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Background: Readmission after acute myocardial infarction in low- and middle-income countries like China is not well characterized. Methods and Results: We approached consecutive patients with acute myocardial infarction hospitalized within 24 hours of symptom onset and discharged alive from 53 geographically diverse hospitals in China. We described rates of unplanned 30-day readmission, their timing and admitting diagnoses, and fit Cox proportional hazards models to identify factors associated with readmission. Among 3387 patients, median (interquartile range) age was 61 (52–69) years, and 76.9% were men. The index median length of stay was 11 (8–14) days. Unplanned 30-day readmission occurred in 6.3% of the cohort; most readmissions (77.7%) were for cardiovascular diagnoses. Nearly half (41.9% of all-cause readmissions; 44.3% of cardiovascular readmissions) occurred within 5 days of discharge. Mini-Global Registry of Acute Coronary Events scores at admission (hazard ratio [HR], 1.15 for every 10-point increase; 95% CI, 1.05–1.25), longer length of stay (HR, 1.03; 95% CI, 1.00–1.06 for each extra day), and in-hospital recurrent angina (HR, 1.40; 95% CI, 1.04–1.89) were associated with higher unplanned all-cause readmission. Revascularization during the index hospitalization (70.2% of the cohort) was associated with lower risks of all-cause readmission (HR, 0.27; 95% CI, 0.18–0.42). In addition, left ventricular ejection fraction Conclusions: In China, most readmissions are for cardiovascular events, and almost half occur within 5 days of discharge. Clinical factors identify patients at higher and lower unplanned readmissions. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01624909.

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 P P P P 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.

Background— Consumer-reported patient–provider communication (PPC) assessed by Consumer Assessment of Health Plans Survey in ambulatory settings is incorporated as a complementary value metric for patient-centered care of chronic conditions in pay-for-performance programs. In this study, we examine the relationship of PPC with select indicators of patient-centered care in a nationally representative US adult population with established atherosclerotic cardiovascular disease. Methods and Results— The study population consisted of a nationally representative sample of 6810 individuals (aged ≥18 years), representing 18.3 million adults with established atherosclerotic cardiovascular disease (self-reported or International Classification of Diseases, Ninth Edition diagnosis) reporting a usual source of care in the 2010 to 2013 pooled Medical Expenditure Panel Survey cohort. Participants responded to questions from Consumer Assessment of Health Plans Survey that assessed PPC, and we developed a weighted PPC composite score using their responses, categorized as 1 (poor), 2 (average), and 3 (optimal). Outcomes of interest were (1) patient-reported outcomes: 12-item Short Form physical/mental health status, (2) quality of care measures: statin and ASA use, (3) healthcare resource utilization: emergency room visits and hospital stays, and (4) total annual and out-of-pocket healthcare expenditures. Atherosclerotic cardiovascular disease patients reporting poor versus optimal were over 2-fold more likely to report poor outcomes; 52% and 26% more likely to report that they are not on statin and aspirin, respectively, had a significantly greater utilization of health resources (odds ratio≥2 emergency room visit, 1.41 [95% confidence interval, 1.09–1.81]; odds ratio≥2 hospitalization, 1.36 [95% confidence interval, 1.04–1.79]), as well as an estimated $1243 ($127–$2359) higher annual healthcare expenditure. Conclusions— This study reveals a strong relationship between PPC and patient-reported outcomes, utilization of evidence-based therapies, healthcare resource utilization, and expenditures among those with established atherosclerotic cardiovascular disease.

Background: It is unknown if financial pressures to reduce hospital readmission rates following passage of the Affordable Care Act (ACA) have had the unintended effect of increasing mortality rates after hospitalization. We therefore examined correlations between paired changes in hospital 30-day readmission rates and 30-day mortality rates among Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008 to 2014. Methods: We used linear regression to calculate monthly changes in hospitals’ 30-day risk-adjusted readmission rates (RARRs) and 30-day risk-adjusted mortality rates (RAMRs) after discharge for HF, AMI, and pneumonia from 2008 to 2014. Adjustment was made for patient age, sex, comorbidities, hospital length of stay, and season. We then examined the correlation of hospitals’ paired monthly changes in 30-day RARRs and monthly changes in 30-day RAMRs after discharge. Results: From 2008 to 2014, we identified 2,962,554, 1,229,939, and 2,544,530 hospitalizations for HF, AMI, and pneumonia at 5,016, 4,772, and 5,057 hospitals, respectively. Hospital 30-day RARRs declined for all three conditions from 2008 to 2014; the monthly change in RARRs was -0.053 (95% CI -0.055, -0.051) for HF, -0.044 (95% CI -0.047, -0.041) for AMI, and -0.033 (95% CI -0.035, -0.031) for pneumonia. In contrast, the monthly change in hospital 30-day RAMRs after discharge varied by admitting condition and was 0.008 (95% CI 0.007, 0.010) for HF, -0.003 (95% CI -0.006, -0.001) for AMI, and 0.001 (95% CI -0.001, 0.003) for pneumonia. The correlation between monthly changes in hospitals’ 30-day RARRs and 30-day RAMRs after discharge was 0.060 for HF (p Conclusion: Changes in hospital readmission rates for HF, AMI, and pneumonia were poorly correlated with changes in mortality rates after hospitalization between 2008 and 2014. These findings suggest that financial incentives to improve hospitals’ readmission performance have not increased mortality after hospitalization.

Background: While it is well established that significant health outcome disparities exist across patients of varying socio-economic status (SES) with established atherosclerotic cardiovascular disease (ASCVD), disparities in patients’ healthcare experiences are not well investigated. We explore income level differences in four central tenets of patient-reported healthcare experience (access to care, provider communication, shared decision making and provider satisfaction) as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, in a nationally representative adult US population with established ASCVD. Methods: The study population consisted of 8223 individuals (age ≥ 18 years) representing 21.6 million with established ASCVD (self-reported or ICD-9 diagnosis) reporting a usual source of care in the 2010-2013 pooled Medical Expenditure Panel Survey (MEPS) cohort. We assessed the responses for each item as: a) difficult access to care (always/almost difficult), b) ineffective communication and shared decision making (never/sometimes), and c) poor provider satisfaction (lowest quartile on a scale of 0-10). We examined the relationship between scores in the lowest quartile of each domain composite scores, derived using the weighted average response from each items scores, with patients’ SES, using the high-income group as reference. Results: Lower SES was consistently associated with greater perceived difficulties in access, poor provider-patient communication, less shared decision making, as well as lower provider satisfaction (Table). Participants classified as poor vs. high income were 47% (95% CI 1.17-1.83) more likely to report difficulty accessing care, 39% (95% CI 1.09-1.78) and 26% (95% CI 0.99-1.60) reported a higher likelihood of experiencing poor communication and shared decision making respectively, as well as a 66% (95% CI 1.31-2.11) higher likelihood of reporting lower provider satisfaction. Conclusion: Among patients with established ASCVD, significant SES disparities exist in all domains of patient reported healthcare experience quality of care metrics. Targeted policies focusing on improving communication, engagement and satisfaction are needed to enhance patient healthcare experience among high-risk vulnerable populations.

Cardiac arrest is a common and treatable cause of death and disability. Each year ≈424 000 people experience emergency medical services (EMS)-assessed out-of-hospital cardiac arrest (OHCA) in the United States.1 The actual burden of OHCA is likely significantly higher because a substantial number go unassessed. In a prospective analysis of deaths in a US county, 5.6% of annual mortality was attributable to cardiac arrest.2 Many patients who suffer OHCA do not receive prompt cardiopulmonary resuscitation (CPR). Among those who receive CPR, a large number do not survive because of an inability to restore spontaneous circulation, or anoxic cerebral injury even after restoration of circulation. Nevertheless, when timely interventions are provided, a small proportion of patients (10.4% of all EMS-treated OHCA) recover to resume normal lives. The key therapeutic interventions that make the difference between life and death, metaphorically characterized as the 5 links in a chain of survival by the American Heart Association, include: (1) immediate recognition of cardiac arrest and activation of the EMS, (2) early CPR with emphasis on chest compression, (3) rapid defibrillation, (4) effective advanced life support, and (5) integrated postcardiac arrest care.3 Resuscitation science has undergone major advances since the origins of modern CPR >50 years ago.4 The field continues to be dynamic with emergence of new therapies such as therapeutic hypothermia5 and improvements in systems of care. However, many questions remain on issues such as optimum compression rate, efficacy of chest compression only CPR (CCCPR), dispatcher-assisted CPR, and benefits of postresuscitation measures such as hypothermia. A critical challenge also lies in the translation of resuscitation science into practice. To improve outcomes, each of the links in the chain of survival needs to be executed promptly and effectively. There remain several lacunae, which need to be overcome to develop an …

Background— Cardiovascular diseases are rising as a cause of death and disability in China. To improve outcomes for patients with these conditions, the Chinese government, academic researchers, clinicians, and >200 hospitals have created China Patient-Centered Evaluative Assessment of Cardiac Events (China PEACE), a national network for research and performance improvement. The first study from China PEACE, the Retrospective Study of Acute Myocardial Infarction (China PEACE-Retrospective AMI Study), is designed to promote improvements in acute myocardial infarction (AMI) quality of care by generating knowledge about the characteristics, treatments, and outcomes of patients hospitalized with AMI across a representative sample of Chinese hospitals during the past decade. Methods and Results— The China PEACE-Retrospective AMI Study will examine >18 000 patient records from 162 hospitals identified using a 2-stage cluster sampling design within economic–geographic regions. Records were chosen from 2001, 2006, and 2011 to identify temporal trends. Data quality will be monitored by a central coordinating center and will, in particular, address case ascertainment, data abstraction, and data management. Analyses will examine patient characteristics, diagnostic testing patterns, in-hospital treatments, in-hospital outcomes, and variation in results by time and site of care. In addition to publications, data will be shared with participating hospitals and the Chinese government to develop strategies to promote quality improvement. Conclusions— The China PEACE-Retrospective AMI Study is the first to leverage the China PEACE platform to better understand AMI across representative sites of care and during the past decade in China. The China PEACE collaboration among government, academicians, clinicians, and hospitals is poised to translate research about trends and patterns of AMI practices and outcomes into improved care for patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01624883.

Background: The use of radial access for percutaneous coronary intervention (r-PCI) is associated with reduced risk of bleeding complications and higher patient satisfaction. However, the use of r-PCI differs greatly by country and is unknown in China. We examined trends in the adoption of r-PCI in China over the past decade and identified factors associated with its use. Methods: We used a two-stage random sampling strategy to create a nationally representative sample of 5,462 patients undergoing percutaneous coronary intervention (PCI) in China in 2001 (n=402; 24 sites), 2006 (n=1,390; 44 sites), and 2011 (n=3,670; 54 sites). We calculated the weighted proportion of patients receiving r-PCI in each time period and conducted multivariable analysis to identify the patient and hospital characteristics associated with not receiving r-PCI in 2011. Results: Among 5,462 patients who underwent PCI, the use of r-PCI increased markedly over time (2001: 3.4% [95% CI 0.0%-8.5%]; 2006: 36.5% [95% CI 34.2%-38.9%], 2011: 74.7% [95% CI 73.9-75.6]; P for trend Conclusion: Over a recent ten-year period, radial access became the predominant strategy for PCI in China, even among high-risk patients. This study demonstrates the responsiveness of the interventional cardiology community to emerging evidence. A deeper understanding of the factors facilitating r-PCI adoption in China may help increase its usage in countries in which r-PCI use remains low.

Background: In the current era of surgical and transcatheter aortic valve replacement (AVR), patients with severe symptomatic aortic stenosis (AS) receiving medical management after referral to a valve treatment center have not been well-described. Methods: The ACC Championing Care for the Patient with AS initiative involved 454 patients referred for assessment of AS treatment options to 9 US valve treatment centers from 11/2012 to 6/2014. We compared clinical characteristics of patients with severe symptomatic AS receiving medical management versus AVR using chi-square, Fisher’s exact, and t-tests. We identified reasons for medical management using summary statistics. Results: Among 454 patients referred to a valve center, 42 (9%) received medical management for insufficient AS severity, 76 (17%) received medical management despite having severe symptomatic AS, and 336 (74%) underwent AVR. Patients receiving medical management despite severe symptomatic AS were older with higher STS predicted mortality than patients treated with AVR (Table). Common reasons for medical management were patient preference (43%, including waiting for commercial TAVR), medical futility (17%), inoperability (11%, including infeasible aortic annulus for TAVR), and temporary bridging with valvuloplasty (15%). Conclusions: In the current era of transcatheter and surgical AVR, medical management often occurs among patients with severe symptomatic AS referred for AVR. As medical futility, inoperability, and patient preferences commonly contribute to this decision, both valve treatment centers and referring physicians should be well versed in supportive care strategies to improve health outcomes in these patients.

Disorders of the cardiac muscle or cardiomyopathies are a broad, yet collectively common, group of conditions. Despite the heterogeneous etiologies, mode of death from these conditions is remarkably similar - progressive decline in cardiac function leading to intractable heart failure (HF) and sustained ventricular arrhythmias resulting in sudden cardiac death (SCD). Nearly 50% of patients die within 5 years of a HF diagnosis.1 Indeed, in the United States, HF alone is thought to cause 55,000 deaths per year2 and further contribute to 1 in 9 deaths overall.1 However, while advanced HF and the risk of SCD were once thought to be untreatable, technological advances has seen the emergence of device therapies as viable treatment options. Specifically, implantable cardioverter-defibrillator (ICD) therapy for treatment of ventricular arrhythmias, cardiac resynchronization therapy (CRT) for restoring cardiac synchrony and mechanical efficiency, and ventricular assist device (VAD) therapy to temporarily or permanently replace the function of the failing heart, have all emerged as highly efficacious therapies. The expanding use of device therapies, however, poses many challenges. First, while the indications for these devices are well summarized in clinical guidelines,3,4 considerable hurdles remain in ensuring eligible patients receive these therapies.5 By the same token, establishing the safety and effectiveness of these therapies in populations that are found in clinical practice, yet commonly excluded from trials, such as the elderly6 and uncommon forms of cardiomyopathies,7 is a high priority. Second, rapid dissemination of technologies frequently results in disparities in care. Indeed, age, gender, and racial disparities, in both receipt of these devices and outcomes following implantation, have been well documented. Whether these disparities have persisted, and the potential causative mechanisms underlying these disparities, however, are uncertain.8,9 Third, these devices are not without significant untoward effects; understanding …

Background: Patients hospitalized with a principal discharge diagnosis of heart failure (HF) are often treated for other common conditions causing shortness of breath such as pneumonia (PNA) and exacerbated COPD. We hypothesized that this pattern could be a more general phenomenon and that patients hospitalized with a principal diagnosis of any of these 3 conditions would often be treated concomitantly with medications indicated for the others. Such treatment would signal frequent diagnostic uncertainty or the concomitant presence of more than one acute condition in real-world practice. Methods: We included hospitalizations with principal discharge diagnoses of HF, PNA, or COPD from 2009-10 Premier, Inc., hospitals with age>65y, known admission source, and non-pediatric attending physician. To increase cohort specificity, length of stay had to be >2 days, the HF cohort required HF treatment (loop diuretics, inotropes, or IV vasodilators) during the first 2 hospital days, the PNA cohort required antibiotic treatment, and the COPD cohort required systemic corticosteroid treatment. To increase treatment specificity, we excluded hospitalizations with present-on-admission codes for ascites, infections besides PNA, and inflammatory, allergic, or autoimmune conditions besides COPD. For each cohort, we noted co-treatment for the other 2 conditions during the first 2 hospital days (for the COPD cohort, only co-treatment for HF was ascertainable as antibiotics are often used for acute COPD). To better understand patient complexity, we also calculated odds of in-hospital mortality among co-treated patients after adjusting for age, sex, and Elixhauser comorbidities. Results: Among 118,061 HF hospitalizations, 38% were co-treated during the first 2 hospital days (34% antibiotics, 9% corticosteroids). Among 91,709 PNA hospitalizations, 32% were co-treated (18% HF treatment, 18% corticosteroids). Among 41,052 COPD hospitalizations, 19% were co-treated (19% HF treatment). Death occurred during 3,483 (3.0%), 3,850 (4.2%), and 846 (2.1%) of hospitalizations for HF, PNA, and COPD, respectively. Adjusted odds of in-hospital mortality among co-treated compared with non co-treated patients were 1.61 (95% CI: 1.49, 1.73), 2.38 (2.22, 2.54), and 2.09 (1.81, 2.42) for HF, PNA, and COPD hospitalizations, respectively. Conclusions: Co-treatment for acute cardiac and pulmonary conditions is common across HF, PNA, and COPD hospitalizations and is a marker for adverse outcomes. These findings reveal the complexity of disease presentation and treatment in typical practice and the variable phenotypes among hospitalizations for common cardiopulmonary conditions. Further research can clarify motivations for co-treatment and its impact on outcomes. In the interim, there is a need for guidelines to reflect the reality of diagnostic uncertainty and co-existing active conditions.

Background: After hospitalization for heart failure (HF) and acute myocardial infarction (AMI), patients experience increased risk of death and hospital readmission. Defining the trajectory and timing of this period of risk may help guide interventions to improve post-discharge outcomes. Methods: We used 2008-10 Medicare data to identify patients ≥65 years discharged alive after HF or AMI hospitalization. Using hazard rates, we characterized the risks of death and first readmission on each day after discharge to describe (1) the maximum daily risks of death and readmission after discharge; (2) risks of death and readmission 1 year after discharge; (3) the time in days after discharge for the risks of death and readmission to reach their maximum daily rates and 50% of their maximum daily rates to characterize the rapidity of decline in risk. We created separate survival models for death and first readmission. Data were censored after 1 year follow up. The readmission model also censored for death prior to readmission. Results: Of 878,963 HF hospitalizations, 367,542 (41.8%) died and 618,283 (70.3%) were readmitted in 1 year. Of 350,509 AMI hospitalizations, 90,623 (25.9%) died and 177,031(50.5%) were readmitted in 1 year. The Figure shows hazard rates by time after discharge. For HF, daily risk of death was 0.0056 maximally and 0.0011 at 1 year (19% of maximum). Daily risk of readmission was 0.013 maximally and 0.002 at 1 year (16% of maximum). Daily risk of death was highest 1 day after discharge and 50% less 11 days after discharge. Daily risk of readmission was highest 4 days after discharge and 50% less 49 days after discharge. For AMI, daily risk of death was 0.010 maximally and 0.0004 at 1 year (4% of maximum). Daily risk of readmission was 0.015 maximally and 0.0011 at 1 year (7% of maximum). Daily risk of death was highest 1 day after discharge and 50% less 6 days after discharge. Daily risk of readmission was highest 2 days after discharge and 50% less 13 days after discharge. Conclusions: After hospitalization for HF and AMI, risk of death is highest on day 1 after discharge and then declines rapidly. In contrast, risk of readmission peaks later and declines more slowly. This extended period of risk for readmission may justify continued vigilance beyond the 30-day period used by Medicare to evaluate hospital readmission performance.

Background: Elderly survivors of acute myocardial infarction (AMI) are at elevated risk for ischemic stroke. Changes in treatment for AMI and proportions of NSTEMI combined with an increasing aging population may have influenced the risk of post-AMI strokes. We sought to characterize temporal trends in the risk for post-AMI strokes older patients and assess whether patterns differed by age, sex, race, revascularization status, and region within the US. Methods: We used 100% of Medicare inpatient claims data to identify fee-for-service (FFS) patients aged >64 years hospitalized for AMI in 1999-2010. We excluded patients who died during AMI hospitalization or were transferred. Revascularization status was identified during the index admission. We used a Cox proportional hazards regression model to estimate risk-adjusted annual changes in one-year ischemic stroke hospitalization after AMI, overall and by subgroups. Changes were adjusted by age, gender, race, medical history and comorbidities. We calculated the 30-day post-stroke mortality. Stroke belt regions were defined as the states with high stroke hospitalization rates in the southeast United States and were compared with non-stroke belt regions. Results: Among 2,433,036 AMI hospitalizations and 58,009 ischemic stroke readmissions, the risk-adjusted one-year readmission rates for ischemic stroke after AMI decreased from 3.3% (95% CI 3.2%-3.4%) in 1999 to 2.6% (95% CI 2.6%-2.7%) in 2010, a relative 21.2% decline. Overall risk-adjusted relative annual decline was 2.6% (95% CI 2.3%-2.9%). Post-AMI stroke rates declined across all age-sex-race groups and most treatment groups (Figure). Thirty-day mortality rates after stroke decreased a relative 8.6% (1999, 21.0% 95% CI 19.7%-22.5%; 2010, 19.2%, 95% CI 18.0%-20.5%). Post-AMI stroke rates were 6% higher in stroke belt regions, but both stroke belt regions and all other regions showed declines over time. Conclusions: From 1999 to 2010, the hospitalization rates of ischemic stroke after AMI decreased overall and for demographic subgroups and those undergoing PCI, CABG, or no revascularization. Declines were seen for all regions, but were consistently higher for stroke belt states. Post-AMI strokes 30-day mortality rates decreased over time.

Background: The intensive care unit (ICU) has been credited with reducing mortality for patients hospitalized with AMI in a past era when life-threatening post-infarction ventricular arrhythmias were more common. With the evolution in the clinical profile and treatment of AMI, the marginal benefit of ICU care for many patients is less clear. As a result, the use of ICU care for patients with AMI may vary substantially among institutions, creating implications for treatment strategies and patient outcomes. Methods: We identified 114,980 hospitalizations for AMI from 311 hospitals in the 2009-10 Premier database using ICD-9-CM codes. We excluded hospitals with Results: ICU admission rates for AMI patients varied markedly among hospitals (median 48%, IQR 35%-61%, range 0%-98%, Figure). Hospitals admitting more AMI patients to the ICU (higher quartiles) were (1) more likely to use critical care therapies in AMI patients overall (mechanical ventilation [Q1 to Q4: 13% to 16%], vasopressors/inotropes [17% to 21%], intra-aortic balloon pumps [4% to 7%], and pulmonary artery catheters [4% to 5%]; p for trend Conclusion: ICU admission rates for AMI vary substantially across hospitals with evidence of greater use of ICU therapies in high admitting hospitals but without evidence of lower overall mortality. There is a need for further research to determine the optimal use of ICU care for contemporary populations of patients with AMI.

Background: Elderly survivors of acute myocardial infarction (AMI) are at elevated risk for hemorrhagic stroke, which has a mortality rate of approximately 50%. Increasing use of warfarin for arterial fibrillation and anti-platelet agents for AMI combined with an increasing aging population may have influenced the risk of post-AMI strokes. We sought to characterize temporal trends in the risk for and mortality from hemorrhagic stroke over 12 years among older AMI survivors of different age, sex, race, revascularization status, and region within the US. Methods: We used 100% of Medicare inpatient claims data to identify all fee-for-service (FFS) patients aged> 64 years who were hospitalized for AMI in 1999-2010. We excluded patients who died during the hospitalization or were transferred. Revascularization procedures were identified during the index admission. We used a Cox proportional-hazards regression model to estimate the risk-adjusted annual changes in one-year hemorrhagic stroke hospitalization after AMI, overall and by subgroups. Changes were adjusted by age, gender, race, medical history and comorbidities. We calculated the 30-day mortality among patients readmitted for hemorrhagic stroke. Stroke belt regions were defined as the states with high stroke hospitalization rates in the southeast United States. Results: Among 2,433,036 AMI hospitalizations and 4,852 hemorrhagic stroke readmissions, the risk-adjusted one-year post-AMI hemorrhagic stroke rate remained stable from 1999 to 2010 (range, 0.2% to 0.3%). No significant trends were found for post-AMI stroke rates across all age-sex-race groups and all treatment groups (Figure). Thirty-day mortality rates for stroke after AMI did not show significant changes (1999, 46.7%, 95% CI 39.9%-53.7%; 2010, 50.7%, 95% CI 45.3%-56.1%; range: 46.5% to 54.6%). No difference was found in post-AMI hemorrhagic stroke rates between the stroke belt and non-stroke belt regions. Conclusions: From 1999 to 2010, the overall hospitalization rates of hemorrhagic stroke after AMI were relatively stable without significant changes across all subgroups. Thirty-day mortality rates remained largely unchanged over time. Stroke risk in the stroke belt was not found significantly higher comparing with non-stroke belt states.

The topic of variation in health care has garnered significant attention since Wennberg and Gittelsohn in 19731 identified up to 10-fold variation in use of tonsillectomy and other surgical procedures in small towns within Maine and Vermont. Wennberg and others further described large differences in the propensity to hospitalize patients in Boston and New Haven that were unrelated to case-fatality but highly related to bed supply.2 These findings suggested that regional treatment variation is in part driven by differences in physician preferences and heath resource capacity rather than the health status of patients. These observations of extensive geographic variation in treatment were most extensively formalized in the Dartmouth Atlas of Health Care, a massive undertaking that used Medicare claims data to describe differences in cost and utilization across more than 300 hospital referral regions (HRRs) that were built from zip codes and hospital service areas. The Dartmouth Atlas has been published by Wennberg and colleagues since 1996. More recently, greater attention has been directed to variation in treatment and outcomes at the hospital level. Health care payers including the Centers for Medicare and Medicaid Services have motivated the creation of performance measures that describe hospital variation in longitudinal outcomes such as rehospitalization and death.3–7 These measures have been endorsed by the National Quality Forum and are currently being used to direct financial penalties to hospitals with higher-than-expected rates of adverse outcomes for common conditions such as heart failure, acute myocardial infarction, and pneumonia. In the future, Medicare will likely assess hospital variation in outcomes for specific cardiovascular treatments including percutaneous coronary intervention and percutaneous valve replacement. Given the increased focus on treatment and outcomes variation at both regional and hospital levels, we have dedicated the reviews in this issue of Circulation: Cardiovascular Quality and Outcomes …

Cardiovascular disease (CVD) in women has been historically understudied. For many years, heart disease had been thought to be primarily a “man’s disease.” Consequently, women have been significantly under-represented in longitudinal studies of disease history and in clinical trials. High-quality data from women at the extremes of age, with multiple co-morbidities, and from racial and ethnic minorities have been particularly rare. In order to increase awareness of cardiovascular prevention among women, in 1999 the American Heart Association (AHA) published its first women-specific clinical recommendations for the prevention of CVD.1 In 2004, the AHA and multiple other collaborating organizations subsequently sponsored “Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women,” which underwent updates in 2007 and 2011. As a result of these and other related initiatives, the rate of public awareness of CVD as the leading cause of death among US women has increased from 30% in 1997 to 54% in 2009.2 CVD-associated death among US women has declined significantly over this time period.3,4 Yet substantial work still needs to be done to improve women’s cardiovascular health. CVD remains the number one killer among women.4 As the obesity epidemic continues, we are actually finding increases in coronary heart disease (CHD) death among young women 35 to 54 years of age.2 Morbidity and mortality from stroke and hypertension remain high.4 In addition, substantial outcomes disparities continue for women from racial and ethnic minorities.4 We have therefore dedicated our topic summaries in this issue of Circulation: Cardiovascular Quality and Outcomes to CVD in women. We have included only those studies where authors provided a convincing a priori reason to study a particular disease process or clinical intervention in women and reported primary endpoints that were sex-specific. We have included articles on the representation of women …

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review. This series will summarize the most important manuscripts, as selected by the Editor, that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes and general cardiology audience. The studies included in this article represent the most significant research in the area of cardiovascular disease in the elderly.

Background: Little is known about cost variation among heart failure (HF) patients across hospitals when controlling for invasive cardiovascular percutaneous and surgical procedures. Methods: We identified all adult HF hospitalizations in 2009-10 Premier, Inc. hospitals with >25 HF hospitalizations. Hospitals were divided into 3 groups by their percent of HF patients receiving invasive percutaneous or surgical procedures: none (0%), moderate (0-10%), and high (>10%) (see figure). The 10% mark was the median across hospitals. For each of the three groups, the median hospitalization cost was calculated for all non-procedural admissions in standard dollar costs (figure). Standard cost assigns each billed item its median cost across all hospitals. The Kruskal-Wallis test was used to assess cost, length of stay, and outcome differences among the 3 groups (p≤0.05). Frequencies of billing categories (e.g. pharmacy, lab, central supply) were calculated and compared across the 3 groups. Results: Median standard dollar costs among non-procedural HF hospitalizations were $5104 (IQR=$3421, $7968), $6108 ($4001, $9934) and $6585 ($4181, $11218) for hospitals with no, moderate and high procedure use, respectively (figure). Respective median lengths of stay were 3, 4, and 4 days, and risk-adjusted mortality was 4.8%, 4.9% and 4.7% (figure). Cost analysis by resource categories showed that the proportion of items billed did not appear to differ by hospital group. Conclusion: The cost of HF hospitalization is higher in more procedure-intense hospitals even among patients who do not receive invasive procedures. Length of stay may contribute to these differences. Despite higher costs, high procedure hospitals do not have materially improved risk-adjusted mortality rates.

Background: Patients hospitalized with heart failure (HF) are often treated for concomitant respiratory disease due to diagnostic uncertainty or coexisting conditions. Testing with natriuretic peptides, chest radiograph (CXR), and transthoracic echocardiogram (TTE) is common and may influence these treatment decisions. We examined hospital variation in diagnostic testing among inpatients with HF and how testing relates to additional treatment for coexisting respiratory conditions. Methods: We identified hospitalizations with a principal discharge diagnosis of HF from 2009-2010 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators), and >2 day hospital stay. We excluded hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD. For hospital days 1-2, we calculated each hospital’s proportion of admissions receiving selected diagnostic tests (natriuretic peptides, CXR, TTE) and respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Treatment categories were mutually exclusive. The proportion of admissions receiving diagnostic testing and respiratory treatments was calculated for each hospital, and summary statistics were reported across hospitals. Results: We identified 164,494 HF hospitalizations among 368 hospitals. Natriuretic peptide testing across hospitals was done in 81% to 92% (IQR; median 87%) of HF admissions, CXR testing was done in 87% to 94% (IQR; median 91%), and TTE testing was done in 39% to 56% (IQR; median 48%). The median proportion of hospitalizations receiving diagnostic testing at the hospital level was similar among patients treated only for HF and those also treated with at least one respiratory therapy (respectively, 88% vs. 90% for natriuretic peptides, 90% vs. 93% for CXR, and 51% vs. 49% for TTE). Detailed description of diagnostic testing among each treatment group at the hospital level is provided in the accompanying table. Conclusion: Hospital use of relatively inexpensive diagnostic tests among HF inpatients including natriuretic peptides and CXR is frequent with little inter-hospital variation. In contrast, more expensive testing with TTE is less common though more variable across hospitals. Although often ordered, natriuretic peptides, CXR, and TTE do not appear to influence physicians’ decisions to treat only for heart failure or also for potential coexisting respiratory conditions.

Background: Inpatients with heart failure (HF) may be treated for other acute conditions such as concomitant respiratory disease due to diagnostic uncertainty, coexisting illness, or other reasons. We investigated the frequency and mortality associated with respiratory treatments added to usual HF care. Methods: We included hospitalizations with a primary discharge diagnosis of HF from 2009-10 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators) and >2 day hospital stay. For hospital days 1-2 and 3-5, we noted receipt of potential respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD were excluded. Hospitalizations were split into mutually exclusive and exhaustive groups based on treatments received in days 1-2 (table); odds of in-hospital mortality were determined for each after adjusting for age, sex, and Elixhauser comorbidities. Results: Among 164,494 HF hospitalizations, 54% (88,122) received treatment for acute respiratory conditions during hospital days 1-2 (table). At least 1 respiratory treatment was continued after day 2 in 60% (52,452) of patients who received initial treatment. Odds of in-hospital mortality increased with receipt of respiratory treatments in days 1-2 (table). Conclusions: HF inpatients are frequently treated for respiratory conditions. As these treatments are often given throughout hospitalization and identify patients at higher risk of death, coexisting comorbidities or a new cardiopulmonary syndrome may often be present, as may diagnostic uncertainty or overtreatment. Greater knowledge of patient complexity can improve treatment guidelines, patient outcomes, and risk-adjustment for performance measures.

Background: Although loop diuretics are frequently used for patients with heart failure (HF), little is known about the variation in patterns of diuretic therapy in US hospitals. We sought to describe such treatment patterns among a diverse group of hospitals. Methods: We studied HF hospitalizations occurring during 2009-10 in Premier Inc. hospitals participating in a collaborative project to pool administrative and charge data, which includes information about drug types, average daily dose, and duration of therapy. We excluded hospitals with less than 25 HF hospitalizations. For ease of comparison, all diuretic doses were converted to bioequivalent doses of intravenous (IV) furosemide: 40mg IV furosemide ∼ 80mg oral furosemide ∼ 20mg (oral or IV) torsemide ∼ 1mg (oral or IV) bumetanide. Summary statistics were calculated. Results: Among 366 studied hospitals (264,675 HF hospitalizations), use of any loop diuretic had an interquartile range (IQR) from 92% to 96% (median: 94%). At the hospital level, the average daily dose IQR varied from 45mg to 64 mg (median: 55 mg) and the median duration of therapy was 4 days (IQR: 4 to 4; median: 4), as was the median length of stay. The IQR for use of furosemide varied from 89% to 94% (median: 92%), and its median average daily dose had an IQR from 40mg to 60 mg (median: 53 mg). Hospital use of bumetanide had an IQR from 2% to 11%, and hospital use of torsemide had an IQR from 0% to 4% (medians of 5% and 1%, respectively). The variation in median average daily dose for bumetanide and torsemide was greater than for furosemide (bumetanide IQR: 79mg to 127 mg, with median of 89 mg; torsemide IQR: 53mg to 120 mg, with median of 80 mg). Use of IV diuretics on the last day before home discharge had an IQR from 16% to 33% (median: 24%) across hospitals. Conclusion: US hospitals administer loop diuretics, particularly furosemide, to the vast majority of HF inpatients. The duration and daily dosage of therapy was similar across most hospitals. In contrast, a minority of hospitals used bumetanide and torsemide for several patients. The daily dosage of these agents showed more marked variation. We observed a high rate of intravenous diuretic use on the last day of hospitalization, with considerable variation across hospitals.

Administration of Intravenous Fluids in Patients Hospitalized with Heart Failure Background: Administration of intravenous (IV) fluids to patients with acute decompensated heart failure (HF) may worsen pulmonary congestion or hemodynamic status. However, little is known about the use of IV fluids in clinical practice. We examined the frequency and volume with which commonly used IV fluid preparations are used among inpatients with HF as well as the association of these treatment patterns with diuretic use and length of stay (LOS). Methods: We identified all hospitalizations in 2009-2010 with a principal discharge diagnosis of heart failure from the Premier, Inc. hospitals. In order to capture inappropriate therapy with intravenous fluids, we limited our study period to the initial two days, a period during which most HF patients undergo diuresis for fluid overload. We excluded patients with a potential indication for fluid resuscitation (concomitant therapy with vasopressors or inotropes, undergoing invasive procedures, or having secondary diagnosis of bleeding, sepsis or anaphylaxis). We also excluded hospitalizations with age < 18 yrs, < 3 day LOS, transfer-ins, and hospitals with < 25 HF cases. We calculated the administration frequency and volume of commonly used IV fluids (normal saline, half normal saline, 5% dextrose, and Lactated Ringer’s), the percentage of patients receiving concomitant therapy with loop diuretics, and the average LOS associated with administration of each of the four fluids. Results: Among 195,652 hospitalizations, 25% (48,611) were administered at least one of the four IV fluids. Normal saline was the most commonly administered fluid (19.4% of hospitalizations), followed by 5% dextrose (6%), half normal saline (2.2%), and Lactated Ringer’s (0.2%). The median volume of fluid administration over the first two days was 1,000 ml (IQR: 250, 1250). Eighty-nine percent of patients receiving fluid therapy received concomitant loop diuretics. Increasing median LOS was noted with increasing fluid volumes across all four individual IV fluid categories (see Table). Conclusion: A substantial proportion of patients hospitalized with HF receive a considerable volume of intravenous fluid during their first 2 hospital days; normal saline was the most commonly administered formulation. Loop diuretic use was very common in those receiving IV fluids. Greater understanding of the concomitant use of intravenous fluids and diuretics and their relation to length of stay may provide an opportunity to improve quality of care.

The following are highlights from the new series, Circulation: Cardiovascular Quality and Outcomes Topic Review . This series will summarize the most important manuscripts (as selected by the Editor) that have published in the Circulation portfolio. The objective of this new series is to provide our readership with a timely, comprehensive selection of important papers that are relevant to the quality and outcomes, and general cardiology audience. The studies included in this article represent the most significant research in the area of health costs, cost-effectiveness, and resource utilization.