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1.  Will Bundled Payments Change Health Care? Examining the Evidence Thus Far in Cardiovascular Care 
Circulation  2015;131(24):2151-2158.
PMCID: PMC4471872  PMID: 26078370
2.  Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study 
Lancet  2014;385(9973):1114-1122.
Recent declines in average door-to-balloon (D2B) times at the population-level have not been associated with decreases in mortality. This study investigated this seemingly paradoxical observation by evaluating individual and population-level components of the association simultaneously. Our hypothesis was that the changing population of patients undergoing primary percutaneous coronary intervention (pPCI) contributed to secular trends toward an increasing mortality risk, despite consistently lower mortality among individual patients with shorter D2B times.
This was a retrospective study of ST-elevation myocardial infarction (STEMI) patients who underwent pPCI between January 2005 and December 2011 in the National Cardiovascular Data Registry (NCDR) CathPCI Registry. Multilevel models were constructed to evaluate the relationship between D2B time and in-hospital and 6-month mortality, including both individual and population-level components of this association after adjusting for patient and procedural factors.
423 hospitals reported data on 150,116 procedures with a 55.4% increase in the number of patients undergoing pPCI between the first and last years of this period at these facilities, as well as numerous changes in patient and procedural factors. Annual D2B times decreased significantly from a median of 86 minutes in 2005 to 63 minutes in 2011 (p<0.001) with a concurrent rise in risk-adjusted in-hospital mortality (4.7% to 5.3%; p=0.06) and risk-adjusted 6-month mortality (12.9% to 14.4%; p=0.001). In multilevel models, shorter patient-specific D2B times were consistently associated at the individual-level with lower in-hospital mortality (adjusted OR for each 10-min decrease, 0.92; 95% CI, 0.91 to 0.93; p<0.001) and 6-month mortality (adjusted OR for each 10-min decrease, 0.94; 95% CI, 0.93 to 0.95; p<0.001). In contrast, risk-adjusted in-hospital and 6-month mortality at the population-level, independent of patient-specific D2B times, rose in the growing and changing population of patients undergoing pPCI during the study period.
Shorter patient-specific D2B times were consistently correlated with lower mortality within years, while secular trends suggest increased mortality risk over time in the pPCI population. The lack of association of annual D2B time and changes in mortality at the population-level should not be interpreted as an indication of its individual-level relationship in STEMI patients, but more likely reflects higher-risk patients undergoing pPCI in later years.
PMCID: PMC4409657  PMID: 25467573
3.  Comparison of Clinical Interpretation with Visual Assessment and Quantitative Coronary Angiography in Patients Undergoing Percutaneous Coronary Intervention in Contemporary Practice: The Assessing Angiography (A2) Project 
Circulation  2013;127(17):1793-1800.
Studies conducted decades ago described substantial disagreement and errors in physicians’ angiographic interpretation of coronary stenosis severity. Despite the potential implications of such findings, no large-scale efforts to measure or improve clinical interpretation were subsequently made.
Methods & Results
We compared clinical interpretation of stenosis severity in coronary lesions with an independent assessment using quantitative coronary angiography (QCA) in 175 randomly selected patients undergoing elective percutaneous coronary intervention (PCI) at 7 U.S. hospitals in 2011. To assess agreement, we calculated mean difference in percent diameter stenosis between clinical interpretation and QCA and a Cohen’s weighted kappa statistic. Of 216 treated lesions, median percent diameter stenosis was 80.0% (Q1 and Q3, 80.0 and 90.0%) with 213 (98.6%) assessed as ≥70%. Mean difference in percent diameter stenosis between clinical interpretation and QCA was +8.2 ± 8.4%, reflecting an average higher percent diameter stenosis by clinical interpretation (P<0.001). A weighted kappa of 0.27 (95% CI, 0.18 to 0.36) was found between the 2 measurements. Of 213 lesions considered ≥70% by clinical interpretation, 56 (26.3%) were <70% by QCA though none was <50%. Differences between the 2 measurements were largest for intermediate lesions by QCA (50 to <70%) with variation existing across sites.
Physicians tended to assess coronary lesions treated with PCI as more severe than measurements by QCA. Almost all treated lesions were ≥70% by clinical interpretation, while approximately a quarter were <70% by QCA. These findings suggest opportunities to improve clinical interpretation of coronary angiography.
PMCID: PMC3908681  PMID: 23470859
Health policy and outcomes research; Quality improvement; Coronary angiography; Percutaneous coronary intervention; Quantitative coronary angiography
4.  What Is the Experience of National Quality Campaigns? Views from the Field 
Health Services Research  2010;45(6 Pt 1):1651-1669.
To identify key characteristics of a national quality campaign that participants viewed as effective, to understand mechanisms by which the campaign influenced hospital practices, and to elucidate contextual factors that modified the perceived influence of the campaign on hospital improvements.
Data Sources
In-depth interviews, hospital surveys, and Health Quality Alliance data.
Study Design
We conducted a qualitative study using in-depth interviews with clinical and administrative staff (N=99) at hospitals reporting strong influence (n=6) as well as hospitals reporting limited influence (n=6) of the Door-to-Balloon (D2B) Alliance, a national quality campaign to improve heart attack care. We analyzed these qualitative data as well as changes in hospital use of recommended strategies reported through a hospital survey and changes in treatment times using Health Quality Alliance data.
Data Collection Methods
In-depth, open-ended interviews; hospital survey.
Principal Findings
Key characteristics of the national quality campaign viewed as enhancing its effectiveness were as follows: credibility of the recommendations, perceived simplicity of the recommendations, alignment with hospitals' strategic goals, practical implementation tools, and breadth of the network of peer hospitals in the D2B Alliance. Perceived mechanisms of the campaign's influence included raising awareness and influencing goals, fostering strategy adoption, and influencing aspects of organizational culture. Modifying contextual factors included perceptions about current performance and internal championship for the recommended changes.
The impact of national quality campaigns may depend on both campaign design features and on the internal environment of participating hospitals.
PMCID: PMC3026952  PMID: 20698898
Quality improvement; campaigns; hospitals; acute myocardial infarction
5.  Operator Experience and Outcomes with Carotid Stenting in Medicare Beneficiaries 
Although the efficacy of carotid stenting has been established in clinical trials, operator experience and outcomes with the procedure in routine clinical practice are less certain.
To correlate outcomes with 2 measures of operator experience: (1) annual volume; and (2) experience at the time of the procedure among new operators who first performed carotid stenting after a national coverage decision by the Centers for Medicare & Medicaid Services (CMS).
Design, Setting, & Patients
Observational study using administrative data on fee-for-service Medicare beneficiaries 65 years or older undergoing carotid stenting between 2005 and 2007.
Main Outcome Measure
30-day mortality stratified by very-low, low, medium, and high annual operator volumes (<6, 6 to 11, 12 to 23, and ≥24 procedures per year) and treatment early versus late during a new operator’s experience (1st to 11th procedure and 12th procedure or higher).
24,701 procedures were performed by 2339 operators. Of these, 11,846 were performed by 1792 new operators who first performed carotid stenting after its national coverage decision. Overall, 30-day mortality was 1.9% and rate of failure to use an embolic protection device was 4.8%. The median annual operator volume in Medicare beneficiaries was 3.0 per year (IQR, 1.4 to 6.5) and 11.6% of operators performed ≥12 procedures per year during the study period. Observed 30-day mortality was higher among patients treated by operators with lower annual volumes (2.5% [95% CI, 2.1%-2.9%], 1.9% [95% CI, 1.6%-2.3%], 1.6% [95% CI, 1.3%-1.9%], and 1.4% [95% CI, 1.1%-1.7%] across the 4 categories; P<0.001) and among patients treated early versus late during a new operator’s experience (2.3% [95% CI, 2.0%-2.7%] and 1.4% [95% CI, 1.1%-1.9%]; P=0.001). After multivariable adjustment, patients treated by very-low volume operators had a higher risk of 30-day mortality when compared with patients treated by high volume operators (adjusted OR, 1.9; 95% CI, 1.4 to 2.7; P<0.001). Similarly, we found a higher risk of 30-day mortality in patients treated early versus late during a new operator’s experience (adjusted OR, 1.7; 95% CI, 1.2 to 2.4; P=0.001).
Among older patients undergoing carotid stenting, lower annual operator volume and early experience were associated with increased 30-day mortality.
PMCID: PMC3208144  PMID: 21954477
6.  Association of Physician Certification in Interventional Cardiology with In-Hospital Outcomes of Percutaneous Coronary Intervention 
Circulation  2015;132(19):1816-1824.
The value of American Board of Internal Medicine (ABIM) certification has been questioned. We evaluated the association of interventional cardiology (ICARD) certification with in-hospital outcomes of patients undergoing percutaneous coronary intervention (PCI) in 2010.
Methods and Results
We identified physicians who performed ≥10 PCIs in 2010 in the CathPCI Registry and determined ICARD status using ABIM data. We compared in-hospital outcomes of patients treated by certified and non-certified physicians using hierarchical multivariable models adjusted for differences in patient characteristics and PCI volume. Primary endpoints were all-cause in-hospital mortality and bleeding complications. Secondary endpoints included emergency coronary artery bypass grafting, vascular complications, and a composite of any adverse outcome. With 510,708 PCI procedures performed by 5,175 physicians, case mix and unadjusted outcomes were similar among certified and non-certified physicians. The adjusted risks of in-hospital mortality (OR 1.10, 95% CI 1.02-1.19) and emergency CABG (OR 1.32, 95% CI 1.12-1.56) were higher in the non-ICARD certified group, but the risks of bleeding, vascular complications, and the composite endpoint were not statistically significantly different between groups.
We did not observe a consistent association between ICARD certification and the outcomes of PCI procedures. Although there was a significantly higher risk of mortality and emergency CABG in patients treated by non-ICARD certified physicians, the risks of vascular complications and bleeding were similar. Our findings suggest that ICARD certification status alone is not a strong predictor of patient outcomes, and indicate a need to enhance the value of subspecialty certification.
PMCID: PMC4641797  PMID: 26384518
angioplasty; registry; revascularization; board certification
7.  Early Coronary Angiography and Survival After Out-Of-Hospital Cardiac Arrest 
While out-of-hospital cardiac arrest is commonly due to acute myocardial infarction, it is unknown whether early coronary angiography is associated with improved survival in these patients.
Methods and Results
Using data from the Cardiac Arrest Registry to Enhance Survival (CARES), we identified 4,029 adult patients admitted to 374 hospitals after successful resuscitation from out-of-hospital cardiac arrest due to ventricular fibrillation, pulseless ventricular tachycardia or unknown shockable rhythm between January 2010 and December 2013. Early coronary angiography (occurring within one calendar day of cardiac arrest) was performed in 1953 (48.5%) patients, of whom 1253 (64.2%) received coronary revascularization. Patients who underwent early coronary angiography were younger (59.9 vs. 62.0 years); more likely to be men (78.1% vs. 64.3%), have a witnessed arrest (84.6% vs. 77.4%), and have ST-elevation myocardial infarction (32.7% vs. 7.9%); and less likely to have known cardiovascular disease (22.8% vs. 35.0%), diabetes (11.0% vs. 17.0%), and renal disease (1.8% vs. 5.8%; P<0.01 for all comparisons). In analysis of 1312 propensity score-matched pairs, early coronary angiography was associated with higher odds of survival to discharge (OR: 1.52, [95% CI 1.28–1.80]), P<0.0001) and survival with favorable neurological outcome (OR 1.47, [95% CI 1.25–1.71], P<0.0001). Further adjustment for coronary revascularization in our models significantly attenuated both ORs, suggesting that revascularization was a key mediator of the survival benefit.
Among initial survivors of out-of-hospital cardiac arrest due to VF or pulseless VT, we found early coronary angiography was associated with higher odds of survival to discharge and favorable neurological outcome.
PMCID: PMC4603281  PMID: 26453686
coronary angiography; cardiac catheterization; cardiac arrest; out-of-hospital cardiac arrest
8.  Standardized Data Collection Practices and the Racial/Ethnic Distribution of Hospitalized Patients 
Medical care  2015;53(8):666-672.
Although frequently used to track healthcare disparities, patient race/ethnicity data collected by hospitals can be unreliable, particularly for smaller minority groups. We sought to determine if the racial/ethnic distribution of hospitalized patients shifted after implementation of a statewide initiative to standardize data collection practices.
We conducted a difference-in-differences analysis of the State Inpatient Databases to estimate changes in the proportion of patients identified as non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and “other,” before (2005–2006) and after (2008–2009) standardized practices were implemented in New Jersey (NJ) relative to New York (NY), a state with similar demographics but no changes to data collection.
Among 12,552,702 hospital discharges, modest relative changes were noted in the proportion of patients identified as non-Hispanic white (+1.1%; 95% CI +0.9 to +1.2) and non-Hispanic black (+1.6%; 95% CI +1.1 to +2.1) in NJ that were attributed to its use of standardized data collection practices as compared with NY. Larger relative changes were noted in the proportion of patients identified as Hispanic (−7.1%; 95% CI −7.8 to −6.4), Asian/Pacific Islander (+26.5%; 95% CI +25.1 to +27.9) and “other” (−24.6%; 95% CI −26.4 to −22.8). This pattern was largely consistent in analyses stratified by gender, age, and Major Diagnostic Category.
Measurement of healthcare disparities fundamentally depends on the racial/ethnic categorization of individuals. By redistributing substantial proportions of patients across smaller minority groups, standardized data collection could lead to shifts in estimates of healthcare disparities for these rapidly growing populations.
PMCID: PMC4503513  PMID: 26147864
9.  Effectiveness of Implantable Cardioverter-Defibrillators in Survivors of In-Hospital Cardiac Arrest 
American heart journal  2015;169(6):870-878.e1.
Although implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with out-of-hospital cardiac arrest, their effectiveness in survivors of in-hospital cardiac arrest—a population with different arrest etiologies and higher illness acuity than out-of-hospital cardiac arrest—is unknown. We therefore sought to conduct a comparative effectiveness study of ICD therapy in survivors of in-hospital cardiac arrest.
We linked data from a national inpatient cardiac arrest registry with Medicare files and identified 1200 adults from 267 hospitals between 2000 and 2008 who were discharged after surviving an in-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia and who otherwise met traditional inclusion and exclusion criteria for secondary prevention ICD trials. The association between ICD treatment and long-term mortality was evaluated using an optimal match (≤ 4 controls for each ICD patient) propensity-score analysis.
Of 1200 survivors, 343 (28.6%) received an ICD during the index hospitalization. Overall, 3-year mortality was 44.2%, with higher unadjusted mortality in the non-ICD vs. the ICD group (46.9% vs. 37.3%; log-rank P<0.001). After successfully matching 343 patients treated with ICDs with 823 untreated patients by propensity score, ICD treatment was associated with a 24% lower mortality rate (adjusted HR, 0.76; 95% CI, 0.60–0.97; P=0.025). This lower mortality was mediated by lower rates of out-of-hospital deaths among ICD-treated patients (22.1% vs. 30.8%; adjusted HR, 0.71 [0.52–0.96], P=0.019), whereas deaths occurring during a readmission were similar (15.2% vs. 16.1%; adjusted HR, 0.89 [95% CI, 0.60–1.32], P=0.56).
ICD therapy in survivors of in-hospital cardiac arrest due to a pulseless ventricular rhythm is used uncommonly but associated with lower long-term mortality. Given that fewer than 3 in 10 eligible survivors are treated with ICDs after surviving an in-hospital cardiac arrest, our findings highlight a potentially modifiable process of care which could improve long-term survival in this high-risk population.
PMCID: PMC4451609  PMID: 26027626
10.  Poorly Cited Articles in Peer-Reviewed Cardiovascular Journals from 1997–2007: Analysis of 5-Year Citation Rates 
Circulation  2015;131(20):1755-1762.
The extent to which articles are cited is a surrogate of the impact and importance of the research conducted; poorly cited papers may identify research of limited use and potential wasted investments. We assessed trends in the rates of poorly cited articles and journals in the cardiovascular literature from 1997–2007.
Methods and Results
We identified original articles published in cardiovascular journals and indexed in the Scopus citation database from 1997–2007. We defined poorly cited articles as those with ≤5 citations in the 5 years following publication and poorly cited journals as those with >75% of journal content poorly cited. We identified 164,377 articles in 222 cardiovascular journals from 1997–2007. From 1997–2007, the number of cardiovascular articles and journals increased by 56.9% and 75.2% respectively. Of all the articles, 75,550 (46.0%) were poorly cited, of which 25,650 (15.6% overall) had no citations. From 1997–2007, the proportion of poorly cited articles declined slightly (52.1% to 46.2%, trend P<0.001), although the absolute number of poorly cited articles increased by 2,595 (trend P<0.001). At a journal level, 44% of cardiovascular journals had more than three quarters of the journal’s content poorly cited at 5 years.
Nearly half of all peer-reviewed articles published in cardiovascular journals are poorly cited 5 years after publication, and many are not cited at all. The cardiovascular literature, and the number of poorly cited articles, have both increased substantially from 1997–2007. The high proportion of poorly cited articles and journals suggest inefficiencies in the cardiovascular research enterprise.
PMCID: PMC4560203  PMID: 25812573
Citation analysis; Bibliometrics; Scopus; Impact Factor
11.  Factors Associated With Longer Time From Symptom Onset to Hospital Presentation for Patients With ST-Elevation Myocardial Infarction 
Archives of internal medicine  2008;168(9):959-968.
Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction.
We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482 327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic.
The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P<.001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those <70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P<.01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes).
Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.
PMCID: PMC4858313  PMID: 18474760
12.  National trends in stroke after acute myocardial infarction among Medicare patients in the United States: 1999 to 2010 
American heart journal  2014;169(1):78-85.e4.
Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade.
To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010.
We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P < .001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke.
From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high.
PMCID: PMC4824179  PMID: 25497251
13.  Defibrillation time intervals and outcomes of cardiac arrest in hospital: retrospective cohort study from Get With The Guidelines-Resuscitation registry 
The BMJ  2016;353:i1653.
Objective To describe temporal trends in the time interval between first and second attempts at defibrillation and the association between this time interval and outcomes in patients with persistent ventricular tachycardia or ventricular fibrillation (VT/VF) arrest in hospital.
Design Retrospective cohort study
Setting 172 hospitals in the United States participating in the Get With The Guidelines-Resuscitation registry, 2004-12.
Participants Adults who received a second defibrillation attempt for persistent VT/VF arrest within three minutes of a first attempt.
Interventions Second defibrillation attempts categorized as early (time interval of up to and including one minute between first and second defibrillation attempts) or deferred (time interval of more than one minute between first and second defibrillation attempts).
Main outcome measure Survival to hospital discharge.
Results Among 2733 patients with persistent VT/VF after the first defibrillation attempt, 1121 (41%) received a deferred second attempt. Deferred second defibrillation for persistent VT/VF increased from 26% in 2004 to 57% in 2012 (P<0.001 for trend). Compared with early second defibrillation, unadjusted patient outcomes were significantly worse with deferred second defibrillation (57.4% v 62.5% for return of spontaneous circulation, 38.4% v 43.6% for survival to 24 hours, and 24.7% v 30.8% for survival to hospital discharge; P<0.01 for all comparisons). After risk adjustment, deferred second defibrillation was not associated with survival to hospital discharge (propensity weighting adjusted risk ratio 0.89, 95% confidence interval 0.78 to 1.01; P=0.08; hierarchical regression adjusted 0.92, 0.83 to 1.02; P=0.1).
Conclusions Since 2004, the use of deferred second defibrillation for persistent VT/VF in hospital has doubled. Deferred second defibrillation was not associated with improved survival.
PMCID: PMC4823520  PMID: 27052620
15.  Longitudinal Functional Recovery after Geriatric Cardiac Surgery 
The Journal of surgical research  2014;194(1):25-33.
Impaired functional and cognitive status is an important outcome for older adults undergoing major cardiac surgery. We conducted this pilot study to gauge feasibility of assessing these outcomes longitudinally, from pre-operatively up to two time-points post-operatively to assess for recovery.
We interviewed patients ≥ age 65 years pre-operatively and repeated functional and cognitive assessments at 4–6 weeks and 4–6 months post-operatively. Simple unadjusted linear regression was used to test whether baseline measures changed at each follow-up time point. Then we used a longitudinal model to predict post-operative recovery overall, adjusting for co-morbidity.
62 patients (age 74.7 ± 5.9) underwent scheduled cardiac surgery. Pre-operative ADL impairment was associated with poorer functional recovery at 4–6 weeks post-operatively with each baseline ADL impairment conferring recovery of 0.5 fewer ADLs (p<.05). By 4–6 months, we could no longer detect a difference in recovery. Pre-operative cognition and physical activity was not associated with post-operative changes in these domains.
A pre- and post-operative evaluation of function and cognition was integrated into the surgical care of older patients. Pre-operative impairments in ADLs may be a means to identify patients who might benefit from careful post-operative planning, especially in terms of assistance with self-care during the first 4–6 weeks after cardiac surgery.
PMCID: PMC4346442  PMID: 25483736
Aging; Elderly; Cardiac Surgery; Outcomes; Functional Status; Cognitive Function
16.  Long‐Term Outcomes Among Elderly Survivors of Out‐of‐Hospital Cardiac Arrest 
Most studies on out‐of‐hospital cardiac arrest have focused on immediate survival. However, little is known about long‐term outcomes and resource use among survivors.
Methods and Results
Within the national CARES registry, we identified 16 206 adults 65 years or older with an out‐of‐hospital cardiac arrest between 2005 and 2010. Among 1127 patients who were discharged alive, we evaluated whether 1‐year mortality, cumulative readmission incidence, and follow‐up inpatient costs differed according to patients’ race, sex, initial cardiac arrest rhythm, bystander delivery of cardiopulmonary resuscitation, discharge neurological status, and functional status (hospital discharge disposition). Overall 1‐year mortality after hospital discharge was 31.8%. Among survivors, there were no long‐term mortality differences by sex, race, or initial cardiac arrest rhythm, but worse functional status and severe neurological disability at discharge were associated with higher mortality. Moreover, compared with first responders, cardiopulmonary resuscitation delivered by bystanders was associated with 23% lower mortality (hazard ratio 0.77 [confidence interval 0.58–1.02]). Besides mortality, 638 (56.6%) patients were readmitted within the first year, and the cumulative readmission incidence was 197 per 100 patient‐years. Mean 1‐year inpatient costs were $23 765±41 002. Younger age, black race, severe neurological disability at discharge, and hospital disposition to a skilled nursing or rehabilitation facility were each associated with higher 1‐year inpatient costs (P for all <0.05).
Among elderly survivors of out‐of‐hospital cardiac arrest, nearly 1 in 3 patients die within the first year. Long‐term mortality and inpatient costs differed substantially by certain demographic factors, whether cardiopulmonary resuscitation was initiated by a bystander, discharge neurological status, and hospital disposition.
PMCID: PMC4943267  PMID: 27068632
cardiac arrest; cost; outcomes research; survival; Cardiopulmonary Arrest; Quality and Outcomes; Mortality/Survival
17.  Implementation of a Pilot ACO Payment Model and the Use of Discretionary and Non-Discretionary Cardiovascular Care 
Circulation  2014;130(22):1954-1961.
Accountable care organizations (ACOs) seek to reduce growth in healthcare spending while ensuring high-quality care. We hypothesized that ACO implementation would selectively limit utilization of discretionary cardiovascular care (defined as care occurring in the absence of indications such as myocardial infarction or stroke), while maintaining high-quality care such as non-discretionary cardiovascular imaging and procedures.
Methods and Results
The intervention group was composed of fee-for-service Medicare patients (n=819,779) from 10 groups participating in a Medicare pilot ACO, the Physician Group Practice Demonstration (PGPD). Matched controls were patients (n=934,621) from non-participating groups in the same regions. We compared utilization of cardiovascular care before (2002-2004) and after (2005-2009) PGPD implementation, studying both discretionary and non-discretionary carotid and coronary imaging and procedures. Our main outcome measure was the difference in the proportion of patients treated with imaging and procedures, among patients of PGPD practices compared to patients in control practices, before and after PGPD implementation (difference-in-difference). For discretionary imaging, the difference-in-difference between PGPD practices and controls was not statistically significant for discretionary carotid imaging (0.17%; 95% CI -0.51% to 0.85%, p=0.595) or discretionary coronary imaging (-0.19%; 95% CI -0.73% to 0.35%, p=0.468). Similarly, the difference-in-difference was also minimal for discretionary carotid revascularization (0.003%; 95% CI -0.008% to 0.002%, p=0.705) and coronary revascularization (-0.02%, 95% CI -0.11% to 0.07%, p=0.06). The difference-in-difference associated with PGPD implementation was also essentially zero for non-discretionary cardiovascular imaging or procedures.
Implementation of a pilot ACO did not limit the utilization of discretionary or non-discretionary cardiovascular care in ten large health systems.
PMCID: PMC4244758  PMID: 25421044
health policy and outcomes research; stroke care; myocardial infarction; outcomes research; health economics
18.  Readmission Rates and Long-Term Hospital Costs Among Survivors of In-Hospital Cardiac Arrest 
Although in-hospital cardiac arrest is common, little is known about readmission patterns and inpatient resource use among survivors of in-hospital cardiac arrest.
Methods and Results
Within a large national registry, we examined long-term inpatient utilization among 6972 adults ≥65 years who survived an in-hospital cardiac arrest. We examined 30-day and 1-year readmission rates and inpatient costs, overall and by patient demographics, hospital disposition (discharge destination), and neurological status at discharge. The mean age was 75.8 ± 7.0 years, 56% were men, and 12% were black. There were a total of 2005 readmissions during the first 30 days (cumulative incidence rate: 35 readmissions/100 patients [95% CI: 33–37]) and 8751 readmissions at 1 year (cumulative incidence rate: 185 readmissions/100 patients [95% CI: 177–190]). Overall, mean inpatient costs were $7,741 ± $2323 at 30 days and $18,629 ± $9411 at 1 year. Thirty-day inpatient costs were higher in patients of younger age (≥85 years: $6052 [reference]; 75–84 years: $7444 [adjusted cost ratio, 1.23 [1.06–1.42]; 65–74 years: $8291 [adjusted cost ratio, 1.37 [1.19–1.59]; both P<0.001]) and black race (whites: $7413; blacks: $9044; adjusted cost ratio, 1.22 [1.05–1.42]; P<0.001), as well as those discharged with severe neurological disability or to skilled nursing or rehabilitation facilities. These differences in resource use persisted at 1 year and were largely due to higher readmission rates.
Survivors of in-hospital cardiac arrest have frequent readmissions and high follow-up inpatient costs. Readmissions and inpatient costs were higher in certain subgroups, including patients of younger age and black race.
PMCID: PMC4241155  PMID: 25351479
cardiac arrest; cost; readmission; outcomes research
A growing number of hospitals have begun to implement policies allowing for family presence during resuscitation (FPDR); the safety of these policies and their affect on patterns of care is unknown.
To measure the association between FPDR and processes and outcomes of care following in-hospital cardiac arrest.
Observational cohort study.
Get With the Guidelines–Resuscitation (GWTG–R) a large, multicenter observational registry capturing in-hospital cardiac arrests.
41,568 adult patients at 252 hospitals in the United States.
The exposure was a hospital-level policy to allow FPDR. Primary outcomes included return of spontaneous circulation (ROSC) and survival to discharge. Secondary outcomes included the quality, interventions, and self-reported potential systems errors associated with resuscitation.
There were no significant differences in ROSC or survival to discharge in hospitals with and without a FPDR policy in unadjusted or adjusted analyses. There was a small, borderline significant decrease in the mean time to defibrillation at hospitals with a FPDR policy compared to hospitals without a FPDR policy during adjusted analysis (p=0.05). Similarly, there was a significant increase in the risk-adjusted median duration of resuscitation among non-survivors in hospitals with FPDR (P=0.04). Other resuscitation quality, pharmacologic and non-pharmacologic interventions, and potential self-reported systems-level resuscitation errors did not meaningfully differ between hospitals with and without a FPDR policy.
GWTG–R may not be representative of all hospitals. Furthermore, it does not collect information on whether families were actually present during the arrests recorded.
Hospitals with a policy allowing families to be present during resuscitation generally have similar outcome and processes of case as hospitals without a FPDR policy suggesting such policies do not negatively impact resuscitation outcomes and processes. Expanding hospital implementation policies allowing FPDR may offer substantial opportunity for enhancing the practice of resuscitation care.
Primary Funding Source
American Heart Association, Agency for Healthcare Research and Quality, National Institutes of Health.
PMCID: PMC4547839  PMID: 25805646
20.  Percutaneous Coronary Intervention Utilization and Appropriateness across the United States 
PLoS ONE  2015;10(9):e0138251.
Substantial geographic variation exists in percutaneous coronary intervention (PCI) use across the United States. It is unclear the extent to which high PCI utilization can be explained by PCI for inappropriate indications. The objective of this study was to examine the relationship between PCI rates across regional healthcare markets utilizing hospital referral regions (HRRs) and PCI appropriateness.
The number of PCI procedures in each HRR was obtained from the 2010 100% Medicare limited data set. HRRs were divided into quintiles of PCI utilization with increasing rates of utilization progressing to quintile 5. NCDR CathPCI Registry® data were used to evaluate patient characteristics, appropriate use criteria (AUC), and outcomes across the HRR quintiles defined by PCI utilization with the study population restricted to HRRs where ≥ 80% of the PCIs were performed at institutions participating in the registry. PCI appropriateness was defined using 2012 AUC by the American College of Cardiology (ACC)/American Heart Association (AHA)/The Society for Cardiovascular Angiography and Interventions (SCAI).
Our study cohort comprised of 380,981 patients treated at 178 HRRs. Mean PCI rates per 1,000 increased from 4.6 in Quintile 1 to 10.8 in Quintile 5. The proportion of non-acute PCIs was 27.7% in Quintile 1 increasing to 30.7% in Quintile 5. Significant variation (p < 0.001) existed across the quintiles in the categorization of appropriateness across HRRs of utilization with more appropriate PCI in lower utilization areas (Appropriate: Q1, 76.53%, Q2, 75.326%, Q3, 75.23%, Q4, 73.95%, Q5, 72.768%; Inappropriate: Q1 3.92%, Q2 4.23%, Q3 4.32%, Q4 4.35%, Q5 4.05%; Uncertain: Q1 8.29%, Q2 8.84%, Q3 8.08%, Q4 9.01%, Q5 8.93%; Not Mappable: Q1 11.26%, Q2 11.67%, Q3 12.37%, Q4 12.69%, Q5 14.34%). There was no difference in risk-adjusted mortality across quintiles of PCI utilization.
Geographic regions with lower PCI rates have a higher proportion of PCIs performed for appropriate indications. Areas that perform more PCIs also appear to perform more elective PCI and many could not be mapped by the AUC.
PMCID: PMC4575022  PMID: 26379053
21.  Body Mass Index and Survival after In-Hospital Cardiac Arrest 
The quality and effectiveness of resuscitation processes may be influenced by patients' body mass index (BMI); however, the relationship between BMI and survival after in-hospital cardiac arrest has not been previously studied.
Methods and Results
We evaluated 21,237 adult patients with an in-hospital cardiac arrest within the National Registry for Cardiopulmonary Resuscitation (NRCPR). We examined the association between BMI (classified as underweight [<18.5 kg/m2], normal [18.5-24.9], overweight [25.0-29.9], obese [30.0-34.9], and very obese [≥35.0]) and survival to hospital discharge using multivariable logistic regression, after stratifying arrests by rhythm type and adjusting for patient characteristics. Of 4,499 patients with ventricular fibrillation or pulseless ventricular tachycardia as initial rhythm, 1,825 (40.6%) survived to discharge. After multivariable adjustment, compared with overweight patients, underweight (Odds Ratio [OR], 0.59 [95% CI: 0.41-0.84]; p=0.003), normal weight (OR, 0.75; [0.63-0.89]; p<.001), and very obese (OR, 0.78 [0.63-0.96]; p=0.02) had lower rates of survival, while obese patients had similar rates of survival (OR, 0.87; 95% CI, 0.72-1.06; p=0.17). In contrast, of 16,738 patients with arrests due to asystole or pulse less electrical activity, only 2,501 (14.9%) survived. After multivariable adjustment, all BMI groups had similar rates of survival except underweight patients (OR, 0.67 [0.54-0.82]; p<.001).
For cardiac arrests due to shockable rhythms, underweight, normal weight, and very obese patients had lower rates of survival to discharge. In contrast, for cardiac arrests due to non-shockable rhythms, survival to discharge was similar across BMI groups, except for underweight patients. Future studies are needed to clarify the extent to which BMI affects the quality and effectiveness of resuscitation measures.
PMCID: PMC4542076  PMID: 20699443
cardiopulmonary resuscitation; obesity; heart arrest; defibrillation
22.  Direct emergency medical services transport in STEMI: breaking the bank for non-PCI capable hospitals? 
Open Heart  2015;2(1):e000139.
PMCID: PMC4493164  PMID: 26167289
Systems of Care; Emergency Medical Services
23.  Association between a Hospital’s Quality Performance for In-Hospital Cardiac Arrest and Common Medical Conditions 
Public reporting on hospital quality has been widely adopted for common medical conditions. Adding a measure of inpatient survival after cardiac arrest is being considered. It is unknown if this measure would be redundant, given evidence that hospital organization and culture can have hospital-wide effects on quality. Therefore, we sought to evaluate the correlation between inpatient survival after cardiac arrest and 30-day risk-standardized mortality rates for common medical conditions.
Methods and Results
Using data between 2007 and 2010 from a national in-hospital cardiac arrest registry, we calculated risk-standardized in-hospital survival rates for cardiac arrest at each hospital. We obtained risk-standardized 30-day mortality rates for acute myocardial infarction (AMI), heart failure (HF), and pneumonia from Hospital Compare for the same period. The relationship between a hospital’s performance on cardiac arrest and these other medical conditions was assessed using weighted Pearson correlation coefficients. Among 26,270 patients with in-hospital cardiac arrest at 130 hospitals, survival rates varied across hospitals, with a median risk-standardized hospital survival rate of 22.1% and an inter-quartile range (IQR) of 19.7% to 24.2%. There were no significant correlations between a hospital’s outcomes for its cardiac arrest patients and its patients admitted for AMI (correlation of −0.12; P=0.16), HF (correlation of −0.05; P=0.57), or pneumonia (correlation of −0.15, P=0.10).
Hospitals that performed better on publicly reported outcomes for three common medical conditions did not necessarily have better cardiac arrest survival rates. Public reporting on cardiac arrest outcomes could provide new information about hospital quality.
PMCID: PMC4465597  PMID: 24221831
resuscitation; heart failure; myocardial infarction
24.  Growth in Medicare Expenditures for Patients With Acute Myocardial Infarction: A Comparison of 1998 Through 1999 and 2008 
JAMA internal medicine  2013;173(22):2055-2061.
Medicare expenditures continue to grow rapidly, but the reasons are uncertain.
To compare expenditures from 1998 through 1999 and 2008 for Medicare beneficiaries hospitalized for acute myocardial infarction (AMI).
Design, Setting, and Participants
Cross-sectional analysis of a random 20% sample of fee-for-service Medicare beneficiaries admitted with AMI from 1998 through 1999 (n = 105 074) and a 100% sample for 2008 (n = 212 329).
Main outcomes and Measures
Per-beneficiary expenditures, standardized for price and adjusted for risk and inflation. Expenditures were measured across 4 periods: overall (index admission to 1 year), index (within the index admission), early (postindex admission to 30 days), and late (31-365 days).
Compared with the subjects from 1998 through 1999, those in 2008 were older and had more comorbidities but slightly less ischemic heart disease and cerebrovascular disease. Although there was a 19.2% decline in the rate of hospitalizations for AMI, overall expenditures per patient increased by 16.5% (absolute difference, $6094). Of the total risk-adjusted increase in expenditures, 25.6% occurred within 30 days (22.0% attributed to the index admission), and 74.4% happened 31 to 365 days after the index admission. Spending per beneficiary within 30 days increased by $1560 (7.5%), and spending between 31 and 365 days increased by $4535 (28.0%). Expenditures for skilled nursing facilities, hospice, home health agency, durable medical equipment, and outpatient care nearly doubled 31 to 365 days after admission. Mortality within 1 year declined from 36.0% in 1998 through 1999 to 31.7% in 2008; of the decline, 3.3% was in the 30 days following admission, and 1.0% was in days 31 to 365.
Conclusions and Relevance
Between 1998 and 2008, Medicare expenditures per patient with an AMI substantially increased, with about three-fourths of the increase in expenditures occurring 31 to 365 days after the date of hospital admission. Although current bundled payment models may contain expenditures within 30 days of an AMI, they do not contain spending beyond 30 days.
PMCID: PMC4454469  PMID: 24061277
25.  Hospital Variability in Use of Anticoagulant Strategies During Acute Myocardial Infarction Treated With an Early Invasive Strategy 
During a myocardial infarction, no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade-offs between treatments.
Methods and Results
We investigated the patterns of use and site-level variability in anticoagulant strategies (unfractionated heparin [UFH] only, low-molecular-weight heparin [LMWH] only, UFH+LMWH, any bivalirudin) of 63 796 patients with a principal diagnosis of myocardial infarction treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of patients received UFH only, 6% UFH+LMWH, 7% LMWH only, and 40% bivalirudin. Compared with UFH, the median odds ratio was 2.90 for LMWH+UFH, 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 “identical” patients would have a 3- to 4-fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low- or high-users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin-using hospitals had higher unadjusted bleeding rates, but the risk-adjusted and anticoagulant-adjusted bleeding rates did not differ across the hospital anticoagulation phenotypes. Risk-standardized mortality and risk-standardized length of stay also did not differ across hospital phenotypes.
We found substantial site-level variability in the choice of anticoagulants for invasively managed acute myocardial infarction patients, even after accounting for patient factors. No single hospital-use pattern was found to be clinically superior. More studies are needed to determine which patients would derive the greatest benefit from various anticoagulants and to support consistent treatment of patients with the optimal anticoagulant strategy.
PMCID: PMC4599539  PMID: 26077589
anticoagulation; bleeding; myocardial infarction; variation

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