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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2009.12.015 Byline: Kingston Okrah (a)(b), Mary Vaughan-Sarrazin (b)(c), Peter Cram (b)(c) Abstract: There is growing concern over the impact of accelerating use of diagnostic imaging services on health care spending. Echocardiography is an important cardiovascular imaging procedure, but little is known about trends in its use or utilization. We examine trends in the utilization of echocardiography in a national health care system. Author Affiliation: (a) Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA (b) Center for Research in the Implementation of Innovative Strategies for Practice (CRIISP), Iowa City Veterans Administration Medical Center, Iowa City, IA (c) Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA Article History: Received 26 August 2009; Accepted 18 December 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2008.02.018 Byline: Ioana Popescu (a)(b), Brahmajee K. Nallamothu (c), Mary S. Vaughan-Sarrazin (a)(b), Peter Cram (a)(b) Abstract: Supporters of specialty hospitals claim these facilities provide better patient care; however, empirical data on quality of care in specialty hospitals are limited. Author Affiliation: (a) The Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP), Iowa City VA Medical Center, Iowa City, IA (b) The Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA (c) The Health Services Research and Development Center of Excellence, Ann Arbor VA Medical Center, Ann Arbor, MI Article History: Received 27 February 2007; Accepted 14 February 2008 Article Note: (footnote) The study is supported by a grants from the National Center for Research Resources, Bethesda, MD (K23 RR01997201), National Heart, Lung, and Blood Institute, Bethesda, MD, and the Robert Wood Johnson Physician Faculty Scholars Program, Stanford, CA (Dr Cram); from the Health Services Research and Development Service, Veterans Health Administration, Department of Veterans Affairs (HFP 04-149) (Dr Vaughan-Sarrazin); and from the Agency for Health care Research and Quality (1R01HS015571-01A1) (Dr Nallamothu). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Background: Patterns of diffusion of TAVR in the United States (U.S.) and its relation to racial disparities in TAVR utilization remain unknown.Methods: We identified TAVR hospitals in the continental U.S. from 2012-2017 using Medicare database and mapped them to Hospital Referral Regions (HRR). We calculated driving distance from each residential ZIP code to the nearest TAVR hospital and calculated the proportion of the U.S. population, in general and by race, that lived <100 miles driving distance from the nearest TAVR center. Using a discrete time hazard logistic regression model, we examined the association of hospital and HRR variables with the opening of a TAVR program.Results: The number of TAVR hospitals increased from 230 in 2012 to 540 in 2017. The proportion of the U.S. population living <100 miles from nearest TAVR hospital increased from 89.3% in 2012 to 94.5% in 2017. Geographic access improved for all racial and ethnic subgroups: Whites (84.1%-93.6%), Blacks (90.0%- 97.4%), and Hispanics (84.9%-93.7%). Within a HRR, the odds of opening a new TAVR program were higher among teaching hospitals (OR 1.48, 95% CI 1.16-1.88) and hospital bed size (OR 1.44, 95% CI 1.37-1.52). Market-level factors associated with new TAVR programs were proportion of Black (per 1%, OR 0.78, 95% CI 0.69-0.89) and Hispanic (per 1%, OR 0.82, 95% CI 0.75-0.90) residents, the proportion of hospitals within the HRR that already had a TAVR program (per 10%, OR 1.07, 95% CI 1.03-1.11), P <.01 for all.Conclusion: The expansion of TAVR programs in the U.S. has been accompanied by an increase in geographic coverage for all racial subgroups. Further study is needed to determine reasons for TAVR underutilization in Blacks and Hispanics. [ABSTRACT FROM AUTHOR]

Background: Research to understand predictors of poor outcomes after total knee arthroplasty (TKA) has largely focused on presurgery factors. We examined whether pain and function 3-month postsurgery were predictive of longer-term outcomes ascertained 2 years after TKA.Methods: Western Ontario McMaster University Osteoarthritis Index pain and physical function scores (scaled 0-20 and 0-68; higher = worse) were recorded pre-TKA and 3, 12, and 24 months post-TKA. A sequential series of regression models was used to examine the relative contribution of baseline score and baseline to 3-month and 3 to 12-month change score to explaining variability (R2) in 2-year pain and function scores, with consideration for presurgery covariates.Results: Data from 560 patients were analyzed. Mean pain and function scores improved significantly presurgery to 2 years postsurgery; 10-4 and 33-16 (P < .001), respectively. Considerable variability in 2-year scores was observed. Overall, 80.3% and 79.9% of changes in pain and function scores over the 2 years occurred within the first 3 months. Change over these 3 months explained the greatest proportion of variability in 2-year scores, 16% and 23% for pain and function, respectively. The influences of these early changes were similar to those of baseline status.Conclusion: Changes in patient-reported pain and function occurring within the first 3 months post-TKA strongly determine pain and function status at 2 years. Research to identify pre-/intra-/early postoperative factors associated with change in this early postoperative period that may be amenable to modification or used to better inform education and decision-making is warranted. [ABSTRACT FROM AUTHOR]

In cross-sectional studies, patient activation has been associated with better health behaviors, health outcomes, and health-care experiences. Moreover, tailored interventions have led to clinically meaningful improvements in patient activation, as well as health outcomes over time. We tested whether a tailored patient-activation letter communicating bone mineral density (BMD) test results plus an educational brochure improved patient activation scores and levels at 12 and 52 wk post-baseline as the mechanism leading to enhanced bone healthcare. In a randomized, controlled, double-blinded, multicenter pragmatic clinical trial, we randomized 7749 patients ≥50 yr old and presenting for BMD testing at 3 medical centers in the United States between February 2012 and August 2014. The outcome measures were patient activation scores and levels based on 6 items taken from the Patient Activation Measure (PAM) that were administered at the baseline, 12-wk, and 52-wk follow-up interviews. Mean age was 66.6 yr, 83.8% were women, and 75.3% were Non-Hispanic-Whites. Overall, PAM activation scores improved from 58.1 at baseline to 76.4 by 12 wk ( p  < 0.001) and to 77.2 ( p  = 0.002) by 52 wk post-baseline. These improvements, however, were not significantly different between the intervention and usual care groups (18.7 vs 18.1, p  = 0.176, at 12 wk) in intention-to-treat analyses. PAM activation scores and levels substantially improved at 12 wk and 52 wk, but no differences were observed in these improvements between the intervention and usual care groups. These null findings may have occurred because the tailoring focused on the patient's BMD and fracture risk results, rather than on the patient's BMD and fracture risk results as well as the patient's baseline PAM activation scores or levels. [ABSTRACT FROM AUTHOR]

Objectives: As many as one-half of patients recommended for osteoporosis pharmacotherapy do not take their medications. To identify intervention targets, we examined patient characteristics associated with nonadherence to recommended pharmacotherapy and their reasons for nonadherence.Methods: Data come from the Patient Activation after DXA Result Notification (PAADRN) study, a randomized controlled trial of 7749 patients aged 50 years or older presenting for dual-energy X-ray absorptiometry (DXA) at 3 health centers in the United States. We focused on the 790 patients who reported receiving a recommendation for new pharmacotherapy at baseline. Using Pearson chi-squared tests for categorical variables, 2-sample t tests for continuous variables, and multivariable multinomial logistic regression, we compared those who reported starting the recommended medication (adherers) with temporary nonadherers and nonadherers on demographics, health habits, DXA impression, 10-year probability of fracture using the assessment tool, and osteoporosis knowledge, and we examined their stated reasons for nonadherence.Results: Mean age was 66.8 years (SD = 8.9); 87.2% were women, and 84.2% were white. One-fourth of patients (24.8%) reported that they did not start their recommended pharmacotherapy. In the unadjusted analyses, the only factor significantly associated with nonadherence was osteoporosis knowledge, with those having better knowledge being less likely to take their medications (P < 0.05). The most common reasons for nonadherence were fear of adverse effects (53.3%), a dislike of taking medicine (25.3%), and the belief that the medication would not help their condition (16.7%).Conclusion: One in 4 patients recommended for osteoporosis pharmacotherapy declined treatment because they feared potential adverse effects, did not like taking medicine, or believed that the medication would not help their condition. Improved patient counseling on the potential adverse effects of osteoporosis treatment and the risk-benefit ratio for these medications may increase adherence. [ABSTRACT FROM AUTHOR]

Objective: This study evaluates rural hospital staff perceptions of a telemedicine ICU (Tele-ICU) before and after implementation. Methods: We conducted a longitudinal qualitative study utilising semistructured group or individual interviews with staff from three rural ICU facilities in the upper Midwest of the United States that received Tele-ICU support. Interviews occurred pre-implementation and at two time points post-implementation. Interviews were conducted with: ICU administrators (n = 6), physicians (n = 3), nurses (n = 9), respiratory therapists (n = 5) and other (n = 1) from July 2011 to May 2013. Transcripts were analysed for thematic content. Findings: Overall, rural ICU staff viewed Tele-ICU as a welcome benefit for their facility. Major themes included: (1) beneficial where recruitment and retention of staff can be challenging; (2) extra support for day shifts and evening, night and weekend shifts; (3) reduction in the number of transfers larger tertiary hospitals in the community; (4) improvement in standardisation of care; and (5) organisational culture of rural ICUs may lead to under-utilisation. Conclusions: ICU staff at rural facilities view Tele-ICU as a positive, useful tool to provide extra support and assistance. However, more research is needed regarding organisational culture to maximise the potential benefits of Tele-ICU in rural hospitals. [ABSTRACT FROM AUTHOR]

We sought to identify temporal, geographic, age and sex-based mortality trends of IE in the US over the past 2 decades. This population-based study utilized the CDC WONDER database to identify IE-related deaths occurring within the US between 1999 and 2019. IE-related crude and age-adjusted mortality rates (CMRs and AAMRs, respectively) were determined. Joinpoint regression was used to determine trends in CMR/AAMR using annual percent change (APC) in the overall sample in addition to demographic (sex, race/ethnicity, age) and geographic (rural/urban, statewide) subgroups. Between 1999 and 2019, a total of 279,154 deaths related to IE were reported. The overall AAMR declined from 54.2/1,000,000 in 1999 to 51.4 in 2019. However, AAMRs increased among several sub-groups over the past decade including men [2009-2019 APC = 0.4%, 95%CI, 0.1%-0.6%], non-Hispanic (NH) whites [APC of 0.8% from 2009 to 2019 (95%CI 0.5%-1.1%)], NH American Indians or Alaskan Natives [APC of 1.4% during the study period (95%CI, 0.7%-2.0%)], and those in rural areas [APC of 1.0% from 2009 to 2019 (95%CI 0.5%-1.5%)]. The CMRs increased among subjects 40-64 years old [APC of 2.8% from 2010 to 2019 (95%CI 2.2%-3.5%)] and 15-39 years old [APC of 16.4% from 2010 to 2017 (95%CI 13.5%-19.4%)]. IE-related CMR/AAMR increased among men, NH whites, NH American Indian or Alaskan Natives, those <65-year-old, and those from rural areas. Discerning the reasons for the increase in IE-related mortality among these groups and examining the impact of the social determinants of health may represent important opportunities to enhance care. [ABSTRACT FROM AUTHOR]

Background: Although controversial, several prior studies have suggested that oral anticoagulants (OACs) are underused in the US atrial fibrillation (AF) population. Appropriate use of OACs is essential because they significantly reduce the risk of stroke in those with AF. In the >2 million Americans with AF, OACs are recommended when the risk of stroke is moderate or high but not when the risk of stroke is low. To quantify trends and guideline adherence, we evaluated OAC use (either warfarin or dabigatran) in a 10-year period in patients with new AF in the Veterans Health Administration.Methods: New AF was defined as at least 2 clinical encounters documenting AF within 120 days of each other and no previous AF diagnosis (N = 297,611). Congestive Heart Failure, Hypertension, Age > 75, Diabetes, and Stroke (CHADS2) scores were determined using age and diagnoses of hypertension, diabetes, heart failure, and stroke or transient ischemic attack during the 12 months before AF diagnosis. Receipt of an OAC within 90 days of a new diagnosis of AF was evaluated using VA pharmacy data.Results: Overall, initiation of an OAC fell from 51.3% in 2002 to 43.1% in 2011. For patients with CHADS2 score of 0, 1, 2, 3, 4, and 5-6, the proportions of patients prescribed an OAC showed a relative decrease of 26%, 23%, 14%, 12%, 9%, and 13%, respectively (P < .001). Clopidogrel use was stable at 10% of the AF population.Conclusions: Among US veterans with new AF and additional risk factors for stroke, only about half receive OAC, and the proportion is declining. [ABSTRACT FROM AUTHOR]

Although prices for medical services are known to vary markedly between hospitals, it remains unknown whether variation in hospital prices is explained by differences in hospital quality or reimbursement from major insurers. We obtained "out-of-pocket" price estimates for coronary artery bypass grafting (CABG) from a random sample of US hospitals for a hypothetical patient without medical insurance. We compared hospital CABG price to (1) "fair price" estimate from Healthcare Bluebook data using each hospital's zip code and (2) Society of Thoracic Surgeons composite CABG quality score and risk-adjusted mortality rate. Of 101 study hospitals, 53 (52.5%) were able to provide a complete price estimate for CABG. The mean price for CABG was $151,271 and ranged from $44,824 to $448,038. Except for geographic census region, which was weakly associated with price, hospital CABG price was not associated with other structural characteristics or CABG volume (p >0.10 for all). Likewise, there was no association between a hospital's price for CABG with average reimbursement from major insurers within the same zip code (ρ = 0.07, p value = 0.6), Society of Thoracic Surgeoncomposite quality score (ρ = 0.08, p value = 0.71), or risk-adjusted CABG mortality (ρ = -0.03 p value = 0.89). In conclusion, the price of CABG varied more than 10-fold across US hospitals. There was no correlation between price information obtained from hospitals and the average reimbursement from major insurers in the same market. We also found no evidence to suggest that hospitals that charge higher prices provide better quality of care. [ABSTRACT FROM AUTHOR]

Percutaneous ventricular assist devices (PVADs) and intraaortic balloon pump (IABP) are used to provide mechanical circulatory support (MCS) for high-risk percutaneous coronary intervention (PCI). Contemporary trends in their utilization and impact on in-hospital mortality are not known. Using the National Inpatient Sample (2004 to 2012), we identified 5,031 patients who received a PVAD and 122,333 who received an IABP on the same day as PCI using International Classification of Diseases, Ninth Edition codes. Utilization of MCS increased from 1.3% of all PCIs in 2004 to 3.4% in 2012 (p trend <0.001), with increase in the use of both PVAD (<1/10,000 PCIs [2004 to 2007] to 38/10,000 [2012]) and IABP (132/10,000 PCIs [2004] to 299/10,000[2012] p <0.0001 for both). PVAD recipients were older (69 vs 65 years), more likely to have heart failure (68% vs 41%), chronic kidney disease (27% vs 11%, p <0.001 for all), and be admitted electively (30% vs 11%), but less likely to have acute myocardial infarction (52% vs 90%), cardiogenic shock (23% vs 50%), or need mechanical ventilation (16% vs 29%) compared with IABP recipients. Unadjusted in-hospital mortality was lower in PVAD compared with IABP recipients (12.8% vs 20.9%, p <0.001). However, in propensity-matched analyses (1:2), in-hospital mortality was similar in both groups (odds ratio 0.88, 95% confidence interval 0.70 to 1.09). In conclusion, there has been a marked increase in the utilization of MCS in patients undergoing PCI. Unadjusted mortality using PVADs is lower than IABP but may be due to their selective use in patients at lower risk. Randomized trials are necessary to establish their effectiveness in supporting high-risk PCI. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is associated with stroke and death. We sought to determine whether there are any racial differences in the outcomes of death and stroke in patients with AF. We used Medicare administrative data from January 1, 2010, to December 31, 2011, to identify 517,941 patients with newly diagnosed AF. Of these, 452,986 patients (87%) were non-Hispanic white, 36,425 (7%) were black, and 28,530 (6%) were Hispanic. The association between race and outcomes of death and stroke were measured using Cox proportional hazard models. Over a median follow-up period of 20.3 months, blacks had a significantly higher hazard of death (hazard ratio [HR] = 1.46; 95% confidence interval [CI] 1.43 to 1.48; p <0.001) and stroke (HR = 1.66; 95% CI 1.57 to 1.75; p <0.001), compared with white patients. After controlling for pre-existing co-morbidities, the higher hazard of death in blacks was eliminated (HR 0.95; 95% CI 0.93 to 0.96; p <0.001) and the relative hazard of stroke was reduced (HR = 1.46; 95% CI 1.38 to 1.55; p <0.001). Similarly, Hispanics had a higher risk of death (HR = 1.11; 95% CI 1.09 to 1.14; p <0.001) and stroke (HR = 1.21; 95% CI 1.13 to 1.29; p <0.001) compared with whites. The relative hazard of death was lower in Hispanics (HR 0.82; 95% CI 0.80 to 0.84; p <0.001) compared with whites, after controlling for pre-existing co-morbidities, and the relative hazard of stroke was also attenuated (HR = 1.11; 95% CI 1.03 to 1.18; p <0.001). In conclusion, in patients >65 years with newly diagnosed AF, the risks of death and stroke are higher in blacks and Hispanics compared with whites. The increased risk was eliminated or significantly reduced after adjusting for pre-existing co-morbidities. AF may be a marker for underlying co-morbidities in black and Hispanic patients who may be at a higher mortality risk. [ABSTRACT FROM AUTHOR]

The article presents information on a study conducted to identify factors related to intensive care unit (ICU) staff acceptance of a telemedicine ICU (Tele-ICU) program. In the study, interviews and site observations were conducted with employees fromTele-ICU departments, followed by a qualitative content analysis of pre-implementation and post-implementation transcripts. The study found that Telemedicine ICU training and organizational factors had an impact on the acceptance of the Tele-ICU.

Abstract: We analyzed the 2009 Medicare inpatient claims data and other databases to estimate Medicare payments for primary or revision total knee arthroplasty (TKA). The average Medicare hospital payment per procedure was $13,464 for primary TKA (n=227,587) and $17,331 for revision TKA (n=18,677). For both primary and revision TKAs Medicare payments varied substantially across patients, hospitals and healthcare markets. Less than one percent of primary TKA cases but seven percent of revision TKA cases triggered Medicare “outlier” payments, which were $10,000 or higher per case beyond regular diagnosis-related-group payments. Urban and major teaching hospitals were more likely to treat these unusually expensive cases. Hospitals in the Northeast and West regions tended to receive higher Medicare payments than hospitals in the Midwest. [Copyright &y& Elsevier]

Abstract: Recently, the government has moved towards public reporting of 30-day readmission rates after elective primary total knee (TKA) and total hip arthroplasty (THA). We identified 11,814 and 8105 patients who underwent primary TKA and THA from the 2011 ACS NSQIP. Overall readmission rates within 30-days of surgery were 4.6% for TKA and 4.2% for THA. Complications associated with readmission were predominantly wound infections, sepsis, thromboembolic, cardiac, and respiratory related. In TKA, multivariate analysis identified age (P =0.002), male gender (P =0.03), cancer history (P =0.008), elevated BUN (P =0.002), a bleeding disorder (P <0.001) and high ASA class (P <0.001) as predictors of readmission. In THA, obesity (P =0.008), steroid use (P =0.037), a bleeding disorder (P =0.002), dependent functional status (P =0.022), and high ASA class (P <0.001) predicted readmission. Understanding characteristics associated with readmission will be essential for equitable patient risk stratification. [Copyright &y& Elsevier]

Abstract: Consecutive patients identified as having osteoporosis on screening dual-energy X-ray absorptiometry (DXA) scans were randomized to: (1) a patient activation intervention consisting of mailing patients their DXA scan results supplemented by a call from a nurse educator or (2) usual care. Three months after the DXA scan, patients were contacted to assess: (1) use of antiresorptive therapy, (2) osteoporosis specific knowledge, and (3) satisfaction with their osteoporosis-related care. A total of 1,035 consecutive patients were screened to identify 422 eligible patients. Of these, 56 patients met inclusion criteria and were subsequently randomized. At follow-up, use of antiresorptive agents was numerically more common in the intervention arm (62%) than the control arm (54%), but this difference was not statistically significant (p =0.58). Patients in the intervention group were more likely to report being notified of their DXA results in a timely fashion (p =0.03), but osteoporosis-specific knowledge was similar. [Copyright &y& Elsevier]

Objcetives: Implantable cardioverter defibrillators (ICDs) are highly effective at preventing cardiac arrest, but their availability is limited by high cost. Automated external defibrillators (AEDs) are likely to be less effective, but also less expensive. We used decision analysis to evaluate the clinical and economic trade-offs of AEDs, ICDs, and emergency medical services equipped with defibrillators (EMS-D) for reducing cardiac arrest mortality. Methods: A Markov model was developed to compare the cost-effectiveness of three strategies in adults meeting entry criteria for the MADIT II Trial: strategy 1, individuals experiencing cardiac arrest are treated by EMS-D; strategy 2, individuals experiencing cardiac arrest are treated with an in-home AED; and strategy 3, individuals receive a prophylactic ICD. The model was then used to quantify the aggregate societal benefit of these three strategies under the conditions of a constrained federal budget. Results: Compared with EMS-D, in-home AEDs produced a gain of 0.05 quality-adjusted life-years (QALYs) at an incremental cost of $5225 ($104,500 per QALY), while ICDs produced a gain of 0.90 QALYs at a cost of $114,660 ($127,400 per QALY). For every $1 million spent on defibrillators, 1.7 additional QALYs are produced by purchasing AEDs (9.6 QALYs/$million) instead of ICDs (7.9 QALYs/$million). Results were most sensitive to defibrillator complication rates and effectiveness, defibrillator cost, and adults’ risk of cardiac arrest. Conclusions: Both AEDs and ICDs reduce cardiac arrest mortality, but AEDs are significantly less expensive and less effective. If financial constraints were to lead to rationing of defibrillators, it might be preferable to provide more people with a less effective and less expensive intervention (in-home AEDs) instead of providing fewer people with a more effective and more costly intervention (ICDs). [ABSTRACT FROM AUTHOR]

Abstract: Evidence suggests that patients diagnosed with osteoporosis are often undertreated. One potential solution to undertreatment is to enhance patient involvement in their osteoporosis care (a.k.a. patient activation) by having the dual-energy X-ray absorptiometry (DXA) center directly provide patients with their test results and educational material. However, little is known about patient interest in such an intervention. Consecutive patients presenting to an academic medical center DXA scanning unit were given a questionnaire to assess their preferences for being informed of their test results and interest in receiving their results plus educational material by mail from the testing center. Two hundred and two (202) of 206 (98%) of patients agreed to complete the survey. Fifty-one percent of participants preferred receiving their results by mail directly from the DXA center, followed by phone call (28%) and office visit (11%). Overall, 90% of patients reported interest in receiving results and educational material by mail. Younger patients were more interested in receiving their results by mail when compared with older patients, but this difference did not reach statistical significance (odds ratio [OR] = 2.40: 95% confidence interval [CI]: 0.91–6.31, p = 0.14). Patients undergoing DXA scanning were interested in receiving their scan results and educational material directly from the testing center. This might represent an effective intervention for improving care of patients with osteoporosis. [Copyright &y& Elsevier]

Abstract Objective: Traditional cost–utility analysis assumes that all benefits from health-related interventions are captured by the quality-adjusted life-years (QALYs) gained by the few individuals whose outcome is improved by the intervention. However, it is possible that many individuals who do not directly benefit from an intervention receive utility, and therefore QALYs, because of the passive benefit (aka sense of security) provided by the existence of the intervention. The objective of this study was to evaluate the impact that varying quantities of passive benefit have on the cost-effectiveness of airline defibrillator programs. Methods: A decision analytic model with Markov processes was constructed to evaluate the cost-effectiveness of defibrillator deployment on domestic commercial passenger aircraft over 1 year. Airline passengers were assigned small incremental utility gains (.001–.01) during an estimated 3-hour flight to evaluate the impact of passive benefit on overall cost-effectiveness. Results: In the base case analysis with no allowance for passive benefit, the cost-effectiveness of airline automated external defibrillator deployment was $34,000 per QALY gained. If 1% of all passengers received utility gain of .01, the cost-effectiveness declined to $30,000. Cost-effectiveness was enhanced when the quantity of passive benefit was raised or the percentage of individuals receiving passive benefit increased. Conclusions: Automated external defibrillator deployment on passenger aircraft is likely to be cost-effective. If a small percentage of airline passengers receive incremental utility gains from passive benefit of automated external defibrillator availability, the impact on overall cost-effectiveness may be substantial. Further research should attempt to clarify the magnitude and percentage of patients who receive passive benefit. [ABSTRACT FROM AUTHOR]

Background: Prescribing rate control medications with or without antiarrhythmic drugs is often the first course treatment for atrial fibrillation (AF). Clinical trial data suggest that antiarrhythmic drugs are only marginally effective and have multiple drawbacks, whereas rate control alone is sufficient for most patients with minimally symptomatic AF. This study investigates changes in the use of oral rate and rhythm control therapy for AF during fiscal years 2002 through 2011 in the US Veterans Affairs (VA) health system. Methods: Patients with new AF episodes were identified in Veterans Health Administration administrative data files, and receipt of oral rate- and rhythm-controlling drugs within 90 days of new AF episodes was determined for each patient. Results: The percentage of patients receiving an oral rate-controlling medication decreased from 74.9% in 2002 through 2003 to 70.9% in 2010 through 2011. The use of digoxin decreased by >50%, whereas the use of β-blockers metoprolol and carvedilol increased. The proportion of patients receiving any oral antiarrhythmic medication decreased from 13.5% in 2002 through 2003 to 11.6% in 2010 through 2011, and use of the most frequently prescribed oral antiarrhythmic, amiodarone, decreased by 17%. Conclusions: Rate control remains the dominant strategy for treating new AF. The decrease in the use of oral antiarrhythmics may be due to lack of concrete data suggesting mortality and morbidity benefit as well as increasing use of the ablation approach. Bullet points: The proportion of patients with new AF episodes who were prescribed oral rate or rhythm control medications decreased modestly from 2002 through 2011. The use of digoxin decreased by >50%, and amiodarone decreased by 17%. Rate control remains the dominant strategy for treating new AF. [Copyright &y& Elsevier]

Abstract: Administrative data are commonly used to evaluate total joint arthroplasty, but analyses have historically been limited by the inability to capture which conditions were present-on-admission (POA). In 2007 Medicare began allowing hospitals to submit POA information. We used Medicare Part A data from 2008 to 2009 to examine POA coding for three common complications (pulmonary embolism [PE], hemorrhage/hematoma, and infection) for primary and revision total knee arthroplasty (TKA). POA information was complete for 60%–75% of complications. There was no evidence that higher TKA volume hospitals or major teaching hospitals were more likely to accurately code POA data. The percentage of complications coded as POA ranged from 6.4% (PE during index admission for primary TKA) to 68.8% (infection during index admission for revision TKA). Early experience suggests that POA coding can significantly enhance the value of Medicare data for evaluating TKA outcomes. [Copyright &y& Elsevier]

Objective: The purpose of this study was to examine the relationship between delivery volume and maternal complications. Study Design: We used administrative data to identify women who had been admitted for childbirth in 2006. Hospitals were stratified into deciles that were based on delivery volume. We compared composite complication rates across deciles. Results: We evaluated 1,683,754 childbirths in 1045 hospitals. Decile 1 and 2 hospitals had significantly higher rates of composite complications than decile 10 (11.8% and 10.1% vs 8.5%, respectively; P < .0001). Decile 9 and 10 hospitals had modestly higher composite complications as compared with decile 6 (8.8% and 8.5% vs 7.6%, respectively; P < .0001). Sixty percent of decile 1 and 2 hospitals were located within 25 miles of the nearest greater volume hospital. Conclusion: Women who deliver at very low-volume hospitals have higher complication rates, as do women who deliver at exceedingly high-volume hospitals. Most women who deliver in extremely low-volume hospitals have a higher volume hospital located within 25 miles. [ABSTRACT FROM AUTHOR]

Abstract: We used Medicare administrative data to examine trends in primary and revision total hip arthroplasty (THA) use and hospital volume. Between 1991 and 2005, primary and revision THA use increased by 40.9% and 16.8%, respectively. The percentage of primary THA procedures performed in high-volume hospitals (those in the highest quintile of volume) increased slightly from 58.0% of all procedures in 1991 to 58.7% in 2005 (P < .01). The percentage of revisions performed in high-volume hospitals increased from 60.9% to 62.4% (P < .01). The percentage of primary THA procedures performed by low-volume hospitals remained relatively stable (P = .36), whereas the percentage of revision THA performed by low-volume hospitals declined (P < .001). In aggregate, these results suggest minimal evidence that regionalization of THA is occurring. [Copyright &y& Elsevier]

Background: In the United States, there continues to be debate about whether certain types of hospitals deliver improved patient outcomes. We sought to assess the association between hospital organizational characteristics and in-hospital outcomes for percutaneous coronary intervention (PCI).Methods: Retrospective analysis of 2004 to 2007 data for 694 US hospitals participating in the CathPCI Registry(®). Our analysis focused on 1,113,554 patients who underwent PCI in 471 not-for-profit (NFP) hospitals, 131 major teaching hospitals, 79 for-profit (FP) hospitals, and 13 physician-owned specialty hospitals. Outcomes included in-hospital mortality, stroke, bleeding, vascular injury, and a composite representing one or more of the individual complications. We used the current CathPCI Registry mortality risk model to calculate risk-standardized mortality ratios (RSMRs) for each category of hospital and compared hospital groupings for all patients in aggregate and in subgroups stratified by patients' indications for PCI.Results: Patients treated in major teaching hospitals were younger, whereas FP hospitals performed a greater proportion of PCI for patients with ST-elevation myocardial infarction (P < .0001). Specialty hospitals treated patients with less acuity, including a lower proportion of patients with ST-elevation myocardial infarction. In unadjusted analyses, specialty hospitals had significantly lower rates of all adverse outcomes compared with NFP, teaching, and FP hospitals including in-hospital mortality (0.7%, 1.2%, 1.4%, and 1.4%, respectively; P < .001) and the composite end point (2.4%, 4.1%, 4.6%, and 4.3%, respectively; P < .001). In adjusted analyses, RSMR was significantly lower for specialty hospitals when compared with the other 3 groups for all patients in aggregate (RSMR 1.05%, 1.30%, 1.38%, 1.39%; P < .001); these differences remained clinically significant but were no longer statistically significant in subgroup analyses.Conclusions: Specialty hospitals appear to have lower rates of most adverse outcomes for PCI. Specialty hospitals may have developed expertise in narrow procedural areas that could be adapted to the larger population of general hospitals. [ABSTRACT FROM AUTHOR]

Background: There are many factors hypothesized as contributing to overuse of percutaneous coronary intervention (PCI) in the United States, including financial ties between physicians and hospitals, but empirical data are lacking. We examined PCI indications in not-for-profit (NFP), major teaching, for-profit (FP), and physician-owned specialty hospitals.Methods: A retrospective cohort study of 1,113,554 patients who underwent PCI in 694 hospitals (NFP 471, teaching 131, FP 79, specialty 13) participating in the CathPCI Registry® between January 1, 2004, and December 31, 2007. Percutaneous coronary intervention indications derived from American College of Cardiology Guidelines were classified as survival benefit (patients with primary reperfusion for ST-elevation myocardial infarction), potential quality of life benefit (patients with non-ST-elevation myocardial infarction, acute coronary syndrome (ACS), positive stress test, or chest pain), or unclear indications (patients receiving PCI without an obvious potential survival or quality of life benefit).Results: The percentage of PCI performed for unclear indications was somewhat higher for specialty hospitals (5.1% of all procedures) as compared with other hospital categories (FP 4.7%, NFP 4.2%, major teaching 4.5%; P < .001). Overall, 17% of hospitals had ≥20% of their total PCI procedures performed for unclear indications, but the proportion of FP, NFP, major teaching, and specialty hospitals reaching this threshold was not statistically different (20%, 16%, 17%, and 15%, respectively; P = .84).Conclusions: A small proportion of PCI procedures were performed in patients with unclear indications, but there was wide variation across hospitals. On average, specialty hospitals performed more PCIs for unclear indications. Efforts to reduce variability should be pursued. [ABSTRACT FROM AUTHOR]

Background: In the United States, there continues to be debate about whether certain types of hospitals deliver improved patient outcomes. We sought to assess the association between hospital organizational characteristics and in-hospital outcomes for percutaneous coronary intervention (PCI). Methods: Retrospective analysis of 2004 to 2007 data for 694 US hospitals participating in the CathPCI Registry®. Our analysis focused on 1,113,554 patients who underwent PCI in 471 not-for-profit (NFP) hospitals, 131 major teaching hospitals, 79 for-profit (FP) hospitals, and 13 physician-owned specialty hospitals. Outcomes included in-hospital mortality, stroke, bleeding, vascular injury, and a composite representing one or more of the individual complications. We used the current CathPCI Registry mortality risk model to calculate risk-standardized mortality ratios (RSMRs) for each category of hospital and compared hospital groupings for all patients in aggregate and in subgroups stratified by patients'' indications for PCI. Results: Patients treated in major teaching hospitals were younger, whereas FP hospitals performed a greater proportion of PCI for patients with ST-elevation myocardial infarction (P < .0001). Specialty hospitals treated patients with less acuity, including a lower proportion of patients with ST-elevation myocardial infarction. In unadjusted analyses, specialty hospitals had significantly lower rates of all adverse outcomes compared with NFP, teaching, and FP hospitals including in-hospital mortality (0.7%, 1.2%, 1.4%, and 1.4%, respectively; P < .001) and the composite end point (2.4%, 4.1%, 4.6%, and 4.3%, respectively; P < .001). In adjusted analyses, RSMR was significantly lower for specialty hospitals when compared with the other 3 groups for all patients in aggregate (RSMR 1.05%, 1.30%, 1.38%, 1.39%; P < .001); these differences remained clinically significant but were no longer statistically significant in subgroup analyses. Conclusions: Specialty hospitals appear to have lower rates of most adverse outcomes for PCI. Specialty hospitals may have developed expertise in narrow procedural areas that could be adapted to the larger population of general hospitals. [ABSTRACT FROM AUTHOR]

Background: There are many factors hypothesized as contributing to overuse of percutaneous coronary intervention (PCI) in the United States, including financial ties between physicians and hospitals, but empirical data are lacking. We examined PCI indications in not-for-profit (NFP), major teaching, for-profit (FP), and physician-owned specialty hospitals. Methods: A retrospective cohort study of 1,113,554 patients who underwent PCI in 694 hospitals (NFP 471, teaching 131, FP 79, specialty 13) participating in the CathPCI Registry® between January 1, 2004, and December 31, 2007. Percutaneous coronary intervention indications derived from American College of Cardiology Guidelines were classified as survival benefit (patients with primary reperfusion for ST-elevation myocardial infarction), potential quality of life benefit (patients with non–ST-elevation myocardial infarction, acute coronary syndrome (ACS), positive stress test, or chest pain), or unclear indications (patients receiving PCI without an obvious potential survival or quality of life benefit). Results: The percentage of PCI performed for unclear indications was somewhat higher for specialty hospitals (5.1% of all procedures) as compared with other hospital categories (FP 4.7%, NFP 4.2%, major teaching 4.5%; P < .001). Overall, 17% of hospitals had ≥20% of their total PCI procedures performed for unclear indications, but the proportion of FP, NFP, major teaching, and specialty hospitals reaching this threshold was not statistically different (20%, 16%, 17%, and 15%, respectively; P = .84). Conclusions: A small proportion of PCI procedures were performed in patients with unclear indications, but there was wide variation across hospitals. On average, specialty hospitals performed more PCIs for unclear indications. Efforts to reduce variability should be pursued. [ABSTRACT FROM AUTHOR]

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined. MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life. A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed. Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions. • Most health economic frameworks emphasize the use of cost-effectiveness and use incremental cost-effectiveness ratios to aid in decisions about funding allocations for different health interventions. • This systematic review involving 97 447 participants found that 20 (71.4%) of 28 studies reported gains in quality of life were valued over marginal gains in survival at the end of life. • These findings suggest that policy evaluations of end-of-life interventions should favor those that improve quality of life. • Quality-adjusted life-years may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions. [ABSTRACT FROM AUTHOR]

Abstract: Background: Public access defibrillation (PAD) programs are a major goal of the American Heart Association (AHA) to ensure that automated external defibrillators and trained lay rescuers are available in public areas where sudden cardiac arrest (SCA) is likely to occur. The Johnson County Early Defibrillation Task Force (JCEDTF) is a volunteer organization which distributed AEDs throughout Johnson County, Iowa. JCEDTF was responsible for initial training but ongoing support was the responsibility of each site. Objective: The purpose of this study was to evaluate compliance of community PAD sites to recommendations for site maintenance as proposed by the American Heart Association (AHA). Methods: Thirty-two surveys were distributed to community PAD sites that received assistance from JCEDTF. PAD sites were categorized into business, educational, or community sites. A twenty-five point scoring system to assess PDA programs was developed based on AHA recommendations. On-site evaluations were conducted to verify survey results and assess barriers to an effective PAD site. Differences among the three categories were measured with ANOVA. Results: No site was able to comply with all the AHA guidelines for a PAD site. The mean score among all sites was 57% of possible points with no significant differences among the three categories. Business sites were more compliant with ongoing training compared to educational and community sites (p <0.022). Conclusions: Community PAD sites in Johnson County currently do not comply with the recommendations for effective PAD sites. After initial training and establishment of community PAD sites, better methods for assuring ongoing training and maintenance are needed for sites to be effective. [Copyright &y& Elsevier]

Objective: To examine variation in the open market cost of a radical prostatectomy (RP) procedure in the US hospitals for an uninsured patient, as many proposals for health care reform highlight the importance of individuals actively participating in selecting care. However, reports suggest that obtaining procedure prices remains challenging and highly variable. Materials and Methods: We used 2011-2012 US News and World Report rankings to identify a cohort of 100 hospitals making an effort to include an equal distribution of both academic and private centers, city size, and geographic region. Each hospital was called and the essence of the script included a caller stating he was a healthy, uninsured 55-year-old man recently diagnosed with Gleason 3 + 4 prostatic adenocarcinoma with no metastases. Facility, surgeon, and anesthesia fees were solicited. Results: Seventy hospitals provided facility prices. Facility estimates averaged $34,720 (±20,335; range, $10,100-$135,000), which was statistically higher at academics centers. No significant differences were seen by region, population, or hospital ranking. Surgeon and anesthesia fees were provided by 10%, averaging $8280 (±$4282; range, $4028-$18,720). Thirty-three hospitals provided discounted fees for prompt payment averaging 34% (±16%; range, 10%-80%). Conclusion: There is wide variation in pricing for RP, with higher rates found in academic centers. Wide variation in facility costs were observed, and nearly all were unable to provide surgeon and/or anesthesia fees. Currently, it appears to be unacceptably difficult for men with prostate cancer without insurance to obtain prices for an RP procedure. [ABSTRACT FROM AUTHOR]

Objective: To examine initial treatments given to men with newly diagnosed lower urinary tract dysfunction (LUTD) within a large integrated health care system in the United States. Methods: We used data from 2003 to 2009 from the Veteran's Health Administration to identify newly diagnosed cases of LUTD using established ICD-9CM codes. Our primary outcome was initial LUTD treatment (3 months), categorized as watchful waiting (WW), medical therapy (MT), or surgical therapy (ST); our secondary outcome was pharmacotherapy class received. We used logistic regression models to examine patient, provider, and health system factors associated with receiving MT or ST when compared with WW. Results: There were 393,901 incident cases of LUTD, of which 58.0% initially received WW, 41.8% MT, and 0.2% ST. Of the MT men, 79.8% received an alpha-blocker, 7.7% a 5-alpha reductase inhibitor, 3.3% an anticholinergic, and 7.3% combined therapy (alpha-blocker and 5-alpha reductase inhibitor). In our regression models, we found that age (higher), race (white/black), income (low), region (northeast/south), comorbidities (greater), prostate-specific antigen (lower), and provider (nonurologist) were associated with an increased odds of receiving MT. We found that age (higher), race (white), income (low), region (northeast/south), initial provider (urologist), and prostate-specific antigen (higher) increased the odds of receiving ST. Conclusion: Most men with newly diagnosed LUTD in the Veteran's Health Administration receive WW, and initial surgical treatment is rare. A large number of men receiving MT were treated with monotherapy, despite evidence that combination therapy is potentially more effective in the long-term, suggesting opportunities for improvement in initial LUTD management within this population. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: To describe the rationale and design of an NIH funded randomized controlled trial: the Patient Activation after DXA Result Notification (PAADRN) study. The aim of this trial is to evaluate the effect that a direct mailing of Dual-Energy X-ray Absorptiometry (DXA) results from bone density testing centers to patients will have on patients'' knowledge, treatment and self-efficacy. Methods: We will enroll approximately 7500 patients presenting for DXA at three study sites, the University of Iowa, the University of Alabama at Birmingham, and Kaiser Permanente of Atlanta, Georgia. We will randomize providers (and their respective patients) to either the intervention arm or usual care. Patients randomized to the intervention group will receive a letter with their DXA results and an educational brochure, while those randomized to usual care will receive their DXA results according to standard practice. The seven discrete outcomes are changes from baseline to 12-weeks and/or 52-weeks post-DXA in: (1) guideline concordant pharmacologic and non-pharmacologic therapy; (2) knowledge of DXA results; (3) osteoporosis-specific knowledge; (4) general health-related quality of life; (5) satisfaction with bone-related health care, (6) patient activation; and, (7) osteoporosis-specific self-efficacy. Conclusion: This trial will offer evidence of the impact of a novel approach—direct-to-patient mailing of test results—to improve patient activation in their bone health care. The results will inform clinical practice for the communication of DXA and other test results. [Copyright &y& Elsevier]

Objective: To evaluate the association between dietary quality and the prevalence of lower urinary tract symptoms (LUTS). Methods: We used urinary symptom and dietary data obtained from the 2000-2001 National Health and Nutrition Examination Survey (NHANES) for the study. Dietary quality was assessed using the 10-component United States Department of Agriculture (USDA) Healthy Eating Index (HEI). We used bivariate methods to examine rates of LUTS among men with poor versus good diets. Multivariable logistic regression was used to calculate odds ratios after applying sample weights and controlling for age, race/ethnicity, smoking status, diabetes, alcohol intake, and exercise. Results: Our study cohort consisted of 1385 men aged ≥40 years, of whom 279 (21.1%) reported LUTS. We found higher rates of LUTS among men with poor dietary intake of dairy (22.4% vs 16.4%, P = .013) and among men with poor intake of protein (24.6% vs 17.9%, P = .012) as well as among those with overall poor diet (25.8 vs 17.8%, P = .018) with little dietary variety (26.1 vs 17.6%, P = .001). On multivariate analysis, an unhealthy diet (odds ratios [OR] = 1.7; 95% confidence interval [CI] = 1.05-2.90) was associated with more LUTS, whereas alcohol intake was protective from LUTS (OR = 0.67; 95% CI = 0.48-0.93). Conclusion: In an analysis of NHANES data, we found that poor diet quality was independently associated with patient-reported LUTS. [ABSTRACT FROM AUTHOR]