Ambulatory Care Fragmentation and Total Health Care Costs.

BACKGROUND: The magnitude of the relationship between ambulatory care fragmentation and subsequent total health care costs is unclear. OBJECTIVE: To determine the association between ambulatory care fragmentation and total health care costs. RESEARCH DESIGN: Longitudinal analysis of 15 years of data (2004-2018) from the national Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 13,680 Medicare beneficiaries who are 65 years and older. MEASURES: We measured ambulatory care fragmentation in each calendar year, defining high fragmentation as a reversed Bice-Boxerman Index ≥0.85 and low as <0.85. We used generalized linear models to determine the association between ambulatory care fragmentation in 1 year and total Medicare expenditures (costs) in the following year, adjusting for baseline demographic and clinical characteristics, a time-varying comorbidity index, and accounting for geographic variation in reimbursement and inflation. RESULTS: The average participant was 70.9 years old; approximately half (53%) were women. One-fourth (26%) of participants had high fragmentation in the first year of observation. Those participants had a median of 9 visits to 6 providers, with the most frequently seen provider accounting for 29% of visits. By contrast, participants with low fragmentation had a median of 8 visits to 3 providers, with the most frequently seen provider accounting for 50% of visits. High fragmentation was associated with $1085 more in total adjusted costs per person per year (95% CI $713 to $1457) than low fragmentation. CONCLUSIONS: Highly fragmented ambulatory care in 1 year is independently associated with higher total costs the following year.

Ambulatory Care Fragmentation, Emergency Department Visits, and Race: a Nationwide Cohort Study in the U.S.

BACKGROUND: It is unclear whether highly fragmented ambulatory care (i.e., care spread across multiple providers without a dominant provider) increases the risk of an emergency department (ED) visit. Whether any such association varies with race is unknown. OBJECTIVE: We sought to determine whether highly fragmented ambulatory care increases the risk of an ED visit, overall and by race. DESIGN AND PARTICIPANTS: We analyzed data for 14,361 participants ≥ 65 years old from the nationwide prospective REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study, linked to Medicare claims (2003-2016). MAIN MEASURES: We defined high fragmentation as a reversed Bice-Boxerman Index ≥ 0.85 (≥ 75th percentile). We used Poisson models to determine the association between fragmentation (as a time-varying exposure) and ED visits, overall and stratified by race, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiologic variables. KEY RESULTS: The average participant was 70.5 years old; 53% were female, and 33% were Black individuals. Participants with high fragmentation had a median of 9 visits to 6 providers, with 29% of visits by the most frequently seen provider; participants with low fragmentation had a median of 7 visits to 3 providers, with 50% of visits by the most frequently seen provider. Overall, high fragmentation was associated with more ED visits than low fragmentation (adjusted risk ratio [aRR] 1.31, 95% confidence interval [CI] 1.29, 1.34). The magnitude of this association was larger among Black (aRR 1.48, 95% CI 1.44, 1.53) than White participants (aRR 1.23, 95% CI 1.20, 1.25). CONCLUSIONS: Highly fragmented ambulatory care was an independent predictor of ED visits, especially among Black individuals.

Insomnia Diagnosis, Prescribed Hypnotic Medication Use, and Risk for Serious Fall Injuries in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study.

STUDY OBJECTIVES: Insomnia is common among older adults and associated with an increased risk for falls. Determining if falls are more strongly associated with insomnia or prescribed hypnotic medications could be used to guide interventions to reduce falls risk. METHODS: We examined the prospective association of a diagnosis of insomnia and/or prescribed hypnotic medication use with the risk for serious fall injuries among 9087 Reasons for Geographic and Racial Differences in Stroke (REGARDS) study participants aged 65 years or older with Medicare fee-for-service health insurance at baseline (2003-2007). A diagnosis of insomnia was based on ICD-9 codes in Medicare claims and prescribed hypnotic medication use was determined through a pill bottle review. Serious fall injuries were identified by Medicare claims between baseline and December 31, 2018. RESULTS: Over a median of 6.8 years, 1660 (18.3%) participants had a serious fall injury. The incidence rates for a serious fall injury per 1000 person-years were 24.8 (95%CI: 23.5, 26.1), 28.8 (95%CI: 18.6, 38.9), 32.6 (95%CI: 28.2, 37.0), and 46.6 (95%CI: 26.7, 66.5) for participants without insomnia or taking prescribed hypnotic medication (-insomnia/-hypnotics), with insomnia only (+insomnia/-hypnotics), taking prescribed hypnotic medication only (-insomnia/+hypnotics), and with insomnia and taking prescribed hypnotic medication (+insomnia/+hypnotics), respectively. Compared with the -insomnia/-hypnotic group, the multivariable-adjusted hazard ratios for a serious fall injury were 1.13 (95%CI: 0.79, 1.61), 1.29 (95%CI: 1.11, 1.50), and 1.60 (95%CI: 1.01, 2.56) for +insomnia/-hypnotics, -insomnia/+hypnotics, and +insomnia/+hypnotics, respectively. CONCLUSIONS: The risk for serious fall injuries was higher for those taking prescribed hypnotic medications but not with an insomnia diagnosis.

Health care fragmentation and blood pressure control among adults taking antihypertensive medication.

OBJECTIVES: To determine the association of fragmented ambulatory health care with uncontrolled blood pressure (BP) and apparent treatment-resistant hypertension (aTRH) among older adults taking antihypertensive medication, overall and by race and gender. STUDY DESIGN: Cross-sectional study using data from 2868 REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants 66 years and older who completed a study examination in 2013-2016, had Medicare fee-for-service coverage, and were taking antihypertensive medication. METHODS: We used logistic regression to analyze the association of fragmented health care with uncontrolled BP and aTRH. Fragmented health care was operationalized as a reversed Bice-Boxerman Index score in the 75th percentile or higher, calculated using the number of ambulatory providers and health care visits in the year preceding the study examination. Uncontrolled BP was defined by systolic BP of at least 140 mm Hg or diastolic BP of at least 90 mm Hg. aTRH was defined by taking 3 or more classes of antihypertensive medication with uncontrolled BP or 4 or more classes with controlled BP. RESULTS: The overall adjusted odds ratios (95% CIs) for uncontrolled BP, aTRH with controlled BP, and aTRH with uncontrolled BP associated with fragmented health care were 1.10 (0.89-1.37), 1.08 (0.80-1.47), and 1.32 (0.96-1.81), respectively. Fragmented health care was not associated with uncontrolled BP or aTRH among White participants, women, or men. Among Black participants, the odds ratio (95% CI) associated with fragmented health care was 1.21 (0.81-1.82) for uncontrolled BP, 1.22 (0.72-2.07) for aTRH with controlled BP, and 1.82 (1.07-3.11) for aTRH with uncontrolled BP. CONCLUSIONS: Fragmented health care may increase the likelihood of aTRH with uncontrolled BP among older Black adults taking antihypertensive medication.

Risk for ischemic stroke and coronary heart disease associated with migraine and migraine medication among older adults.

BACKGROUND: Migraine has been associated with cardiovascular disease (CVD) events among middle-aged adults. The objective of this study was to determine the risk for ischemic stroke and coronary heart disease (CHD) events among older adults with versus without migraine. METHODS: This retrospective cohort study was conducted using data from US adults ≥66 years of age with Medicare health insurance between 2008 and 2017. After stratification by history of CVD, patients with a history of migraine were matched 1:4 to those without a history of migraine, based on calendar year, age, and sex. Patients were followed through December 31, 2017 for ischemic stroke and CHD events including myocardial infarction or coronary revascularization. All analyses were done separately for patients with and without a history of CVD. RESULTS: Among patients without a history of CVD (n = 109,950 including n = 21,990 with migraine and n = 87,960 without migraine), 1789 had an ischemic stroke and 3552 had a CHD event. The adjusted hazard ratio (HR) among patients with versus without migraine was 1.20 (95% confidence interval [95%CI], 1.07-1.35) for ischemic stroke and 1.02 (95%CI, 0.93-1.11) for CHD events. Compared to patients without migraine, those with migraine who were taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.43 [95%CI, 1.20-1.69]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.79 [95%CI, 0.67-0.93]). Among patients with a history of CVD (n = 79,515 including n = 15,903 with migraine and n = 63,612 without migraine), 2960 had an ischemic stroke and 7981 had a CHD event. The adjusted HRs (95%CI) for ischemic stroke and CHD events associated with migraine were 1.27 (1.17-1.39) and 0.99 (0.93-1.05), respectively. Patients with migraine taking an opioid medication had a higher risk for ischemic stroke (adjusted HR 1.21 [95%CI, 1.07-1.36]), while those taking a triptan had a lower risk for CHD events (adjusted HR 0.83 [95%CI, 0.72-0.95]), each versus those without migraine. CONCLUSIONS: Older adults with migraine are at increased risk for ischemic stroke. The risk for ischemic stroke among older adults with migraine may differ by migraine medication classes.

Risk for recurrent cardiovascular disease events among patients with diabetes and chronic kidney disease.

BACKGROUND: Adults who have experienced multiple cardiovascular disease (CVD) events have a very high risk for additional events. Diabetes and chronic kidney disease (CKD) are each associated with an increased risk for recurrent CVD events following a myocardial infarction (MI). METHODS: We compared the risk for recurrent CVD events among US adults with health insurance who were hospitalized for an MI between 2014 and 2017 and had (1) CVD prior to their MI but were free from diabetes or CKD (prior CVD), and those without CVD prior to their MI who had (2) diabetes only, (3) CKD only and (4) both diabetes and CKD. We followed patients from hospital discharge through December 31, 2018 for recurrent CVD events including coronary, stroke, and peripheral artery events. RESULTS: Among 162,730 patients, 55.2% had prior CVD, and 28.3%, 8.3%, and 8.2% had diabetes only, CKD only, and both diabetes and CKD, respectively. The rate for recurrent CVD events per 1000 person-years was 135 among patients with prior CVD and 110, 124 and 171 among those with diabetes only, CKD only and both diabetes and CKD, respectively. Compared to patients with prior CVD, the multivariable-adjusted hazard ratio for recurrent CVD events was 0.92 (95%CI 0.90-0.95), 0.89 (95%CI: 0.85-0.93), and 1.18 (95%CI: 1.14-1.22) among those with diabetes only, CKD only, and both diabetes and CKD, respectively. CONCLUSION: Following MI, adults with both diabetes and CKD had a higher risk for recurrent CVD events compared to those with prior CVD without diabetes or CKD.

Metabolomic Markers of Southern Dietary Patterns in the Jackson Heart Study.

SCOPE: New biomarkers are needed that are representative of dietary intake. METHODS AND RESULTS: We assess metabolites associated with Southern dietary patterns in 1401 Jackson Heart Study participants. Three dietary patterns are empirically derived using principal component analysis: meat and fast food, fish and vegetables, and starchy foods. We randomly select two subsets of the study population: two-third sample for discovery (n = 934) and one-third sample for replication (n = 467). Among the 327 metabolites analyzed, 14 are significantly associated with the meat and fast food dietary pattern, four are significantly associated with the fish and vegetables dietary pattern, and none are associated with the starchy foods dietary pattern in the discovery sample. In the replication sample, nine remain associated with the meat and fast food dietary pattern [indole-3-propanoic acid, C24:0 lysophosphatidylcholine (LPC), N-methyl proline, proline betaine, C34:2 phosphatidylethanolamine (PE) plasmalogen, C36:5 PE plasmalogen, C38:5 PE plasmalogen, cotinine, hydroxyproline] and three remain associated with the fish and vegetables dietary pattern [1,7-dimethyluric acid, C22:6 lysophosphatidylethanolamine, docosahexaenoic acid (DHA)]. CONCLUSION: Twelve metabolites are discovered and replicated in association with dietary patterns detected in a Southern U.S. African-American population, which could be useful as biomarkers of Southern dietary patterns.

Differences in ambulatory care fragmentation by race.

BACKGROUND: More fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with more subsequent healthcare utilization (such as more tests, procedures, emergency department visits, and hospitalizations) than less fragmented ambulatory care. It is not known if race and socioeconomic status are associated with fragmented ambulatory care. METHODS: We conducted a longitudinal analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, using the REGARDS baseline visit plus the first year of follow-up. We included participants ≥65 years old, who had linked fee-for-service Medicare claims, and ≥ 4 ambulatory visits in the first year of follow-up. We used Tobit regression to determine the associations between race, annual household income, and educational attainment at baseline and fragmentation score in the subsequent year (as measured with the reversed Bice-Boxerman Index). Covariates included other demographic characteristics, medical conditions, medication use, health behaviors, and psychosocial variables. Additional analyses categorized visits by the type of provider (primary care vs. specialist). RESULTS: The study participants (N = 6799) had an average age of 73.0 years, 53% were female, and 30% were black. Nearly half had low annual household income (<$35,000) and 41% had a high school education or less. Overall, participants had a median of 10 ambulatory visits to 4 providers in the 12 months following their baseline study visit. Participants in the highest quintile of fragmentation scores had a median of 11 visits to 7 providers. Black race was associated with an absolute adjusted 3% lower fragmentation score compared to white race (95% confidence interval (2% lower to 4% lower; p < 0.001). This difference was explained by blacks seeing fewer specialists than whites. Income and education were not independent predictors of fragmentation scores. CONCLUSIONS: Among Medicare beneficiaries, blacks had less fragmented ambulatory care than whites, due to lower utilization of specialty care. Future research is needed to determine the effect of fragmented care on health outcomes for blacks and whites.

Ambulatory Care Fragmentation and Subsequent Hospitalization: Evidence From the REGARDS Study.

BACKGROUND: Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. OBJECTIVE: The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. DESIGN: Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS: A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. MEASURES: We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. RESULTS: The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). CONCLUSION: Highly fragmented ambulatory care is an independent risk factor for hospitalization.

Healthcare Fragmentation and Incident Acute Coronary Heart Disease Events: a Cohort Study.

BACKGROUND: Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE: To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS: We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES: We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS: The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION: High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.

Sex Differences in Incident and Recurrent Coronary Events and All-Cause Mortality.

BACKGROUND: Women have lower age-specific rates of incident coronary heart disease (CHD) than men. It is unclear whether women remain at lower risk for CHD events versus men following a myocardial infarction (MI). OBJECTIVES: This study assessed sex differences in recurrent MI, recurrent CHD events, and mortality among patients with MI and compared these associations with sex differences in a control group without a history of CHD. METHODS: This study analyzed data for 171,897 women and 167,993 men age 21 years or older with health insurance in the United States who had a MI hospitalization in 2015 or 2016. Patients with a MI were frequency matched by age and calendar year to 687,588 women and 671,972 men without CHD. Beneficiaries were followed until December 2017 for MI, CHD (i.e., MI or coronary revascularization), and in Medicare for all-cause mortality. RESULTS: Age-standardized rates of MI per 1,000 person-years were 4.5 in women and 5.7 in men without CHD (hazard ratio [HR]: 0.64; 95% confidence interval [CI]: 0.62 to 0.67) and 60.2 in women and 59.8 in men with MI (HR: 0.94; 95% CI: 0.92 to 0.96). CHD rates in women versus men were 6.3 versus 10.7 among those without CHD (HR: 0.53; 95% CI: 0.51 to 0.54) and 84.5 versus 99.3 among those with MI (HR: 0.87; 95% CI: 0.85 to 0.89). All-cause mortality rates in women versus men were 63.7 versus 59.0 among those without CHD (HR: 0.72; 95% CI: 0.71 to 0.73) and 311.6 versus 284.5 among those with MI (HR: 0.90; 95% CI: 0.89 to 0.92). CONCLUSIONS: The lower risk for MI, CHD, and all-cause mortality in women versus men is considerably attenuated following a MI.

Projections of incident atherosclerotic cardiovascular disease and incident type 2 diabetes across evolving statin treatment guidelines and recommendations: A modelling study.

BACKGROUND: Experimental and observational research has suggested the potential for increased type 2 diabetes (T2D) risk among populations taking statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). However, few studies have directly compared statin-associated benefits and harms or examined heterogeneity by population subgroups or assumed treatment effect. Thus, we compared ASCVD risk reduction and T2D incidence increases across 3 statin treatment guidelines or recommendations among adults without a history of ASCVD or T2D who were eligible for statin treatment initiation. METHODS AND FINDINGS: Simulations were conducted using Markov models that integrated data from contemporary population-based studies of non-Hispanic African American and white adults aged 40-75 years with published meta-analyses. Statin treatment eligibility was determined by predicted 10-year ASCVD risk (5%, 7.5%, or 10%). We calculated the number needed to treat (NNT) to prevent one ASCVD event and the number needed to harm (NNH) to incur one incident case of T2D. The likelihood to be helped or harmed (LHH) was calculated as ratio of NNH to NNT. Heterogeneity in statin-associated benefit was examined by sex, age, and statin-associated T2D relative risk (RR) (range: 1.11-1.55). A total of 61,125,042 U.S. adults (58.5% female; 89.4% white; mean age = 54.7 years) composed our primary prevention population, among whom 13-28 million adults were eligible for statin initiation. Overall, the number of ASCVD events prevented was at least twice as large as the number of incident cases of T2D incurred (LHH range: 2.26-2.90). However, the number of T2D cases incurred surpassed the number of ASCVD events prevented when higher statin-associated T2D RRs were assumed (LHH range: 0.72-0.94). In addition, females (LHH range: 1.74-2.40) and adults aged 40-50 years (LHH range: 1.00-1.14) received lower absolute benefits of statin treatment compared with males (LHH range: 2.55-3.00) and adults aged 70-75 years (LHH range: 3.95-3.96). Projected differences in LHH by age and sex became more pronounced as statin-associated T2D RR increased, with a majority of scenarios projecting LHHs < 1 for females and adults aged 40-50 years. This study's primary limitation was uncertainty in estimates of statin-associated T2D risk, highlighting areas in which additional clinical and public health research is needed. CONCLUSIONS: Our projections suggest that females and younger adult populations shoulder the highest relative burden of statin-associated T2D risk.

Agreement of claims-based methods for identifying sepsis with clinical criteria in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort.

BACKGROUND: Claims-based algorithms are commonly used to identify sepsis in health services research because the laboratory features required to define clinical criteria may not be available in administrative data. METHODS: We evaluated claims-based sepsis algorithms among adults in the US aged ≥65 years with Medicare health insurance enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Suspected infections from baseline (2003-2007) through December 31, 2012 were analyzed. Two claims-based algorithms were evaluated: (1) infection plus organ dysfunction diagnoses or sepsis diagnoses (Medicare-Implicit/Explicit) and (2) Centers for Medicare and Medicaid Services Severe Sepsis/Septic Shock Measure diagnoses (Medicare-CMS). Three classifications based on clinical criteria were used as standards for comparison: (1) the sepsis-related organ failure assessment (SOFA) score (REGARDS-SOFA), (2) "quick" SOFA (REGARDS-qSOFA), and (3) Centers for Disease Control and Prevention electronic health record criteria (REGARDS-EHR). RESULTS: There were 2217 suspected infections among 9522 participants included in the current study. The total number of suspected infections classified as sepsis was 468 for Medicare-Implicit/Explicit, 249 for Medicare-CMS, 541 for REGARDS-SOFA, 185 for REGARDS-qSOFA, and 331 for REGARDS-EHR. The overall agreement between Medicare-Implicit/Explicit and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR was 77, 79, and 81%, respectively, sensitivity was 46, 53, and 57%, and specificity was 87, 82, and 85%. Comparing Medicare-CMS and REGARDS-SOFA, REGARDS-qSOFA, and REGARDS-EHR, agreement was 77, 87, and 85%, respectively, sensitivity was 27, 41, and 36%, and specificity was 94, 92, and 93%. Events meeting the REGARDS-SOFA classification had a lower 90-day mortality rate (140.7 per 100 person-years) compared with the Medicare-CMS (296.1 per 100 person-years), REGARDS-qSOFA (238.6 per 100 person-years), Medicare-Implicit/Explicit (219.4 per 100 person-years), and REGARDS-EHR classifications (201.8 per 100 person-years). CONCLUSION: Claims-based sepsis algorithms have high agreement and specificity but low sensitivity when compared with clinical criteria. Both claims-based algorithms identified a patient population with similar 90-day mortality rates as compared with classifications based on qSOFA and EHR criteria but higher mortality relative to SOFA criteria.

Excess Risk for Atherosclerotic Cardiovascular Outcomes Among US Adults With HIV in the Current Era.

Background In the 2000s, adults with HIV had a higher risk for atherosclerotic cardiovascular disease (ASCVD) compared with those without HIV. There is uncertainty if this excess risk still exists in the United States given changes in antiretroviral therapies and increased statin use. Methods and Results We compared the risk for ASCVD events between US adults aged ≥19 years with and without HIV who had commercial or supplemental Medicare health insurance between January 1, 2011, and December 31, 2016. Beneficiaries with HIV (n=82 426) were frequency matched 1:4 on age, sex, and calendar year to those without HIV (n=329 704). Beneficiaries with and without HIV were followed up through December 31, 2016, for ASCVD events, including myocardial infarction, stroke, and lower extremity artery disease hospitalizations. Most beneficiaries were aged <55 years (79%) and men (84%). Over a median follow-up of 1.6 years (maximum, 6 years), there were 3287 ASCVD events, 2190 myocardial infarctions, 891 strokes, and 322 lower extremity artery disease events. The rate per 1000 person-years among beneficiaries with and without HIV was 5.53 and 3.49 for ASCVD, respectively, 3.58 and 2.34 for myocardial infarction, respectively, 1.49 and 0.94 for stroke, respectively, and 0.65 and 0.31 for lower extremity artery disease hospitalizations, respectively. The multivariable-adjusted hazard ratio (95% CI) for ASCVD, myocardial infarction, stroke, and lower extremity artery disease hospitalizations comparing beneficiaries with versus without HIV was 1.29 (1.18-1.40), 1.26 (1.13-1.39), 1.30 (1.11-1.52), and 1.46 (1.11-1.92), respectively. Conclusions Adults with HIV in the United States continue to have a higher ASCVD risk compared with their counterparts without HIV.

Association of Region and Hospital and Patient Characteristics With Use of High-Intensity Statins After Myocardial Infarction Among Medicare Beneficiaries.

Importance: High-intensity statin use after myocardial infarction (MI) varies by patient characteristics, but little is known about differences in use by hospital or region. Objective: To explore the relative strength of associations of region and hospital and patient characteristics with high-intensity statin use after MI. Design, Setting, and Participants: This retrospective cohort analysis used Medicare administrative claims and enrollment data to evaluate fee-for-service Medicare beneficiaries 66 years or older who were hospitalized for MI from January 1, 2011, through June 30, 2015, with a statin prescription claim within 30 days of discharge. Data were analyzed from January 4, 2017, through May 12, 2019. Exposures: Beneficiary characteristics were abstracted from Medicare data. Hospital characteristics were obtained from the 2014 American Hospital Association Survey and Hospital Compare quality metrics. Nine regions were defined according to the US Census. Main Outcomes and Measures: Intensity of the first statin claim after discharge characterized as high (atorvastatin calcium, 40-80 mg, or rosuvastatin calcium, 20-40 mg/d) vs low to moderate (all other statin types and doses). Trends in high-intensity statins were examined from 2011 through 2015. Associations of region and beneficiary and hospital characteristics with high-intensity statin use from January 1, 2014, to June 15, 2015, were examined using Poisson distribution mixed models. Results: Among the 139 643 fee-for-service beneficiaries included (69 968 men [50.1%] and 69 675 women [49.9%]; mean [SD] age, 76.7 [7.5] years), high-intensity statin use overall increased from 23.4% in 2011 to 55.6% in 2015, but treatment gaps persisted across regions. In models considering region and beneficiary and hospital characteristics, region was the strongest correlate of high-intensity statin use, with 66% higher use in New England than in the West South Central region (risk ratio [RR], 1.66; 95% CI, 1.47-1.87). Hospital size of at least 500 beds (RR, 1.15; 95% CI, 1.07-1.23), medical school affiliation (RR, 1.11; 95% CI, 1.05-1.17), male sex (RR, 1.10; 95% CI, 1.07-1.13), and patient receipt of a stent (RR, 1.35; 95% CI, 1.31-1.39) were associated with greater high-intensity statin use. For-profit hospital ownership, patient age older than 75 years, prior coronary disease, and other comorbidities were associated with lower use. Conclusions and Relevance: This study's findings suggest that geographic region is the strongest correlate of high-intensity statin use after MI, leading to large treatment disparities.

Medical Expenditures Among Medicare Beneficiaries with Statin-Associated Adverse Effects Following Myocardial Infarction.

PURPOSE: Compare medical expenditures among adults with statin-associated adverse effects (SAAE) and high statin adherence (HSA) following myocardial infarction (MI). METHODS: We analyzed expenditures in 2016 US dollars among Medicare beneficiaries with SAAE (n = 1741) and HSA (n = 55,567) who were ≥ 66 years of age and initiated moderate/high-intensity statins following an MI in 2007-2013. SAAE were identified through a claims-based algorithm, which included down-titrating statins and initiating ezetimibe, switching to ezetimibe monotherapy, having a rhabdomyolysis or antihyperlipidemic adverse event followed by statin down-titration or discontinuation, or switching between ≥ 3 statin types within 365 days following MI. HSA was defined by having a statin available to take for ≥ 80% of the days in the 365 days following MI. RESULTS: Expenditures among beneficiaries with SAAE and HSA were $40,776 (95% CI $38,329-$43,223) and $26,728 ($26,482-$26,974), respectively, in the 365 days following MI, and $34,238 ($31,396-$37,080) and $29,053 ($28,605-$29,500), respectively, for every year after the first 365 days. Multivariable-adjusted ratios comparing expenditures among beneficiaries with SAAE versus HSA in the first 365 days and after the first 365 days following MI were 1.51 (95% CI 1.43-1.59) and 1.23 (1.12-1.34), respectively. Inpatient and outpatient expenditures were higher among beneficiaries with SAAE versus HSA during and after the first 365 days following MI. Compared to beneficiaries with HSA, medication expenditures among those with SAAE were similar in the 365 days following MI, but higher afterwards. Other medical expenditures were higher among beneficiaries with SAAE versus HSA. CONCLUSION: SAAE are associated with increased expenditures following MI compared with HSA.

Use of Medicare Claims Data for the Identification of Myocardial Infarction: The Reasons for Geographic And Racial Differences in Stroke Study.

OBJECTIVES: Assess the validity of Medicare claims for identifying myocardial infarction (MI). METHODS: We used data from 9951 Medicare beneficiaries 65 years and above in the Reasons for Geographic And Racial Differences in Stroke study. Between 2003 and 2012, 669 participants had an MI identified and adjudicated through study procedures (ie, the gold standard), and 552 had an overnight inpatient claim with a code for MI (ICD-9 code 410.x0 or 410.x1) in any discharge diagnosis position. RESULTS: Using Medicare claims with a discharge diagnosis code for MI in any position, the positive predictive value (PPV) was 84.3% [95% confidence interval (CI), 80.9%-87.3%] and the sensitivity was 49.0% (95% CI, 44.9%-53.1%). Sensitivity was lower for men (45.8%) versus women (55.1%), microsize MIs (13.7%) versus other MIs (64.7%), type 2 (30.9%), and 4-5 MIs (11.1%) versus type 1 MIs (76.6%), and MIs occurring in-hospital (28.8%) versus out-of-hospital (66.7%). Using Medicare claims with a code for MI in the primary discharge diagnosis position, the PPV was 89.7% (95% CI, 86.3%-92.5%) and sensitivity was 40.1% (95% CI, 36.1%-44.2%). The sensitivity of claims with a code for MI in the primary discharge diagnosis position was lower for microsize versus other MIs, type 2 and 4-5 MIs versus type 1 MIs and MIs occurring in-hospital versus out-of-hospital. Hazard ratios for MI associated with participant characteristics were similar using adjudicated MIs identified through study procedures or claims for MI without further adjudication. CONCLUSIONS: Medicare claims have a high PPV but low sensitivity for identifying MI and can be used to investigate individual-level characteristics associated with MI.

Titration to High-Intensity Statin Therapy Following Acute Myocardial Infarction in Patients With and Without Diabetes Mellitus.

BACKGROUND: Patients with diabetes mellitus (DM) have a high risk for cardiovascular disease (CVD) events after an acute myocardial infarction (AMI). High-intensity statins reduce CVD risk following AMI among patients with and without DM. METHODS: We determined the proportion of Medicare beneficiaries 66 to 75 years of age taking a low/moderate-intensity statin with (n = 6718) and without (n = 6414) DM who titrated to a high-intensity statin dosage (i.e., atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg) following an AMI hospitalization in 2014-2015. All patients had a pharmacy claim for a statin fill within 365 days prior to, and within 30 days after their AMI hospitalization. We excluded beneficiaries without Medicare fee-for-service coverage including pharmacy benefits during the study period and those with a pharmacy claim for a high-intensity statin prior to their AMI. RESULTS: The first statin fill following hospital discharge was for a high-intensity dosage among 37.7% and 44.4% of patients with and without DM, respectively. After multivariable adjustment, the risk ratio (RR) for titrating to a high-intensity statin comparing patients with versus without DM was 1.01 (95% CI 0.96, 1.06). Among patients whose first statin fill post-AMI was for a low/moderate-intensity dosage, 7.5% of those with DM titrated to a high-intensity statin within 182 days, compared with 9.2% of those without DM (multivariable-adjusted RR 0.90 [95% CI 0.75, 1.08]). CONCLUSIONS: Most patients taking a low/moderate-intensity statin were not titrated to a high-intensity dosage following AMI irrespective of their diabetes status, potentially leaving substantial residual risk for recurrent CVD events.

Healthcare Utilization and Statin Re-Initiation Among Medicare Beneficiaries With a History of Myocardial Infarction.

BACKGROUND: Contact with the healthcare system represents an opportunity for individuals who discontinue statins to re-initiate treatment. To help identify opportunities for healthcare providers to emphasize the risk-lowering benefits accrued through restarting statins, we determined the types of healthcare utilization associated with statin re-initiation among patients with history of a myocardial infarction. METHODS AND RESULTS: Medicare beneficiaries with a statin pharmacy fill claim within 30 days of hospital discharge for a myocardial infarction in 2007 to 2012 (n=158 795) were followed for 182 days postdischarge to identify treatment discontinuation, defined as 60 continuous days without statins (n=24 461). Re-initiation was defined as a statin fill within 365 days of the discontinuation date (n=13 136). Using a case-crossover study design and each beneficiary as their own control, healthcare utilization during 0 to 14 days before statin re-initiation (case period) was compared with healthcare utilization 30 to 44 days before statin re-initiation (control period). The mean age of beneficiaries was 75.4 years; 52.8% were women and 81.9% were white. For routine healthcare utilization, the odds ratio (95% confidence interval) for statin re-initiation associated with lipid panel testing was 2.65 (1.93-3.65), outpatient primary care was 1.31 (1.23-1.40), and outpatient cardiologist care was 1.38 (1.28-1.50). For acute healthcare utilization, the odds ratio (95% confidence interval) for statin re-initiation associated with emergency department visits was 1.77 (1.31-2.40), coronary heart disease (CHD) hospitalizations was 3.16 (2.41-4.14) and non-coronary heart disease hospitalizations was 1.73 (1.49-2.01). CONCLUSIONS: The weaker association of routine versus acute healthcare utilization with statin re-initiation suggests missed opportunities to reinforce the importance of statin therapy for secondary prevention.

Development of algorithms for identifying fatal cardiovascular disease in Medicare claims.

BACKGROUND: Cause of death is often not available in administrative claims data. OBJECTIVE: To develop claims-based algorithms to identify deaths due to fatal cardiovascular disease (CVD; ie, fatal coronary heart disease [CHD] or stroke), CHD, and stroke. METHODS: Reasons for Geographic and Racial Differences in Stroke (REGARDS) study data were linked with Medicare claims to develop the algorithms. Events adjudicated by REGARDS study investigators were used as the gold standard. Stepwise selection was used to choose predictors from Medicare data for inclusion in the algorithms. C-index, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were used to assess algorithm performance. Net reclassification index (NRI) was used to compare the algorithms with an approach of classifying all deaths within 28 days following hospitalization for myocardial infarction and stroke to be fatal CVD. RESULTS: Data from 2,685 REGARDS participants with linkage to Medicare, who died between 2003 and 2013, were analyzed. The C-index for discriminating fatal CVD from other causes of death was 0.87. Using a cut-point that provided the closest observed-to-predicted number of fatal CVD events, the sensitivity was 0.64, specificity 0.90, PPV 0.65, and NPV 0.90. The algorithms resulted in positive NRIs compared with using deaths within 28 days following hospitalization for myocardial infarction and stroke. Claims-based algorithms for discriminating fatal CHD and fatal stroke performed similarly to fatal CVD. CONCLUSION: The claims-based algorithms developed to discriminate fatal CVD events from other causes of death performed better than the method of using hospital discharge diagnosis codes.