Interaction Between Race and Income on Cardiac Outcomes After Percutaneous Coronary Intervention.

Background Compared with White Americans, Black Americans have a greater prevalence of cardiac events following percutaneous coronary intervention. We evaluated the association between race and neighborhood income on post-percutaneous coronary intervention cardiac events and assessed whether income modifies the effect of race on this relationship. Methods and Results Consecutive patients (n=23 822) treated with percutaneous coronary intervention from January 1, 2000, to December 31, 2016, were included. All-cause mortality and major adverse cardiac event were assessed at 3 years. Extended 10-year follow-up was performed for those residing locally (n=1285). Neighborhood income was derived using median adjusted annual gross household income reported within the patient's zip code. We compared differences in treatment and outcomes, adjusting for race, income, and their interaction. In total, 3173 (13.3%) patients self-identified as Black Americans, and 20 649 (86.7%) self-identified as White Americans. Black Americans had a worse baseline cardiac risk profile and lower neighborhood income compared with White Americans. Although risk profile improved with increasing income in White Americans, no difference was observed across incomes among Black Americans. Despite similar long-term outpatient cardiology follow-up and medication prescription, risk profiles among Black Americans remained worse. At 3 years, unadjusted all-cause mortality (18.0% versus 15.2%; P<0.001) and major adverse cardiac event (37.3% versus 34.6%; P<0.001) were greater among Black Americans and with lower income (both P<0.001); race, income, and their interaction were not significant predictors in multivariable models. At 10-year follow-up, increasing income was associated with improved outcomes only in White Americans but not Black Americans. In multivariable models for major adverse cardiac event, income (hazard ratio [HR], 0.97 [95% CI, 0.96-0.98]; P=0.005), Black race (HR, 1.77 [95% CI, 1.58-1.96]; P=0.006), and their interaction (HR, 0.98 [95% CI, 0.97-0.99]; P=0.003) were significant predictors. Similar findings were observed for cardiac death. Conclusions Early 3-year post-percutaneous coronary intervention outcomes were driven by worse risk factor profiles in both Black Americans and those with lower neighborhood income. However, late 10-year outcomes showed an independent effect of race and income, with improving outcomes with greater income limited to White Americans. These findings illustrate the importance of developing novel care strategies that address both risk factor modification and social determinants of health to mitigate disparities in cardiac outcomes.

Hospital Readmission in Patients With Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) can present with various clinical symptoms, including chest pain, syncope, and sudden cardiac death, particularly in those without atherosclerotic risk factors. In this contemporary analysis, we aimed to identify the causes and predictors of 30-day hospital readmission in SCAD patients. We utilized the latest Nationwide Readmissions Database from 2016 - 2017 to identify patients with a primary discharge diagnosis of SCAD. The primary outcome was 30-day readmission. Among 795 patients admitted with a principal discharge diagnosis of SCAD, 85 (11.3%) were readmitted within 30 days of discharge from index admission (69.8% women, mean age of 54.3 ± 0.8). More than half of the readmissions (57%) were cardiac-related readmissions. Common cardiac causes for 30-day hospital readmission were acute coronary syndrome (27.3%), chest pain/unspecified angina (24.6%), heart failure (17.5%), and recurrent SCAD (8.3%). In conclusion, we found that following hospitalization for SCAD, almost one-tenth of patients were readmitted within 30 days, largely due to cardiac cause . Risk stratifying patients with SCAD, identifying high-risk features or atypical phenotypes of SCAD, and using appropriate management strategies may prevent hospital readmissions and reduce healthcare-related costs. Further studies are warranted to confirm these causes of readmission in SCAD patients.

Five years of a comprehensive ST-elevation myocardial infarction protocol and its association with sex disparities.

Aims: To determine whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol is associated with reduced sex disparities over 5 years. Methods and results: This was an observational cohort study of 1833 consecutive STEMI patients treated with percutaneous coronary intervention (PCI) before (1 January 2011-14 July 2014, control group) and after (15 July 2014-15 July 2019, protocol group) implementation of a protocol for early guideline-directed medical therapy (GDMT), rapid door to balloon time (D2BT), and use of trans-radial PCI. In the control group, females had less GDMT (77.1% vs. 68.1%, P = 0.03), similarly low trans-radial PCI (19.0% vs. 17.6%, P = 0.73), and longer D2BT [104 min (79, 133) vs. 112 min (85, 147), P = 0.02] corresponding to higher in-hospital mortality [4.5% vs. 10.3%, odds ratio (OR) 2.44 (1.34-4.46), P = 0.004], major adverse cardiac and cerebrovascular events [MACCE, 9.8% vs. 16.3%, OR 1.79 (1.14-2.84), P = 0.01], and net adverse clinical events [NACE, 16.1% vs. 28.3%, OR 2.06 (1.42-2.99), P < 0.001]. In the protocol group, no significant sex differences were observed in GDMT (87.2% vs. 86.4%, P = 0.81) or D2BT [85 min (64-106) vs. 89 min (65-111), P = 0.06], but trans-radial PCI was used less in females (77.6% vs. 71.2%, P = 0.03). In-hospital mortality [2.5% vs. 4.4%, OR 1.78 (0.91-3.51), P = 0.09] and MACCE [9.0% vs. 11.1%, OR 1.27 (0.83-1.92), P = 0.26] were similar between sexes, but higher NACE in females approached significance [14.8% vs. 19.4%, OR 1.38 (0.99-1.92), P = 0.05] due to higher bleeding risk [7.2% vs. 11.1%, OR 1.60 (1.04-2.46), P = 0.03]. Conclusions: A comprehensive STEMI protocol was associated with sustained reductions for in-hospital ischaemic outcomes over 5 years, but higher bleeding rates in females persisted.

Estimated cost for cardiovascular disease risk-based management at a primary healthcare center in Nepal.

Background: Low- and middle-income countries are facing an increasing burden of disability and death due to cardiovascular diseases. Policy makers and healthcare providers alike need resource estimation tools to improve healthcare delivery and to strengthen healthcare systems to address this burden. We estimated the direct medical costs of primary prevention, screening, and management for cardiovascular diseases in a primary healthcare center in Nepal based on the Global Hearts evidence based treatment protocols for risk-based management. Methods: We adapted the World Health Organization's non-communicable disease costing tool and built a model to predict the annual cost of primary CVD prevention, screening, and management at a primary healthcare center level. We used a one-year time horizon and estimated the cost from the Nepal government's perspective. We used Nepal health insurance board's price for medicines and laboratory tests, and used Nepal government's salary for human resource cost. With the model, we estimated annual incremental cost per case, cost for the entire population, and cost per capita. We also estimated the amount of medicines for one-year, annual number of laboratory tests, and the monthly incremental work load of physicians and nurses who deliver these services. Results: For a primary healthcare center with a catchment population of 10,000, the estimated cost to screen and treat 50% of eligible patients is USD21.53 per case and averages USD1.86 per capita across the catchment population. The cost of screening and risk profiling only was estimated to be USD2.49 per case. At same coverage level, we estimated that an average physician's workload will increase annually by 190 h and by 111 h for nurses, i.e., additional 28.5 workdays for physicians and 16.7 workdays for nurses. The total annual cost could amount up to USD18,621 for such a primary healthcare center. Conclusion: This is a novel study for a PHC-based, primary CVD risk-based management program in Nepal, which can provide insights for programmatic and policy planners at the Nepalese municipal, provincial and central levels in implementing the WHO Global Hearts Initiative. The costing model can serve as a tool for financial resource planning for primary prevention, screening, and management for cardiovascular diseases in other low- and middle-income country settings globally.

Predictors of long-term outcomes greater than 10 years after cardiac resynchronization therapy implantation.

BACKGROUND: Cardiac resynchronization therapy (CRT) is indicated in patients with medically refractory heart failure and wide QRS duration. While much is known about predictors of left ventricular (LV) remodeling after CRT implantation and short-term mortality, limited data exist on long-term outcomes after CRT placement. METHODS: We retrospectively reviewed all patients undergoing CRT implantation at our center between 2003 and 2008 and examined mortality using institutional electronic records, social security death index, and online obituary search. We included only patients with preimplant echoes with LV ejection fraction (LVEF) 35% or below. Variable selection was performed using stepwise regression and models were compared using goodness-of-fit criteria. A final model was validated with the bootstrap regression method. RESULTS: Out of the 877 CRT patients undergoing implantation during this time, 287 (32.7%) survived longer than 10 years. Significant (P < .05) predictors of survival in our multivariate model were age, left ventricular diastolic diameter, sex, presence of nonischemic vs ischemic cardiomyopathy, QRS duration, atrial fibrillation, BNP levels, and creatinine levels at the time of CRT implantation. A model using the odds ratios from these variables had a receiver operating curve with an area under the curve score of 0.816 (standard error, 0.019) at predicting survival or freedom from LVAD or heart transplant for longer than 10 years after CRT implantation. The specificity for factors 3 or above and 5 or above was 68% and 77%, respectively. CONCLUSION: A large proportion of patients are still alive 10 years after CRT implantation. Variables at the time of CRT implant can help provide prognostic information to patients and electrophysiologists to determine the long-term benefit and survival of patients after CRT implantation.

Assessment of Barriers and Facilitators to the Delivery of Care for Noncommunicable Diseases by Nonphysician Health Workers in Low- and Middle-Income Countries: A Systematic Review and Qualitative Analysis.

Importance: Cardiovascular disease, cancer, and other noncommunicable diseases (NCDs) are the leading causes of mortality in low- and middle-income countries. Previous studies show that nonphysician health workers (NPHWs), including nurses and volunteers, can provide effective diagnosis and treatment of NCDs. However, the factors that facilitate and impair these programs are incompletely understood. Objective: To identify health system barriers to and facilitators of NPHW-led care for NCDs in low- and middle-income countries. Data Sources: All systematic reviews in PubMed published by May 1, 2018. Study Selection: The search terms used for this analysis included "task shifting" and "non-physician clinician." Only reviews of NPHW care that occurred entirely or mostly in low- and middle-income countries and focused entirely or mostly on NCDs were included. All studies cited within each systematic review that cited health system barriers to and facilitators of NPHW care were reviewed. Data Extraction and Synthesis: Assessment of study eligibility was performed by 1 reviewer and rechecked by another. The 2 reviewers extracted all data. Reviews were performed from November 2017 to July 2018. All analyses were descriptive. Main Outcomes and Measures: All barriers and facilitators mentioned in all studies were tallied and sorted according to the World Health Organization's 6 building blocks for health systems. Results: This systematic review and qualitative analysis identified 15 review articles, which cited 156 studies, of which 71 referenced barriers to and facilitators of care. The results suggest 6 key lessons: (1) select qualified NPHWs embedded within the community they serve; (2) provide detailed, ongoing training and supervision; (3) authorize NPHWs to prescribe medication and render autonomous care; (4) equip NPHWs with reliable systems to track patient data; (5) furnish NPHWs consistently with medications and supplies; and (6) compensate NPHWs adequately commensurate with their roles. Conclusions and Relevance: Although the health system barriers to NPHW screening, treatment, and control of NCDs and their risk factors are numerous and complex, a diverse set of care models has demonstrated strategies to address nearly all of these challenges. These facilitating approaches-which relate chiefly to strong, consistent NPHW training, guidance, and logistical support-generate a blueprint for the creation and scale-up of such programs adaptable across multiple chronic diseases, including in high-income countries.

Strengthening value-based medication management in a free clinic for the uninsured: Quality interventions aimed at reducing costs and enhancing adherence.

Skyrocketing costs of prescription medications in the USA pose a significant threat to the financial viability of safety net clinics that opt to supply medications at low to no out-of-pocket costs to patients. At the East Harlem Health Outreach Partnership clinic of the Icahn School of Medicine at Mount Sinai, a physician-directed student-run comprehensive primary care clinic for uninsured adults of East Harlem, expenditures on pharmaceuticals represent nearly two-thirds of annual costs. The practice of minimising costs while maintaining quality, referred to as high-value care, represents a critical cost-saving opportunity for safety net clinics as well as for more economical healthcare in general. In this paper, we discuss a series of quality improvement initiatives aimed at reducing pharmacy-related expenditures through two distinct yet related mechanisms: (A) promoting value-conscious prescribing by providers and (B) improving patient adherence to medication regimens. Interventions aimed at promoting value-conscious prescribing behaviour included blacklisting a costly medication on our clinic's formulary and adding a decision tree in our mobile clinician reference application to promote value-conscious prescribing. Interventions targeted to improving patient adherence involved an automated text messaging system with English and Spanish refill reminders to encourage timely pick-up of medication refills. As a result of these processes, the free clinic experienced a 7.3%, or $3768, reduction in annual pharmacy costs. Additionally, medication adherence in patients with diabetes on oral antihyperglycaemic medications increased from 55% to 67%. Simultaneous patient-based and provider-based interventions may be broadly applicable to addressing rising pharmacy costs in healthcare across the USA.