RESUMO
BACKGROUND: The healthcare burden posed by the coronavirus disease 2019 (COVID-19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. METHODS: We conducted a web-based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. RESULTS: Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID-19 related duties. More than two-thirds of PDs believed that the COVID-19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one-fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one-third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. CONCLUSIONS: The COVID-19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.
Assuntos
COVID-19/epidemiologia , Cateterismo Cardíaco , Cardiologia/educação , Educação de Pós-Graduação em Medicina/organização & administração , Bolsas de Estudo/organização & administração , Intervenção Coronária Percutânea/educação , Acreditação , Humanos , New Jersey , Cidade de Nova Iorque , Diretores Médicos , Inquéritos e QuestionáriosRESUMO
Background Readmission after ST-segment-elevation myocardial infarction (STEMI) poses an enormous economic burden to the US healthcare system. There are limited data on the association between length of hospital stay (LOS), readmission rate, and overall costs in patients who underwent primary percutaneous coronary intervention for STEMI. Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database from 2010 to 2014. From the patients who underwent primary percutaneous coronary intervention, we examined the 30-day outcomes including readmission, mortality, reinfarction, repeat revascularization, and hospital charges/costs according to LOS (1-2, 3, 4, 5, and >5 days) stratified by infarct locations. The 30-day readmission rate after percutaneous coronary intervention for STEMI was 12.0% in the anterior wall (AW) STEMI group and 9.9% in the non-AW STEMI group. Patients with a very short LOS (1-2 days) were readmitted less frequently than those with a longer LOS regardless of infarct locations. However, patients with a very short LOS had significantly increased 30-day readmission mortality versus an LOS of 3 days (hazard ratio, 1.91; CI, 1.16-3.16 [P=0.01]) only in the AW STEMI group. Total costs (index admission+readmission) were the lowest in the very short LOS cohort in both the AW STEMI group (P<0.001) and the non-AW STEMI group (P<0.001). Conclusions For patients who underwent primary percutaneous coronary intervention for STEMI, a very short LOS was associated with significantly lower 30-day readmission and lower cumulative cost. However, a very short LOS was associated with higher 30-day mortality compared with at least a 3-day stay in the AW STEMI cohort.
Assuntos
Infarto Miocárdico de Parede Anterior/economia , Infarto Miocárdico de Parede Anterior/terapia , Custos Hospitalares , Tempo de Internação/economia , Readmissão do Paciente/economia , Intervenção Coronária Percutânea/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Infarto Miocárdico de Parede Anterior/diagnóstico , Infarto Miocárdico de Parede Anterior/mortalidade , Redução de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Recidiva , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Background Readmission after ST-segment-elevation myocardial infarction ( STEMI ) poses an enormous economic burden to the US healthcare system. Efforts to prevent readmissions should be based on understanding the timing and causes of these readmissions. This study aimed to investigate contemporary causes, timing, and cost of 30-day readmissions after STEMI . Methods and Results All STEMI hospitalizations were selected in the Nationwide Readmissions Database ( NRD ) from 2010 to 2014. The 30-day readmission rate as well as the primary cause and cost of readmission were examined. Multivariate regression analysis was performed to identify the predictors of 30-day readmission and increased cumulative cost. From 2010 to 2014, the 30-day readmission rate after STEMI was 12.3%. Within 7 days of discharge, 43.9% were readmitted, and 67.3% were readmitted within 14 days. The annual rate of 30-day readmission decreased by 19% from 2010 to 2014 ( P<0.001). Female sex, AIDS , anemia, chronic kidney disease , collagen vascular disease, diabetes mellitus, hypertension, pulmonary hypertension, congestive heart failure , atrial fibrillation, and increased length of stay were independent predictors of 30-day readmission. A large proportion of patients (41.6%) were readmitted for noncardiac reasons. After multivariate adjustment, 30-day readmission was associated with a 47.9% increase in cumulative cost ( P<0.001). Conclusions Two thirds of patients were readmitted within the first 14 days after STEMI , and a large proportion of patients were readmitted for noncardiac reasons. Thirty-day readmission was associated with an ≈50% increase in cumulative hospitalization costs. These findings highlight the importance of closer surveillance of both cardiac and general medical conditions in the first several weeks after STEMI discharge.
Assuntos
Custos Hospitalares , Medicare/economia , Readmissão do Paciente/tendências , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Idoso , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/economia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Recent studies have shown improving survival after cardiac arrest. However, data regarding sex-based disparities in treatment and outcomes after cardiac arrest are limited. METHODS AND RESULTS: We performed a retrospective analysis of all patients suffering cardiac arrest between 2003 and 2012 using the Nationwide Inpatient Sample database. Annual rates of cardiac arrest, rates of utilization of coronary angiography/percutaneous coronary interventions/targeted temperature management, and sex-based outcomes after cardiac arrest were examined. Among a total of 1 436 052 discharge records analyzed for cardiac arrest patients, 45.4% (n=651 745) were females. Women were less likely to present with ventricular tachycardia/ventricular fibrillation arrests compared with men throughout the study period. The annual rates of cardiac arrests have increased from 2003 to 2012 by 14.0% (Ptrend<0.001) and ventricular tachycardia/ventricular fibrillation arrests have increased by 25.9% (Ptrend<0.001). Women were less likely to undergo coronary angiography, percutaneous coronary interventions, or targeted temperature management in both ventricular tachycardia/ventricular fibrillation and pulseless electrical activity/asystole arrests. Over a 10-year study period, there was a significant decrease in in-hospital mortality in women (from 69.1% to 60.9%, Ptrend<0.001) and men (from 67.2% to 58.6%, Ptrend<0.001) after cardiac arrest. In-hospital mortality was significantly higher in women compared with men (64.0% versus 61.4%; adjusted odds ratio 1.02, P<0.001), particularly in the ventricular tachycardia/ventricular fibrillation arrest cohort (49.4% versus 45.6%; adjusted odds ratio 1.11, P<0.001). CONCLUSIONS: Women presenting with cardiac arrests are less likely to undergo therapeutic procedures, including coronary angiography, percutaneous coronary interventions, and targeted temperature management. Despite trends in improving survival after cardiac arrest over 10 years, women continue to have higher in-hospital mortality when compared with men.
Assuntos
Parada Cardíaca/terapia , Adulto , Idoso , Feminino , Disparidades nos Níveis de Saúde , Parada Cardíaca/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Distribuição por Sexo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Hospitalizations for heart failure with preserved ejection fraction (HFpEF) are increasing. There are limited data examining national trends in patients hospitalized with HFpEF. METHODS: Using the Nationwide Inpatient Sample, we examined 5,046,879 hospitalizations with a diagnosis of acute heart failure in 2003-2012, stratifying hospitalizations by HFpEF and heart failure with reduced ejection fraction (HFrEF). Patient and hospital characteristics, in-hospital mortality, and length of stay were examined. RESULTS: Compared with HFrEF, those with HFpEF were older, more commonly female, and more likely to have hypertension, atrial fibrillation, chronic lung disease, chronic renal failure, and anemia. Over time, HFpEF comprised increasing proportions of men and patients aged ≥75 years. In-hospital mortality rate for HFpEF decreased by 13%, largely due to improved survival in those aged ≥65 years. Multivariable regression analyses showed that pulmonary circulation disorders, liver disease, and chronic renal failure were independent predictors of in-hospital mortality, whereas treatable diseases including hypertension, coronary artery disease, and diabetes were inversely associated. CONCLUSIONS: This study represents the largest cohort of patients hospitalized with HFpEF to date, yielding the following observations: number of hospitalizations for HFpEF was comparable with that of HFrEF; patients with HFpEF were most often women and elderly, with a high burden of comorbidities; outcomes appeared improved among a subset of patients; pulmonary hypertension, liver disease, and chronic renal failure were strongly associated with poor outcomes.
Assuntos
Insuficiência Cardíaca/epidemiologia , Mortalidade Hospitalar/tendências , Hospitalização/estatística & dados numéricos , Seguro Saúde/classificação , Alta do Paciente/estatística & dados numéricos , Volume Sistólico/fisiologia , Doença Aguda , Adolescente , Adulto , Distribuição por Idade , Idoso , Comorbidade , Feminino , Hospitalização/tendências , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Análise de Regressão , Distribuição por Sexo , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: This study sought to identify the temporal trends of presenting diagnoses and vascular procedures performed for peripheral arterial disease (PAD) along with the rates of procedures and in-hospital outcomes by payer status. BACKGROUND: Previous studies suggest that patients with Medicare, Medicaid, or lack of insurance receive poorer quality of care leading to worse outcomes. METHODS: We analyzed 196,461,055 discharge records to identify all hospitalized patients with PAD records (n=1,687,724) from January 2007 through December 2011 in the Nationwide Inpatient Sample database. RESULTS: The annual frequency of vascular procedures remained unchanged during the study period. Patients with Medicaid were more likely to present with gangrenes, whereas patients with Medicare were more likely to present with ulcers. After adjustment, patients with Medicare and Medicaid were more likely to undergo amputations when compared with private insurance/HMO (OR=1.13, 95% CI=1.10-1.16 and OR=1.24, 95% CI=1.20-1.29, respectively). Patients with both Medicare and Medicaid were less likely to undergo bypass surgery (OR=0.82, 95% CI=0.81-0.84 and OR=0.87, 95% CI=0.85-0.90, respectively), but more likely to undergo endovascular procedures (OR=1.18, 95% CI=1.17-1.20 and OR=1.03, 95% CI=1.01-1.06, respectively). Medicare and Medicaid status versus private insurance/HMO was associated with worse adjusted odds of in-hospital outcomes, including mortality after amputations, endovascular procedures, and bypass surgeries. CONCLUSIONS: In this analysis, patients with Medicare and Medicaid had more comorbid conditions at baseline when compared with private insurance/HMO cohorts, were more likely to present with advanced stages of PAD, undergo amputations, and develop in-hospital complications. These data unveil a critical gap and an opportunity for quality improvement in the elderly and those with poor socioeconomic status.
Assuntos
Procedimentos Endovasculares/tendências , Disparidades em Assistência à Saúde/tendências , Custos Hospitalares/tendências , Hospitais/tendências , Seguro Saúde/tendências , Doença Arterial Periférica/terapia , Avaliação de Processos em Cuidados de Saúde/tendências , Indicadores de Qualidade em Assistência à Saúde/tendências , Enxerto Vascular/tendências , Idoso , Idoso de 80 Anos ou mais , Amputação Cirúrgica/tendências , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/normas , Feminino , Gastos em Saúde/tendências , Disparidades em Assistência à Saúde/economia , Disparidades em Assistência à Saúde/normas , Custos Hospitalares/normas , Mortalidade Hospitalar/tendências , Hospitais/normas , Humanos , Seguro Saúde/economia , Seguro Saúde/normas , Salvamento de Membro/tendências , Modelos Logísticos , Masculino , Medicaid/tendências , Pessoas sem Cobertura de Seguro de Saúde , Medicare/tendências , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/economia , Doença Arterial Periférica/mortalidade , Setor Privado/tendências , Avaliação de Processos em Cuidados de Saúde/economia , Avaliação de Processos em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/economia , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Enxerto Vascular/efeitos adversos , Enxerto Vascular/economia , Enxerto Vascular/mortalidadeRESUMO
The aim of this study was to compare in-hospital cost and outcomes between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR). TAVI is an effective treatment option in patients with symptomatic aortic stenosis who are at high risk for traditional SAVR. Several studies using trial data or outside United States registry data have addressed TAVI cost issues, although there is a paucity of cost data involving commercial cases in the United States. Using Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Nationwide Inpatient Sample files, a propensity score-matched analysis of all commercial TAVI and SAVR cases performed in 2011 was conducted. Overall hospital cost and length of stay, as well as procedural complications, were compared between the 2 matched cohorts: 595 TAVI patients were matched to 1,785 SAVR patients in a 1:3 ratio. There was no difference in mean ($181,912 vs $196,298) or median ($152,993 vs $155,974) hospital cost between TAVI and SAVR (p = 0.60). The TAVI group had significantly shorter lengths of hospital stay than the SAVR group (mean 9.76 vs 12.01 days, p <0.001). There was no difference in postprocedural in-hospital death or stroke, but TAVI patients were more likely to have bleeding complications, to have vascular complications, and to require pacemakers. In conclusion, when analyzing in-hospital cost of commercial TAVI and SAVR cases using the Nationwide Inpatient Sample data set, TAVI is an economically satisfactory alternative to SAVR and results in an approximately 2-day shorter length of stay during the index hospitalization.