Health Service Utilization Patterns Among Adults With Congenital Heart Disease: A Population-Based Study.

Background Several studies have examined hospitalizations among patients with adult congenital heart disease (ACHD). Few investigated other services or utilization patterns. Our aim was to study service utilization patterns and predictors among patients with ACHD. Methods and Results We identified 11 653 patients with ACHD aged ≥18 years (median, 47 years), through electronic records of 2 large Israeli healthcare providers (2007-2011). The association between patient, disease, and sociogeographic characteristics and healthcare resource utilization were modeled as recurrent events accounting for the competing death risk. Patients with ACHD had high healthcare utilization rates compared with the general population. The highest standardized service utilization ratios (SSRs) were found among patients with complex congenital heart disease including primary care visits (SSR, 1.53; 95% CI, 1.47-1.58), cardiology outpatient visits (SSR, 5.17; 95% CI, 4.69-5.64), hospitalizations (SSR, 6.68; 95% CI, 5.82-7.54), and days in hospital (SSR, 15.37; 95% CI, 14.61-16.12). Adjusted resource utilization hazard increased with increasing lesion complexity. Hazard ratios (HRs) for complex versus simple disease were: primary care (HR, 1.14; 95% CI, 1.06-1.23); cardiology outpatient visits (HR, 1.40; 95% CI, 1.24-1.59); emergency department visits (HR, 1.19; 95% CI, 1.02-1.39); and hospitalizations (HR, 1.75; 95% CI, 1.49-2.05). Effects attenuated with age for cardiology outpatient visits and hospitalizations and increased for emergency department visits. Female sex, geographic periphery, and ethnic minority were associated with more primary care visits, and female sex (HR versus men, 0.89 [95% CI, 0.84-0.94]) and periphery (HR, 0.72 [95% CI, 0.58-0.90] for very peripheral versus very central) were associated with fewer cardiology visits. Arab minority patients also had high hospitalization rates compared with the majority group of Jewish or other patients. Conclusions Healthcare utilization rates were high among patients with ACHD. Female sex, geographic periphery, and ethnicity were associated with less optimal service utilization patterns. Further research should examine strategies to optimize service utilization in these groups.

Depression and anxiety are associated with high health care utilization and mortality among adults with congenital heart disease.

BACKGROUND: The significance of depression/anxiety among ACHD patients in terms of health care utilization is unknown and data on the association with mortality are scarce. METHODS: Analyses comprised 8334 ACHD patients, age ≥ 18 years, insured by a large healthcare organization (2007-2011). Depression/anxiety were determined by diagnoses and treatments recorded in the organization database. Adjusted utilization relative rates (RRs) were estimated with negative binomial models and mortality hazard ratios (HRs) with the Cox proportional hazard model. RESULTS: ACHD patients with depression/anxiety (N = 2950, 35%) were more likely to be older (mean ±â€¯SD: 54 ±â€¯17 vs. 45 ±â€¯18 years), women (61% vs. 45%), and have comorbidities than counterparts without depression/anxiety. Following multivariable adjustment, patients with depression/anxiety had more primary care and cardiology clinic visits, more emergency department visits and more hospitalizations. RRs (95% confidence interval) were: 1.31 (1.27-1.35); 1.07 (1.01-1.13); 1.60 (1.46-1.77); and 1.18 (1.08-1.29) respectively, for diagnosis before the study period, and 1.36 (1.31-1.42); 1.22 (1.14-1.30); 1.43 (1.24-1.60) and 1.47 (1.33-1.64), respectively, for diagnosis during the study. Stratifying by age, the highest adjusted primary care and cardiology visit RRs were found among 18-24 years old patients and the lowest among patients ≥65 years. Between 2007 and 2017, 905 patients died. Depression/anxiety were associated with increased mortality risk with adjusted HRs: 1.10 (95% CI: 0.94-1.29) for past diagnosis and 1.40 (1.17-1.67) for study period depression/anxiety diagnosis. CONCLUSIONS: Depression/anxiety in ACHD patients is associated with increased health-care utilization and a higher risk of death. The efficacy of addressing patients' psychosocial needs in optimizing health-care utilization and improving prognosis needs further evaluation.

Rescue percutaneous coronary intervention after failed thrombolysis: results from the Acute Coronary Syndrome Israel Surveys (ACSIS).

BACKGROUND: The benefit of rescue percutaneous coronary intervention (PCI) in acute myocardial infarction patients, who fail to show signs of reperfusion after full dose thrombolysis, is still an unresolved issue. AIM: To assess the outcomes of patients who underwent rescue PCI after full-dose thrombolytic therapy and compare them to patients treated only with thrombolysis in the Acute Coronary Syndrome Israel Surveys (ACSIS). METHODS: ACSIS is a biannual survey on acute myocardial infarction performed in all 26 intensive cardiac care units in Israel during a two-month period. 2,018 patients were admitted with acute myocardial infarction during the two-month period in the 2000 and 2002 surveys, and 796 of them were treated with thrombolytic therapy. RESULTS: Rescue PCI was performed in 99 patients who failed to show signs of reperfusion. The control group consisted of patients with unsuccessful thrombolysis and no further intervention. Patients who underwent rescue PCI had a numerically higher incidence of anterior wall myocardial infarction, diabetes, higher Killip class on admission and cardiogenic shock. Furthermore, almost half of these patients had reduced left ventricular function (P = 0.03). During hospitalization, there was a significantly higher prevalence of recurrent ischemic events and major bleeding complications in patients who underwent rescue PCI. In-hospital, 30-day and one-year mortality rates were similar between the two groups. By multivariate analyses, Killip class 3-4 (OR: 2.62, CI = 0.95-6.58, P = 0.05) and streptokinase treatment (OR: 0.623, CI = 0.4-0.97, P = 0.05) were independent predictors of rescue PCI. Rescue angioplasty was associated with 15% risk-reduction (CI = 0.45-1.97, P = 0.05) in 30-day mortality and recurrent emergent hospitalization. CONCLUSIONS: Patients who underwent rescue PCI had similar short- and long-term mortality rates compared to patients treated with thrombolysis alone, despite differences in baseline characteristics. Rescue angioplasty was associated with a 15% risk reduction in mortality at 30-days, at the cost of higher rate of recurrent ischemic events and bleeding complications. Therefore, rescue angioplasty may be an equalizer in severely ill patients who receive thrombolytic therapy and fail to show signs of reperfusion.