Impact of a dedicated center for atrial fibrillation on resource utilization and costs.

BACKGROUND: Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. HYPOTHESIS: We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. METHODS: The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. RESULTS: We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. CONCLUSION: Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Outcomes of Blacks Versus Whites with Cardiomyopathy.

Racial disparities in health outcomes have been widely documented in medicine, including in cardiovascular care. While some progress has been made, these disparities have continued to plague our healthcare system. Patients with cardiomyopathy are at an increased risk of death and cardiovascular hospitalizations. In the present analysis, we examined the baseline characteristics and outcomes of black and white men and women with cardiomyopathy. All patients with cardiomyopathy (left ventricular ejection fraction (LVEF) < 50%) cared for at University of Pittsburgh Medical Center (UPMC) between 2011 and 2017 were included in this analysis. Patients were stratified by race, and outcomes were compared between Black and White patients using Cox proportional hazard models. Of a total of 18,003 cardiomyopathy patients, 15,804 were white (88%), 1,824 were black (10%) and 375 identified as other (2%). Over a median follow-up time of 3.4 years, 7,899 patients died. Black patients were on average a decade younger (p <0.001) and demonstrated lower unadjusted all-cause mortality (hazard ratio [HR]: 0.83%; 95% CI 0.77 to 0.90; p < 0.001). However, after adjusting for age and other comorbidities, black patients had higher all-cause mortality compared to white patients (HR: 1.15, 95% CI 1.07 to 1.25; p < 0.001). These differences were seen in both men (HR:1.19, 95% CI 1.08 to 1.33; p < 0.001) and women (HR:1.12, 95% CI 0.99 to 1.25; p = 0.065). In conclusion, our data demonstrate higher all-cause mortality in black compared to white men and women with cardiomyopathy. These findings are likely explained, at least in part, by significantly higher rates of comorbidities in black patients. Earlier interventions targeting these comorbidities may mitigate the risk of progression to heart failure and improve outcomes.

Symptom assessment and exercise impairment in surgical decision making in hypertrophic obstructive cardiomyopathy: Relationship to outcomes.

OBJECTIVES: We sought to assess the long-term outcomes in patients with hypertrophic cardiomyopathy and severe left ventricular outflow tract obstruction, in whom the decision regarding surgery (vs conservative management) was based on assessment of symptoms or exercise capacity. METHODS: This was an observational study of 1530 patients with hypertrophic cardiomyopathy (aged 50 ± 13 years, 63% were men) with severe left ventricular outflow tract obstruction (excluding those aged <18 years, with left ventricular ejection fraction <50%, and with left ventricular outflow tract gradient <30 mm Hg). A composite end point of death (excluding noncardiac causes) and/or implantable defibrillator discharge was assessed. RESULTS: Coronary artery disease, family history of hypertrophic cardiomyopathy, and syncope were present in 15%, 17%, and 18% of patients, respectively, whereas 73% patients were in New York Heart Association class II or greater. Mean left ventricular ejection fraction, basal septal thickness, and left ventricular outflow tract gradient (resting or provocable) were 62% ± 5%, 2.2 ± 1 cm, and 101 ± 39 mm Hg, respectively. A total of 858 patients (56%) underwent exercise echocardiography, of whom 503 (59%) had exercise capacity impairment. At 8.1 ± 6 years, 990 patients (65%) underwent surgical relief of left ventricular outflow tract obstruction, and 540 patients (35%) did not. There were 156 events (10%) (134 deaths), with 0% 30-day mortality in the surgical group. On multivariable Cox proportional hazard analysis, increasing age (hazard ratio [HR], 1.20), coronary artery disease (HR, 1.68), worse New York Heart Association class (HR, 1.46), and atrial fibrillation (HR, 1.90) predicted higher events, whereas surgery (time-dependent covariate HR, 0.57) was associated with improved event-free survival (all P < .01). CONCLUSIONS: In patients with hypertrophic cardiomyopathy and severe left ventricular outflow tract obstruction, in whom the decision regarding surgery was based on the presence of intractable symptoms and impaired exercise capacity, surgery was associated with significant improvement in long-term composite outcomes.