Patterns of Digoxin Prescribing for Medicare Beneficiaries in the United States 2013-2019.

Background: Studies show that digoxin use is declining but is still prevalent. Recent data on digoxin prescription and characteristics of digoxin prescribers are unknown, which can help understand its contemporary use. Methods: Using Medicare Part D data from 2013 to 2019, we studied the change in number and proportion of digoxin prescriptions and digoxin prescribers, overall and by specialty. Using logistic regression, we identified prescriber characteristics associated with digoxin prescription. Results: From 2013 to 2019, total digoxin prescriptions (4.6 to 1.8 million) and proportion of digoxin prescribers decreased (9.1% to 4.3% overall; 26.6% to 11.8% among General Medicine prescribers and 65.4% to 48.9% among Cardiology). Of digoxin prescribers from 2013 practicing in 2019 (91.2% remained active), 59.1% did not prescribe digoxin at all, 31.7% reduced, and 9.2% maintained or increased prescriptions. The proportion of all digoxin prescriptions that were prescribed by General Medicine prescribers declined from 59.7% to 48.2% and increased for Cardiology (29% to 38.5%). Among new prescribers in 2019 (N = 85,508), only 1.9% prescribed digoxin. Digoxin prescribers when compared to non-digoxin prescribers were more likely male, graduated from medical school earlier, were located in the Midwest or South, and belonged to Cardiology (all P < .001). Conclusions: Digoxin prescriptions continue to decline with over half of 2013 prescribers no longer prescribing digoxin in 2019. This may be a result of the increasing availability of newer heart failure therapies. The decline in digoxin prescription was greater among general medicine physicians than cardiologists, suggesting a change in digoxin use to a medication prescribed increasingly by specialists.

Evaluation of Temporal Trends in Racial and Ethnic Disparities in Sleep Duration Among US Adults, 2004-2018.

Importance: Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years. Objective: To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US. Design, Setting, and Participants: This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022. Exposures: Self-reported race, ethnicity, household income, and sex. Main Outcomes and Measures: Temporal trends and racial and ethnic differences in short (<7 hours in 24 hours) and long (>9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age. Results: The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P < .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P < .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age. Conclusions and Relevance: The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.

Risk and predictors of mortality after implantable cardioverter-defibrillator implantation in patients with sarcoid cardiomyopathy.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) are recommended for patients with cardiac sarcoidosis (CS) with an indication for pacing, prior ventricular arrhythmias, cardiac arrest, or left ventricular ejection fraction <35%, but data on outcomes are limited. METHODS: Using data from the National Cardiovascular Data Registry ICD Registry between April 1, 2010 and December 31, 2015, we evaluated a propensity matched cohort of CS patients implanted with ICDs versus non-ischemic cardiomyopathies (NICM). We compared mortality using Kaplan-Meier survival curves and Cox proportional hazards models. RESULTS: We identified 1,638 patients with CS and 8,190 propensity matched patients with NICM. The rate of death at 1 and 2 years was similar in patients with CS and patients with NICM (5.2% vs 5.4%, P = 0.75 and 9.0% vs 9.3%, P = 0.72, respectively). After adjusting for other covariates, patients with CS had similar mortality at 2 years after ICD implantations compared with NICM patients (RR 1.03, 95% CI 0.87-1.23). Among patients with CS, multivariable logistic regression identified 6 factors significantly associated with increased 2-year mortality: presence of heart failure (HR 1.92, 95% CI 1.44-3.22), New York Heart Association (NYHA) Class III heart failure (HR 1.68, 95% CI 1.16-2.45), NYHA Class IV heart failure (HR 3.08, 95% CI 1.49-6.39), atrial fibrillation/flutter (HR 1.66, 95% CI 1.17-2.35), chronic lung disease (HR 1.64, 95% CI 1.17-2.29), creatinine >2.0 mg/dL (HR 4.07, 95% CI 2.63-6.30), and paced rhythm (HR 2.66, 95% CI 1.07-6.59). CONCLUSION: Mortality following ICD implantation was similar in CS patients compared with propensity matched NICM patients. Presence of heart failure, NYHA class, atrial fibrillation/flutter, chronic lung disease, renal dysfunction, and paced rhythm at time of implantation were all predictors of increased 2-year mortality among CS patients with ICDs.

Trends in Differences in Health Status and Health Care Access and Affordability by Race and Ethnicity in the United States, 1999-2018.

IMPORTANCE: The elimination of racial and ethnic differences in health status and health care access is a US goal, but it is unclear whether the country has made progress over the last 2 decades. OBJECTIVE: To determine 20-year trends in the racial and ethnic differences in self-reported measures of health status and health care access and affordability among adults in the US. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of National Health Interview Survey data, 1999-2018, that included 596 355 adults. EXPOSURES: Self-reported race, ethnicity, and income level. MAIN OUTCOMES AND MEASURES: Rates and racial and ethnic differences in self-reported health status and health care access and affordability. RESULTS: The study included 596 355 adults (mean [SE] age, 46.2 [0.07] years, 51.8% [SE, 0.10] women), of whom 4.7% were Asian, 11.8% were Black, 13.8% were Latino/Hispanic, and 69.7% were White. The estimated percentages of people with low income were 28.2%, 46.1%, 51.5%, and 23.9% among Asian, Black, Latino/Hispanic, and White individuals, respectively. Black individuals with low income had the highest estimated prevalence of poor or fair health status (29.1% [95% CI, 26.5%-31.7%] in 1999 and 24.9% [95% CI, 21.8%-28.3%] in 2018), while White individuals with middle and high income had the lowest (6.4% [95% CI, 5.9%-6.8%] in 1999 and 6.3% [95% CI, 5.8%-6.7%] in 2018). Black individuals had a significantly higher estimated prevalence of poor or fair health status than White individuals in 1999, regardless of income strata (P < .001 for the overall and low-income groups; P = .03 for middle and high-income group). From 1999 to 2018, racial and ethnic gaps in poor or fair health status did not change significantly, with or without income stratification, except for a significant decrease in the difference between White and Black individuals with low income (-6.7 percentage points [95% CI, -11.3 to -2.0]; P = .005); the difference in 2018 was no longer statistically significant (P = .13). Black and White individuals had the highest levels of self-reported functional limitations, which increased significantly among all groups over time. There were significant reductions in the racial and ethnic differences in some self-reported measures of health care access, but not affordability, with and without income stratification. CONCLUSIONS AND RELEVANCE: In a serial cross-sectional survey study of US adults from 1999 to 2018, racial and ethnic differences in self-reported health status, access, and affordability improved in some subgroups, but largely persisted.

Characteristics of cardiac catheterization laboratory directors at the 2017 U.S. News & World Report top 100 U.S. cardiovascular hospitals.

INTRODUCTION: The cardiac catheterization laboratory (CCL) is a focal point for cardiovascular programs and the CCL director represents the key personnel. We outline profiles of CCL directors at the 2017 U.S. News & World Report top 100 U.S. cardiovascular hospitals. METHODS: Using hospital websites, LinkedIn, Healthgrades, Medicare Provider Utilization and Payment Data 2017, and Scopus, we described CCL directors (in 2017) by age, gender, years since medical graduation, international medical school graduate (IMG) status, academic rank, provider clinical focus, and Hirsch (h)-index. RESULTS: Nearly all CCL directors were male (97%). The median age (interquartile range [IQR]) was 53 (49-61) years and median (IQR) years since medical school graduation was 28 (23-35) years. Over a third of CCL directors (39.4%) were IMGs and 38.4% had completed fellowship training at the same facility where they were CCL director. The median (IQR) h-index was 11 (6-22). Of the 69.7% CCL directors who held faculty positions, 60.9% were professors and 30.4% were associate professors. From Medicare data, 45.5% performed only percutaneous coronary interventions, 41.4% performed structural interventions, 3.0% peripheral interventions, and 2.0% performed both structural and peripheral. CCL directors at the top 25 hospitals had higher h-indexes, and more likely to have completed fellowship training at their own institution. CONCLUSIONS: There are very few women CCL directors at the top U.S. cardiovascular hospitals. A third of the CCL directors were IMGs. A significant proportion of CCL directors primarily performed structural interventions and trained at the same institution, more so at the top 25 hospitals.

A neuromuscular-based analysis of the open payments program.

INTRODUCTION: In August 2013, the Centers for Medicare and Medicaid Services (CMS) Open Payments Program (OPP) made eligible payment information publicly available. Data about industry payments to neuromuscular neurologists are lacking. METHOD: Financial relationships were investigated between industry and US neuromuscular neurologists from January 2014 through December 2018 using the CMS OPP database. RESULTS: The total annual payments increased more than 6-fold during the study period. The top 10% of physician-beneficiaries collected 80% to 90% of total industry payments except in 2014. In 2018, the most common drugs associated with payments to neuromuscular neurologists were nusinersen, vortioxetine, eteplirsen, alglucosidase alpha, edaravone, and intravenous immunoglobulin. DISCUSSION: A substantial increase in the annual payments to neuromuscular physicians during the study period is likely due to the development of new treatments, including gene therapy.

Paclitaxel-coated devices in the treatment of femoropopliteal stenosis among patients ≥65 years old: An ACC PVI Registry Analysis.

BACKGROUND: The connection between paclitaxel-coated devices (PCD) use during peripheral vascular interventions (PVI) and mortality is debated. We aimed to analyze patterns of PCD use and the safety and effectiveness of PCD use in the superficial femoral and/or popliteal arteries. METHODS: Patients undergoing PVI of femoropopliteal lesions with and without PCD between January 1, 2015 and June 30, 2017 were compared using the American College of Cardiology's National Cardiovascular Data Registry PVI Registry. Outcomes were derived from Centers for Medicare & Medicaid claims data. The primary outcome was all-cause mortality at 6-, 12-, and 24-months following PVI. Inverse probability weighting and frailty models were used to assess the differences between groups. The analysis was IRB-approved. RESULTS: In the overall cohort consisting of 6,302 femoropopliteal PVIs, PCD-PVI patients were more likely to be treated for claudication (63.5% vs 51.3%, P< .001), less likely to have a chronic total occlusion (24.6% vs 34.7%, P < .001), and more likely to be treated in certain geographic and practice settings. In the analytic cohort consisting of 1,666 femoropopliteal PVIs with linked claims outcomes (888 PCD-PVI, 53.3%), unadjusted rates of all outcomes were lower in PCD-PVI patients. After adjustment, there were no significant differences in mortality following PCD-PVI versus non-PCD PVI at 1 year (adjusted RR 0.78, 95% CI 0.60-1.01, P= .055) or 2 years (aRR 0.98, 95% CI 0.77-1.24, P= .844). CONCLUSION: There were significant differences between the patients in whom and settings in which PCD-PVI was versus was not used. PCD-PVI was not associated with an increased risk of 2-year mortality in real-world use.

Analysis of payments to GI physicians in the United States: Open payments data study.

BACKGROUND AND AIM: The purpose of this study was to review and analyze the nature of industry payments to gastroenterology and hepatology (GI) physicians. METHODS: We conducted a retrospective study of open payments (OP) data for the year 2017. Payments to individual physicians were aggregated using a unique physician profile identification number. General payments to Centers for Medicare and Medicaid Services regions were also analyzed. The nature of financial transactions in general payments was reported overall and per physician payment. Research, ownership, and general payments were aggregated and analyzed by drug/device companies. RESULTS: During the study period, more GI physicians received contributions in the form of general payments compared to ownership or research payments. A small percentage of physicians received contributions greater than $100 000. The most frequent contributions were for food and beverages. Only 10 manufacturers made about 71% ($43 271 938) of general payments. CONCLUSIONS: We found that only a small number of GI physicians received a significant portion of industry payments. A large portion of those payments came from drug or device companies. The impact of these payments on gastroenterologists needs to be examined further.

Racial and Ethnic Disparities in Health of Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.

IMPORTANCE: Thirty-five years ago, the Heckler Report described health disparities among minority populations in the US. Since then, policies have been implemented to address these disparities. However, a recent evaluation of progress towards improving the health and health equity among US adults is lacking. OBJECTIVES: To evaluate racial/ethnic disparities in the physical and mental health of US adults over the last 2 decades. DESIGN: Cross-sectional. SETTING: National Health Interview Survey data, years 1999-2018. PARTICIPANTS: Adults aged 18-85 years. EXPOSURE: Race/ethnicity subgroups (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic). MAIN OUTCOME AND MEASURES: Proportion of adults reporting poor/fair health status, severe psychological distress, functional limitation, and insufficient sleep. We also estimated the gap between non-Hispanic White and the other subgroups for these four outcomes. RESULTS: We included 596,355 adults (mean age 46 years, 51.8% women), of which 69.7%, 13.8%, 11.8% and 4.7% identified as non-Hispanic White, Hispanic, non-Hispanic Black, and non-Hispanic Asian, respectively. Between 1999 and 2018, Black individuals fared worse on most measures of health, with 18.7% (95% CI 17.1-20.4) and 41.1% (95% CI 38.7-43.5) reporting poor/fair health and insufficient sleep in 2018 compared with 11.1% (95% CI 10.5- 11.7) and 31.2% (95% CI 30.3-32.1) among White individuals. Notably, between 1999-2018, there was no significant decrease in the gap in poor/fair health status between White individuals and Black (-0.07% per year, 95% CI -0.16-0.01) and Hispanic (-0.03% per year, 95% CI -0.07- 0.02) individuals, and an increase in the gap in sleep between White individuals and Black (+0.2% per year, 95% CI 0.1-0.4) and Hispanic (+0.3% per year, 95% CI 0.1-0.4) individuals. Additionally, there was no significant decrease in adults reporting poor/fair health status and an increase in adults reporting severe psychological distress, functional limitation, and insufficient sleep. CONCLUSIONS AND RELEVANCE: The marked racial/ethnic disparities in health of US adults have not improved over the last 20 years. Moreover, the self-perceived health of US adults worsened during this time. These findings highlight the need to re-examine the initiatives seeking to promote health equity and improve health.

Racial and Ethnic Disparities in Access to Health Care Among Adults in the United States: A 20-Year National Health Interview Survey Analysis, 1999-2018.

IMPORTANCE: Racial and ethnic disparities plague the US health care system despite efforts to eliminate them. To understand what has been achieved amid these efforts, a comprehensive study from the population perspective is needed. OBJECTIVES: To determine trends in rates and racial/ethnic disparities of key access to care measures among adults in the US in the last two decades. DESIGN: Cross-sectional. SETTING: Data from the National Health Interview Survey, 1999-2018. PARTICIPANTS: Individuals >18 years old. EXPOSURE: Race and ethnicity: non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, Hispanic. MAIN OUTCOME AND MEASURES: Rates of lack of insurance coverage, lack of a usual source of care, and foregone/delayed medical care due to cost. We also estimated the gap between non-Hispanic White and the other subgroups for these outcomes. RESULTS: We included 596,355 adults, of which 69.7% identified as White, 11.8% as Black, 4.7% as Asian, and 13.8% as Hispanic. The proportion uninsured and the rates of lacking a usual source of care remained stable across all 4 race/ethnicity subgroups up to 2009, while rates of foregone/delayed medical care due to cost increased. Between 2010 and 2015, the percentage of uninsured diminished for all, with the steepest reduction among Hispanics (-2.1% per year). In the same period, rates of no usual source of care declined only among Hispanics (-1.2% per year) while rates of foregone/delayed medical care due to cost decreased for all. No substantial changes were observed from 2016-2018 in any outcome across subgroups. Compared with 1999, in 2018 the rates of foregone/delayed medical care due to cost were higher for all (+3.1% among Whites, +3.1% among Blacks, +0.5% among Asians, and +2.2% among Hispanics) without significant change in gaps; rates of no usual source of care were not significantly different among Whites or Blacks but were lower among Hispanics (-4.9%) and Asians (-6.4%). CONCLUSIONS AND RELEVANCE: Insurance coverage increased for all, but millions of individuals remained uninsured or underinsured with increasing rates of unmet medical needs due to cost. Those identifying as non-Hispanic Black and Hispanic continue to experience more barriers to health care services compared with non-Hispanic White individuals. KEY POINTS: Question: In the last 2 decades, what has been achieved in reducing barriers to access to care and race/ethnicity-associated disparities?Findings: Using National Health Interview Survey data from 1999-2018, we found that insurance coverage increased across all 4 major race/ethnicity groups. However, rates of unmet medical needs due to cost increased without reducing the respective racial/ethnic disparities, and little-to-no change occurred in rates of individuals who have no usual source of care.Meaning: Despite increased coverage, millions of Americans continued to experience barriers to access to care, which were disproportionately more prevalent among those identifying as Black or Hispanic.

Association Between Industry Payments to Physicians and Device Selection in ICD Implantation.

Importance: Little is known about the association between industry payments and medical device selection. Objective: To examine the association between payments from device manufacturers to physicians and device selection for patients undergoing first-time implantation of a cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D). Design, Setting, and Participants: In this cross-sectional study, patients who received a first-time ICD or CRT-D device from any of the 4 major manufacturers (January 1, 2016-December 31, 2018) were identified. The data from the National Cardiovascular Data Registry ICD Registry was linked with the Open Payments Program's payment data. Patients were categorized into 4 groups (A, B, C, and D) corresponding to the manufacturer from which the physician who performed the implantation received the largest payment. For each patient group, the proportion of patients who received a device from the manufacturer that provided the largest payment to the physician who performed implantation was determined. Within each group, the absolute difference in proportional use of devices between the manufacturer that made the highest payment and the proportion of devices from the same manufacturer in the entire study cohort (expected prevalence) was calculated. Exposures: Manufacturers' payments to physicians who performed an ICD or CRT-D implantation. Main Outcomes and Measures: The primary outcome of the study was the manufacturer of the device used for the implantation. Results: Over a 3-year period, 145 900 patients (median age, 65 years; 29.6% women) received ICD or CRT-D devices from the 4 manufacturers implanted by 4435 physicians at 1763 facilities. Among these physicians, 4152 (94%) received payments from device manufacturers ranging from $2 to $323 559 with a median payment of $1211 (interquartile range, $390-$3702). Between 38.5% and 54.7% of patients received devices from the manufacturers that had provided physicians with the largest payments. Patients were substantially more likely to receive devices made by the manufacturer that provided the largest payment to the physician who performed implantation than they were from each other individual manufacturer. The absolute differences in proportional use from the expected prevalence were 22.4% (95% CI, 21.9%-22.9%) for manufacturer A; 14.5% (95% CI, 14.0%-15.0%) for manufacturer B; 18.8% (95% CI, 18.2%-19.4%) for manufacturer C; and 30.6% (95% CI, 30.0%-31.2%) for manufacturer D. Conclusions and Relevance: In this cross-sectional study, a large proportion of ICD or CRT-D implantations were performed by physicians who received payments from device manufacturers. Patients were more likely to receive ICD or CRT-D devices from the manufacturer that provided the highest total payment to the physician who performed an ICD or CRT-D implantation than each other manufacturer individually.

Survival Following Implantable Cardioverter-Defibrillator Implantation in Patients With Amyloid Cardiomyopathy.

Background Outcomes data in patients with cardiac amyloidosis after implantable cardioverter-defibrillator (ICD) implantation are limited. We compared outcomes of patients with ICDs implanted for cardiac amyloidosis versus nonischemic cardiomyopathies (NICMs) and evaluated factors associated with mortality among patients with cardiac amyloidosis. Methods and Results Using National Cardiovascular Data Registry's ICD Registry data between April 1, 2010 and December 31, 2015, we created a 1:5 propensity-matched cohort of patients implanted with ICDs with cardiac amyloidosis and NICM. We compared mortality between those with cardiac amyloidosis and matched patients with NICM using Kaplan-Meier survival curves and Cox proportional hazards models. We also evaluated risk factors associated with 1-year mortality in patients with cardiac amyloidosis using multivariable Cox proportional hazards regression models. Among 472 patients with cardiac amyloidosis and 2360 patients with propensity-matched NICMs, 1-year mortality was significantly higher in patients with cardiac amyloidosis compared with patients with NICMs (26.9% versus 11.3%, P<0.001). After adjustment for covariates, cardiac amyloidosis was associated with a significantly higher risk of all-cause mortality (hazard ratio [HR], 1.80; 95% CI, 1.56-2.08). In a multivariable analysis of patients with cardiac amyloidosis, several factors were significantly associated with mortality: syncope (HR, 1.78; 95% CI, 1.22-2.59), ventricular tachycardia (HR, 1.65; 95% CI, 1.15-2.38), cerebrovascular disease (HR, 2.03; 95% CI, 1.28-3.23), diabetes mellitus (HR, 1.55; 95% CI, 1.05-2.27), creatinine = 1.6 to 2.5 g/dL (HR, 1.99; 95% CI, 1.32-3.02), and creatinine >2.5 (HR, 4.34; 95% CI, 2.72-6.93). Conclusions Mortality after ICD implantation is significantly higher in patients with cardiac amyloidosis than in patients with propensity-matched NICMs. Factors associated with death among patients with cardiac amyloidosis include prior syncope, ventricular tachycardia, cerebrovascular disease, diabetes mellitus, and impaired renal function.

Switching warfarin to direct oral anticoagulants in atrial fibrillation: Insights from the NCDR PINNACLE registry.

BACKGROUND: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. HYPOTHESIS: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC. METHODS: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed. RESULTS: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P < .001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA2 DS2 -VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10-1.13 per 1-point increase HAS-BLED). There was substantial variation at the practice-level (MOR, 2.33; 95%CI, 2.12-2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43-1.49). CONCLUSIONS: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.

Industry Payment to Vascular Neurologists: A 6-Year Analysis of the Open Payments Program From 2013 Through 2018.

Background and Purpose- Industry payments to physicians raise concerns regarding conflicts of interest that could impact patient care. We explored nonresearch and nonownership payments from industry to vascular neurologists to identify trends in compensation. Methods- Using Centers for Medicare and Medicaid Services and American Board of Psychiatry and Neurology data, we explored financial relationships between industry and US vascular neurologists from 2013 to 2018. We analyzed payment characteristics, including payment categories, payment distribution among physicians, regional trends, and biomedical manufacturers. Furthermore, we analyzed the top 1% (by compensation) of vascular neurologists with detailed payment categories, their position, and their contribution to stroke guidelines. Results- The number of board certified vascular neurologist increased from 1169 in 2013 to 1746 in 2018. The total payments to vascular neurologist increased from $99 749 in 2013 to $1 032 302 in 2018. During the study period, 16% to 17% of vascular neurologists received industry payments. Total payments from industry and mean physician payments increased yearly over this period, with consulting fee (31.1%) and compensation for services other than consulting (30.7%) being the highest paid categories. The top 10 manufacturers made the majority of the payments, and the top 10 products changed from drug or biological products to devices. Physicians from south region of the United States received the highest total payment (38.72%), which steadily increased. Payments to top 1% vascular neurologists increased from 64% to 79% over the period as payments became less evenly distributed. Among the top 1%, 42% specialized in neuro intervention, 11% contributed to American Heart Association/American Stroke Association guidelines, and around 75% were key leaders in the field. Conclusions- A small proportion of US vascular neurologists consistently received the majority of industry payments, the value of which grew over the study period. Only 11% of the top 1% receiving industry payments have authored American Heart Association/American Stroke Association guidelines, but ≈75% seem to be key leaders in the field. Whether this influences clinical practice and behavior requires further investigation.

The National Institutes of Health funding for clinical research applying machine learning techniques in 2017.

Machine learning (ML) techniques have become ubiquitous and indispensable for solving intricate problems in most disciplines. To determine the extent of funding for clinical research projects applying ML techniques by the National Institutes of Health (NIH) in 2017, we searched the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER) system using relevant keywords. We identified 535 projects, which together received a total of $264 million, accounting for 2% of the NIH extramural budget for clinical research.

Patient and hospital characteristics associated with ticagrelor uptake in acute MI: An analysis of the Chest Pain-MI Registry.

BACKGROUND: ACC/AHA guidelines support the use of the P2Y12 inhibitors clopidogrel, prasugrel, or ticagrelor in acute myocardial infarction (AMI). Little is known about trends in P2Y12 inhibitor selection over time. METHODS: Multicenter, longitudinal analysis of patients and hospitals in the National Cardiovascular Data Registry (NCDR) Chest Pain - MI Registry from the third quarter of 2013 to the first quarter of 2017. RESULTS: A total of 362,354 AMI patients treated at 801 hospitals were included in our analysis. Ticagrelor use increased over time, from 6.1% in 2013 to 33.7% in 2017, with corresponding reductions in the use of clopidogrel and prasugrel (p < 0.001 for all trends). In multivariable models, patients of white race, with private insurance, or STEMI were more likely to receive ticagrelor (p < 0.05 for all). Hospitals in the highest quartile of ticagrelor uptake had use rates ranging from 29% to 88%, and were more likely to have the lowest volume of MI patients. The correlation between prasugrel and ticagrelor adoption was weakly positive (correlation coefficient: 0.15, p = 0.004); hospitals with the lowest early adoption of prasugrel started with the lowest rate of ticagrelor use and had the slowest rate of increase in ticagrelor use. CONCLUSIONS: There has been a rapid increase in use of ticagrelor since its approval by the FDA and both patient and hospital characteristics were associated with variation in its adoption and utilization. Further examination of the characteristics associated with the rapid adoption of new evidence may provide insights about improving health system performance.

Association of cardiovascular risk factor profile and financial hardship from medical bills among non-elderly adults in the United States.

BACKGROUND: While optimal cardiovascular risk factor (CRF) profile is associated with lower mortality, morbidity, and healthcare expenditures among individuals with atherosclerotic cardiovascular disease (ASCVD), less is known regarding its impact on financial hardship from medical bills. Therefore, we assessed whether an optimal CRF profile is associated with a lower burden of financial hardship from medical bills and a reduction in cost-related barriers to health. METHODS: We used a nationally representative sample of adults between 18 and 64 years from the National Health Interview Survey between 2013 and 2017. We assessed ASCVD status and the number of risk factors to categorize the study population into 4 mutually exclusive categories: ASCVD (irrespective of CRF profile) and non-ASCVD with poor, average, and optimal CRF profile. Adjusted logistic regression model was used to determine the association of ASCVD/CRF profile with financial hardship from medical bills and cost-related barriers to health (cost-related medication non-adherence (CRN), foregone/delayed care, and high financial distress). RESULTS: We included 119,388 non-elderly adults, representing 189 million individuals annually across the United States. Non-ASCVD/optimal CRF profile individuals had a lower prevalence of financial hardship and an inability paying medical bills when compared with individuals with ASCVD (24% vs 45% and 6% vs 19%, respectively). Among individuals without ASCVD and an optimal CRF profile, the prevalence of each cost-related barrier to health was <50% compared with individuals with ASCVD. Poor/low income and uninsured individuals within non-ASCVD/average CRF profile strata had a lower prevalence of financial hardship and an inability paying medical bills when compared with middle/high income and insured individuals with ASCVD. Non-ASCVD individuals with optimal CRF profile had the lowest odds of all barriers to health. CONCLUSION: Optimal CRF profile is associated with a lower prevalence of financial hardship from medical bills and cost-related barriers to health despite lower income and lack of insurance.

Trends in Performance and Opportunities for Improvement on a Composite Measure of Acute Myocardial Infarction Care.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P<0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P<0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P<0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P<0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P<0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.