Cardiovascular hospitalizations and mortality among adults aged 25-64 years in the USA.

BACKGROUND AND AIMS: Declines in cardiovascular mortality have stagnated in the USA since 2011. There is growing concern that these patterns reflect worsening cardiovascular health in younger adults. However, little is known about how the burden of acute cardiovascular hospitalizations and mortality has changed in this population. Changes in cardiovascular hospitalizations and mortality among adults aged 25-64 years were evaluated, overall and by community-level income. METHODS: Using the National Inpatient Sample, age-standardized annual hospitalization and in-hospital mortality rates for acute myocardial infarction (AMI), heart failure, and ischaemic stroke were determined among adults aged 25-64 years. Quasi-Poisson and quasi-binominal regression models were fitted to compare outcomes between individuals residing in low- and higher-income communities. RESULTS: Between 2008 and 2019, age-standardized hospitalization rates for AMI increased among younger adults from 155.0 (95% confidence interval: 154.6, 155.4) per 100 000 to 160.7 (160.3, 161.1) per 100 000 (absolute change +5.7 [5.0, 6.3], P < .001). Heart failure hospitalizations also increased (165.3 [164.8, 165.7] to 225.3 [224.8, 225.8], absolute change +60.0 (59.3, 60.6), P < .001), as ischaemic stroke hospitalizations (76.3 [76.1, 76.7] to 108.1 [107.8, 108.5], absolute change +31.7 (31.2, 32.2), P < .001). Across all conditions, hospitalizations rates were significantly higher among younger adults residing in low-income compared with higher-income communities, and disparities did not narrow between groups. In-hospital mortality decreased for all conditions over the study period. CONCLUSIONS: There was an alarming increase in cardiovascular hospitalizations among younger adults in the USA from 2008 to 2019, and disparities between those residing in low- and higher-income communities did not narrow.

Long term risk of death and readmission after hospital admission with covid-19 among older adults: retrospective cohort study.

OBJECTIVES: To characterize the long term risk of death and hospital readmission after an index admission with covid-19 among Medicare fee-for-service beneficiaries, and to compare these outcomes with historical control patients admitted to hospital with influenza. DESIGN: Retrospective cohort study. SETTING: United States. PARTICIPANTS: 883 394 Medicare fee-for-service beneficiaries age ≥65 years discharged alive after an index hospital admission with covid-19 between 1 March 2020 and 31 August 2022, compared with 56 409 historical controls discharged alive after a hospital admission with influenza between 1 March 2018 and 31 August 2019. Weighting methods were used to account for differences in observed characteristics. MAIN OUTCOME MEASURES: All cause death within 180 days of discharge. Secondary outcomes included first all cause readmission and a composite of death or readmission within 180 days. RESULTS: The covid-19 cohort compared with the influenza cohort was younger (77.9 v 78.9 years, standardized mean difference -0.12) and had a lower proportion of women (51.7% v 57.3%, -0.11). Both groups had a similar proportion of black beneficiaries (10.3% v 8.1%, 0.07) and beneficiaries with dual Medicaid-Medicare eligibility status (20.1% v 19.2%; 0.02). The covid-19 cohort had a lower comorbidity burden, including atrial fibrillation (24.3% v 29.5%, -0.12), heart failure (43.4% v 49.9%, -0.13), and chronic obstructive pulmonary disease (39.2% v 52.9%, -0.27). After weighting, the covid-19 cohort had a higher risk (ie, cumulative incidence) of all cause death at 30 days (10.9% v 3.9%; standardized risk difference 7.0%, 95% confidence interval 6.8% to 7.2%), 90 days (15.5% v 7.1%; 8.4%, 8.2% to 8.7%), and 180 days (19.1% v 10.5%; 8.6%, 8.3% to 8.9%) compared with the influenza cohort. The covid-19 cohort also experienced a higher risk of hospital readmission at 30 days (16.0% v 11.2%; 4.9%, 4.6% to 5.1%) and 90 days (24.1% v 21.3%; 2.8%, 2.5% to 3.2%) but a similar risk at 180 days (30.6% v 30.6%;-0.1%, -0.5% to 0.3%). Over the study period, the 30 day risk of death for patients discharged after a covid-19 admission decreased from 17.9% to 7.2%. CONCLUSIONS: Medicare beneficiaries who were discharged alive after a covid-19 hospital admission had a higher post-discharge risk of death compared with historical influenza controls; this difference, however, was concentrated in the early post-discharge period. The risk of death for patients discharged after a covid-19 related hospital admission substantially declined over the course of the pandemic.

Cardiovascular hospitalizations for Medicare advantage beneficiaries in the United States, 2009 to 2019.

BACKGROUND: Federal programs measuring hospital quality of care for acute cardiovascular conditions are based solely on Medicare fee-for-service (FFS) beneficiaries, and exclude Medicare Advantage (MA) beneficiaries. In this study we characterize the proportion of Medicare beneficiaries enrolled in MA at the time of acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke hospitalization. METHODS: Retrospective cross-sectional study of short-term acute care hospitals using Medicare claims in 2009 and 2019. RESULTS: There were 2,653 hospitals in 2009 and 2,732 hospitals in 2019. Across hospitals, the proportion of Medicare beneficiaries hospitalized for AMI who were enrolled in MA increased between 2009 (hospital-level median 14.4% [IQR 5.1%-26.0%]) and 2019 (33.3% [IQR 20.6%-45.2%]), with substantial variation across hospitals. Similar patterns were observed for HF (13.0% [IQR 5.3%-24.3%] to 31.0% [IQR 20.2%-42.3%]) and ischemic stroke (14.6% [IQR 5.3%-26.7%] to 33.3% [IQR 20.9%-46.0%]). Within each hospital referral region, hospital size (large 36.3% vs small 24.5%; adjusted difference 6.7%, 95% CI, 4.5%-8.8%), teaching status (teaching 34.5% vs nonteaching 28.2%; 2.8%, 1.4%-4.1%), and ownership status (private nonprofit 32.3% vs public 24.5%; 5.2%, 3.5%-6.9%) were each associated with a higher hospital MA proportion. CONCLUSIONS: The proportion of Medicare beneficiaries hospitalized for AMI, HF, and ischemic stroke enrolled in MA doubled between 2009 and 2019, with substantial variation across hospitals. These findings have implications for federal efforts to measure and improve quality, which currently focus only on FFS beneficiaries.

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings.

BACKGROUND: Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE: To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS: Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS: Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION: Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION: Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE: Laura and John Arnold Foundation.

Enriching the American Heart Association COVID-19 Cardiovascular Disease Registry Through Linkage With External Data Sources: Rationale and Design.

Background The AHA Registry (American Heart Association COVID-19 Cardiovascular Disease Registry) captures detailed information on hospitalized patients with COVID-19. The registry, however, does not capture information on social determinants of health or long-term outcomes. Here we describe the linkage of the AHA Registry with external data sources, including fee-for-service (FFS) Medicare claims, to fill these gaps and assess the representativeness of linked registry patients to the broader Medicare FFS population hospitalized with COVID-19. Methods and Results We linked AHA Registry records of adults ≥65 years from March 2020 to September 2021 with Medicare FFS claims using a deterministic linkage algorithm and with the American Hospital Association Annual Survey, Rural Urban Commuting Area codes, and the Social Vulnerability Index using hospital and geographic identifiers. We compared linked individuals with unlinked FFS beneficiaries hospitalized with COVID-19 to assess the representativeness of the AHA Registry. A total of 10 010 (47.0%) records in the AHA Registry were successfully linked to FFS Medicare claims. Linked and unlinked FFS beneficiaries were similar with respect to mean age (78.1 versus 77.9, absolute standardized difference [ASD] 0.03); female sex (48.3% versus 50.2%, ASD 0.04); Black race (15.1% versus 12.0%, ASD 0.09); dual-eligibility status (26.1% versus 23.2%, ASD 0.07); and comorbidity burden. Linked patients were more likely to live in the northeastern United States (35.7% versus 18.2%, ASD 0.40) and urban/metropolitan areas (83.9% versus 76.8%, ASD 0.18). There were also differences in hospital-level characteristics between cohorts. However, in-hospital outcomes were similar (mortality, 23.3% versus 20.1%, ASD 0.08; home discharge, 45.5% versus 50.7%, ASD 0.10; skilled nursing facility discharge, 24.4% versus 22.2%, ASD 0.05). Conclusions Linkage of the AHA Registry with external data sources such as Medicare FFS claims creates a unique and generalizable resource to evaluate long-term health outcomes after COVID-19 hospitalization.

Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease.

BACKGROUND: Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown. METHODS: We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability. RESULTS: The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare. CONCLUSIONS: Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.

Health Care Access and Management of Cardiovascular Risk Factors Among Working-Age Adults With Low Income by State Medicaid Expansion Status.

Importance: Medicaid expansion led to gains in insurance coverage among working-age adults with low income. To date, the extent to which disparities in access and cardiovascular care persist for this population in Medicaid nonexpansion and expansion states is unknown. Objective: To compare insurance coverage, health care access, and cardiovascular risk factor management between working-age adults (age 18-64 years) with low income in Medicaid nonexpansion and expansion states and between uninsured and insured adults in these states. Design, Setting, and Participants: This cross-sectional study analyzed data on adults aged 18 to 64 years with low income from the Behavioral Risk Factor Surveillance System from January 1 to December 31, 2019. Exposures: State Medicaid expansion and insurance status. Main Outcomes and Measures: The main outcomes were health care access and monitoring and treatment of cardiovascular risk factors. The estimated adjusted risk difference (RD) in outcomes was estimated to compare adults in Medicaid nonexpansion and expansion states and uninsured and insured individuals in nonexpansion and expansion states. Results: The weighted study population consisted of 28 028 451 working-age adults with low income, including 10 094 994 (36.0%) in Medicaid nonexpansion states (63.4% female) and 17 933 457 (64.0%) in expansion states (59.2% female). Adults in nonexpansion states had higher uninsurance rates (42.4% [95% CI, 40.2%-44.7%] vs 23.8% [95% CI, 22.8%-24.8%]), were less likely to have a usual source of care (55.4% [95% CI, 53.1%-57.6%] vs 65.4% [95% CI, 64.3%-66.5%]; adjusted RD, -11.4% [95% CI, -13.9% to -8.8%]) or a recent examination (78.9% [95% CI, 77.0%-80.9%] vs 84.4% [95% CI, 83.5%-85.2%]; RD, -6.2% [95% CI, -8.4% to -4.0%]), and were more likely to have deferred care owing to cost (36.1% [95% CI, 34.0%-38.2%] vs 21.8% [95% CI, 20.9%-22.8%]; RD, 14.2% [95% CI, 11.9%-16.6%]) than were those in expansion states. There were no significant differences in cardiovascular risk factor management between these groups. In nonexpansion states, uninsured adults had significantly worse access to care across these measures and were less likely to receive indicated monitoring of cholesterol (72.6% [95% CI, 67.7%-77.4%] vs 93.7%; [95% CI, 92.4%-95.0%]; RD, -17.2% [95% CI, -21.8% to -12.6%]) and hemoglobin A1c (55.2% [95% CI, 40.0%-72.5%] vs 88.5% [95% CI, 79.2%-97.9%]; RD, -25.8% [95% CI, -47.6% to -4.1%]) levels or to receive treatment for hypertension (49.4% [95% CI, 43.3%-55.6%] vs 74.7% [95% CI, 71.5%-78.0%]; RD, -16.3% [95% CI, -23.2% to -9.4%]) and hyperlipidemia (30.2% [95% CI, 23.5%-36.8%] vs 58.7% [95% CI, 53.9%-63.5%]; RD, -19.3% [95% CI, -27.9% to -10.7%]) compared with insured adults. These patterns were similar for uninsured and insured adults in expansion states. Conclusions and Relevance: In this study, working-age adults with low income in Medicaid nonexpansion states experienced higher uninsurance rates and worse access to care than did those in expansion states; however, cardiovascular risk factor management was similar and treatment rates were low. In nonexpansion states, uninsured adults were less likely to receive appropriate cardiovascular risk factor management compared with insured adults.

HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes Management.

BACKGROUND: Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs). OBJECTIVE: To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5-10.5% managed by PCPs. DESIGN: Cluster-randomized matched cohort study with implementation evaluation. PARTICIPANTS: PCPs affiliated with Massachusetts General Hospital (MGH). INTERVENTIONS: Unsolicited endocrinology eConsultation. MAIN MEASURES: The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits. KEY RESULTS: 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs -3.1%, p=0.03) and sulfonylureas (1.5% vs -6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications. CONCLUSIONS: The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c. TRIAL REGISTRATION: Clinicaltrials.gov registration: NCT03542084.

Beyond the stethoscope: managing ambulatory heart failure during the COVID-19 pandemic.

There have been nearly 70 million cases of COVID-19 worldwide, with over 1.5 million deaths at the time of this publication. This global pandemic has mandated dramatic changes in healthcare delivery with a particular focus on social distancing in order to reduce viral transmission. Heart failure patients are among the highest utilizers of health care and are at increased risk for COVID-related vulnerabilities. Effectively managing this complex and resource-intensive patient population from a distance presents new and unique challenges. Here, we review relevant data on telemedicine and remote monitoring strategies for heart failure patients and provide a framework to help providers treat this population during the COVID-19 pandemic. This includes (i) dedicated pre-visit contact and planning (i.e. confirm clinical appropriateness, presence of compatible technology, and patient comfort); (ii) utilization of virtual clinic visits (use of telehealth platforms, a video-assisted exam, self-reported vital signs, and weights); and (iii) use of existing remote heart failure monitoring sensors when applicable (CardioMEMS, Optivol, and HeartLogic). While telemedicine and remote monitoring strategies are not new, these technologies are emerging as an important tool for the effective management of heart failure patients during the COVID-19 pandemic. In general, these strategies appear to be safe; however, additional data will be needed to determine their effectiveness with respect to both process and outcomes measures.

Changes in hospital admissions for urgent conditions during COVID-19 pandemic.

OBJECTIVES: To determine whether patients are deferring necessary care for urgent conditions during the coronavirus disease 2019 (COVID-19) pandemic and, if so, to what extent. STUDY DESIGN: Cross-sectional study. METHODS: Using billing data from 8 acute care hospitals, we identified 9 principal medical diagnoses from International Classification of Diseases, Tenth Revision codes across 4 medical specialties (cardiology, gastroenterology, neurology, and urology). In addition, we defined a combined obstetrical falsification end point. We compared daily admission rates during the pandemic period (3/1/2020-4/30/2020) with the same dates in 2019 (3/1/2019-4/30/2019). As a reference, we also compared a prepandemic period in the same years (1/1/2019-2/28/2019 and 1/1/2020-2/29/2020). We compared admission rates between years using t tests. RESULTS: There were 3219 admissions for the conditions of interest during the study period in 2019 and 2661 in 2020. There was no difference in prepandemic daily admission rates in 2020 compared with 2019 (29.04 vs 27.63 admissions per day; -4.9%; P = .50). During the pandemic period, there was a 33.7% decrease in admission rates for all conditions combined in 2020 compared with 2019 (24.68 vs 16.37; -33.7%; P = .03). By specialty, the combined gastroenterology (10.22 vs 7.20; -29.6%; P = .02) and cardiovascular (2.34 vs 1.29; -44.7%; P = .05) end points demonstrated reduction in daily admission rates. CONCLUSIONS: Daily admission rates during the COVID-19 pandemic were lower for these acute medical conditions. Public awareness campaigns are urgently needed to reassure the public about the safety of presenting for care.

Early experiences with cardiology electronic consults: A systematic review.

Many health systems have begun implementing electronic consultation programs. The clinical and financial impact of these programs in cardiology and the potential for more widespread adoption remains unknown. OBJECTIVES: To systematically review the current literature related to electronic consultation in cardiology. METHODS: Following the PRISMA guidelines, we conducted a systematic review in August 2018 of English literature. We searched PubMed, the Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for studies related to electronic consultation in cardiology. RESULTS: A total of 21 studies were included. Two of the studies were randomized controlled trials, 16 were quantitative studies with defined endpoints, and 3 were qualitative descriptions. Most studies were conducted in the United States and Canada. The available literature suggests cardiology e-consult programs can be implemented in different practice settings, have good patient and provider satisfaction, deliver greater and timelier access to outpatient cardiac care, and do so in a cost saving fashion. While studies suggest cardiology e-consultation is safe, there are no studies evaluating hard clinical outcomes. CONCLUSIONS: Cardiology e-consults appear to be a promising tool for increasing access to outpatient cardiac care. Further investigation is required to evaluate the effects of cardiology electronic consultation on the quality of care. CONDENSED ABSTRACT: Here we present the first systematic review of electronic consultation in cardiology. The available literature suggests cardiology e-consult programs can be implemented in different practice settings, have good patient and provider satisfaction, deliver greater and timelier access to outpatient cardiac care, and do so in a cost saving fashion. While studies suggest cardiology e-consultation is safe, there are no studies evaluating hard clinical outcomes. Overall, cardiology e-consults appear to be a promising tool for increasing access to outpatient cardiac care. Further investigation is required to evaluate the effects of cardiology electronic consultation on the quality of care.

A "Hospital-Day-1" Model to Predict the Risk of Discharge to a Skilled Nursing Facility.

OBJECTIVE: To derive and validate a model to predict a patient's probability of skilled nursing facility (SNF) discharge using data available from day 1 of hospitalization. DESIGN: Using a retrospective cohort of 11,380 hospitalized patients, we obtained administrative and electronic medical data to identify predictors of SNF discharge. SETTING AND PARTICIPANTS: Single, urban academic medical center. Patients older than 50 years admitted to the medical service from July 2014 to August 2015. METHODS: Primary outcome defined as SNF discharge. We split the cohort into derivation and validation sets (80/20). We created 1000 bootstrapped samples of the derivation set and used backward selection logistic regression on each bootstrapped sample. The final model included variables selected in ≥60% of the samples. To create a point-based index, a point value was assigned to each predictor variable relative to the logistic regression coefficient. The model's discrimination, calibration, positive predictive value, and negative predictive value tested in the validation set. RESULTS: The overall frequency of SNF discharge was 12%. The final model included 11 variables. Significant demographic variables included age, marital status, insurance type, living alone, residence, and distance from hospital. The final model included 2 significant functional variables (mobility, bathing) and 3 significant clinical variables (admission mode, admission diagnosis, admission day of week). Impairment in mobility [odds ratio (OR) 1.8, 95% confidence interval (CI) 1.4-2.2] and impairment in bathing (OR 1.9, 95% CI 1.6-2.4) were both significant predictors of SNF discharge. The final model discriminated well in the validation cohort (c-statistic = 0.82) and was well calibrated. CONCLUSIONS/IMPLICATIONS: It is possible to predict the day of admission with good accuracy and clinical usability a patient's risk of SNF discharge. The ability to identify early in the hospitalization patients likely to use post-acute services has implications for clinicians, administrators, and policy makers working to improve discharge planning and care transitions.