Heart failure with reduced ejection fraction: clinical and economic burden and insights into current and emerging treatments.

Heart failure (HF) imposes a large and growing burden on the population, with a prevalence that is projected to increase to more than 8 million adults by 2030. The high risk of morbidity and mortality associated with HF is further exacerbated by the frequent presence of comorbidities. The coexistence of HF and comorbid conditions can result in emergency department visits and hospitalizations that not only affect patients and their families but also pose a growing economic burden on health care systems. The largest costs arise from hospitalization for HF, with outpatient care and associated medication costs comprising the second largest component. For patients with HF with reduced ejection fraction (HFrEF), defined as left ventricular ejection fraction of 40% or less, remarkable improvements in outcomes have been observed in recent decades due to the availability of disease-modifying therapies. However, the management of HFrEF remains suboptimal, with many patients either not receiving guideline-directed medical therapy (GDMT) or experiencing delays in receiving target doses. Since this can result in preventable hospitalizations and deaths, action is needed to ensure rapid initiation of GDMT. Optimal treatment can be hindered by such patient factors as the presence of comorbidities and socioeconomic barriers that include the cost of multiple treatments. Furthermore, poor treatment adherence is common among patients with HF. Measures aimed at tailoring therapies to individual patients and reducing medical costs are important to increase the uptake of and adherence to therapy and therefore improve clinical outcomes.

Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation.

Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84-0.90; P<0.001), but had a higher risk of post-transplant death (aHR, 1.14; CI, 1.04-1.24; P=0.004). There were no differences in transplantation likelihood or post-transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79-0.99; P=0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post-transplantation death.

Regional-Level Correlations in Inappropriate Imaging Rates for Prostate and Breast Cancers: Potential Implications for the Choosing Wisely Campaign.

IMPORTANCE: The association between regional norms of clinical practice and appropriateness of care is incompletely understood. Understanding regional patterns of care across diseases might optimize implementation of programs like Choosing Wisely, an ongoing campaign to decrease wasteful medical expenditures. OBJECTIVE: To determine whether regional rates of inappropriate prostate and breast cancer imaging were associated. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using the the Surveillance, Epidemiology, and End Results-Medicare linked database. We identified patients diagnosed from 2004 to 2007 with low-risk prostate (clinical stage T1c/T2a; Gleason score, ≤6; and prostate-specific antigen level, <10 ng/mL) or breast cancer (in situ, stage I, or stage II disease), based on Choosing Wisely definitions. MAIN OUTCOMES AND MEASURES: In a hospital referral region (HRR)-level analysis, our dependent variable was HRR-level imaging rate among patients with low-risk prostate cancer. Our independent variable was HRR-level imaging rate among patients with low-risk breast cancer. In a subsequent patient-level analysis we used multivariable logistic regression to model prostate cancer imaging as a function of regional breast cancer imaging and vice versa. RESULTS: We identified 9219 men with prostate cancer and 30,398 women with breast cancer residing in 84 HRRs. We found high rates of inappropriate imaging for both prostate cancer (44.4%) and breast cancer (41.8%). In the first, second, third, and fourth quartiles of breast cancer imaging, inappropriate prostate cancer imaging was 34.2%, 44.6%, 41.1%, and 56.4%, respectively. In the first, second, third, and fourth quartiles of prostate cancer imaging, inappropriate breast cancer imaging was 38.1%, 38.4%, 43.8%, and 45.7%, respectively. At the HRR level, inappropriate prostate cancer imaging rates were associated with inappropriate breast cancer imaging rates (ρ = 0.35; P < .01). At the patient level, a man with low-risk prostate cancer had odds ratios (95% CIs) of 1.72 (1.12-2.65), 1.19 (0.78-1.81), or 1.76 (1.15-2.70) for undergoing inappropriate prostate imaging if he lived in an HRR in the fourth, third, or second quartiles, respectively, of inappropriate breast cancer imaging, compared with the lowest quartile. CONCLUSIONS AND RELEVANCE: At a regional level, there is an association between inappropriate prostate and breast cancer imaging rates. This finding suggests the existence of a regional-level propensity for inappropriate imaging utilization, which may be considered by policymakers seeking to improve quality of care and reduce health care spending in high-utilization areas.

For-profit hospital ownership status and use of brachytherapy after breast-conserving surgery.

BACKGROUND: Little is known about the relationship between operative care for breast cancer at for-profit hospitals and subsequent use of adjuvant radiation therapy (RT). Among Medicare beneficiaries, we examined whether hospital ownership status is associated with the use of breast brachytherapy--a newer and more expensive modality--as well as overall RT. METHODS: We conducted a retrospective study of female Medicare beneficiaries who received breast-conserving surgery for invasive breast cancer in 2008 and 2009. We assessed the relationship between hospital ownership and receipt of brachytherapy or overall RT by using hierarchical generalized linear models. RESULTS: The sample consisted of 35,118 women, 8.0% of whom had breast-conserving operations at for-profit hospitals. Among patients who received RT, those who underwent operation at for-profit hospitals were more likely to receive brachytherapy (20.2%) than patients treated at not-for-profit hospitals (15.2%; odds ratio [OR] for for-profit versus not-for-profit: 1.50; 95% confidence interval [95% CI] 1.23-1.84; P < .001). Among women aged 66-79 years, there was no relationship between hospital ownership status and overall use of RT. Among women ages 80-94 years of age--the group least likely to benefit from RT due to shorter life expectancy--undergoing breast-conserving operations at a for-profit hospital was associated with greater overall use of RT (OR 1.22; 95% CI 1.03-1.45, P = .03) and brachytherapy use (OR 1.66; 95% CI 1.18-2.34, P = .003). CONCLUSION: Operative care at for-profit hospitals was associated with increased use of the newer and more expensive RT modality, brachytherapy. Among the oldest women who are least likely to benefit from RT, operative care at a for-profit hospital was associated with greater overall use of RT, with this difference largely driven by the use of brachytherapy.

Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer.

BACKGROUND: Little is known about the cost-effectiveness of external beam radiation therapy (EBRT) or newer radiation therapy (RT) modalities such as intensity modulated radiation (IMRT) or brachytherapy among older women with favorable-risk breast cancer. METHODS: Using a Markov model, we estimated the cost-effectiveness of no RT, EBRT, and IMRT over 10 years. We estimated the incremental cost-effectiveness ratio (ICER) of IMRT compared with EBRT under different scenarios to determine the necessary improvement in effectiveness for newer modalities to be cost-effective. We estimated model inputs using women in the Surveillance, Epidemiology, and End Results-Medicare database fulfilling the Cancer and Leukemia Group B C9343 trial criteria. RESULTS: The incremental cost of EBRT compared with no RT was $9500 with an ICER of $44600 per quality-adjusted life year (QALY) gained. The ICERs increased with age, ranging from $38300 (age 70-74 years) to $55800 (age 80 to 94 years) per QALY. The ICERs increased to more than $63800 per QALY for women aged 70 to 74 years with an expected 10-year survival of 25%. Reduction in local recurrence by IMRT compared with EBRT did not have a substantial impact on the ICER of IMRT. IMRT would have to increase the utility of baseline state by 20% to be cost-effective (<$100000 per QALY). CONCLUSIONS: EBRT is cost-effective for older women with favorable risk breast cancer, but substantially less cost-effective for women with shorter expected survival. Newer RT modalities would have to be substantially more effective than existing therapies in improving quality of life to be cost-effective.