Sex-specific racial and ethnic variations in short-term outcomes among patients with first or recurrent ischemic stroke: Paul Coverdell National Acute Stroke Program, 2016-2020.

BACKGROUND AND PURPOSE: To understand the association of sex-specific race and ethnicity on the short-term outcomes of initial and recurrent ischemic stroke events. METHODS: Using the Paul Coverdell National Acute Stroke Program from 2016-2020, we examined 426,062 ischemic stroke admissions from 629 hospitals limited to non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic patients. We performed multivariate logistic regression analyses to assess the combined effects of sex-specific race and ethnicity on short-term outcomes for acute ischemic stroke patients presenting with initial or recurrent stroke events. Outcomes assessed include rates of in-hospital death, discharge to home, and symptomatic intracranial hemorrhage (sICH) after reperfusion treatment. RESULTS: Among studied patients, the likelihood of developing sICH after reperfusion treatment for initial ischemic stroke was not significantly different. The likelihood of experiencing in-hospital death among patients presenting with initial stroke was notably higher among NHW males (AOR 1.59 [95 % CI 1.46, 1.73]), NHW females (AOR 1.34 [95 % CI 1.23, 1.45]), and Hispanic males (AOR 1.57 [95 % CI 1.36, 1.81]) when compared to NHB females. Hispanic females were more likely to be discharged home when compared to NHB females after initial stroke event (AOR 1.32 [95 % CI 1.23, 1.41]). NHB males (AOR 0.90 [95 % CI 0.87, 0.94]) and NHW females (AOR 0.89 [95 % CI 0.86, 0.92]) were less likely to be discharged to home. All groups with recurrent ischemic strokes experienced higher likelihood of in-hospital death when compared to NHB females with the highest likelihood among NHW males (AOR 2.13 [95 % CI 1.87, 2.43]). Hispanic females had a higher likelihood of discharging home when compared to NHB females hospitalized for recurrent ischemic stroke, while NHB males and NHW females with recurrent ischemic stroke hospitalizations were less likely to discharge home. CONCLUSIONS: Sex-specific race and ethnic disparities remain for short-term outcomes in both initial and recurrent ischemic stroke hospitalizations. Further studies are needed to address disparities among recurrent ischemic stroke hospitalizations.

Contemporary Trends in the Treatment of Mild Ischemic Stroke with Intravenous Thrombolysis: Paul Coverdell National Acute Stroke Program.

BACKGROUND: Presentation with mild symptoms is a common reason for intravenous thrombolysis (IVT) nonuse among acute ischemic stroke (AIS) patients. We examined the impact of IVT on the outcomes of mild AIS over time. METHODS: Using the Paul Coverdell National Stroke Program data, we examined trends in IVT utilization from 2010 to 2019 among AIS patients presenting with National Institutes of Health Stroke Scale (NIHSS) scores ≤5. Outcomes adjudicated included rates of discharge to home and ability to ambulate independently at discharge. We used generalized estimating equation models to examine the effect of IVT on outcomes of AIS patients presenting with mild symptoms and calculated adjusted odds ratio (AOR) with 95% confidence intervals (CI). RESULTS: During the study period, 346,762 patients presented with mild AIS symptoms. Approximately 6.2% were treated with IVT. IVT utilization trends increased from 3.7% in 2010 to 7.7% in 2019 (p < 0.001). Patients treated with IVT had higher median NIHSS scores upon presentation (IVT 3 [2, 4] vs. no IVT 2 [0, 3]). Rates of discharge to home (AOR 2.06, 95% CI: 1.99-2.13) and ability to ambulate at time of discharge (AOR 1.82, 95% CI: 1.76-1.89) were higher among those treated with IVT. CONCLUSION: There was an increased trend in IVT utilization among AIS patients presenting with mild symptoms. Utilization of IVT increased the odds of being discharged to home and the ability to ambulate at discharge independently in patients with mild stroke.

Emergency Medical Services Utilization for Acute Stroke Care: Analysis of the Paul Coverdell National Acute Stroke Program, 2014-2019.

Objective: Emergency medical service (EMS) transportation after acute stroke is associated with shorter symptom-to-arrival times and more rapid medical attention when compared to patient transportation by private vehicle. Methods: We analyzed data from the Paul Coverdell National Acute Stroke Program from 2014 to 2019 among stroke (ischemic and hemorrhagic) and transient ischemic attack (TIA) patients to examine patterns in EMS utilization. Results: Of 500,829 stroke and TIA patients (mean age 70.9 years, 51.3% women) from 682 participating hospitals during the study period, 60% arrived by EMS. Patients aged 18-64 years vs. ≥65 years (AOR 0.67) were less likely to utilize EMS. Severe stroke patients (AOR 2.29, 95%CI, 2.15-2.44) and hemorrhagic stroke patients vs. ischemic stroke patients (AOR 1.47, 95% CI, 1.43-1.51) were more likely to utilize EMS. Medicare (AOR 1.35, 95% CI, 1.32-1.38) and Medicaid (AOR 1.41, 95% CI, 1.37-1.45) beneficiaries were more likely than privately insured patients to utilize EMS, but no difference was found between no insurance/self-pay patients and privately insured patients on EMS utilization. Overall, there was a decreasing trend in the utilization of EMS (59.6% to 59.3%, p = 0.037). The decreasing trend was identified among ischemic stroke (p < 0.0001) patients but not among TIA (p = 0.89) or hemorrhagic stroke (p = 0.44) patients. There was no observed trend in pre-notification among stroke patients' arrival by EMS across the study period (56.9% to 56.5%, p = 0.99). Conclusions: Strategies to help increase stroke awareness and utilization of EMS among those with symptoms of stroke should be considered in order to help improve stroke outcomes.

Racial/Ethnic and Geographic Variations In Long-Term Survival Among Medicare Beneficiaries After Acute Ischemic Stroke.

INTRODUCTION: Little information is available about racial/ethnic and geographic variations in long-term survival among older patients (≥65) after acute ischemic stroke (AIS). METHODS: We examined data on 1,019,267 Medicare fee-for-service (FFS) beneficiaries aged 66 or older, hospitalized with a primary diagnosis of AIS from 2008 through 2012. Survival was defined as the time from the date of AIS to date of death, or an end of follow-up date of December 31, 2017. We used Cox proportional hazard models to estimate 5-year survival after AIS, adjusted for age, sex, race and Hispanic ethnicity, poverty level, Charlson Comorbidity Index, and state. RESULTS: Among 1,019,267 Medicare FFS beneficiaries hospitalized with AIS from 2008 through 2012, we documented 701,718 deaths (68.8%) during a median of 4 years of follow-up with 4.08 million person-years. The overall adjusted 5-year survival was 44%. Non-Hispanic Black men had the lowest 5-year survival, and 5-year survival varied significantly by state, from the highest at 49.1% (North Dakota) to the lowest at 40.5% (Hawaii). The ranges between the highest and lowest 5-year survival rates across states also varied significantly by racial/ethnic groups, with percentage point differences of 9.6 among non-Hispanic White, 11.3 among non-Hispanic Black, 17.7 among Hispanic, and 28.5 among other racial/ethnic beneficiaries. CONCLUSION: We identified significant racial/ethnic and geographic variations in 5-year survival rates after AIS among 2008-2012 Medicare FFS beneficiaries. Further study is needed to understand the reasons for these variations and develop prevention strategies to improve survival and racial disparities in survival after AIS.

Effect of Insurance Status on Outcomes of Acute Ischemic Stroke Patients Receiving Intra-Arterial Treatment: Results from the Paul Coverdell National Acute Stroke Program.

BACKGROUND: Stroke continues to be a leading cause of death and disability in the United States. Rates of intra-arterial reperfusion treatments (IAT) for acute ischemic stroke (AIS) are increasing, and these treatments are associated with more favorable outcomes. We sought to examine the effect of insurance status on outcomes for AIS patients receiving IAT within a multistate stroke registry. METHODS: We used data from the Paul Coverdell National Acute Stroke Program (PCNASP) from 2014 to 2019 to quantify rates of IAT (with or without intravenous thrombolysis) after AIS. We modeled outcomes based on insurance status: private, Medicare, Medicaid, or no insurance. Outcomes were defined as rates of discharge to home, in-hospital death, symptomatic intracranial hemorrhage (sICH), or life-threatening hemorrhage during hospitalization. RESULTS: During the study period, there were 486,180 patients with a clinical diagnosis of AIS (mean age 70.6 years, 50.3% male) from 674 participating hospitals in PCNASP. Only 4.3% of patients received any IAT. As compared to private insurance, uninsured patients receiving any IAT were more likely to experience in-hospital death (AOR 1.36 [95% CI 1.07-1.73]). Medicare (AOR 0.78 [95% CI 0.71-0.85]) and Medicaid (AOR 0.85 [95% CI 0.75-0.96]) beneficiaries were less likely but uninsured patients were more likely (AOR 1.90 [95% CI 1.61-2.24]) to be discharged home. Insurance status was not found to be independently associated with rates of sICH. CONCLUSIONS: Insurance status was independently associated with in-hospital death and discharge to home among AIS patients undergoing IAT.

Trends and Factors Associated With Concordance Between International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification Codes and Stroke Clinical Diagnoses.

Background and Purpose- International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification (ICD-9-CM and ICD-10-CM) codes are often used for disease surveillance. We examined changes in concordance between ICD-CM codes and clinical diagnoses before and after the transition to ICD-10-CM in the United States (October 1, 2015), and determined if there were systematic variations in concordance by patient and hospital characteristics. Methods- We included Paul Coverdell National Acute Stroke Program patient discharges from 2014 to 2017. Concordance between ICD-CM codes and the clinical diagnosis documented by the physician (assumed as accurate) was calculated for each diagnosis category: ischemic stroke, transient ischemic attack, subarachnoid hemorrhage, and intracerebral hemorrhage. Results- In total, 314 857 patient records were included in the analysis (n=280 hospitals), 55.9% of which were obtained after the transition to ICD-10-CM. While concordance was generally high, a small, and temporary decline occurred from the last calendar quarter of ICD-9-CM (average unadjusted concordance =92.8%) to the first quarter of ICD-10-CM use (91.0%). Concordance differed by diagnosis category and was generally highest for ischemic stroke. In the analysis of ICD-10-CM records, disagreements often occurred between ischemic stroke and transient ischemic attack records and between subarachnoid and intracerebral hemorrhage records. Compared with the smallest hospitals (≤200 beds), larger hospitals had significantly higher odds of concordance (ischemic stroke adjusted odds ratio for ≥400 beds, 1.7; 95% CI, 1.5-1.9). Conclusions- This study identified a small and transient decline in concordance between ICD-CM codes and stroke clinical diagnoses during the coding transition, indicating no substantial impact on the overall identification of stroke patients. Researchers and policymakers should remain aware of potential changes in ICD-CM code accuracy over time, which may affect disease surveillance. Systematic variations in the accuracy of codes by hospital and patient characteristics have implications for quality-of-care studies and hospital comparative assessments.

The Burden of Cerebrovascular Disease in the United States.

INTRODUCTION: Little is known about trends in the overall combined burden of fatal and nonfatal cerebrovascular disease events in the United States. Our objective was to describe the combined burden by age, sex, and region from 2006 through 2014. METHODS: We used data on adults aged 35 and older from 2006 through 2014 Nationwide Emergency Department Sample, National Inpatient Sample of the Healthcare Cost and Utilization Project, and the National Vital Statistics System. We calculated age-standardized cerebrovascular disease event rates by using the 2010 US Census population. Trends in rates were assessed by calculating the relative percentage change (RPC) between 2006 and 2014, and by using Joinpoint to obtain P values for overall trends. RESULTS: The age-standardized rate increased significantly for total cerebrovascular disease events (primary plus comorbid events) from 1,050 per 100,000 in 2006 to 1,147 per 100,000 in 2014 (P < .05 for trend). Treat-and-release emergency department visits with comorbid cerebrovascular disease events increased significantly, from 114 per 100,000 in 2006 to 213 per 100,000 in 2014 (RPC of 87%, P < .05 for trend). Significant rate increases were identified among adults aged 35 to 64 with an RPC of 19% in primary cerebrovascular disease events, 48% in comorbid cerebrovascular disease events, and 36% in total events. CONCLUSION: Our findings have important implications for the increasing cerebrovascular disease burden among adults aged 35 to 64. Focused prevention strategies should be implemented, especially among young adults who may be unaware of existing modifiable risk factors.

Vital Signs: Prevalence of Key Cardiovascular Disease Risk Factors for Million Hearts 2022 - United States, 2011-2016.

INTRODUCTION: Despite decades-long reductions in cardiovascular disease (CVD) mortality, CVD mortality rates have recently plateaued and even increased in some subgroups, and the prevalence of CVD risk factors remains high. Million Hearts 2022, a 5-year initiative, was launched in 2017 to address this burden. This report establishes a baseline for the CVD risk factors targeted for reduction by the initiative during 2017-2021 and highlights recent changes over time. METHODS: Risk factor prevalence among U.S. adults was assessed using data from the National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, and National Health Interview Survey. Multivariate analyses were performed to assess differences in prevalence during 2011-2012 and the most recent cycle of available data, and across subgroups. RESULTS: During 2013-2014, the prevalences of aspirin use for primary and secondary CVD prevention were 27.4% and 74.9%, respectively, and of statin use for cholesterol management was 54.5%. During 2015-2016, the average daily sodium intake was 3,535 mg/day and the prevalences of blood pressure control, combustible tobacco use, and physical inactivity were 48.5%, 22.3%, and 29.1%, respectively. Compared with 2011-2012, significant decreases occurred in the prevalences of combustible tobacco use and physical inactivity; however, a decrease also occurred for aspirin use for primary or secondary prevention. Disparities in risk factor prevalences were observed across age groups, genders, and racial/ethnic groups. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Millions of Americans have CVD risk factors that place them at increased risk for having a cardiovascular event, despite the existence of proven strategies for preventing or managing CVD risk factors. A concerted effort to implement these strategies will be needed to prevent one million acute cardiovascular events during the 5-year initiative.

Characteristics of Health Care Practices and Systems That Excel in Hypertension Control.

Approximately 1 in 3 US adults has hypertension, but only half have their blood pressure controlled. We identified characteristics of health care practices and systems (hereinafter practices) effective in achieving control rates at or above 70% by using data collected via applications submitted from April through June 2017 for consideration in the Million Hearts Hypertension Control Challenge. We included 96 practices serving 635,000 patients with hypertension across 34 US states in the analysis. Mean hypertension control rate was 77.1%; 27.1% of practices had a control rate of 80% or greater. Although many practices served large populations with multiple risk factors for uncontrolled hypertension, high control rates were achieved with implementation of evidenced-based strategies.

Unexplained Variation for Hospitals' Use of Inpatient Rehabilitation and Skilled Nursing Facilities After an Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Rehabilitation is recommended after a stroke to enhance recovery and improve outcomes, but hospital's use of inpatient rehabilitation facilities (IRFs) or skilled nursing facility (SNF) and the factors associated with referral are unknown. METHODS: We analyzed clinical registry and claims data for 31 775 Medicare beneficiaries presenting with acute ischemic stroke from 918 Get With The Guidelines-Stroke hospitals who were discharged to either IRF or SNF between 2006 and 2008. Using a multilevel logistic regression model, we evaluated patient and hospital characteristics, as well as geographic availability, in relation to discharge to either IRF or SNF. After accounting for observed factors, the median odds ratio was reported to quantify hospital-level variation in the use of IRF versus SNF. RESULTS: Of 31 775 patients, 17 662 (55.6%) were discharged to IRF and 14 113 (44.4%) were discharged to SNF. Compared with SNF patients, IRF patients were younger, more were men, had less health-service use 6 months prestroke, and had fewer comorbid conditions and in-hospital complications. Use of IRF or SNF varied significantly across hospitals (median IRF use, 55.8%; interquartile range, 34.8%-75.0%; unadjusted median odds ratio, 2.59; 95% confidence interval, 2.44-2.77). Hospital-level variation in discharge rates to IRF or SNF persisted after adjustment for patient, clinical, and geographic variables (adjusted median odds ratio, 2.87; 95% confidence interval, 2.68-3.11). CONCLUSIONS: There is marked unexplained variation among hospitals in their use of IRF versus SNF poststroke even after accounting for clinical characteristics and geographic availability. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT02284165.

CDC Grand Rounds: Public Health Strategies to Prevent and Treat Strokes.

Worldwide, stroke is the second leading cause of death and a leading cause of serious long-term disability. In the United States, nearly 800,000 strokes occur each year; thus stroke is the fifth leading cause of death overall and the fourth leading cause of death among women (1). Major advances in stroke prevention through treatment of known risk factors has led to stroke being considered largely preventable. For example, in the United States, stroke mortality rates have declined 70% over the past 50 years, in large part because of important reductions in hypertension, tobacco smoking, and more recently, increased use of anticoagulation for atrial fibrillation (2,3). Although the reduction in stroke mortality is recognized as one of the 10 great public health achievements of the 20th century (4), gains can still be made. Approximately 80% of strokes could be prevented by screening for and addressing known risks with measures such as improving hypertension control, smoking cessation, diabetes prevention, cholesterol management, increasing use of anticoagulation for atrial fibrillation, and eliminating excessive alcohol consumption (5,6).

CDC Grand Rounds: Improving Medication Adherence for Chronic Disease Management - Innovations and Opportunities.

Adherence to prescribed medications is associated with improved clinical outcomes for chronic disease management and reduced mortality from chronic conditions (1). Conversely, nonadherence is associated with higher rates of hospital admissions, suboptimal health outcomes, increased morbidity and mortality, and increased health care costs (2). In the United States, 3.8 billion prescriptions are written annually (3). Approximately one in five new prescriptions are never filled, and among those filled, approximately 50% are taken incorrectly, particularly with regard to timing, dosage, frequency, and duration (4). Whereas rates of nonadherence across the United States have remained relatively stable, direct health care costs associated with nonadherence have grown to approximately $100-$300 billion of U.S. health care dollars spent annually (5,6). Improving medication adherence is a public health priority and could reduce the economic and health burdens of many diseases and chronic conditions (7).

Vital Signs: Recent Trends in Stroke Death Rates - United States, 2000-2015.

INTRODUCTION: The prominent decline in U.S. stroke death rates observed for more than 4 decades has slowed in recent years. CDC examined trends and patterns in recent stroke death rates among U.S. adults aged ≥35 years by age, sex, race/ethnicity, state, and census region. METHODS: Trends in the rates of stroke as the underlying cause of death during 2000-2015 were analyzed using data from the National Vital Statistics System. Joinpoint software was used to identify trends in stroke death rates, and the excess number of stroke deaths resulting from unfavorable changes in trends was estimated. RESULTS: Among adults aged ≥35 years, age-standardized stroke death rates declined 38%, from 118.4 per 100,000 persons in 2000 to 73.3 per 100,000 persons in 2015. The annual percent change (APC) in stroke death rates changed from 2000 to 2015, from a 3.4% decrease per year during 2000-2003, to a 6.6% decrease per year during 2003-2006, a 3.1% decrease per year during 2006-2013, and a 2.5% (nonsignificant) increase per year during 2013-2015. The last trend segment indicated a reversal from a decrease to a statistically significant increase among Hispanics (APC = 5.8%) and among persons in the South Census Region (APC = 4.2%). Declines in stroke death rates failed to continue in 38 states, and during 2013-2015, an estimated 32,593 excess stroke deaths might not have occurred if the previous rate of decline could have been sustained. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Prior declines in stroke death rates have not continued in recent years, and substantial variations exist in timing and magnitude of change by demographic and geographic characteristics. These findings suggest the importance of strategically identifying opportunities for prevention and intervening in vulnerable populations, especially because effective and underused interventions to prevent stroke incidence and death are known to exist.

An International Standard Set of Patient-Centered Outcome Measures After Stroke.

BACKGROUND AND PURPOSE: Value-based health care aims to bring together patients and health systems to maximize the ratio of quality over cost. To enable assessment of healthcare value in stroke management, an international standard set of patient-centered stroke outcome measures was defined for use in a variety of healthcare settings. METHODS: A modified Delphi process was implemented with an international expert panel representing patients, advocates, and clinical specialists in stroke outcomes, stroke registers, global health, epidemiology, and rehabilitation to reach consensus on the preferred outcome measures, included populations, and baseline risk adjustment variables. RESULTS: Patients presenting to a hospital with ischemic stroke or intracerebral hemorrhage were selected as the target population for these recommendations, with the inclusion of transient ischemic attacks optional. Outcome categories recommended for assessment were survival and disease control, acute complications, and patient-reported outcomes. Patient-reported outcomes proposed for assessment at 90 days were pain, mood, feeding, selfcare, mobility, communication, cognitive functioning, social participation, ability to return to usual activities, and health-related quality of life, with mobility, feeding, selfcare, and communication also collected at discharge. One instrument was able to collect most patient-reported subdomains (9/16, 56%). Minimum data collection for risk adjustment included patient demographics, premorbid functioning, stroke type and severity, vascular and systemic risk factors, and specific treatment/care-related factors. CONCLUSIONS: A consensus stroke measure Standard Set was developed as a simple, pragmatic method to increase the value of stroke care. The set should be validated in practice when used for monitoring and comparisons across different care settings.

Treatment patterns and short-term outcomes in ischemic stroke in pregnancy or postpartum period.

BACKGROUND: Stroke, which is a rare but devastating event during pregnancy, occurs in 34 of every 100,000 deliveries; obstetricians are often the first providers to be contacted by symptomatic patients. At least one-half of pregnancy-related strokes are likely to be of the ischemic stroke subtype. Most pregnant or newly postpartum women with ischemic stroke do not receive acute stroke reperfusion therapy, although this is the recommended treatment for adults. Little is known about these therapies in pregnant or postpartum women because pregnancy has been an exclusion criterion for all reperfusion trials. Until recently, pregnancy and obstetric delivery were specifically identified as warnings to intravenous alteplase tissue plasminogen activator in Federal Drug Administration labeling. OBJECTIVE: The primary study objective was to compare the characteristics and outcomes of pregnant or postpartum vs nonpregnant women with ischemic stroke who received acute reperfusion therapy. STUDY DESIGN: Pregnant or postpartum (<6 weeks; n = 338) and nonpregnant (n = 24,303) women 18-44 years old with ischemic stroke from 1991 hospitals that participated in the American Heart Association's Get With the Guidelines-Stroke Registry from 2008-2013 were identified by medical history or International Classification of Diseases, Ninth Revision, codes. Acute stroke reperfusion therapy was defined as intravenous tissue plasminogen activator, catheter-based thrombolysis, or thrombectomy or any combination thereof. A sensitivity analysis was done on patients who received intravenous tissue plasminogen activator monotherapy only. Chi-square tests were used for categoric variables, and Wilcoxon Rank-Sum was used for continuous variables. Conditional logistic regression was used to assess the association of pregnancy with short-term outcomes. RESULTS: Baseline characteristics of the pregnant or postpartum vs nonpregnant women with ischemic stroke revealed a younger group who, despite greater stroke severity, were less likely to have a history of hypertension or to arrive via emergency medical services. There were similar rates of acute stroke reperfusion therapy in the pregnant or postpartum vs nonpregnant women (11.8% vs 10.5%; P = .42). Pregnant or postpartum women were less likely to receive intravenous tissue plasminogen activator monotherapy (4.4% vs 7.9%; P = .03), primarily because of pregnancy and recent surgery. There was a trend toward increased symptomatic intracranial hemorrhage in the pregnant or postpartum patients who were treated with tissue plasminogen activator, yet no cases of major systemic bleeding or in-hospital death occurred, and there were similar rates of discharge to home. Data on the timing of pregnancy, which were available in 145 of 338 cases, showed that 44.8% of pregnancy-related strokes were antepartum, that 2.8% occurred during delivery, and that 52.4% were during the postpartum period. CONCLUSIONS: Using data from the Get With the Guidelines-Stroke Registry to assemble the largest cohort of pregnant or postpartum ischemic stroke patients who had been treated with reperfusion therapy, we observed that pregnant or postpartum women had similarly favorable short-term outcomes and equal rates of total reperfusion therapy to nonpregnant women, despite lower rates of intravenous tissue plasminogen activator use. Future studies should identify the characteristics of pregnant and postpartum ischemic stroke patients who are most likely to safely benefit from reperfusion therapy.

Hospital costs associated with atrial fibrillation for patients with ischemic stroke aged 18-64 years in the United States.

BACKGROUND AND PURPOSE: Hospital costs associated with atrial fibrillation (AFib) among patients with stroke have not been well-studied, especially among people aged <65 years. We estimated the AFib-associated hospital costs in US patients aged 18 to 64 years. METHODS: We identified hospital admissions with a primary diagnosis of ischemic stroke from the 2010 to 2012 MarketScan Commercial Claims and Encounters inpatient data sets, excluding those with capitated health insurance plans, aged <18 or >64 years, missing geographic region, hospital costs below the 1st or above 99th percentile, and having carotid intervention (n=40 082). We searched the data for AFib and analyzed the costs for nonrepeat and repeat stroke admissions separately. We estimated the AFib-associated costs using multivariate regression models controlling for age, sex, geographic region, and Charlson comorbidity index. RESULTS: Of the 33 500 nonrepeat stroke admissions, 2407 (7.2%) had AFib. Admissions with AFib cost $4991 more than those without AFib ($23 770 versus $18 779). For the 6582 repeat stroke admissions, 397 (6.0%) had AFib. The costs were $3260 more for those with AFib than those without ($24 119 versus $20 929). After controlling for potential confounders, AFib-associated costs for nonrepeat stroke admissions were $4905, representing 20.6% of the total costs for the admissions. Both the hospital costs and the AFib-associated costs were associated with age, but not with sex. AFib-associated costs for repeat stroke admissions were not significantly higher than for non-AFib patients, except for those aged 55 to 64 years ($3537). CONCLUSIONS: AFib increased the hospital cost of ischemic stroke substantially. Further investigation on AFib-associated costs for repeat stroke admissions is needed.

Use of Aspirin for Prevention of Recurrent Atherosclerotic Cardiovascular Disease Among Adults ­ 20 States and the District of Columbia, 2013.

The effectiveness of regular aspirin therapy in reducing risk (secondary prevention) for myocardial infarction, ischemic stroke, and fatal coronary events among persons with preexisting atherosclerotic cardiovascular disease (ASCVD) is well established and recommended in current guidelines. Reported use of aspirin or other antiplatelet agents for secondary ASCVD prevention has varied widely across settings and data collection methods, from 54% of outpatient visits for those with ischemic vascular disease to 98% at the time of discharge for acute coronary syndrome. To estimate the prevalence of aspirin use for secondary ASCVD prevention among community-dwelling adults, CDC analyzed 2013 Behavioral Risk Factor Surveillance System (BRFSS) data from 20 states and the District of Columbia. Overall, 70.8% of adult respondents with existing ASCVD reported using aspirin regularly (every day or every other day). Within this group, 93.6% reported using aspirin for heart attack prevention, 79.6% for stroke prevention and 76.2% for both heart attack and stroke prevention. Differences in use were found by age, sex, race/ethnicity, and ASCVD risk status, and state. Most of the state differences were not statistically significant; however, these estimates can be used to promote the use of aspirin as a low-cost and highly effective intervention.

Vital Signs: Predicted Heart Age and Racial Disparities in Heart Age Among U.S. Adults at the State Level.

INTRODUCTION: Cardiovascular disease is a leading cause of morbidity and mortality in the United States. Heart age (the predicted age of a person's vascular system based on their cardiovascular risk factor profile) and its comparison with chronological age represent a new way to express risk for developing cardiovascular disease. This study estimates heart age and differences between heart age and chronological age (excess heart age) and examines racial, sociodemographic, and regional disparities in heart age among U.S. adults aged 30-74 years. METHODS: Weighted 2011 and 2013 Behavioral Risk Factor Surveillance System data were applied to the sex-specific non-laboratory-based Framingham risk score models, stratifying the results by age and race/ethnic group, educational and income level, and state. These results were then translated into age-standardized heart age values, mean excess heart age was calculated, and the findings were compared across groups. RESULTS: Overall, average predicted heart age for adult men and women was 7.8 and 5.4 years older than their chronological age, respectively. Statistically significant (p<0.05) racial/ethnic, sociodemographic, and regional differences in heart age were observed: heart age among non-Hispanic black men (58.7 years) and women (58.9 years) was greater than other racial/ethnic groups, including non-Hispanic white men (55.3 years) and women (52.5 years). Excess heart age was lowest for men and women in Utah (5.8 and 2.8 years, respectively) and highest in Mississippi (10.1 and 9.1 years, respectively). CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: The predicted heart age among U.S. adults aged 30-74 years was significantly higher than their chronological age. Use of predicted heart age might 1) simplify risk communication and motivate more persons to live heart-healthy lifestyles and better comply with recommended therapeutic interventions, and 2) motivate communities to implement programs and policies that support cardiovascular health.