Association between neighborhood household income and inpatient atrial fibrillation outcomes.

BACKGROUND: The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described. OBJECTIVE: The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF. METHODS: We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed. RESULTS: Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients. CONCLUSION: We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups.

Cumulative social disadvantage and health-related quality of life: national health interview survey 2013-2017.

BACKGROUND: Evidence for the association between social determinants of health (SDoH) and health-related quality of life (HRQoL) is largely based on single SDoH measures, with limited evaluation of cumulative social disadvantage. We examined the association between cumulative social disadvantage and the Health and Activity Limitation Index (HALex). METHODS: Using adult data from the National Health Interview Survey (2013-2017), we created a cumulative disadvantage index by aggregating 47 deprivations across 6 SDoH domains. Respondents were ranked using cumulative SDoH index quartiles (SDoH-Q1 to Q4), with higher quartile groups being more disadvantaged. We used two-part models for continuous HALex scores and logistic regression for poor HALex (< 20th percentile score) to examine HALex differences associated with cumulative disadvantage. Lower HALex scores implied poorer HRQoL performance. RESULTS: The study sample included 156,182 respondents, representing 232.8 million adults in the United States (mean age 46 years; 51.7% women). The mean HALex score was 0.85 and 17.7% had poor HALex. Higher SDoH quartile groups had poorer HALex performance (lower scores and increased prevalence of poor HALex). A unit increase in SDoH index was associated with - 0.010 (95% CI [-0.011, -0.010]) difference in HALex score and 20% higher odds of poor HALex (odds ratio, OR = 1.20; 95% CI [1.19, 1.21]). Relative to SDoH-Q1, SDoH-Q4 was associated with HALex score difference of -0.086 (95% CI [-0.089, -0.083]) and OR = 5.32 (95% CI [4.97, 5.70]) for poor HALex. Despite a higher burden of cumulative social disadvantage, Hispanics had a weaker SDoH-HALex association than their non-Hispanic White counterparts. CONCLUSIONS: Cumulative social disadvantage was associated with poorer HALex performance in an incremental fashion. Innovations to incorporate SDoH-screening tools into clinical decision systems must continue in order to accurately identify socially vulnerable groups in need of both clinical risk mitigation and social support. To maximize health returns, policies can be tailored through community partnerships to address systemic barriers that exist within distinct sociodemographic groups, as well as demographic differences in health perception and healthcare experience.

Coronary artery calcium scoring for cardiovascular risk assessment in patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD) is associated with higher incidence of atherosclerotic cardiovascular disease (ASCVD). Data investigating the role of coronary artery calcium (CAC) scoring in identifying subclinical atherosclerotic disease in IBD patients is scarce. METHODS: Using data obtained from the CLARIFY registry, a prospective study of no-charge coronary artery calcium (CAC) testing at University Hospitals, we reviewed patients with ulcerative colitis (UC) or Crohn's disease (CD) who underwent CAC scoring from 2014 to 2020. We investigated the concordance between CAC risk and 10-year estimated ASCVD risk by AHA/ACC pooled cohort equation using pre-established thresholds for statin prescription (CAC≥100, 10-year ASCVD risk ≥7.5%). We additionally investigated the association between CAC, preventive therapy initiation and Major Adverse Cardiovascular Events (MACE). RESULTS: A total of 369 patients with IBD were included (174 UC, 195 CD), with median age of 60 years. The median CAC score was 14.9 with no significant difference between UC and CD (P = .76). Overall, 151 (41%) had CAC of 0, 108 (29%) had CAC 1-99, 61 (17%) had CAC 100 to 399, and 49 (13%) had CAC ≥400 with no difference in CAC distribution between CD and UC (P = .17). There was no difference in median CAC between IBD or age/sex-matched controls (P = .34). Approximately half of the patients (52%) with IBD had 10-year estimated ASCVD risk of 7.5% or higher. Among patients with ASCVD risk <7.5% (n = 163), 29 (18%) had CAC≥100 and among patients with ASCVD risk ≥7.5% (n = 178), 102 (57%) had CAC <100. There was no difference between CAC<100 vs CAC≥100 with respect to CRP, use of immunosuppressive or amino-salicylate therapy, IBD severity or complications. CAC score (AUROC 0.67 [0.56-0.78]), but not PCE ASCVD risk (AUROC 0.60 [0.48-0.73]), was predictive of MACE. The best cut-off for CAC score was 76 (sensitivity = 60%, specificity = 69%), and was associated with 4-fold increase in MACE (Hazard Ratio 4.0 [2.0-8.1], P < .001). CONCLUSION: Subclinical atherosclerosis, as evaluated by CAC scoring, is prevalent in patients with IBD, and is associated with cardiovascular events. Further studies are needed to understand underlying biological processes of increased atherosclerotic disease risk among adults with IBD.

Implications of Social Disadvantage Score in Cardiovascular Outcomes and Risk Assessment: Findings From the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Social determinants of health contribute to disparate cardiovascular outcomes, yet they have not been operationalized into the current paradigm of cardiovascular risk assessment. METHODS: Data from the Multi-Ethnic Study of Atherosclerosis, which includes participants from 6 US field centers, were used to create an index of baseline Social Disadvantage Score (SDS) to explore its association with incident atherosclerotic cardiovascular disease (ASCVD) and all-cause mortality and impact on ASCVD risk prediction. SDS, which ranges from 0 to 4, was calculated by tallying the following social factors: (1) household income less than the federal poverty level; (2) educational attainment less than a high school diploma; (3) single-living status; and (4) experience of lifetime discrimination. Cox models were used to examine the association between SDS and each outcome with adjustment for traditional cardiovascular risk factors. Changes in the discrimination and reclassification of ASCVD risk by incorporating SDS into the pooled cohort equations were examined. RESULTS: A total of 6434 participants (mean age, 61.9±10.2 years; female 52.8%; non-white 60.9%) had available SDS 1733 (26.9%) with SDS 0; 2614 (40.6%) with SDS 1; 1515 (23.5%) with SDS 2; and 572 (8.9%) with SDS ≥3. In total, 775 incident ASCVD events and 1573 deaths were observed over a median follow-up of 17.0 years. Increasing SDS was significantly associated with incident ASCVD and all-cause mortality after adjusting for traditional risk factors (ASCVD: per unit increase in SDS hazard ratio, 1.15 [95% CI, 1.07-1.24]; mortality: per unit increase in SDS hazard ratio, 1.13 [95% CI, 1.08-1.19]). Adding SDS to pooled cohort equations components in a Cox model for 10-year ASCVD risk prediction did not significantly improve discrimination (P=0.208) or reclassification (P=0.112). CONCLUSIONS: Although SDS is independently associated with incident ASCVD and all-cause mortality, it does not improve 10-year ASCVD risk prediction beyond pooled cohort equations.

Lifetime healthcare expenses across demographic and cardiovascular risk groups: The application of a novel modeling strategy in a large multiethnic cohort study.

Objective: To understand the burden of healthcare expenses over the lifetime of individuals and evaluate differences among those with cardiovascular risk factors and among disadvantaged groups based on race/ethnicity and sex. Methods: We linked data from the longitudinal multiethnic Dallas Heart Study, which recruited participants between 2000 and 2002, with inpatient and outpatient claims from all hospitals in the Dallas-Fort Worth metroplex through December 2018, capturing encounter expenses. Race/ethnicity and sex, as well as five risk factors, hypertension, diabetes, hyperlipidemia, smoking, and overweight/obesity, were defined at cohort enrollment. For each individual, expenses were indexed to age and cumulated between 40 and 80 years of age. Lifetime expenses across exposures were evaluated as interactions in generalized additive models. Results: A total of 2184 individuals (mean age, 45±10 years; 61% women, 53% Black) were followed between 2000 and 2018. The mean modeled lifetime cumulative healthcare expenses were $442,629 (IQR, $423,850 to $461,408). In models that included 5 risk factors, Black individuals had $21,306 higher lifetime healthcare spending compared with non-Black individuals (P < .001), and men had modestly higher expenses than women ($5987, P < .001). Across demographic groups, the presence of risk factors was associated with progressively higher lifetime expenses, with significant independent association of diabetes ($28,075, P < .001), overweight/obesity ($8816, P < .001), smoking ($3980, P = .009), and hypertension ($528, P = .02) with excess spending. Conclusion: Our study suggests Black individuals have higher lifetime healthcare expenses, exaggerated by the substantially higher prevalence of risk factors, with differences emerging in older age.

Coronary Artery Calcium Scoring for Risk Assessment in Patients With Severe Hypercholesterolemia.

The American College of Cardiology and the American Heart Association guidelines recommend treatment of patients with severe hypercholesterolemia (low-density lipoprotein cholesterol [LDL-C] ≥190 mg/100 ml) with a high-intensity statin. However, atherosclerotic cardiovascular disease (ASCVD) risk, even among those with severe hypercholesterolemia, is heterogeneous, and coronary artery calcium (CAC) scoring may be used to clarify risk. We sought to evaluate CAC in patients with severe hypercholesterolemia and measure its impact on real-world statin prescriptions. We identified patients with at least 1 LDL-C ≥190 mg100 ml who had a CAC scoring in the Community Benefit of No-Charge Calcium Score Screening Program (CLARIFY) study (NCT04075162) between 2014 and 2020. We explored the CAC distribution, factors associated with CAC >0, and ASCVD risk (myocardial infarction, stroke, revascularization, death). A total of 1,904 patients (1.257 women, aged 57.8 ± 9.3 years) with severe hypercholesterolemia were included. LDL-C ranged from 190 to 524 mg100 ml (mean 215.5 ± 27 mg100 ml). A total of 864 patients (45.4%) had CAC = 0 and 1,561 (82%) had CAC <100. In patients with LDL-C ≥250 mg100 ml, 67 (36.6%) had CAC = 0. Age, male gender, smoking, diabetes, systolic blood pressure, and obesity (ps ≤0.001) were associated with CAC >0. In patients with LDL-C ≥190 mg100 ml, CAC was associated with a higher risk for ASCVD events (CAC ≥100 vs CAC <100, hazard ratio 3.57 [1.81 to 7.04], p <0.001). A higher CAC category was associated with increased statin use after CAC scoring (p <0.001). In patients with severe hypercholesterolemia, 45% had CAC = 0, which was associated with a significantly lower ASCVD risk. CAC was associated with statin prescription and cholesterol lowering. In conclusion, CAC scoring may be used to clarify ASCVD risk in this heterogeneous population with severe hypercholesterolemia.

Clinical and Economic Profile of Homeless Young Adults with Stroke in the United States, 2002-2017.

Homelessness is a major social determinant of health. We studied the clinical and economic profile of homeless young adults hospitalized with stroke. We studied the National Inpatient Sample database (2002-2017) to evaluate trends of stroke hospitalization, clinical outcomes, and health expenditure in homeless vs non-homeless young adults (<45 years). We identified 3134 homeless individuals out of 648,944 young adults. Homeless patients were more likely to be men, Black adults and had a higher prevalence of cardiometabolic risk factors and psychiatric disorders than non-homeless adults. Both homeless and non-homeless adults had a similar prevalence of ischemic and hemorrhagic stroke. Between 2002 and 2017, hospitalization rates per million increased for both non-homeless (295.8-416.8) and homeless adults (0.5-3.6) (P ≤ 0.01). Between 2003 and 2017, the decline in in-hospital mortality was limited to non-homeless adults (11%-9%), while it has increased in homeless adults (3%-11%) (P < 0.01). The prevalence of acute myocardial infarction (6.8% vs 3.3%, P < 0.01), and acute kidney injury (13.1% vs 9.4%, P < 0.01) was also higher in homeless vs. non-homeless adults. The length of stay and inflation-adjusted care cost were comparable between both study groups. Finally, a higher proportion of homeless patients left the hospital against medical advice than non-homeless adults. Homeless young stroke patients had significant comorbidities, increased hospitalization rates, and adverse clinical outcomes. Therefore, public health interventions should focus on multidisciplinary care to reduce health care disparities among young homeless adults.

Habitual sleep duration and its relationship with cardiovascular health, healthcare costs, and resource utilization in a working population.

OBJECTIVE: Little is known about the relationship between habitual sleep duration, cardiovascular health (CVH) and their impact on healthcare costs and resource utilization. We describe the relationship between sleep duration and ideal CVH, and the associated burden of healthcare expenditure and utilization in a large South Florida employee population free from known cardiovascular disease. METHODS: The study used data obtained from a 2014 voluntary Health Risk Assessment among 8629 adult employees of Baptist Health South Florida. Health expenditures and resource utilization information were obtained through medical claims data. Frequencies of the individual and cumulative CVH metrics across sleep duration were computed. Mean and marginal per-capita healthcare expenditures were estimated. RESULTS: The mean age was 43 years, 57% were of Hispanic ethnicity. Persons with 6-8.9hours and ≥9 hours of sleep were significantly more likely to report optimal goals for diet, physical activity, body mass index, and blood pressure when compared to those who slept less than 6 hours. Compared to those who slept less than 6 hours, those sleeping 6-8.9hours and ≥9hours had approximately 2- (odds ratio 2.1, 95% confidence interval: 1.9-3.0) and 3-times (odds ratio 3.0, 95% confidence interval: 1.6-5.6) higher odds of optimal CVH. Both groups with 6 or more hours of sleep had lower total per-capita expenditure (approximately $2000 and $2700 respectively), lower odds of visiting an emergency room, or being hospitalized compared to those who slept < 6 hours. CONCLUSION: Sleeping 6 or more hours was associated with better CVH, lower healthcare expenditures, and reduced healthcare resource utilization.

Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. METHODS: Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. RESULTS: Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. CONCLUSIONS: An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.

Cumulative Social Disadvantage and All-Cause Mortality in the United States: Findings from a National Study.

The extent to which cumulative social disadvantage-defined as aggregate social risk resulting from multiple co-occurring adverse social determinants of health (SDOH)-affects the risk of all-cause mortality, independent of demographic and clinical risk factors, is not well understood. The objective of this study was to examine the association between cumulative social disadvantage, measured using a comprehensive 47-factor SDOH framework, and mortality in a nationally representative sample of adults in the United States. The authors conducted secondary analysis of pooled data for 63,540 adult participants of the 2013-2015 National Death Index-linked National Health Interview Survey. Age-adjusted mortality rates (AAMRs) were reported by quintiles of aggregate SDOH burden, with higher quintiles denoting greater social disadvantage. Cox proportional hazards models were used to examine the association between cumulative social disadvantage and risk of all-cause mortality. AAMR increased significantly with greater SDOH burden, ranging from 631 per 100,000 person-years (PYs) for participants in SDOH-Q1 to 1490 per 100,000 PYs for those in SDOH-Q5. In regression models adjusted for demographics, being in SDOH-Q5 was associated with 2.5-fold higher risk of mortality, relative to Q1 (adjusted hazard ratio [aHR] = 2.57 [95% confidence interval, CI = 1.94-3.41]); the observed association persisted after adjusting for comorbidities, with over 2-fold increased risk of mortality for SDOH-Q5 versus Q1 (aHR = 2.02 [95% CI = 1.52-2.67]). These findings indicate that cumulative social disadvantage is associated with increased risk of all-cause mortality, independent of demographic and clinical factors. Population level interventions focused on improving individuals' social, economic, and environmental conditions may help reduce the burden of mortality and mitigate persistent disparities.

The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status.

Disparities in cardiovascular outcomes are persistent in our society. The objective was to track the trends before and after the passage of the Affordable Care Act in socioeconomic status (SES) disparities in utilization of cardiovascular disease (CVD) preventive services among nonelderly adults aged 18-64 years. This study used the National Health Interview Survey (2011-2017) to compare utilization of blood pressure, cholesterol, glycemic screening, and diet and smoking cessation advice over time between groups stratified by SES and race using difference-in-difference analysis. This study also measured the differences over time in specific vulnerable population subgroups (Hispanic, low-income and uninsured vs. White, middle-high-income, and insured). The study population included 176,961 surveyed individuals (mean age 40 [±13] years; 51% female; 67.7% non-Hispanic White) between 2011 and 2017, translating to 194.8 million nonelderly US adults per year. Most individuals were from high-income SES (40.0%), followed by middle-income (28.1%), low-income (13.6%), and lowest income SES (18.3%). The proportion of CVD preventive services increased over all SES categories through the study period. The biggest relative changes were seen among low-income individuals. The difference in blood pressure checks, cholesterol checks, and smoking cessation advise between high- and lowest income groups showed a statistically significant decrease at 5.2%, 4.8%, and 11.2%, respectively, between 2011 and 2017. The findings demonstrate a trend in reduction of CVD preventive care disparities between SES groups. However, a gap still exists, and this study highlights the need for continuous improvement to eliminate SES disparities.

Measures of Financial Hardship From Health Care Expenses Among Families With a Member With Atherosclerotic Cardiovascular Disease in the US.

Importance: Patients with atherosclerotic cardiovascular disease (ASCVD) face substantial financial burden from health care costs as assessed by many disparate measures. However, evaluation of the concordance of existing measures and the prevalence of financial burden based on these measures is lacking. Objective: To compare subjectively reported and objectively measured financial burden from health care in families of patients with ASCVD. Design Setting and Participants: This cross-sectional study used data from the Medical Expenditure Panel Survey, a nationally representative survey of individuals and families in the US, and included all families with 1 or more members with ASCVD from 2014 to 2018. Analyses were conducted from October 2021 to April 2022. Main Outcomes and Measures: Using accepted definitions, objective financial hardship represented annual out-of-pocket medical expenses exceeding 20% of annual postsubsistence income, and subjective financial hardship represented self-reported problems paying medical bills or paying them over time. Prevalence of financial hardship was identified based on individual definitions and their concordance was assessed. Factors associated with each type of financial hardship were examined using risk-adjusted survey logistic regression. Multivariable logistic regression was used to model the odds of subjective financial hardship vs objective financial hardship across subgroups. The association between measures of financial hardship and self-reported deferral of care was also assessed. Results: Among 10 975 families of patients with ASCVD, representing 22.5 million families nationally (mean [SD] age of index individual, 66 [24] years; estimated 54% men]), 37% experienced either objective or subjective financial hardship. This group included 11% (95% CI, 10%-11%) with objective financial hardship, 21% (95% CI, 20%-22%) with subjective financial hardship, and 5% (95% CI, 5%-6%) with both objective and subjective financial hardship. Mean age was 70 (95% CI, 68-71) years vs 61 (95% CI, 60-62) years for index patients in families reporting objective financial hardship only vs subjective financial hardship only, with no difference in sex (50% [95% CI, 46%-54%] of men vs 49% [95% CI, 47%-52%] of women). In risk-adjusted analyses, among families of patients with ASCVD, patient age of 65 years or older was associated with lower odds of subjective financial hardship than objective financial hardship (odds ratio [OR], 0.39; 95% CI, 0.20-0.76), whereas higher income (OR, 6.08; 95% CI, 3.93-9.42 for an income of >100%-200% of the federal poverty level [FPL] vs ≤100% of the FPL and OR, 20.46; 95% CI, 11.45-36.56 for >200% of FPL vs ≤100% of FPL), public insurance (OR, 6.60; 95% CI, 4.20-10.37), and being uninsured (OR, 5.36; 95% CI, 2.61-10.98) were associated with higher odds of subjective financial hardship than objective financial hardship. Subjective financial hardship alone was associated with significantly higher adjusted odds of self-reporting deferred or forgone care compared with objective financial hardship alone (OR, 2.69; 95% CI, 1.79-4.06). Conclusions and Relevance: In this cross-sectional study of US adults, 2 in 5 families of patients with ASCVD experienced health care-related financial hardship, but a focus on objective or subjective measures alone would have captured only half the burden and not identified those deferring health care. The findings suggest that a comprehensive framework that evaluates both objective and subjective measures is essential to monitor financial consequences of health care.

Inequalities by Income in the Prevalence of Cardiovascular Disease and Its Risk Factors in the Adult Population of Catalonia.

Background Understanding the magnitude of cardiovascular disease (CVD) inequalities is the first step toward addressing them. The linkage of socioeconomic and clinical data in universal health care settings provides critical information to characterize CVD inequalities. Methods and Results We employed a prospective cohort design using electronic health records data from all residents of Catalonia aged 18+ between January and December of 2019 (N=6 332 228). We calculated age-adjusted sex-specific prevalence of 5 CVD risk factors (diabetes, hypertension, hyperlipidemia, obesity, and smoking), and 4 CVDs (coronary heart disease, cerebrovascular disease, atrial fibrillation, and heart failure). We categorized income into high, moderate, low, and very low according to individual income (tied to prescription copayments) and receipt of welfare support. We found large inequalities in CVD and CVD risk factors among men and women. CVD risk factors with the largest inequalities were diabetes, smoking, and obesity, with prevalence rates 2- or 3-fold higher for those with very low (versus high) income. CVDs with the largest inequalities were cerebrovascular disease and heart failure, with prevalence rates 2 to 4 times higher for men and women with very low (versus high) income. Inequalities varied by age, peaking at midlife (30-50 years) for most diseases, while decreasing gradually with age for smoking. Conclusions We found wide and heterogeneous inequalities by income in 5 CVD risk factors and 4 CVD. Our findings in a region with a high-quality public health care system and universal coverage stress that strong equity-promoting policies are necessary to reduce disparities in CVD.

Subjective Financial Hardship due to Medical Bills Among Patients With Heart Failure in the United States: The 2014-2018 Medical Expenditure Panel Survey.

BACKGROUND: Heart failure (HF) poses a substantial economic burden on the United States (US) health care system. In contrast, little is known about the financial challenges faced by patients with HF. In this study, we examined the scope and sociodemographic predictors of subjective financial hardship due to medical bills incurred by patients with HF. METHODS: In the Medical Expenditure Panel Survey (MEPS; years 2014--2018), a US nationally representative database, we identified all patients who reported having HF. Any subjective financial hardship due to medical bills was assessed based on patients' reporting either themselves or their families (1) having difficulties paying medical bills in the past 12 months, (2) paying bills late or (3) being unable to pay bills at all. Logistic regression was used to evaluate independent predictors of financial hardship among patients with HF. All analyses took into consideration the survey's complex design. RESULTS: A total of 116,563 MEPS participants were included in the analysis, of whom 858 (0.7%) had diagnoses of HF, representing 1.8 million (95% CI 1.6-2.0) patients annually. Overall, 33% (95% CI 29%-38%) reported any financial hardship due to medical bills, and 13.2% were not able to pay bills at all. Age ≤ 65 years and lower educational attainment were independently associated with higher odds of subjective financial hardship due to medical bills. CONCLUSION: Subjective financial hardship is a prevalent issue for patients with HF in the US, particularly those who are younger and have lower educational attainment. There is a need for policies that reduce out-of-pocket costs for the care of HF, an enhanced identification of this phenomenon in the clinical setting, and approaches to help minimize financial toxicity in patients with HF while ensuring optimal quality of care.

Cost-Effectiveness of Using the Coronary Artery Calcium Score in Guiding Therapeutic Decisions in Primary Prevention in the Brazilian Population. / Custo-Efetividade do Emprego do Escore de Cálcio Coronariano na Orientação para a Decisão Terapêutica na Prevenção Primária, na População Brasileira.

BACKGROUND: The use of the coronary artery calcium score to aid cardiovascular risk stratification may be a more cost-effective tool than the conventional strategy. OBJECTIVES: Evaluation of the cost-effectiveness of the use of the calcium score in therapeutic guidance for primary cardiovascular prevention. METHODS: A microsimulation model to assess the clinical and economic consequences of atherosclerotic cardiovascular disease, comparing the prevention strategy using the calcium score and the conventional strategy. RESULTS: The results obtained demonstrated a better cost-effectiveness of the therapeutic strategy guided by the calcium score, by reducing incremental costs and increasing quality-adjusted life years (QALY), which corresponds, in number, to improving the quality of life of the individual. CONCLUSIONS: The use of the coronary artery calcium score proved to be more cost-effective than the conventional strategy, both in terms of cost and QALY, in most of the scenarios studied.

FUNDAMENTO: O emprego do escore de cálcio no auxílio da estratificação de risco cardiovascular pode ser ferramenta com melhor custo-efetividade em comparação à estratégia convencional. OBJETIVOS: Avaliação da custo-efetividade do emprego do escore de cálcio na orientação terapêutica para a prevenção primária cardiovascular. MÉTODOS: Modelo de microssimulação para avaliar as consequências clínicas e econômicas da doença cardiovascular aterosclerótica, comparando-se a estratégia de prevenção pelo uso do escore de cálcio e a estratégia convencional. RESULTADOS: Resultados obtidos demonstram melhor custo-efetividade da estratégia terapêutica guiada pelo escore de cálcio, por meio da redução do custo incremental, e aumento nos anos de vida ajustados por qualidade (QALY), que corresponde, em número, ao benefício incorporado à qualidade de vida do indivíduo. CONCLUSÕES: O emprego do escore de cálcio mostrou-se mais custo-efetivo que a estratégia convencional tanto em custo como em QALY, na maioria dos cenários estudados.