Publications

BACKGROUND: Patients who undergo cardiac surgery for drug use-associated infective endocarditis (DUA-IE) have high rates of readmissions for recurrent endocarditis, substance use disorder (SUD), and septicemia. Our primary objective was to assess whether exposure to an addiction consult team (ACT) was associated with reduced readmissions in this population.

METHODS: This single-center retrospective analysis identified patients who underwent cardiac surgery for DUA-IE between 1/2012-9/2022 using the Society for Thoracic Surgeons database, and compared the cumulative incidence of readmissions at 1, 3, 6, and 12 months among those cared for before and after the implementation of an ACT in 9/2017, accounting for competing risk of mortality and adjusted for measured confounders using inverse probability of treatment weighting.

RESULTS: The 58 patients (35 pre-ACT and 23 post-ACT) were young (36.4 +/- 7.7 years) and predominantly White (53.4%) and male (70.7%). The post-ACT cohort had a significantly lower risk of readmission at 1 month (adjusted risk difference [RD] -23.8% [95% CI -94.4%, -8.3%], P = 0.005) and 3 months (RD -34.1% [-55.1%, -13.1%], P = 0.005), but not at 6 or 12 months. In a sensitivity analysis, the post-ACT cohort also had significantly lower risk of readmissions for SUD complications at 3 months.

DISCUSSION AND CONCLUSION: ACT exposure was associated with a lower risk of short-term readmission among patients with surgically managed DUA-IE, possibly due to a reduction in SUD-related complications. Additional studies are needed to replicate these findings and to identify ways to sustain the potential benefits of ACTs over the longer term.

BACKGROUND: High and rising prescription drug costs for asthma and chronic obstructive pulmonary disease (COPD) contribute to medication nonadherence and poor clinical outcomes. The recently enacted Inflation Reduction Act includes provisions that will cap out-of-pocket prescription drug spending at $2,000 per year and expand low-income subsidies. However, little is known about how these provisions will impact out-of-pocket drug spending for Medicare beneficiaries with asthma and COPD.

OBJECTIVE: To estimate the impact of the Inflation Reduction Act's out-of-pocket spending cap and expansion of low-income subsidies on Medicare beneficiaries with obstructive lung disease.

DESIGN: We calculated the number of Medicare beneficiaries ≥ 65 years with asthma and/or COPD and out-of-pocket prescription drug spending > $2,000/year, and then estimated their median annual out-of-pocket savings under the Inflation Reduction Act's spending cap. We then estimated the number of beneficiaries with incomes > 135% and ≤ 150% of the federal poverty level who would become newly eligible for low-income subsidies under this policy.

PARTICIPANTS: Respondents to the 2016-2019 Medical Expenditure Panel Survey (MEPS).

MAIN MEASURES: Annual out-of-pocket prescription drug spending.

KEY RESULTS: An annual estimated 5.2 million Medicare beneficiaries had asthma and/or COPD. Among them, 360,160 (SE ± 38,021) experienced out-of-pocket drug spending > $2,000/year, with median out-of-pocket costs of $3,003/year (IQR $2,360-$3,941). Therefore, median savings under the Inflation Reduction Act's spending cap would be $1,003/year (IQR $360-$1,941), including $738/year and $1,137/year for beneficiaries with asthma and COPD, respectively. Total annual estimated savings would be $504 million (SE ± $42 M). In addition, 232,155 (SE ± 4,624) beneficiaries would newly qualify for low-income subsidies, which will further reduce prescription drug costs.

CONCLUSIONS: The Inflation Reduction Act will have major implications on out-of-pocket prescription drug spending for Medicare beneficiaries with obstructive lung disease resulting in half-a-billion dollars in total out-of-pocket savings per year, which could ultimately have implications on medication adherence and clinical outcomes.

OBJECTIVE: To assess the association between state policies and sociodemographic characteristics and state mean fair share spending at non-profit hospitals. Fair share spending is a hospital's charity care and community investment less the estimated value of their tax-exempt status.

BACKGROUND: Hospitals with non-profit status in the United States are exempt from paying taxes. In return, they are expected to provide community benefits by subsidizing medical care for those who cannot pay and investing in the health and social needs of their community.

METHODS: We used a multivariable linear regression model to determine the association of state-level sociodemographics and policies with state-level mean fair share spending in 2019. Fair share spending data was obtained from the Lown Institute.

RESULTS: We found no association between the percentage of people living in poverty, in rural areas, or U.S. region and fair share spending. Similarly, there was no association found for state minimum community benefit and reporting requirements. The state percentage of racial/ethnic minorities was associated with higher mean fair share spending [+$1.48 million for every 10% increase (95% CI: 0.01 to 2.96 million)]. Medicaid expansion status was associated with a 6.9-million-dollar decrease (95% CI: -10.4 to -3.3 million).

CONCLUSIONS: State-level community benefit policies have been ineffective at raising community benefit spending to levels comparable to the value of non-profit hospital tax-exempt status.

Social determinants of health (SDoH) significantly impacts health outcomes and disparities. While the Centers for Medicare and Medicaid Services has mandated hospitals to collect standardized SDoH data, existing tools lack key elements. This systematic review identified 78 studies and 20 screening tools addressing various SDoH domains. However, most tools were missing several key domains and lacked standardization. We propose a comprehensive tool meeting essential criteria: validated questions, brevity, actionability, cultural appropriateness, workflow integration, and community linkage. Our tool addresses gaps in available tools and incorporates standardized and validated questions to enable patient-centered screening for diverse social and environmental determinants of health. It uniquely includes detailed race/ethnicity data collection, housing characteristics, physical activity assessment, access to healthy food measures, and environmental exposure evaluation. The tool aims to provide actionable data for immediate interventions while informing broader population health strategies and policy initiatives. By offering a holistic assessment of SDoH across multiple domains, our tool enables standardized data collection, risk stratification, and focused initiatives to address health inequities at both individual and population levels. Further research is needed to develop evidence-based pathways for integrating SDoH data into real-world patient care workflows, improve risk prediction algorithms, address health-related social needs, and reduce disparities.

IMPORTANCE: Inferior vena cava filters (IVCFs) are commonly used to prevent pulmonary embolism in selected clinical scenarios, despite limited evidence to support their use. Current recommendations from professional societies and the US Food and Drug Administration endorse timely IVCF retrieval when clinically feasible. Current IVCF treatment patterns and outcomes remain poorly described.

OBJECTIVES: To evaluate temporal trends and practice patterns in IVCF insertion and retrieval among older US patients and report the incidence of periprocedural and long-term safety events of indwelling and retrieved IVCFs.

DESIGN, SETTING, AND PARTICIPANTS: Prespecified, retrospective, observational cohort of Medicare Fee-for-Service (FFS) beneficiaries, leveraging 100% of samples of inpatient and outpatient claims data from January 1, 2013, to December 31, 2021.

EXPOSURE: First-time IVCF insertion while insured by Medicare FFS.

MAIN OUTCOMES AND MEASURES: The primary safety outcome was the composite of all-cause death, filter-related complications (eg, fracture, embolization), operating room visits following filter-related procedures, or new diagnosis of deep vein thrombosis (DVT). Events were considered periprocedural if they occurred within 30 days of IVCF insertion or retrieval and long-term if they occurred more than 30 days after.

RESULTS: Among 270 866 patients with IVCFs placed during the study period (mean age, 75.1 years; 52.8% female), 64.9% were inserted for first-time venous thromboembolism (VTE), 26.3% for recurrent VTE, and 8.8% for VTE prophylaxis. Of these patients, 63.3% had major bleeds or trauma within 30 days of IVCF insertion. The volume of insertions decreased from 44 680 per year in 2013 to 19 501 per year in 2021. The cumulative incidence of retrieval was 15.3% at a median of 1.2 years and 16.8% at maximum follow-up of 9.0 years. Older age, more comorbidities, and Black race were associated with a decreased likelihood of retrieval, whereas placement at a large teaching hospital was associated with an increased likelihood of retrieval. The incidence of caval thrombosis and DVT among patients with nonretrieved IVCFs was 2.2% (95% CI, 2.1%-2.3%) and 9.2% (95% CI, 9.0%-9.3%), respectively. The majority (93.5%) of retrieval attempts were successful, with low incidence of 30-day complications (mortality, 0.7% [95% CI, 0.6%-0.8%]; filter-related complications, 1.4% [95% CI, 1.2%-1.5%]).

CONCLUSIONS AND RELEVANCE: In this large, US real-world analysis, IVCF insertion declined, yet retrievals remained low. Strategies to increase timely retrieval are needed, as nonretrieved IVCFs may have long-term complications.

BACKGROUND: Left atrial appendage occlusion (LAAO) is increasingly used as an alternative to oral anticoagulation for stroke prevention in select patients with atrial fibrillation. Data on outcomes in racial and ethnic minority individuals are limited. This analysis assessed differences in the use and outcomes of LAAO by race and ethnicity in a large national registry.

METHODS AND RESULTS: This analysis acquired data on patients who underwent WATCHMAN FLX implantation from the retrospective NCDR (National Cardiovascular Data Registry) LAAO registry through September 2022. All patients with an attempted WATCHMAN FLX implantation and known race and ethnicity were included. Baseline characteristics and 1-year event rates were compared. A total of 97 185 patients were analyzed; 87 339 were White individuals (90%), 3750 Black individuals (3.9%), and 2866 Hispanic individuals (Hispanic/Latinx), 2.9%). Black and Hispanic patients were younger, with a higher incidence of prior stroke and significant bleeding compared with White patients. Black and Hispanic patients were treated with LAAO in smaller numbers relative to their proportion of the US population. Rates of procedural success were similar between groups. Though direct oral anticoagulants were prescribed in most patients across the groups, dual and single antiplatelet therapy were prescribed more often in Black patients. Black patients had significantly higher rates of 1-year death and bleeding compared with White and Hispanic patients.

CONCLUSIONS: Patients from racial and ethnic minority groups comprise a disproportionately small fraction of all patients who undergo LAAO. Black and Hispanic patients were younger but had significantly higher comorbidities compared with White patients. Procedural success was similar among the groups, but Black patients experienced higher rates of death and bleeding at 1 year.

BACKGROUND: There is substantial hospital-level variation in 30-day risk-standardized mortality rate (RSMR) and risk-standardized readmission rate (RSRR) after transcatheter aortic valve replacement (TAVR). However, the relationship between hospital RSMRs and RSRRs has not been well characterized.

METHODS: We analyzed data on 141,905 Medicare fee-for-service beneficiaries who underwent TAVR across 512 hospitals between October 1, 2015 and December 31, 2020. The primary and secondary outcomes of interest were 30-day all-cause mortality and 30-day all-cause readmissions, respectively. Hierarchical logistic regression models with random hospital-level intercepts were used to estimate RSMRs and RSRRs for each hospital. We used Pearson correlation coefficient (r) and restricted cubic spline regression to determine the relationship between RSMR and RSRR in the overall cohort and within subgroups based on hospital characteristics.

RESULTS: The median (IQR) hospital-level 30-day RSMR was 2.2% (2.1%-2.4%), ranging from 1.3% to 3.5%. Similarly, the median (IQR) hospital-level 30-day RSRR was 13.2% (12.7%-13.8%), ranging from 10.6% to 16.8%. In the overall cohort, there was weak correlation between 30-day RSMR and RSRR after TAVR (r=0.25, 95% CI 0.17-0.33, p<0.001). Subgroup analyses by hospital characteristics demonstrated weakest correlation between RSMR and RSRR for non-JCAHO accredited hospitals (r=0.07), hospitals in the Midwest (r=0.12) and West (r=0.14), and hospitals with low TAVR volume (r=0.15).

CONCLUSIONS: Risk-standardized mortality and readmission rates after TAVR are weakly correlated, suggesting that hospital practices and processes of care influencing mortality are likely different from those influencing readmissions after TAVR, thereby necessitating measurement of both outcomes and developing specific interventions to decrease mortality and readmissions.