables and board certification status were associated with 30 day mortality rates after percutaneous coronary interventions (PCI) in New York State. Methods: Using the New York State PCI registry we obtained 30 day risk adjusted mortality rates after PCI procedures for all interventional cardiologists practicing between 2010-2012. Educational and certification variables were obtained using publicly available sources. Mortality rates were adjusted using a hierarchical Poisson shrinkage estimator. Hierarchical regression modeling was used to assess associations between mortality rates and education and certification markers (graduation from American vs. foreign medical school, years since medical school graduation, board certification in interventional cardiology and maintenance of certification for board certified physicians in 2016) with and without adjustment for caseload. Excluding correlated covariates, a regression model including caseload, board certification and US graduates was also constructed. Results: A total of 346 interventional cardiologists performed an average of 427.41 ± 402.52 cases with 3.90 ± 3.51 deaths. The average shrinkage estimator adjusted mortality rate was 1.00 ± 0.16. Only interventional cardiology board certification (75.8% of providers) was associated with lower mortality rate in univariate analysis (β = -0.06; p = 0.03). No other variables had a significant association with the outcomes. After adjusting for caseload, the association with board certification became non-significant. In the multivariate regression model including the above noted covariates, the association between caseload and the outcome remained significant (β = -0.001; p Conclusion: Risk-adjusted mortality rate after PCI is not associated with any education or certification markers, including board certification in interventional cardiology or maintenance of certification, after adjustment for caseload. Caseload was the only predictor of mortality rate in multivariate modeling.

Importance Higher income is associated with lower incident cardiovascular disease (CVD). However, there is limited research on the association between changes in income and incident CVD. Objective To examine the association between change in household income and subsequent risk of CVD. Design, Setting, and Participants The Atherosclerosis Risk In Communities (ARIC) study is an ongoing, prospective cohort of 15 792 community-dwelling men and women, of mostly black or white race, from 4 centers in the United States (Jackson, Mississippi; Washington County, Maryland; suburbs of Minneapolis, Minnesota; and Forsyth County, North Carolina), beginning in 1987. For our analysis, participants were followed up until December 31, 2016. Exposures Participants were categorized based on whether their household income dropped by more than 50% (income drop), remained unchanged/changed less than 50% (income unchanged), or increased by more than 50% (income rise) over a mean (SD) period of approximately 6 (0.3) years between ARIC visit 1 (1987-1989) and visit 3 (1993-1995). Main Outcomes and Measures Our primary outcome was incidence of CVD after ARIC visit 3, including myocardial infarction (MI), fatal coronary heart disease, heart failure (HF), or stroke during a mean (SD) of 17 (7) years. Analyses were adjusted for sociodemographic variables, health behaviors, and CVD biomarkers. Results Of the 8989 included participants (mean [SD] age at enrollment was 53 [6] years, 1820 participants were black [20%], and 3835 participants were men [43%]), 900 participants (10%) experienced an income drop, 6284 participants (70%) had incomes that remained relatively unchanged, and 1805 participants (20%) experienced an income rise. After full adjustment, those with an income drop experienced significantly higher risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 1.17; 95% CI, 1.03-1.32). Those with an income rise experienced significantly lower risk of incident CVD compared with those whose incomes remained relatively unchanged (hazard ratio, 0.86; 95% CI, 0.77-0.96). Conclusions and Relevance Income drop over 6 years was associated with higher risk of subsequent incident CVD over 17 years, while income rise over 6 years was associated with lower risk of subsequent incident CVD over 17 years. Health professionals should have greater awareness of the influence of income change on the health of their patients.

This study evaluates the designation of center of excellence by insurance payers for hospitals performing percutaneous coronary intervention.

IMPORTANCE: Medicaid expansion under the Patient Protection and Affordable Care Act led to one of the largest gains in health insurance coverage for nonelderly adults in the United States. However, its association with cardiovascular mortality is unclear. OBJECTIVE: To investigate the association of Medicaid expansion with cardiovascular mortality rates in middle-aged adults. DESIGN, SETTING, AND PARTICIPANTS: This study used a longitudinal, observational design, using a difference-in-differences approach with county-level data from counties in 48 states (excluding Massachusetts and Wisconsin) and Washington, DC, from 2010 to 2016. Adults aged 45 to 64 years were included. Data were analyzed from November 2018 to January 2019. EXPOSURES: Residence in a Medicaid expansion state. MAIN OUTCOMES AND MEASURES: Difference-in-differences of annual, age-adjusted cardiovascular mortality rates from before Medicaid expansion to after expansion. RESULTS: As of 2016, 29 states and Washington, DC, had expanded Medicaid eligibility, while 19 states had not. Compared with counties in Medicaid nonexpansion states, counties in expansion states had a greater decrease in the percentage of uninsured residents at all income levels (mean [SD], 7.3% [3.2%] vs 5.6% [2.7%]; P

Percutaneous coronary intervention (PCI) is the treatment of choice for acute myocardial infarction (AMI). In New York state (NY), there has been public reporting and ranking of hospital PCI mortality for decades, but only more recently, has there been public reporting and ranking of hospital

RATIONALE, AIMS AND OBJECTIVES Dyslipidaemia is a cardiovascular risk factor, and national screening and treatment guidelines have been established, but achievement of these remains inadequate. Multidisciplinary approaches, such as the chronic care model, have been applied to other chronic diseases and likely would be applicable to the management of dyslipidaemia. We therefore aimed to comprehensively study the different components of a multidisciplinary management approach to dyslipidaemia in a large health care system for patients at a high risk for cardiovascular events. METHODS All patients at a Veterans Affairs Medical Center in the United States over 3 years with diabetes and/or coronary artery disease were included. Various clinical and demographic variables were collected and achievement of national cholesterol goals was determined. Univariate and multivariate analyses were conducted to determine the association of different health care variables with improved patient cholesterol guideline achievement. RESULTS There were 3559 patients in the study population and 51.0% had achieved national cholesterol goals. Multivariate analyses showed that patients who had achieved goals were more likely to have attended cardiology clinic [odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3-2.01] and nutrition clinic (OR = 1.3, 95% CI = 1.04-1.7) and were more likely to have primary care providers who were nurse practitioners (OR = 1.6, 95% CI = 1.2-2.0), practicing full-time (OR = 1.8, 95% CI = 1.5-2.1) and at the main hospital-based clinics (OR = 1.5, 95% CI = 1.3-1.9). CONCLUSIONS Our study identifies different components of a multidisciplinary approach to management of dyslipidaemia that are efficacious and these results may help guide future investment in this area.