Publications

OBJECTIVE: To estimate changes in healthcare spending in the US after implementation of the No Surprises Act (NSA) in 2022 among adults with direct purchase private insurance.

DESIGN: Quasi-experimental difference-in-differences study.

SETTING: 24 US states.

PARTICIPANTS: Adults aged 19-64 years with direct purchase private insurance who participated in the Annual Social and Economic Supplement of the Current Population Survey 2019-24 and resided in states that gained NSA surprise billing protections (intervention states) or in states with comprehensive protections already in place (control states).

MAIN OUTCOME MEASURES: Inflation adjusted out-of-pocket spending, insurance premium spending, and high burden medical spending (defined as spending >10% of total family income on both out-of-pocket and premium costs).

RESULTS: The study population included 17 351 privately insured adults, with 8204 residing in the 18 intervention states and 9147 in the six control states. After implementation of the NSA, out-of-pocket spending showed a decline among privately insured adults in intervention states (from $3674 (£2776; €3214) to $2922, relative percentage change -16.5%, 95% confidence interval (CI) -27.9% to -3.2%), but not among privately insured adults in control states ($2704 to $2550, 1.9%, -11.6% to 17.4%). A significant differential reduction was observed in out-of-pocket spending among privately insured adults in intervention states compared with control states after the NSA (relative percentage change -18.0%, -30.2% to -3.7%; absolute change -$567, 95% CI -$1031 to -$102; P=0.02). In contrast, no differential changes were observed in premium spending (relative percentage change 1.9%, -13.9% to 20.7%; absolute change $93, -$737 to $924; P=0.82) and in high burden medical spending (absolute percentage point change -1.0%, 95% CI -5.2% to 3.1%, P=0.62) between the two groups. These findings were consistent across sociodemographic characteristics, including sex, race/ethnicity, poverty status, education level, and employment status.

CONCLUSIONS: Substantial declines occurred in out-of-pocket spending among direct purchase privately insured adults who gained NSA surprise billing protections. In contrast, premium spending and high burden medical spending did not change. Additional policy efforts are needed to reduce healthcare related financial strain in the US.

BACKGROUND: Despite reported racial disparities between Black and White adults in short-term outcomes after abdominal aortic aneurysmal intervention, there is a paucity of literature aimed at understanding long-term disparities. The present study aims to characterize racial disparities in long-term outcomes, perioperative outcomes, and health care use after endovascular aortic aneurysm repair.

METHODS: We conducted a retrospective cohort study from 2011 to 2019 with outcome assessment through 2020. Using a 100% sample of national Medicare data, we identified beneficiaries ≥66 years of age who underwent intact infrarenal endovascular aortic aneurysm repair. The primary outcome was a composite of endovascular or open aortic reintervention, late aneurysm rupture, and all-cause mortality. Secondary outcomes included other reinterventions, perioperative outcomes, and annual rates of health care use.

RESULTS: A cohort of 107 636 Black (3.9%) and White (96.1%) beneficiaries was identified. The cumulative incidence of the primary outcome was 72.9% (95% CI, 71.8%-73.9%) in White patients versus 80.0% (95% CI, 76.4-83.0) in Black patients (P<0.0001). The adjusted hazard of the primary outcome was not significantly different between Black and White adults (adjusted hazard ratio [HR] 1.04 [95% CI, 0.99-1.09]); however, when death was treated as a competing risk, a significantly higher hazard for the composite outcome was observed for Black patients (subdistribution HR, 1.56 [95% CI, 1.39-1.76]). Components of the primary outcome were also greater among Black compared with White patients. Black patients had higher rates of medical complications in the perioperative period, including acute renal failure (subdistribution HR, 1.18 [95% CI, 1.01-1.38]), dialysis initiation (subdistribution HR, 2.75 [95% CI, 2.03-3.7]), and deep vein thrombosis (subdistribution HR, 1.54 [95% CI, 1.05-2.26]). Black patients had lower rates of vascular office visits after intervention (adjusted rate ratio, 0.96 [95% CI, 0.93-0.99]) but higher rates of emergency department visits (adjusted rate ratio, 1.05 [95% CI, 1.02-1.09]) and hospital readmissions (adjusted rate ratio, 1.13 [95% CI, 1.08-1.18]).

CONCLUSIONS: Black patients demonstrated increased risk of late aortic-related events after endovascular aortic aneurysm repair after accounting for the competing risk of death and controlling for baseline covariates. Further investigation into structural barriers affecting optimal preoperative medical management and barriers to postoperative health care access is necessary to further elucidate underlying mechanisms for the observed disparities.

IMPORTANCE: Percutaneous coronary intervention (PCI) is the criterion standard for acute ST-elevation myocardial infarction (STEMI). Achieving target first medical contact (FMC)-to-device time is a quality metric in STEMI care.

OBJECTIVES: To describe site-level variability in achieving target FMC-to-device time (≤90 minutes for primary presentations to PCI-capable hospitals and ≤120 minutes for transfers), compare treatment times according to hospital performance, location, and primary PCI volume, and assess whether these aspects are associated with clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective cross-sectional study from the American Heart Association Get With the Guidelines-Coronary Artery Disease registry from 2020 to 2022. Patients were recruited from a multicenter quality-improvement registry across 503 US hospitals. Patients with STEMI or STEMI equivalent who underwent primary PCI were included in this analysis.

EXPOSURES: FMC-to-device time.

MAIN OUTCOMES AND MEASURES: Hospital performance was determined by the proportion of patients meeting target FMC-to-device time at each site. Treatment times and outcomes were compared by hospital performance, location, and primary PCI volume.

RESULTS: A total of 73 826 patients were analyzed (median [IQR] age, 62 [54-71] years; 53 474 male [72.4%]). Of 60 109 patients who presented directly to PCI-capable hospitals (primary presentations), 35 783 (59.5%) achieved an FMC-to-device time of 90 minutes or less, whereas 6900 (50.3%) of 13 717 transfers had an FMC-to-device time of 120 minutes or less. There was substantial institutional variability in achieving target FMC-to-device time for both primary presentations (median [IQR], 60.8% [51.2%-68.8%]) and transfers (median [IQR], 50.0% [32.5%-66.9%]). High-performing centers met all target treatment times more frequently. Low-performing sites experienced prolonged emergency department stays, catheterization laboratory arrival-to-PCI times, and transfer delays, varying by mode of presentation. Compared with urban centers, presentation to rural hospitals did not affect the odds of meeting target FMC-to-device time for primary presentations (adjusted odds ratio [aOR], 1.20; 95% CI, 0.96-1.50) or transfers (aOR, 0.86; 95% CI, 0.50-1.47). Failure to achieve target FMC-to-device time was associated with increased in-hospital mortality risk for primary presentations (aOR, 2.21; 95% CI, 2.02-2.42) and transfers (aOR, 2.44; 95% CI, 1.90-3.12). Low hospital performance was associated with increased mortality risk compared with high performance in primary presentations (aOR, 1.16; 95% CI, 1.00-1.34). Outcomes were similar between rural vs urban and low vs high primary PCI volume centers.

CONCLUSIONS AND RELEVANCE: In this large cross-sectional study of patients with STEMI, there was substantial hospital-level variability in achieving target treatment times. Patients in whom target FMC-to-device time was not met and those presenting to low-performing hospitals had worse outcomes.

Although transcatheter aortic valve replacement (TAVR) devices can impair coronary access, there are limited real-world data comparing outcomes of percutaneous coronary intervention (PCI) in post-TAVR versus non-TAVR patients. In this study, we compare procedural characteristics and outcomes between patients with versus without a history of TAVR who undergo PCI. We used claims data for the Medicare population to evaluate the incidence of PCI after TAVR between 2011 and 2017. Then, using the CathPCI Registry, we compared PCI outcomes between patients with a history of TAVR versus propensity score-matched non-TAVR patients. Of the 52,780 Medicare patients who underwent TAVR between 2011 and 2017, the incidence of acute myocardial infarction (AMI) was 10.2% and of PCI was 5.1% at 5 years. At 5 years, the incidence of stroke was 5.0% and of death was 64.0%. In the CathPCI Registry, procedural success for PCI was similar between 1,309 post-TAVR patients versus 5,236 propensity-score matched patients without prior TAVR. However, post-TAVR patients required greater fluoroscopic time (21.9 vs 17.7 minutes, p <0.001) and had higher rates of post-procedural stroke (0.8% vs 0.4%, p = 0.02) and bleeding (5.1% vs 2.9%, p <0.001). Post-TAVR patients were more likely to have repeat PCI in the 3 years post-PCI (HR: 1.36, 95% C.I: 1.09, 1.70) and had higher rates of stroke (HR: 1.65, C.I.: 1.07 to 2.56, p = 0.023) and death (HR: 1.23, C.I.: 1.11-1.38, p <0.001) compared to non-TAVR patients. In conclusion, in the CathPCI Registry, patients with a history of TAVR appeared to have similar procedural success but longer fluoroscopic times, more frequent post-procedural bleeding and stroke, and a higher likelihood of a repeat PCI compared with matched patients without a history of TAVR.

BACKGROUND: Catheter ablation is an effective therapy for ventricular tachycardia (VT) and is increasing in use. Assessment of contemporary real-world outcomes of VT ablation requires data inclusive of both inpatient and outpatient encounters.

OBJECTIVE: We aimed to assess factors associated with 1-year in-hospital mortality, all-cause readmission, and recurrent readmission for VT after VT ablation along with the associated costs of care.

METHODS: Inpatient and outpatient VT ablations were captured in the Healthcare Cost and Utilization Project data in Florida, Maryland, and New York from 2016 to 2020 with 1-year follow-up through 2021. Cox proportional hazards regression was used to identify risk factors associated with 1-year in-hospital mortality, all-cause readmission, and recurrent VT readmission. Costs of inpatient cases and readmission were captured.

RESULTS: Of 3899 patients undergoing VT ablation, 2% died during the initial episode of care. The 1-year in-hospital mortality rate, all-cause readmission rate, and recurrent VT readmission rate were 6.8%, 43.4%, and 16.9%, respectively, and were broadly stable during the study period. Coronary artery disease, chronic kidney disease, and heart failure were independently associated with an increased risk of in-hospital mortality and all-cause readmission within 1 year (P < .05). Recurrent VT was the most common cause of readmission. All-cause readmissions increased costs by 55%.

CONCLUSION: Mortality, long-term readmission, and recurrent VT remain high after VT ablation and include measurably important costs. Strategies to improve freedom from recurrent VT while managing comorbid conditions may serve as targets for improving the efficacy and cost-effectiveness of an important procedure applied to a vulnerable population.

OBJECTIVE: To understand how health insurance coverage and employment changed among working age adults with low incomes in Georgia, the first state to implement Medicaid expansion with work requirements under the Pathways to Coverage program.

DESIGN: Quasi-experimental difference-in-differences study.

SETTING: Georgia, which expanded Medicaid with work requirements on 1 July 2023; Alabama, Florida, Mississippi, South Carolina, and Tennessee, which neighbor Georgia and did not expand Medicaid; and South Dakota, which simultaneously expanded Medicaid without work requirements.

PARTICIPANTS: Adults aged 19-64 years with low incomes defined as ≤100% of the federal poverty level who completed the US Census Bureau's household pulse survey between 2021 and 2024.

MAIN OUTCOME MEASURES: Medicaid coverage, uninsured rate, and employment.

RESULTS: The study population consisted of 3303 adults in Georgia (intervention state) and 14 148 in neighboring states that did not expand Medicaid (controls). After the implementation of Pathways to Coverage, Medicaid coverage did not change in Georgia (35.5% to 32.4%) or in neighboring control states (39.6% to 39.3%), resulting in no differential change in Medicaid coverage between these states (adjusted difference-in-differences -3.0 percentage points, 95% confidence interval -7.6 to 1.6). These patterns were similar for the uninsured rate (-2.3 percentage points, -6.9 to 2.3). Additionally, employment did not increase in Georgia compared with control states (-1.6 percentage points, -8.7 to 5.4). In a secondary analysis that aimed to isolate the effects of work requirements, Medicaid coverage did not change in Georgia (35.5% to 32.4%) but increased in South Dakota (36.6% to 44.6%)-a state that expanded Medicaid without work requirements-resulting in a differential decrease in coverage in Georgia relative to South Dakota (-11.7 percentage points, -19.5 to -3.9). There was no differential change in employment (-0.1 percentage points, -9.8 to 9.6) between these states.

CONCLUSIONS: The implementation of work requirements with Medicaid expansion in Georgia did not increase health insurance coverage or employment during the first 15 months of the program. These findings have important implications as US policy makers recently enacted legislation that will mandate work requirements in Medicaid programs across all US states beginning in 2026.

BACKGROUND AND AIMS: Radial access site for percutaneous coronary intervention (PCI) is recommended by clinical practice guidelines because of superior outcomes compared with femoral access site. Historically, the adoption of radial access site in the USA has lagged behind much of the rest of the world, but contemporary data on access site selection across the spectrum of clinical presentations and its association with outcomes are lacking.

METHODS: A retrospective cohort study from the National Cardiovascular Data Registry's CathPCI Registry was conducted including PCIs performed between 1 January 2013 and 30 June 2022. The comparative safety of radial vs femoral access site for PCI was evaluated with instrumental variable analysis, a technique that can be used to support causal inference, exploiting operator variation in access site preferences as the instrumental variable.

RESULTS: Overall, 6 658 479 PCI procedures were performed during the study period, of which 40.4% (n = 2 690 355) were performed via radial access site, increasing from 20.3% in 2013 to 57.5% in 2022. This increase was seen in all geographic regions and across the full spectrum of presentations, with the largest relative increase seen in patients with ST-elevation myocardial infarction. Overall, 2 420 805 PCIs met inclusion criteria for the comparative safety analysis. In instrumental variable analyses, radial access site was associated with lower in-hospital mortality [absolute risk difference (ARD) -.15%, 95% confidence interval (CI) -.20 to -.10], major access site bleeding (ARD -.64%, 95% CI -.68 to -.60), and other major vascular complications (ARD -.21%, 95% CI -.23 to -.18) but a higher risk of ischaemic stroke (ARD .05%, 95% CI .03-.08). There was no association with the falsification endpoint of gastrointestinal or genitourinary bleeding (ARD .00%, 95% CI -.03-.03).

CONCLUSIONS: Over the past decade, use of radial access site for PCI has increased 2.8-fold in the USA and now represents the dominant form of access site across all procedural indications. Based on instrumental variable analyses, PCI with radial access site had lower rates of in-hospital mortality, major access site bleeding, and other major vascular complications compared with femoral access site but a slightly higher risk of ischaemic stroke in contemporary practice.