Prescribing of Proton Pump Inhibitors for Prevention of Upper Gastrointestinal Bleeding in US Outpatient Visits.

Antisecretory medications, primarily proton pump inhibitors (PPIs), have proven effective in reducing upper gastrointestinal toxicities, including upper gastrointestinal bleeding (UGIB), associated with nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin, which are among the most commonly used medications in the United States.1 Accordingly, professional guidance recommends PPIs for patients at high risk for UGIB.2-4 However, little is known about trends in use of antisecretory medications for gastrointestinal prophylaxis ("gastroprotection"). Herein, we examined contemporary use and prescribing of antisecretory medications in visits by patients at high risk for UGIB, relative to visits by patients diagnosed with acid-related disorders.

Student-directed interactive animation for learning cytochrome P450-mediated drug metabolism.

INTRODUCTION: In this study, we introduced a student self-directed interactive animation tool created to enhance student understanding of cytochrome P450 (CYP450) mediated drug metabolism. METHODS: The online learning tool was constructed in HTML5 computer code. It was implemented over four years in a second year pharmacy degree course where CYP450 metabolism was taught. Assessment was by comparing test scores of students using the learning tool with a previous class that did not and through survey data from the student users. RESULTS: Use of the Cyber-CYP learning tool enhanced test performance on CYP450 metabolism-related questions in all years tested. Survey responses indicated that the learning tool was easy to use and facilitated student learning of CYP450-mediated drug metabolism. CONCLUSIONS: This study has shown that complex and dynamic processes, such as CYP450 metabolism, can be more effectively communicated using student-centered, self-paced and interactive animations.

The impact of p53 on the early stage replication of retrovirus.

BACKGROUND: The function of p53 in cancer biology has been studied extensively, but its role in anti-retrovirus infection has been elusive for many years. The restriction of retrovirus early stage replication by p53 was investigated in this study. METHOD: VSV-G pseudotyped retrovirus with GFP reporter gene was used to infect both HCT116 p53+/+ cells and its isogenic p53 knockout HCT116 p53-/- cells. The infection was detected by flow cytometry. Reverse transcription products were quantified by real time PCR. Mutation analysis was performed after 1-LTR cycle and 2-LTR cycle DNA were amplified and PCR products were sequenced. Transcription and translation of cyclin-dependent kinase inhibitor 1 (p21Cip1) and SAM domain and HD domain-containing protein 1 (SAMHD1) were analyzed by TaqMan PCR and Western blot experiments. siRNA experiment was applied to study the role of p53 downstream gene p21Cip1 in the restriction of retrovirus infection. RESULTS: It was found that the block of retrovirus infection in non-cycling cells was significantly attenuated in HCT116 p53-/- cells when compared to HCT116 p53+/+ cells. It was found that both late reverse transcription products and viral 2-LTR cycle DNA were significantly increased in infected non-cycling HCT116 p53-/- cells. Furthermore, the mutation frequency detected in 1-LTR DNA from HCT116 p53+/+ cells were significantly decreased in comparison to HCT116 p53-/- cells. A higher number of insertion and deletion mutations were detected in the joint region of 2-LTR cycle DNA in infected p53+/+ cells. Cell cycle analysis showed retrovirus infection promoted host cell replication. Higher levels of mRNA and protein of p21Cip1 were found in HCT116 p53+/+ cells in comparison to the HCT116 p53-/- cells. Furthermore, knockdown of p21Cip1 in non-cycling HCT116 p53+/+ cells significantly increased the infection. CONCLUSIONS: The results of this study showed that p53 is an important restriction factor that interferes with retrovirus infection in its early stage of replication. Our results suggested that p53 mediates the inhibition of retrovirus infection in non-cycling cells through it downstream gene p21Cip1, and p53 also functions to influence formation of 1-LTR cycle and 2-LTR cycle DNA.

Disparities in the Use of Drug-Eluting Coronary Stents by Race, Ethnicity, Payer, and Hospital.

BACKGROUND: Many studies have shown that drug-eluting stents (DESs) are associated with better outcomes for patients receiving coronary stents, and earlier studies showed disparities in use by race and payer. It is of interest to know whether these differences persist in an era of higher use of DESs and to examine DES use differences across providers. METHODS: New York State's percutaneous coronary intervention registry was used to identify significant predictors of DES vs bare-metal stent use among patients receiving stents, including race, ethnicity, sex, payer, and numerous patient clinical risk factors in 2011-2012. Variations in DES use across hospitals and operators were also examined. RESULTS: African Americans (adjusted odds ratio [AOR], 0.70; 95% confidence interval [CI], 0.66-0.75) and Hispanics (AOR, 0.80; 95% CI, 0.74-0.85) were less likely to receive DESs than their counterparts. Patients with private insurance were more likely to receive DESs than patients in all other payer categories. More than one third of the 60 hospitals in the study had significantly lower adjusted use of DESs than the mean rate of 83%. For these hospitals, adjusted rates ranged from 52%-80%, and 5 of these hospitals had adjusted rates < 70%. Twenty-five percent of the total variation in the use of DESs was related to differences across hospitals that were unrelated to patient characteristics. CONCLUSIONS: Disparities by race, ethnicity, and insurance status persist in the use of DESs among patients receiving coronary stents. There are also large differences in use among hospitals that are unrelated to patient clinical characteristics and demographics.

Lactate dehydrogenase as a biomarker for early renal damage in patients with sickle cell disease.

Among many complications of sickle cell disease, renal failure is the main contributor to early mortality. It is present in up to 21% of patients with sickle cell disease. Although screening for microalbuminuria and proteinuria is the current acceptable practice to detect and follow renal damage in patients with sickle cell disease, there is a crucial need for other, more sensitive biomarkers. This becomes especially true knowing that those biomarkers start to appear only after more than 60% of the kidney function is lost. The primary purpose of this study is to determine whether lactate dehydrogenase (LDH) correlates with other, direct and indirect bio-markers of renal insufficiency in patients with sickle cell disease and, therefore, could be used as a biomarker for early renal damage in patients with sickle cell disease. Fifty-five patients with an established diagnosis of sickle cell disease were recruited to in the study. Blood samples were taken and 24-h urine collection samples were collected. Using Statcrunch, a data analysis tool available on the web, we studied the correlation between LDH and other biomarkers of kidney function as well as the distribution and relationship between the variables. Regression analysis showed a significant negative correlation between serum LDH and creatinine clearance, R (correlation coefficient) = -0.44, P = 0.0008. This correlation was more significant at younger age. This study shows that in sickle cell patients LDH correlates with creatinine clearance and, therefore, LDH could serve as a biomarker to predict renal insufficiency in those patients.

Effect of Vitamin D Supplementation on Glucose Control and Inflammatory Response in Type II Diabetes: A Double Blind, Randomized Clinical Trial.

BACKGROUND: Diabetes mellitus (DM) and vitamin D deficiency are major health concerns around the world. Evidence suggests a possible role of vitamin D in improvement of insulin secretion and sensitivity. OBJECTIVES: We assessed whether vitamin D supplementation could be used in vitamin D deficient-type II diabetes to improve glucose metabolism, components of metabolic syndrome (MetS) and specific inflammatory biomarkers. PATIENTS AND METHODS: A double blind, randomized clinical trial was conducted in King Khalid University Hospital, Saudi Arabia to evaluate the effect of cholecalciferol supplementation on glycemic control, MetS components and specific inflammatory biomarkers including tumor necrosis factor-alpha (TNF-α), Interleukin (IL-6), leptin, adiponectin and vascular cell adhesion molecule-1 (VCAM-1). Twenty-two patients with type II diabetes with insulin resistance, glycated hemoglobin (HbA1c) ≥ 6 (42 mmol/mol) and serum 25(OH)D < 50 nmol/L were randomized using a computer program to receive either supplementation with cholecalciferol (5000 IU/day) or placebo for 12 weeks. The primary outcome was change in HbA1c levels from baseline. RESULTS: Median [IQR] 25(OH)D levels increased significantly in the vitamin D group as 58.1 [48, 67.3] nmol/L (P = 0.002). There was no significant difference in the change of HbA1c between the groups (P = 0.5) with a decrease of -0.1% [-1, 0.5] in the vitamin D group and an increase of 0.15% [0.1, 0.2] in the placebo group. A significant improvement was observed in the homeostasis model of assessment of ß-cell activity (HOMA-%B) (P = 0.03) with vitamin D supplementation compared to baseline. CONCLUSIONS: Vitamin D repletion for 12 weeks increased serum vitamin D concentrations and improved ß-cell activity in vitamin D-deficient type II diabetes with no significant changes in HbA1c or insulin sensitivity.

Anti-metastasis efficacy and safety of non-anticoagulant heparin derivative versus low molecular weight heparin in surgical pancreatic cancer models.

Heparin and its derivatives are known to attenuate cancer metastasis in preclinical models, but have not been used clinically due to adverse bleeding effects. This study compared the efficacy of S-NACH (a sulfated non-anticoagulant heparin) versus tinzaparin (a low molecular weight heparin) in inhibiting metastasis of a growing primary tumor and following surgical excision of primary tumor in a pancreatic cancer mouse model. The efficacy of S-NACH versus tinzaparin on metastasis of the primary tumor was evaluated in each experiment using IVIS imaging. Athymic female mice were treated with S-NACH or tinzaparin, and 30 min later luciferase-transfected pancreatic cancer cells (Mpanc96) were implanted into the spleen; treatment was continued daily until termination. Next we studied the effect of S-NACH versus tinzaparin on metastasis after surgical excision of the primary tumor after 3 weeks of daily treatment with S-NACH or tinzaparin. S-NACH reduced surgically induced metastasis (p<0.01) and tumor recurrence (p<0.05) relative to control. Histopathological studies demonstrated significant increase in tumor necrosis mediated by S-NACH and to lesser extent by tinzaparin as compared to control group. Furthermore, either S-NACH or tinzaparin upregulated the expression of the junctional adhesion molecule E-cadherin in pancreatic cancer cells where its low expression enhances cancer cell migration and invasion. In terms of bleeding time (BT), S-NACH did not affect BT as compared to tinzaparin, which doubled BT. These data suggest that S-NACH is an effective and safe anti-metastatic agent and warrants further clinical evaluation.

Risk score for predicting in-hospital/30-day mortality for patients undergoing valve and valve/coronary artery bypass graft surgery.

BACKGROUND: Risk scores are simplified linear formulas for predicting mortality or other adverse outcomes at the bedside without personal digital assistants or calculators. Although risk scores are available for valve surgery, they do not predict short-term mortality (within 30 days of surgery) after hospital discharge. METHODS: New York's Cardiac Surgery Reporting System 2007 to 2009 data were matched to vital statistics data to identify valve surgery with and without concomitant coronary artery bypass graft (CABG) surgery deaths occurring in the index admission or within 30 days after the procedure in any location. Risk scores were created to easily predict these outcomes by modifying more complicated logistic regression models. RESULTS: There were 13,455 isolated valve surgery patients and 8,373 valve/CABG surgery patients in the study. The respective in-hospital/30-day mortality rates were 4.03% and 6.60%. There are 11 risk factors comprising the isolated valve surgery score, with risk factor scores ranging from 1 to 8, and the highest observed total score is 28. There are 14 risk factors comprising the valve/CABG surgery score, with risk factor scores ranging from 1 to 6, and the highest observed total score is 19. The scores accurately predicted mortality in 2007 to 2009 as well as in 2004 to 2006, and were strongly correlated with complications and length of stay. CONCLUSIONS: The risk scores that were developed provide quick and accurate estimates of patients' chances of short-term mortality after cardiac valve surgery.

Out-of-hospital deaths within 30 days following hospitalization where percutaneous coronary intervention was performed.

Much has been learned about predictors of in-hospital death after percutaneous coronary intervention (PCI), but little is known about the predictors of short-term death after discharge. This is particularly important for PCI, with its short postprocedural hospitalization and concern about postprocedural events such as stent thrombosis and need for emergency cardiac surgery. The focus of this study was all 51,695 patients who underwent PCI in New York State from January 1, 2007, and December 31, 2007, who were discharged alive by December 31, 2007. All patients were followed for 30 days after discharge to determine if they died after discharge within 30 days. The in-hospital and 30-day mortality rate for PCI patients was 0.94%, the in-hospital mortality rate was 0.56%, and the mortality rate for deaths that occurred after discharge within 30 days of the procedure was 0.38%. Of the PCI deaths that occurred either in the index admission or after discharge within 30 days, 40.5% occurred after discharge. The percentage of short-term (in-hospital or within 30 days) deaths in hospitals with ≥10 short-term deaths ranged from 15% to 71%. In conclusion, compared to PCI patients dying in the index admission, patients who died <30 days after discharge were younger, had better ventricular function, were less likely to have had recent myocardial infarctions, and were less likely to have had postprocedural complications. Most deaths in the 30-day group were cardiovascular, and most were cardiac and acute. A small percentage were related to chronic cardiac disease or to vascular disease.

Risk factors for coronary artery bypass graft chest surgical site infections in New York State, 2008.

BACKGROUND: All hospitals in New York State (NYS) are required to report surgical site infections (SSIs) occurring after coronary artery bypass graft surgery. This report describes the risk adjustment method used by NYS for reporting hospital SSI rates, and additional methods used to explore remaining differences in infection rates. METHODS: All patients undergoing coronary artery bypass graft surgery in NYS in 2008 were monitored for chest SSI following the National Healthcare Safety Network protocol. The NYS Cardiac Surgery Reporting System and a survey of hospital infection prevention practices provided additional risk information. Models were developed to standardize hospital-specific infection rates and to assess additional risk factors and practices. RESULTS: The National Healthcare Safety Network risk score based on duration of surgery, American Society of Anesthesiologists score, and wound class were not highly predictive of chest SSIs. The addition of diabetes, obesity, end-stage renal disease, sex, chronic obstructive pulmonary disease, and Medicaid payer to the model improved the discrimination between procedures that resulted in SSI and those that did not by 25%. Hospital-reported infection prevention practices were not significantly related to SSI rates. CONCLUSIONS: Additional risk factors collected using a secondary database improved the prediction of SSIs, however, there remained unexplained variation in rates between hospitals.

Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice?

BACKGROUND: The American College of Cardiology and the American Heart Association have issued guidelines for the use of coronary artery bypass graft surgery (CABG) and percutaneous coronary interventions (PCI) for many years, but little is known about the impact of these evidence-based guidelines on referral decisions. METHODS AND RESULTS: A cardiac catheterization laboratory database used by 19 hospitals in New York State was used to identify treatment (CABG surgery, PCI, medical treatment, or nothing) recommended by the catheterization laboratory cardiologist for patients undergoing catheterization with asymptomatic/mild angina, stable angina, and unstable angina/non-ST-elevation myocardial infarction between January 1, 2005, and August 31, 2007. The recommended treatment was compared with indications for these patients based on American College of Cardiology/American Heart Association guidelines. Of the 16 142 patients undergoing catheterization who were found to have coronary artery disease, the catheterization laboratory cardiologist was the final source of recommendation for 10 333 patients (64%). Of these 10 333 patients, 13% had indications for CABG surgery, 59% for PCI, and 17% for both CABG surgery and PCI. Of the patients who had indications for CABG surgery, 53% were recommended for CABG and 34% for PCI. Of the patients with indications for PCI, 94% were recommended for PCI. For the patients who had indications for both CABG surgery and PCI, 93% were recommended for PCI and 5% for CABG surgery. Catheterization laboratory cardiologists in hospitals with PCI capability were more likely to recommend patients for PCI than hospitals in which only catheterization was performed. CONCLUSIONS: Patients with coronary artery disease receive more recommendations for PCI and fewer recommendations for CABG surgery than indicated in the American College of Cardiology/American Heart Association guidelines.

Outcomes for patients with ST-elevation myocardial infarction in hospitals with and without onsite coronary artery bypass graft surgery: the New York State experience.

BACKGROUND: The benefit of primary percutaneous coronary interventions (P-PCI) for patients with ST-elevation myocardial infarction (STEMI) has been well documented. However, controversy still exists as to whether PCI should be expanded to hospitals without coronary artery bypass graft surgery. METHODS AND RESULTS: Patients who were discharged after PCI for STEMI between January 1, 2003, and December 12, 2006, in P-PCI centers (hospitals with no coronary artery bypass graft surgery, and PCI only for patients with STEMI) were propensity matched with patients in full service centers, and mortality and subsequent revascularization rates were compared. For patients undergoing PCI, there were no differences for in-hospital/30-day mortality (2.3% for P-PCI centers versus 1.9% for full service centers [P=0.40]), emergency coronary artery bypass graft surgery immediately after PCI (0.06% versus 0.35%, P=0.06), 3-year mortality (7.1% versus 5.9%, P=0.07), or 3-year subsequent revascularization (23.8% versus 21.5%, P=0.52). P-PCI centers had a lower same/next day coronary artery bypass graft rate (0.23% versus 0.69%, P=0.046) and higher repeat target vessel PCI rates (12.1% versus 9.0%, P=0.003). For patients with STEMI who did not undergo PCI, P-PCI centers had higher in-hospital mortality (28.5% versus 22.3%; adjusted odds ratio, 1.38; 95% CI, 1.10 to 1.75). CONCLUSIONS: No differences between P-PCI centers and full service centers were found in in-hospital/30-day mortality, the need for emergency surgery, 3-year mortality or subsequent revascularization, but P-PCI centers had higher repeat target vessel PCI rates and higher mortality rates for patients who did not undergo PCI. P-PCI centers should be monitored closely, including the monitoring of patients with STEMI who did not undergo PCI.

Safety and efficacy of drug-eluting and bare metal stents: comprehensive meta-analysis of randomized trials and observational studies.

BACKGROUND: The safety and efficacy of drug-eluting stents (DES) among more generalized "real-world" patients than those enrolled in pivotal randomized controlled trials (RCTs) are controversial. We sought to perform a meta-analysis of DES studies to estimate the relative impact of DES versus bare metal stents (BMS) on safety and efficacy end points, particularly for non-Food and Drug Administration-labeled indications. METHODS AND RESULTS: Comparative DES versus BMS studies published or presented through February 2008 with > or =100 total patients and reporting mortality data with cumulative follow-up of > or =1 year were identified. Data were abstracted from studies comparing DES with BMS; original source data were used when available. Data from 9470 patients in 22 RCTs and from 182 901 patients in 34 observational studies were included. RCT and observational data were analyzed separately. In RCTs, DES (compared with BMS) were associated with no detectable differences in overall mortality (hazard ratio [HR], 0.97; 95% confidence interval [CI], 0.81 to 1.15; P=0.72) or myocardial infarction (HR, 0.95; 95% CI, 0.79 to 1.13; P=0.54), with a significant 55% reduction in target vessel revascularization (HR, 0.45; 95% CI, 0.37 to 0.54; P<0.0001); point estimates were slightly lower in off-label compared with on-label analyses. In observational studies, DES were associated with significant reductions in mortality (HR, 0.78; 95% CI, 0.71 to 0.86), myocardial infarction (HR, 0.87; 95% CI, 0.78 to 0.97), and target vessel revascularization (HR, 0.54; 95% CI, 0.48 to 0.61) compared with BMS. CONCLUSIONS: In RCTs, no significant differences were observed in the long-term rates of death or myocardial infarction after DES or BMS use for either off-label or on-label indications. In real-world nonrandomized observational studies with greater numbers of patients but the admitted potential for selection bias and residual confounding, DES use was associated with reduced death and myocardial infarction. Both RCTs and observational studies demonstrated marked and comparable reductions in target vessel revascularization with DES compared with BMS. These data in aggregate suggest that DES are safe and efficacious in both on-label and off-label use but highlight differences between RCT and observational data comparing DES and BMS.

The effect of preoperative and hospital characteristics on costs for coronary artery bypass graft.

OBJECTIVE: This study aimed at exploring the effect of preoperative risk factors and hospital characteristics on costs of coronary artery bypass graft (CABG) hospitalizations. BACKGROUND: The considerable investment in hospital-based cardiac programs has not been coupled with comparable efforts to explore cost drivers of associated procedures. METHODS: Data sources included (a) New York State's Cardiac Surgery Reporting System, (b) New York State's Statewide Planning and Research Cooperative System dataset, (c) American Hospital Association dataset, and (d) Medicare Hospital Cost Report Public Use files and wage index files. The study population comprised New York state residents who underwent an isolated CABG procedure in a New York State hospital and were discharged in 2003. The outcome measure was inpatient costs. Independent variables included patient (demographic and clinical) and hospital characteristics. RESULTS: The total number of cases was 12,016. Findings revealed that selected demographic characteristics, including older age, female gender, and being black, were associated with higher costs. Several clinical characteristics were found to affect CABG discharge costs such as lower ejection fraction, the duration between CABG admission and the occurrence of myocardial infarction, number of diseased vessels, previous open heart operations, and a number of comorbidities. Furthermore, larger hospitals were associated with higher CABG discharge costs, while costs significantly decreased with higher CABG volume. CONCLUSIONS: Hospitals should explore ways to address patient (patient management) and hospital (case volume), when possible, associated with higher CABG discharge costs in its efforts to contain costs.

Comparison of coronary artery stenting outcomes in the eras before and after the introduction of drug-eluting stents.

BACKGROUND: Few studies have compared medium-term outcomes for drug-eluting stents (DES) and bare metal stents, and most are relatively small randomized controlled trials. Furthermore, since the introduction of DES, there has been increased use and duration of use of clopidogrel, statins, and other evidence-based therapies. The purpose of the present study was to compare outcomes for patients who underwent stenting in the eras before and after the introduction of DES. METHODS AND RESULTS: New York state patients undergoing stenting in all nonfederal hospitals in the state were studied. Patients were excluded if they had a previous revascularization. Risk factors that were significant predictors of adverse outcomes were used to adjust adverse outcome rates. The study included 11,436 patients who received stents between October 1, 2002, and March 31, 2003, and 12,926 patients who underwent stenting between October 1, 2003, and March 31, 2004. Death rates, the combined end point of death and myocardial infarction (MI), nonfatal MI requiring readmission, target vessel revascularization, and target lesion revascularization were compared at 2 years. Patients in the DES era had significantly better risk-adjusted outcomes for death/MI (adjusted hazard ratio, 0.90; 95% confidence interval, 0.83 to 0.97), 9.9% versus 10.8%; nonfatal MI requiring readmission (adjusted hazard ratio, 0.86; 95% confidence interval, 0.76 to 0.97); target vessel revascularization (adjusted hazard ratio, 0.60; 95% confidence interval, 0.56 to 0.64), 11.2% versus 17.9%; and target lesion revascularization (hazard ratio, 0.55; 95% confidence interval, 0.51 to 0.59), 8.4% versus 14.7%. CONCLUSIONS: Patients in the DES era experienced lower rates of death/MI, nonfatal MI, target vessel revascularization, and target lesion revascularization, but there were no differences in the rates of death. These improvements are likely a result of increased use of clopidogrel, statins, and dual antiplatelet therapy, in addition to the introduction of DES.

Drug-eluting versus bare-metal stents in the treatment of patients with ST-segment elevation myocardial infarction.

OBJECTIVES: The purpose of this study was to compare outcomes for drug-eluting stents (DES) and bare-metal stents (BMS) for patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Despite some controversy related to late stent thromboses, DES are approved for use in many patients undergoing stenting. However, there are several types of patients in whom implanting a DES would be regarded as off-label use, and this study compares DES and BMS for one of these groups. METHODS: New York's percutaneous coronary intervention registry was used to identify 772 patients undergoing percutaneous coronary intervention (PCI) for STEMI who received BMS and 1,154 STEMI patients who received DES between October 1, 2003, and December 31, 2004. These patients were tracked through December 31, 2005. Mortality, target vessel PCI, and subsequent coronary artery bypass graft (CABG) surgery within 2 years of undergoing the procedure were captured. Adverse outcomes were adjusted using proportional hazards methods to account for baseline differences in patients' severity of illness. RESULTS: The BMS patients had significantly higher mortality (adjusted hazard ratio [HR] vs. DES = 2.01, 95% confidence interval [CI] 1.21 to 3.34, risk-adjusted mortality = 8.6% vs. 5.0%, p = 0.007) and significantly higher subsequent CABG surgery (adjusted HR vs. DES = 2.33, 95% CI 1.31 to 4.16, risk-adjusted rate = 6.4% vs. 3.0%, p = 0.004) rates. There was no difference by type of DES (adjusted HR for paclitaxel-eluting stent versus sirolimus-eluting stent; mortality 0.72, 95% CI 0.30 to 1.72), subsequent CABG surgery (adjusted HR = 0.60, 95% CI 0.26 to 1.40), and target vessel PCI (adjusted HR = 0.74, 95% CI 0.35 to 1.58). CONCLUSIONS: In this observational study, DES were associated with lower mortality and subsequent CABG surgery when used for STEMI patients.

Differences in utilization of drug-eluting stents by race and payer.

Numerous disparities in access to health care by race and gender have been identified in the literature. This study examines differences in the use of drug-eluting stents (DES) versus bare-metal stents (BMS) by race, payer, and income level. Data from New York State's Percutaneous Coronary Intervention Reporting System from July 2003 to December 2004 were used to examine use of DES (20,165 patients) relative to BMS (4,547 patients) by race, payer, and annual income level, controlling for a variety of patient and hospital characteristics. African-Americans were found to be less likely to receive DES than other races between July 2003 and March 2004 (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.50 to 0.65) and between April 2004 and December 2004 (adjusted OR 0.74, 95% CI 0.61 to 0.90). These disparities were reduced (respective adjusted ORs 0.67, 95% CI 0.58 to 0.77 and 0.81, 95% CI 0.66 to 0.91) when controlling for admitting hospital and hospital volume, but were still significant. Medicaid/self-pay patients, and patients living in zip codes with median annual incomes between $20,000 and $30,000 were also less likely to receive DES in the first time period (adjusted respective ORs 0.80, 95% CI 0.68 to 0.93) and 0.85, 95% CI 0.75 to 0.96). In conclusion, African-Americans and low income groups receive DES less frequently than their counterparts compared with BMS. This is related to the hospitals where they are admitted, but not entirely.

A comparison of mortality, myocardial infarction, and repeated revascularization for sirolimus-eluting and paclitaxel-eluting coronary stents.

BACKGROUND: Drug-eluting stents are now used in most percutaneous coronary interventions. There are only 2 approved devices: sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES). Only a few population-based studies have compared their patient outcomes. METHODS: All New York State patients undergoing SES or PES in nonfederal hospitals in the state between April 1 and December 31, 2004, except those with a previous revascularization, left main coronary artery disease, or a recent myocardial infarction (MI) or shock (4867 patients with PES and 6914 with SES) were followed up through the end of 2005. We compared SES and PES with respect to inhospital and 18-month mortality, 18-month mortality/MI, and subsequent target vessel and target lesion revascularization (TVR and TLR) after adjusting for differences in patient risk factors. RESULTS: By 18 months after receiving a PES, 4.0% of the patients died compared with 4.1% for SES patients, 5.9% of PES patients experienced mortality/MI compared with 6.3% of SES patients, 6.8% of the PES patients had a subsequent TVR within 18 months compared with 7.8% for SES patients, and 4.5% of the PES patients had a subsequent TLR within 18 months compared with 5.3% for SES patients. The respective adjusted hazards ratios (PES/SES) for these adverse outcomes were 1.02 (95% CI 0.82-1.26, P = .86), 0.94 (95% CI 0.78-1.13, P = .52), 0.89 (95% CI 0.75-1.06, P = .20), and 0.86 (95% CI 0.70-1.05, P = .14). CONCLUSIONS: Patients receiving PES and SES do not have significantly different 18-month mortality, mortality/MI, subsequent TVR, or subsequent TLR rates.

Veterans Health Administration patients' use of the private sector for coronary revascularization in New York: opportunities to improve outcomes by directing care to high-performance hospitals.

OBJECTIVE: We sought to quantify Veterans Health Administration (VA) patients' utilization of coronary revascularization in the private sector and to assess the potential impact of directing this care to high-performance hospitals. METHODS: Using VA and New York State administrative and clinical databases, we conducted a retrospective cohort study examining residents of New York State who were enrolled in the VA and underwent either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 1999 or 2000 (n=6562) in either the VA or the private sector. We first calculated the proportion of revascularizations obtained in the VA and the private sector. We then identified the private sector hospitals in which these men obtained revascularizations and determined potential changes in mortality and travel burden associated with directing private sector care to high performance hospitals. RESULTS: VA patients in New York were much more likely to undergo revascularization in the private sector than in VA hospitals: 83% of CABGs (2341/2829) and 87% of PCIs (4054/4665) were obtained in the private sector. Private sector utilization was distributed evenly across high- and low-mortality hospitals. Directing private-sector CABG surgery to high-performance hospitals could have reduced expected mortality by 24% (from 2.3% to 1.7%) and would only increase median travel time from 21 to 30 minutes. The benefit of redirecting PCI care is minimal. CONCLUSIONS: For high-mortality procedures that veterans frequently obtain in the private sector, like CABG, directing care to high-performance hospitals may be an effective way to improve outcomes for veterans.

Impact of completeness of percutaneous coronary intervention revascularization on long-term outcomes in the stent era.

BACKGROUND: The importance of completeness of revascularization by percutaneous coronary intervention in patients with multivessel disease is unclear in that there is little information on the impact of incomplete revascularization outside of randomized trials. The objective of this study is to compare long-term mortality and subsequent revascularization for percutaneous coronary intervention patients receiving stents who were completely revascularized (CR) with those who were incompletely revascularized (IR). METHODS AND RESULTS: Patients from New York State's Percutaneous Coronary Interventions Reporting System were subdivided into patients who were CR and IR. Then subsets of IR patients were contrasted with CR patients. Differences in long-term survival and subsequent revascularization for CR and IR patients were compared after adjustment for differences in preprocedural risk. A total of 68.9% of all stent patients with multivessel disease who were studied were IR, and 30.1% of all patients had total occlusions and/or > or =2 IR vessels. At baseline, the following patients were at higher risk: those who were older and those with more comorbid conditions, worse ejection fraction, and more renal disease and stroke. After adjustment for these baseline differences, IR patients were significantly more likely to die at any time (adjusted hazard ratio=1.15; 95% confidence interval, 1.01 to 1.30) than CR patients. IR patients with total occlusions and a total of > or =2 IR vessels were at the highest risk compared with CR patients (hazard ratio=1.36; 95% confidence interval, 1.12 to 1.66). CONCLUSIONS: IR with stenting is associated with an adverse impact on long-term mortality, and consideration should be given to either achieving CR, opting for surgery, or monitoring percutaneous coronary intervention patients with IR more closely after discharge.