Association between the food and physical activity environment, obesity, and cardiovascular health across Maine counties.

BACKGROUND: Accounting for nearly one-third of all deaths, cardiovascular disease is the leading cause of mortality and morbidity in the United States. Adverse health behaviors are major determinants of this high incidence of disease. Examining local food and physical activity environments and population characteristics in a poor, rural state may highlight underlying drivers of these behaviors. We aimed to identify demographic and environmental factors associated with both obesity and overall poor cardiovascular health (CVH) behaviors in Maine counties. METHODS: Our cross-sectional study analyzed 40,398 Behavioral Risk Factor Surveillance System (BRFSS) 2011-2014 respondents alongside county-level United States Department of Agriculture (USDA) Food Environment Atlas 2010-2012 measures of the built environment (i.e., density of restaurants, convenience stores, grocery stores, and fitness facilities; food store access; and county income). Poor CVH score was defined as exhibiting greater than 5 out of the 7 risk factors defined by the American Heart Association (current smoking, physical inactivity, obesity, poor diet, hypertension, diabetes, and high cholesterol). Multivariable logistic regression models described the contributions of built environment variables to obesity and overall poor CVH score after adjustment for demographic controls. RESULTS: Both demographic and environmental factors were associated with obesity and overall poor CVH. After adjustment for demographics (age, sex, personal income, and education), environmental characteristics most strongly associated with obesity included low full-service restaurant density (OR 1.34; 95% CI 1.24-1.45), low county median household income (OR 1.31; 95% CI 1.21-1.42) and high convenience store density (OR 1.21; 95% CI 1.12-1.32). The strongest predictors of overall poor CVH behaviors were low county median household income (OR 1.30; 95% CI 1.13-1.51), low full-service restaurant density (OR 1.38; 95% CI 1.19-1.59), and low fitness facility density (OR 1.27; 95% CI 1.11-1.46). CONCLUSIONS: In a rural state, both demographic and environmental factors predict overall poor CVH. These findings may help inform communities and policymakers of the impact of both social determinants of health and local environments on health outcomes.

Characteristics of new cardiac surgery programs in the United States: mitigating the learning curve.

BACKGROUND: New cardiac surgery programs continue to open across the United States, and it is not known how new programs deal with potentially low volumes during their start-up period. We compared patient, procedure, and physician characteristics and short-term mortality at established cardiac surgery programs, new programs in general hospitals, and new specialty cardiac hospitals. METHODS: We used Medicare Provider Analysis and Review, part B physician claims, and denominator files to evaluate established and new programs performing coronary artery bypass graft surgery (CABG) from 1994-2003. Short-term mortality was defined as death in-hospital or within 30 days. RESULTS: From 1994-2003, 257 new programs in general hospitals and 20 new specialty hospitals opened; and 884 established programs were in operation. New programs in general hospitals had much lower CABG volume than established programs and performed fewer concomitant valves and reoperations. New specialty hospitals had high CABG volume from inception, similar valve and reoperation rates to established programs, and conducted more elective procedures. Short-term mortality was significantly lower at new programs in general hospitals. CONCLUSIONS: Start-up strategies used by new specialty hospitals and new programs in general hospitals differed markedly. By choosing to conduct safer procedures on low-risk patients, new general programs may have offset potential concerns about operating at low volume. Neither type of new program exhibited an increased risk of short-term mortality. The high volume at specialty hospitals may reassure patients and policy makers, although the high proportion of elective procedures and the new program's effect on surrounding hospitals require further consideration.

Behavioral Risk Factors and Regional Variation in Cardiovascular Health Care and Death.

INTRODUCTION: Reducing the burden of death from cardiovascular disease includes risk factor reduction and medical interventions. METHODS: This was an observational analysis at the hospital service area (HSA) level, to examine regional variation and relationships between behavioral risks, health services utilization, and cardiovascular disease mortality (the outcome of interest). HSA-level prevalence of cardiovascular disease behavioral risks (smoking, poor diet, physical inactivity) were calculated from the Behavioral Risk Factor Surveillance System; HSA-level rates of stress tests, diagnostic cardiac catheterization, and revascularization from a statewide multi-payer claims data set from Maine in 2013 (with 606,260 patients aged ≥35 years), and deaths from state death certificate data. Analyses were done in 2016. RESULTS: There were marked differences across 32 Maine HSAs in behavioral risks: smoking (12.4%-28.6%); poor diet (43.6%-73.0%); and physical inactivity (16.4%-37.9%). After adjustment for behavioral risks, rates of utilization varied by HSA: stress tests (28.2-62.4 per 1,000 person-years, coefficient of variation=17.5); diagnostic cardiac catheterization (10.0-19.8 per 1,000 person-years, coefficient of variation=17.3); and revascularization (4.6-6.2 per 1,000 person-years; coefficient of variation=9.1). Strong HSA-level associations between behavioral risk factors and cardiovascular disease mortality were observed: smoking (R2=0.52); poor diet (R2=0.38); and physical inactivity (R2=0.35), and no association between revascularization and cardiovascular disease mortality after adjustment for behavioral risk factors (R2=0.02). HSA-level behavioral risk factors were also strongly associated with all-cause mortality: smoking (R2=0.57); poor diet (R2=0.49); and physical inactivity (R2=0.46). CONCLUSIONS: There is substantial regional variation in behavioral risks and cardiac utilization. Behavioral risk factors are associated with cardiovascular disease mortality regionally, whereas revascularization is not. Efforts to reduce cardiovascular disease mortality in populations should focus on prevention efforts targeting modifiable risk factors.

Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001.

BACKGROUND: Rates of invasive testing and treatment for coronary artery disease have increased over time. Less is known about trends in the utilization of noninvasive cardiac testing for coronary artery disease. The objective of this study was 2-fold: to explore temporal trends in the utilization of noninvasive and invasive cardiac services in relation to changes in the prevalence of cardiac disease, and to examine whether temporal increases have been targeted to potentially underserved populations. METHODS AND RESULTS: We performed an annual cross-sectional population-based study of Medicare patients from 1993 to 2001. We identified stress testing, cardiac catheterization, and revascularization procedures, as well as hospitalizations for acute myocardial infarction, during each year and calculated population-based rates for each using the total fee-for-service Medicare population as the denominator and adjusting for age, gender, and race. We observed marked growth in the utilization rates of cardiac services over time, with relative rates nearly doubling for most services. Acute myocardial infarction hospitalization rates have remained stable over the study period. Although rates of all procedures except coronary artery bypass increased in all subgroups, differences in rates of cardiac testing and treatment between nonblack men and other subgroups persisted over time. CONCLUSIONS: Temporal increases in the use of noninvasive and invasive cardiac services are not explained by changes in disease prevalence and have not succeeded in narrowing preexisting treatment differences by gender and race. Such increases, although conferring benefit for some, may expose others to risk and cost without benefit.

Surgeon volume and operative mortality in the United States.

BACKGROUND: Although the relation between hospital volume and surgical mortality is well established, for most procedures, the relative importance of the experience of the operating surgeon is uncertain. METHODS: Using information from the national Medicare claims data base for 1998 through 1999, we examined mortality among all 474,108 patients who underwent one of eight cardiovascular procedures or cancer resections. Using nested regression models, we examined the relations between operative mortality and surgeon volume and hospital volume (each in terms of total procedures performed per year), with adjustment for characteristics of the patients and other characteristics of the providers. RESULTS: Surgeon volume was inversely related to operative mortality for all eight procedures (P=0.003 for lung resection, P<0.001 for all other procedures). The adjusted odds ratio for operative death (for patients with a low-volume surgeon vs. those with a high-volume surgeon) varied widely according to the procedure--from 1.24 for lung resection to 3.61 for pancreatic resection. Surgeon volume accounted for a large proportion of the apparent effect of the hospital volume, to an extent that varied according to the procedure: it accounted for 100 percent of the effect for aortic-valve replacement, 57 percent for elective repair of an abdominal aortic aneurysm, 55 percent for pancreatic resection, 49 percent for coronary-artery bypass grafting, 46 percent for esophagectomy, 39 percent for cystectomy, and 24 percent for lung resection. For most procedures, the mortality rate was higher among patients of low-volume surgeons than among those of high-volume surgeons, regardless of the surgical volume of the hospital in which they practiced. CONCLUSIONS: For many procedures, the observed associations between hospital volume and operative mortality are largely mediated by surgeon volume. Patients can often improve their chances of survival substantially, even at high-volume hospitals, by selecting surgeons who perform the operations frequently.

Hospital volume and surgical mortality in the United States.

BACKGROUND: Although numerous studies suggest that there is an inverse relation between hospital volume of surgical procedures and surgical mortality, the relative importance of hospital volume in various surgical procedures is disputed. METHODS: Using information from the national Medicare claims data base and the Nationwide Inpatient Sample, we examined the mortality associated with six different types of cardiovascular procedures and eight types of major cancer resections between 1994 and 1999 (total number of procedures, 2.5 million). Regression techniques were used to describe relations between hospital volume (total number of procedures performed per year) and mortality (in-hospital or within 30 days), with adjustment for characteristics of the patients. RESULTS: Mortality decreased as volume increased for all 14 types of procedures, but the relative importance of volume varied markedly according to the type of procedure. Absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals ranged from over 12 percent (for pancreatic resection, 16.3 percent vs. 3.8 percent) to only 0.2 percent (for carotid endarterectomy, 1.7 percent vs. 1.5 percent). The absolute differences in adjusted mortality rates between very-low-volume hospitals and very-high-volume hospitals were greater than 5 percent for esophagectomy and pneumonectomy, 2 to 5 percent for gastrectomy, cystectomy, repair of a nonruptured abdominal aneurysm, and replacement of an aortic or mitral valve, and less than 2 percent for coronary-artery bypass grafting, lower-extremity bypass, colectomy, lobectomy, and nephrectomy. CONCLUSIONS: In the absence of other information about the quality of surgery at the hospitals near them, Medicare patients undergoing selected cardiovascular or cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

Differences in cardiac stress testing by sex and race among Medicare beneficiaries.

BACKGROUND: Although there is a wide literature demonstrating sex and race differences in the receipt of invasive cardiac tests and treatments, much less is known about the influence of such characteristics on receipt of a stress test, the first event in the diagnostic/treatment cascade for many patients. We explored the influence of patient characteristics on receipt of a stress test, with special attention to sex and race. METHODS: We performed a nested case-control study of Medicare beneficiaries who were aged 66 years and older during 1999-2001 and were free of cardiac diagnoses and procedures for at least 1 year. Cases were recipients of a stress test. RESULTS: Cases were younger, less likely to be female or black, but more likely to live in high-income, highly educated, and urban areas than controls. Nonblack men were more likely to receive a stress test than women and black men, controlling for age, area characteristics, and clinical characteristics (odds ratio for nonblack men compared with black women 1.71). These results were not explained by physician visit frequency. CONCLUSIONS: Efforts at minimizing disparities in cardiac care must attend to what is, for many patients, the entry into the cardiac care system: the stress test. Our findings suggest that simple "access," as measured by physician visit frequency, is not a rate-limiting factor.

Adjusting surgical mortality rates for patient comorbidities: more harm than good?

Background. Studies of medical admissions have questioned the validity of using claims data to adjust for preexisting medical conditions (comorbidities), but the impact of using comorbidities from claims data to risk-adjust mortality rates for high-risk surgery is not well characterized. The purpose of this study was to evaluate the relationship between comorbidities and mortality in administrative data in surgical populations and identify better risk-adjustment methods. Methods. Using the national Medicare database (1994-1997), we identified admissions for elective abdominal aortic aneurysm repair (140,577) and pancreaticoduodenectomy (10,530). We calculated the relative risk of mortality (adjusted for age, sex, race, and admission acuity) for 5 chronic conditions that are known (from clinical series) to increase the risk of postoperative mortality and are commonly used in claims-based risk-adjustment models. To explore the potential value of alternative risk-adjustment strategies, we examined relationships between surgical mortality and comorbidities using diagnosis codes identified from previous admissions. Results. Overall, in-hospital mortality for elective abdominal aortic aneurysm (AAA) repair and pancreaticoduodenectomy were 5.1% and 10.4%, respectively. For both procedures, 3 of the 5 comorbidities were associated with decreased risk of mortality: prior myocardial infarction (MI) [RR = 0.38; 95% confidence interval (CI), 0.33-0.43 for AAA; RR = 0.38; 95% CI, 0.21-0.69 for pancreaticoduodenectomy), malignancy (RR = 0.67; 95% CI, 0.59-0.76 for AAA; RR = 0.74; 95% CI, 0.45-1.21 for pancreaticoduodenectomy], and diabetes (RR = 0.76; 95% CI, 0.64-0.84 for AAA; RR = 0.59; 95% CI, 0.49-0.69 for pancreaticoduodenectomy). Using comorbidities identified from prior admissions increased the mortality risk estimates for prior MI (RR = 1.22; 95% CI, 1.08-1.38 for AAA; RR = 0.80; 95% CI, 0.49-1.30 for pancreaticoduodenectomy) and diabetes (RR = 1.41; 95% CI, 1.25-1.59 for AAA; RR = 0.94; 95% CI, 0.78-1.14 for pancreaticoduodenectomy). Conclusions. Because comorbidities coded on the index admission appear protective, incorporating them in risk-adjustment models for studies comparing surgical performance may penalize providers for taking care of sicker patients. When available, comorbidity information from prior hospitalizations may be more useful for risk adjustment.

Is surgery getting safer? National trends in operative mortality.

BACKGROUND: Although mortality rates for some cardiovascular procedures seem to have declined, it is unclear whether other high-risk procedures are becoming safer over time. STUDY DESIGN: We examined national trends between 1994 and 1999 in operative mortality for 14 high-risk cardiovascular and cancer procedures in the national population of Medicare beneficiaries over age 65. Secular trends were examined using logistic regression adjusting for age, gender, race, socioeconomic status, admission acuity, comorbidities, and hospital volume. RESULTS: Observed mortality rates varied widely across the 14 procedures, from 2% (carotid endarterectomy) to 16% (esophagectomy). Over the 6-year study period, average patient age increased for all procedures, and patients were more likely to undergo operation at high-volume hospitals for some procedures (pancreatic resection, esophagectomy, cystectomy, and pneumonectomy). After accounting for these changes, operative mortality declined significantly for three cardiovascular procedures, as evidenced by adjusted odds ratios (OR) for the 6-year effect on operative mortality (coronary artery bypass graft OR = 0.85, 95% confidence interval [CI] 0.81 to 0.88; carotid endarterectomy OR = 0.86,95% CI 0.80 to 0.93; mitral valve replacement OR = 0.89, 95% CI 0.81 to 0.97). In contrast, operative mortality did not decline for any of the cancer procedures. In fact, adjusted mortality increased for colectomy for colon cancer (OR= 1.13, 95% CI 1.07 to 1.19). CONCLUSIONS: Although risks of some cardiovascular procedures are declining over time, there is no evidence that other types of high-risk surgery are becoming safer. These findings suggest the need for systematic efforts to monitor and improve surgical performance.

Outcomes of percutaneous coronary interventions performed at centers without and with onsite coronary artery bypass graft surgery.

CONTEXT: An ongoing debate focuses on whether institutions should perform percutaneous coronary interventions (PCIs) without an onsite coronary artery bypass graft (CABG) surgery program. OBJECTIVE: To compare patient outcomes following PCI at US institutions performing this procedure without and with onsite cardiac surgery. DESIGN, SETTING, AND PATIENTS: Medicare hospital (part A) data were used to identify PCIs performed on fee-for-service Medicare enrollees (n = 625,854) aged at least 65 years at acute care facilities between January 1, 1999, and December 1, 2001. Hospitals without and with onsite cardiac surgery were identified based on the presence of claims for CABG surgery. Patients were characterized as undergoing primary/rescue PCI, defined as an emergency procedure performed on the same day of admission for an acute myocardial infarction (MI), vs all other PCIs. MAIN OUTCOME MEASURES: Post-PCI CABG surgery and combined in-hospital and 30-day mortality. RESULTS: A total of 178 hospitals performed PCIs without onsite cardiac surgery and 943 hospitals performed PCIs with onsite cardiac surgery. Patients undergoing PCIs in hospitals without onsite cardiac surgery were similar to those with onsite cardiac surgery with respect to age, sex, race, and measurable comorbidities; however, patients undergoing PCIs in hospitals without onsite cardiac surgery were more likely to have a primary/rescue PCI (22.0% vs 5.6%, P < .001). Patients undergoing PCIs in hospitals without cardiac surgery were more likely to die (6.0% vs 3.3%; adjusted odds ratio [OR], 1.29; 95% confidence interval [CI], 1.14-1.47; P < .001). After accounting for baseline differences, mortality for patients with primary/rescue PCI was similar in institutions without and with cardiac surgery (adjusted OR, 0.93; 95% CI, 0.80-1.08; P = .34). However, for the larger non-primary/rescue PCI population, mortality was higher in hospitals without onsite cardiac surgery (adjusted OR, 1.38; 95% CI, 1.14-1.67; P=.001). This increase in mortality was primarily confined to hospitals performing 50 or less Medicare PCIs per year. CONCLUSIONS: Percutaneous coronary interventions in hospitals without onsite cardiac surgery are often performed for reasons other than immediate treatment of an MI and are associated with a higher risk of adverse outcomes. Policies aimed at increasing access to primary/rescue PCI through promoting PCI in hospitals without cardiac surgery may inadvertently lead to an overall increase in mortality related to PCI.

Regionalization of high-risk surgery and implications for patient travel times.

CONTEXT: Given the strong volume-outcome relationships observed with many surgical procedures, restricting some procedures to hospitals exceeding a minimum volume standard is advocated. However, such regionalization policies might cause unreasonable travel burdens for surgical patients. OBJECTIVE: To estimate how minimum volume standards for esophagectomy and pancreatic resection would affect how long patients must travel for these procedures. DESIGN, SETTING, AND PATIENTS: Simulated trial based on Medicare claims and US road network data. All US hospitals in the 48 continental states were in the study if their surgical procedures included esophagectomy and pancreatic resection. Data from Medicare patients (N = 15,796) undergoing these 2 procedures for cancer between 1994 and 1999 were used. MAIN OUTCOME MEASURE: Additional travel time for patients required to change to higher-volume centers as a result of alternative hospital volume standards (procedures per year). RESULTS: With low-volume standards (1/year for pancreatectomy; 2/year for esophagectomy), approximately 15% of patients would change to higher-volume centers, with negligible effect on their travel times. Most patients would need to travel less than 30 additional minutes (74% pancreatectomy; 76% esophagectomy). Many patients already lived closer to a higher-volume hospital (25% pancreatectomy; 26% esophagectomy). Conversely, with very high-volume standards (>16/year for pancreatectomy; >19/year for esophagectomy), approximately 80% of patients would change to higher-volume centers. More than 50% of these patients would increase their travel time by more than 60 minutes. Travel times would increase most for patients living in rural areas. CONCLUSIONS: Many patients travel past a higher-volume center to undergo surgery at a low-volume hospital. If not set too high, hospital volume standards could be implemented for selected operations without imposing unreasonable travel burdens on patients.

Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?

BACKGROUND: Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. METHODS AND RESULTS: We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization. CONCLUSIONS: Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

U.S. trends in CABG hospital volume: the effect of adding cardiac surgery programs.

Hospital coronary artery bypass graft (CABG) volume is inversely related to mortality--with low-volume hospitals having the highest mortality. Medicare data (1992-2003) show that the number of CABG procedures increased from 158,000 in 1992 to a peak of 190,000 in 1996 and then fell to 152,000 in 2003, while the number of hospitals performing CABG increased steadily. Predictably, the proportion of CABG procedures performed at low-volume hospitals increased, and the proportion in high-volume hospitals declined. An unintended consequence of starting new cardiac surgery programs is declining CABG hospital volume--a side effect that might increase mortality.

Race and surgical mortality in the United States.

OBJECTIVE: This study describes racial differences in postoperative mortality following 8 cardiovascular and cancer procedures and assesses possible explanations for these differences. SUMMARY BACKGROUND DATA: Although racial disparities in the use of surgical procedures are well established, relationships between race and operative mortality have not been assessed systematically. METHODS: We used national Medicare data to identify all patients undergoing one of 8 cardiovascular and cancer procedures between 1994 and 1999. We used multiple logistic regression to assess differences in operative mortality (death within 30 days or before discharge) between black patients and white patients, controlling for patient characteristics. Adding hospital indicators to these models, we then assessed the extent to which racial differences in operative mortality could be accounted for by the hospital in which patients were cared for. RESULTS: Black patients had higher crude mortality rates than white patients for 7 of the 8 operations, including coronary artery bypass, aortic valve replacement, abdominal aortic aneurysm repair, carotid endarterectomy, radical cystectomy, pancreatic resection, and esophagectomy. Among these 7 procedures, odds ratios of mortality (black versus white) ranged from 1.23 (95% confidence interval, 1.18-1.29) for CABG to 1.61 (95% confidence interval, 1.28-2.03) for esophagectomy. Adjusting for patient characteristics had modest or no effect on odds ratios of mortality by race. However, there remained few clinically or statistically significant differences in mortality by race after we accounted for hospital. Hospitals that treated a large proportion of black patients had higher mortality rates for all 8 procedures, for white as well as black patients. CONCLUSIONS: Black patients have higher operative mortality risks across a wide range of surgical procedures, in large part because of higher mortality rates at the hospitals they attend.

Perioperative and long-term prognostic value of dipyridamole Tc-99m sestamibi myocardial tomography in patients evaluated for elective vascular surgery.

BACKGROUND: Patients with peripheral vascular disease are at increased risk for perioperative and long-term cardiac morbidity and mortality. Substantial data exist supporting the use of preoperative clinical risk stratification and planar thallium myocardial scintigraphy. Only limited data are available assessing the role of technetium-99m (Tc-99m) single photon emission computed tomography (SPECT) for preoperative evaluation in this population. METHODS AND RESULTS: In our study 153 patients who underwent peripheral vascular surgery were followed up for up to 4 years after preoperative dipyridamole Tc-99m sestamibi SPECT to determine clinical and SPECT predictors of perioperative and long-term adverse cardiac events by multivariate analysis. There were no statistically significant clinical or SPECT predictors of perioperative risk, although no perioperative events occurred in patients with normal scans. Abnormality in the left anterior descending (LAD) territory (risk ratio = 3.1; 95% confidence interval, 1.4-7.1) was the only statistically significant univariate predictor of long-term death or myocardial infarction. Only abnormality in the LAD territory appeared to improve model fit beyond clinical risk (risk ratio = 2.9; 95% confidence interval, 1.2-7.3; P =.02). CONCLUSIONS: Patients with normal preoperative scans have a low risk of perioperative cardiac events and may safely undergo peripheral vascular surgery without further coronary intervention. However, scan abnormality in the LAD distribution confers poor long-term prognosis, suggesting that patients with this finding before peripheral vascular surgery should receive aggressive medical therapy and possibly invasive intervention to improve long-term survival.