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Importance: Amid efforts in the US to promote health equity, there is a need to assess recent progress in reducing excess deaths and years of potential life lost among the Black population compared with the White population., Objective: To evaluate trends in excess mortality and years of potential life lost among the Black population compared with the White population., Design, Setting, and Participants: Serial cross-sectional study using US national data from the Centers for Disease Control and Prevention from 1999 through 2020. We included data from non-Hispanic White and non-Hispanic Black populations across all age groups., Exposures: Race as documented in the death certificates., Main Outcomes and Measures: Excess age-adjusted all-cause mortality, cause-specific mortality, age-specific mortality, and years of potential life lost rates (per 100 000 individuals) among the Black population compared with the White population., Results: From 1999 to 2011, the age-adjusted excess mortality rate declined from 404 to 211 excess deaths per 100 000 individuals among Black males (P for trend <.001). However, the rate plateaued from 2011 through 2019 (P for trend = .98) and increased in 2020 to 395-rates not seen since 2000. Among Black females, the rate declined from 224 excess deaths per 100 000 individuals in 1999 to 87 in 2015 (P for trend <.001). There was no significant change between 2016 and 2019 (P for trend = .71) and in 2020 rates increased to 192-levels not seen since 2005. The trends in rates of excess years of potential life lost followed a similar pattern. From 1999 to 2020, the disproportionately higher mortality rates in Black males and females resulted in 997 623 and 628 464 excess deaths, respectively, representing a loss of more than 80 million years of life. Heart disease had the highest excess mortality rates, and the excess years of potential life lost rates were largest among infants and middle-aged adults., Conclusions and Relevance: Over a recent 22-year period, the Black population in the US experienced more than 1.63 million excess deaths and more than 80 million excess years of life lost when compared with the White population. After a period of progress in reducing disparities, improvements stalled, and differences between the Black population and the White population worsened in 2020.

Background: Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions., Methods: We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR)., Results: There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03)., Conclusions: An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The COVID-19 pandemic has disproportionately affected Hispanic or Latino, non-Hispanic Black (Black), non-Hispanic American Indian or Alaska Native (AI/AN), and non-Hispanic Native Hawaiian or Other Pacific Islander (NH/PI) populations in the United States. These populations have experienced higher rates of infection and mortality compared with the non-Hispanic White (White) population (1-5) and greater excess mortality (i.e., the percentage increase in the number of persons who have died relative to the expected number of deaths for a given place and time) (6). A limitation of existing research on excess mortality among racial/ethnic minority groups has been the lack of adjustment for age and population change over time. This study assessed excess mortality incidence rates (IRs) (e.g., the number of excess deaths per 100,000 person-years) in the United States during December 29, 2019-January 2, 2021, by race/ethnicity and age group using data from the National Vital Statistics System. Among all assessed racial/ethnic groups (non-Hispanic Asian [Asian], AI/AN, Black, Hispanic, NH/PI, and White populations), excess mortality IRs were higher among persons aged ≥65 years (426.4 to 1033.5 excess deaths per 100,000 person-years) than among those aged 25-64 years (30.2 to 221.1) and those aged <25 years (-2.9 to 14.1). Among persons aged <65 years, Black and AI/AN populations had the highest excess mortality IRs. Among adults aged ≥65 years, Black and Hispanic persons experienced the highest excess mortality IRs of >1,000 excess deaths per 100,000 person-years. These findings could help guide more tailored public health messaging and mitigation efforts to reduce disparities in mortality associated with the COVID-19 pandemic in the United States,* by identifying the racial/ethnic groups and age groups with the highest excess mortality rates., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Zhenqiu Lin reports contract support from the Centers for Medicare & Medicaid Services (CMS) to develop and maintain measures of hospital performance that are publicly reported. Harlan M. Krumholz reports the following outside the current work: honoraria for presentations at various educational events; grants from Medtronic and the Food and Drug Administration, Medtronic and Johnson & Johnson, Shenzhen Center for Health Information, Foundation for a Smoke-Free World, and Connecticut Department of Public Health and CMS; payment from law firms Martin/Baughman, Arnold & Porter, and Siegfried & Jensen for expert testimony; chairmanship or member of United Healthcare cardiac scientific advisory board, IBM Watson Health life sciences board, Element Science scientific advisor, Aetna health care advisory board, and Facebook advisory board; and ownership of Hugo Health and Refractor Health. No other potential conflicts of interest were disclosed.

There are wide disparities in health across the US population. The identification of geographic health priority areas for Medicare could inform efforts to eliminate health disparities and improve health care. In a sample of 3,282 counties with more than 73 million unique Medicare beneficiaries in the period 1999-2014, we identified geographical areas-"hot spots"-with persistently higher adjusted mortality rates for older adults compared with the rest of the country. During the study period, the risk-standardized mortality rates decreased from 5.52 percent to 4.61 percent (a 0.91-percentage-point change) for the priority areas and from 5.16 percent to 4.11 percent (a 1.05-percentage-point change) for other areas. Faced with decisions surrounding allocation of scarce resources and marked geographic disparities, the identification and prioritization of hot spots may be one way to eliminate disparities and improve health care.

Background: Little is known regarding the relationship between hospital performance on adverse event rates and hospital performance on 30-day mortality and unplanned readmission rates for Medicare fee-for-service patients hospitalized for acute myocardial infarction (AMI)., Methods and Results: Using 2009-2013 medical record-abstracted patient safety data from the Agency for Healthcare Research and Quality's Medicare Patient Safety Monitoring System and hospital mortality and readmission data from the Centers for Medicare & Medicaid Services, we fitted a mixed-effects model, adjusting for hospital characteristics, to evaluate whether hospital performance on patient safety, as measured by the hospital-specific risk-standardized occurrence rate of 21 common adverse event measures for which patients were at risk, is associated with hospital-specific 30-day all-cause risk-standardized mortality and unplanned readmission rates for Medicare patients with AMI. The unit of analysis was at the hospital level. The final sample included 793 acute care hospitals that treated 30 or more Medicare patients hospitalized for AMI and had 40 or more adverse events for which patients were at risk. The occurrence rate of adverse events for which patients were at risk was 3.8%. A 1% point change in the risk-standardized occurrence rate of adverse events was associated with average changes in the same direction of 4.86% points (95% CI, 0.79-8.94) and 3.44% points (95% CI, 0.19-6.68) for the risk-standardized mortality and unplanned readmission rates, respectively., Conclusions: For Medicare fee-for-service patients discharged with AMI, hospitals with poorer patient safety performance were also more likely to have poorer performance on 30-day all-cause mortality and on unplanned readmissions., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: While older adults (age 75 and over) represent a large and growing proportion of patients with acute myocardial infarction (AMI), they have traditionally been under-represented in cardiovascular studies. Although chronological age confers an increased risk for adverse outcomes, our current understanding of the heterogeneity of this risk is limited. The Comprehensive Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study was designed to address this gap in knowledge by evaluating risk factors (including geriatric impairments, such as muscle weakness and cognitive impairments) for hospital readmission, mortality, and health status decline among older adults hospitalized for AMI., Methods/design: SILVER-AMI is a prospective cohort study that is enrolling 3000 older adults hospitalized for AMI from a recruitment network of approximately 70 community and academic hospitals across the United States. Participants undergo a comprehensive in-hospital assessment that includes clinical characteristics, geriatric impairments, and health status measures. Detailed medical record abstraction complements the assessment with diagnostic study results, in-hospital procedures, and medications. Participants are subsequently followed for six months to determine hospital readmission, mortality, and health status decline. Multivariable regression will be used to develop risk models for these three outcomes., Discussion: SILVER-AMI will fill critical gaps in our understanding of AMI in older patients. By incorporating geriatric impairments into our understanding of post-AMI outcomes, we aim to create a more personalized assessment of risk and identify potential targets for interventions., Trial Registration Number: NCT01755052 .

Background: The increase in hospitalist-provided inpatient care may be accompanied by an expectation of improvement on patient outcomes. To date, the association between utilization of hospitalists and the publicly reported patient outcomes is unknown., Objective: Assess the relationship between hospitalist utilization and performance on 6 publicly reported patient outcomes., Design: Cross-sectional study., Participants: Representatives of 598 hospitals in the United States with direct knowledge of inpatient service models., Intervention: Survey of hospital personnel with knowledge of hospitalist use and hospitalist programs., Measurements: Six publicly reported quality outcome measures across 3 medical conditions: acute myocardial infarction (AMI), congestive heart failure (HF), and pneumonia. Using multivariable regression models, we assessed the relationship between presence of hospitalists and performance on each outcome measure; we further assessed the relationship between the percentage of patients admitted by hospitalists and each outcome measure., Results: Of 598 respondents, 429 (72%) reported the use of hospitalist services. In the comparison of hospitals with and without hospitalists, there was no statistically significant difference on any of the mortality or readmissions measures with the exception of the risk-stratified readmission rate for heart failure. For hospitals that used hospitalists, there was no significant change in any of the outcome measures with increasing percentage of patients admitted by hospitalists., Conclusions: The presence of hospitalists is not an independent predictor of performance on publicly reported mortality and readmissions measures for AMI, HF, or pneumonia. It is likely that broader system or organizational interventions are required to improve performance on patient outcomes., (Copyright © 2012 Society of Hospital Medicine.)

Purpose: Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999., Subjects and Methods: We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-cause mortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993., Results: Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01)., Conclusion: We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population.

Background Many communities have implemented systems of regionalized care to improve access to timely care for patients with ST-segment-elevation myocardial infarction. However, patients who are ultimately diagnosed with non-ST-segment-elevation myocardial infarctions (NSTEMIs) may also be affected, and the impact of regionalization programs on NSTEMI treatment and outcomes is unknown. We set out to determine the effects of ST-segment-elevation myocardial infarction regionalization schemes on treatment and outcomes of patients diagnosed with NSTEMIs. Methods and Results The cohort included all patients receiving care in emergency departments diagnosed with an NSTEMI at all nonfederal hospitals in California from January 1, 2005 to September 30, 2015. Data were analyzed using a difference-in-differences approach. The main outcomes were 1-year mortality and angiography within 3 days of the index admission. A total of 293 589 patients with NSTEMIs received care in regionalized and nonregionalized communities. Over the study period, rates of early angiography increased by 0.5 and mortality decreased by 0.9 percentage points per year among the overall population (95% CI, 0.4-0.6 and -1.0 to -0.8, respectively). Regionalization was not associated with early angiography (-0.5%; 95% CI, -1.1 to 0.1) or death (0.2%; 95% CI, -0.3 to 0.8). Conclusions ST-segment-elevation myocardial infarction regionalization programs were not statistically associated with changes in guideline-recommended early angiography or changes in risk of death for patients with NSTEMI. Increases in the proportion of patients with NSTEMI who underwent guideline-directed angiography and decreases in risk of mortality were accounted for by secular trends unrelated to regionalization policies.

Despite the substantial evidence on the health effects of short-term exposure to ambient fine particles (PM2.5), including increasing studies focusing on those from wildland fire smoke, the impacts of long-term wildland fire smoke PM2.5 exposure remain unclear. We investigated the association between long-term exposure to wildland fire smoke PM2.5 and nonaccidental mortality and mortality from a wide range of specific causes in all 3,108 counties in the contiguous United States, 2007 to 2020. Controlling for nonsmoke PM2.5, air temperature, and unmeasured spatial and temporal confounders, we found a nonlinear association between 12-mo moving average concentration of smoke PM2.5 and monthly nonaccidental mortality rate. Relative to a month with the long-term smoke PM2.5 exposure below 0.1 µg/m³, nonaccidental mortality increased by 0.16 to 0.63 and 2.11 deaths per 100,000 people per month when the 12-mo moving average of PM2.5 concentration was of 0.1 to 5 and 5+ µg/m³, respectively. Cardiovascular, ischemic heart disease, digestive, endocrine, diabetes, mental, and chronic kidney disease mortality were all found to be associated with long-term wildland fire smoke PM2.5 exposure. Smoke PM2.5 contributed to approximately 11,415 nonaccidental deaths/y (95% CI: 6,754, 16,075) in the contiguous United States. Higher smoke PM2.5-related increases in mortality rates were found for people aged 65 and above. Positive interaction effects with extreme heat were also observed. Our study identified the detrimental effects of long-term exposure to wildland fire smoke PM2.5 on a wide range of mortality outcomes, underscoring the need for public health actions and communications that span the health risks of both short-and long-term exposure. [ABSTRACT FROM AUTHOR]

Aim: We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. Methods and results: In a population‐based retrospective study (2007–2019), we examined the association of material deprivation with 1‐year all‐cause mortality, cause‐specific hospitalization, and 90‐day processes of care. Using cause‐specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66–84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all‐cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10–1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19–1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08–1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09–1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter‐defibrillator/cardiac resynchronization therapy‐pacemaker implantation (p = 0.023), compared to the least deprived. Conclusion: Patients with newly‐diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived. [ABSTRACT FROM AUTHOR]

* OBJECTIVES To examine the association between (1) comorbid conditions related to diabetes mellitus, clinical findings on arrival at the hospital and characteristics of the myocardial infarction and (2) risk [...]

Background: Coronary artery bypass graft (CABG) surgery is a focus of bundled and alternate payment models that capture outcomes up to 90 days postsurgery. While clinical registry risk models perform well, measures encompassing mortality beyond 30 days do not currently exist. We aimed to develop a risk-adjusted hospital-level 90-day all-cause mortality measure intended for assessing hospital performance in payment models of CABG surgery using administrative data.Methods: Building upon Centers for Medicare and Medicaid Services hospital-level 30-day all-cause CABG mortality measure specifications, we extended the mortality timeframe to 90 days after surgery and developed a new hierarchical logistic regression model to calculate hospital risk-standardized 90-day all-cause mortality rates for patients hospitalized for isolated CABG. The model was derived from Medicare claims data for a 3-year cohort between July 2014 to June 2017. The data set was randomly split into 50:50 development and validation samples. The model performance was evaluated with C statistics, overfitting indices, and calibration plot. The empirical validity of the measure result at the hospital level was evaluated against the Society of Thoracic Surgeons composite star rating.Results: Among 137 819 CABG procedures performed in 1183 hospitals, the unadjusted mortality rate within 30 and 90 days were 3.1% and 4.7%, respectively. The final model included 27 variables. Hospital-level 90-day risk-standardized mortality rates ranged between 2.04% and 11.26%, with a median of 4.67%. C statistics in the development and validation samples were 0.766 and 0.772, respectively. We identified a strong positive correlation between 30- and 90-day risk-standardized mortality rates, with a regression slope of 1.09. Risk-standardized mortality rates also showed a stepwise trend of lower 90-day mortality with higher Society of Thoracic Surgeons composite star ratings.Conclusions: We present a measure of hospital-level 90-day risk-standardized mortality rates following isolated CABG. This measure complements Centers for Medicare and Medicaid Services' existing 30-day CABG mortality measure by providing greater insight into the postacute recovery period. It offers a balancing measure to ensure efforts to reduce costs associated with CABG recovery and rehabilitation do not result in unintended consequences. [ABSTRACT FROM AUTHOR]

Aims: National 30‐day mortality and readmission rates after heart failure (HF) hospitalisations are a focus of US policy intervention and yet have rarely been assessed in other comparable countries. We examined the frequency, trends and institutional variation in 30‐day mortality and unplanned readmission rates after HF hospitalisations in Australia and New Zealand. Methods and results: We included patients >18 years hospitalised with HF at all public and most private hospitals from 2010–15. The primary outcomes were the frequencies of 30‐day mortality and unplanned readmissions, and the institutional risk‐standardised mortality rate (RSMR) and readmission rate (RSRR) evaluated using separate cohorts. The mortality cohort included 153 592 patients (mean age 78.9 ± 11.8 years, 51.5% male) with 16 442 (10.7%) deaths within 30 days. The readmission cohort included 148 704 patients (mean age 78.6 ± 11.9 years, 51.7% male) with 33 158 (22.3%) unplanned readmission within 30 days. In 392 hospitals with at least 25 HF hospitalisations, the median RSMR was 10.7% (range 6.1–17.3%) with 59 hospitals significantly different from the national average. Similarly, in 391 hospitals with at least 25 HF hospitalisations, the median RSRR was 22.3% (range 17.7–27.1%) with 24 hospitals significantly different from the average. From 2010–15, the adjusted 30‐day mortality [odds ratio (OR) 0.991/month, 95% confidence interval (CI) 0.990–0.992, P < 0.01] and unplanned readmission (OR 0.998/month, 95% CI 0.998–0.999, P < 0.01) rates declined. Conclusion: Within 30 days of a HF hospitalisation, one in 10 patients died and almost a quarter of those surviving experienced an unplanned readmission. The risk of these outcomes varied widely among hospitals suggesting disparities in HF care quality. Nevertheless, a substantial decline in 30‐day mortality and a modest decline in readmissions occurred over the study period. [ABSTRACT FROM AUTHOR]

Background: Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts.Objective: To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments.Design: Prospective cohort study. (ClinicalTrials.gov: NCT01755052).Setting: 94 hospitals throughout the United States.Participants: 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive.Measurements: Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality.Results: Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment.Limitation: The model was not externally validated.Conclusion: A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge.Primary Funding Source: National Heart, Lung, and Blood Institute of the National Institutes of Health. [ABSTRACT FROM AUTHOR]

This study uses national death certificate data to characterize trends in death and excess mortality from drug overdoses, homicides, unintentional injuries, motor vehicle crashes, and suicide during the first 6 months of the pandemic in the US. [ABSTRACT FROM AUTHOR]

Rationale: Characterization of the dynamic nature of posthospital risk in chronic obstructive pulmonary disease (COPD) is needed to provide counseling and plan clinical services.Objectives: To analyze risk of readmission and death after discharge for COPD among Medicare beneficiaries aged 65 years and older and to determine the association between ventilator support and risk trajectory.Methods: We computed daily absolute risks of hospital readmission and death for 1 year after discharge for COPD, stratified by ventilator support. We determined the time required for risks to decline by 50% from maximum daily values after discharge and for daily risks to plateau. We compared risks with those found in the general elderly population.Measurements and Main Results: Among 2,340,637 hospitalizations, the readmission rate at 1 year was 64.2%, including 63.5%, 66.0%, and 64.1% among those receiving invasive, noninvasive, and no ventilation, respectively. Among 1,283,069 hospitalizations, mortality at 1 year was 26.2%, including 45.7%, 41.8%, and 24.4% among those same respective groups. Daily risk of readmission declined by 50% within 28, 39, and 43 days and plateaued at 46, 54, and 61 days among those receiving invasive, noninvasive, and no ventilation, respectively. Risk of death declined by 50% by 3, 4, and 17 days and plateaued by 21, 18, and 24 days in the same respective groups. Risks of hospitalization and death were significantly higher after discharge for COPD than among the general Medicare population.Conclusions: Discharge from the hospital is associated with prolonged risks of readmission and death that vary with need for ventilator support. Interventions limited to the first month after discharge may be insufficient to improve longitudinal outcomes. [ABSTRACT FROM AUTHOR]

Importance: The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown.Objective: To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge.Design, Setting, and Participants: Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014.Exposure: Thirty-day risk-adjusted readmission rate (RARR).Main Outcomes and Measures: Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital's 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals' paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition.Results: In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were -0.053% (95% CI, -0.055% to -0.051%) for HF, -0.044% (95% CI, -0.047% to -0.041%) for AMI, and -0.033% (95% CI, -0.035% to -0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, -0.003% (95% CI, -0.005% to -0.001%); and pneumonia, 0.001% (95% CI, -0.001% to 0.003%). However, correlation coefficients in hospitals' paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality.Conclusions and Relevance: Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions. [ABSTRACT FROM AUTHOR]

Objectives To determine the prognostic value of slow gait in predicting outcomes 1 year after acute myocardial infarction ( AMI). Design Observational cohort with longitudinal follow-up. Setting Twenty-four U.S. hospitals participating in the Translational Research Investigating Underlying disparities in recovery from acute Myocardial infarction: Patients' Health status Registry. Participants Older adults (≥65) with in-home gait assessment 1 month after AMI (N = 338). Measurements Baseline characteristics and 1-year mortality or hospital readmission adjusted using Cox proportional hazards regression in older adults with slow (<0.8 m/s) versus preserved (≥0.8 m/s) gait speed. Results Slow gait was present in 181 participants (53.6%). Those with slow gait were older, more likely to be female and nonwhite, and had a higher prevalence of heart failure and diabetes mellitus. They were also more likely to die or be readmitted to the hospital within 1 year than those with preserved gait (35.4% vs 18.5%, log-rank P = .006). This association remained significant after adjusting for age, sex, and race (slow vs preserved gait hazard ratio ( HR) = 1.76, 95% confidence interval ( CI)=1.08-2.87, P = .02) but was no longer significant after adding clinical factors ( HR = 1.23, 95% CI=0.74-2.04, P = .43). Conclusion Slow gait, a marker of frailty, is common 1 month after AMI in older adults and is associated with nearly twice the risk of dying or hospital readmission at 1 year. Understanding its prognostic importance independent of comorbidities and whether routine testing of gait speed can improve care requires further investigation. [ABSTRACT FROM AUTHOR]

Objective: Smokers have lower short-term mortality after acute myocardial infarction (AMI) than non-smokers; however, little is known about the long-term effects of smoking on life expectancy after AMI. This study aimed to quantify the burden of smoking after AMI using life expectancy and years of life lost.Methods: We analysed data from the Cooperative Cardiovascular Project, a medical record study of 158,349 elderly Medicare patients with AMI and over 17 years of follow-up, to evaluate the age-specific association of smoking with life expectancy and years of life lost after AMI.Results: Our sample included 23,447 (14.8%) current smokers. Current smokers had lower crude mortality up to 5 years, which was largely explained by their younger age at AMI. After adjustment other patient characteristics, smoking was associated with lower 30-day (HR 0.91, 95% CI 0.87 to 0.94) but higher long-term mortality (17-year HR 1.19, 95% CI 1.17 to 1.20) after AMI. Overall, crude life expectancy estimates were lower for current smokers than non-smokers at all ages, which translated into sizeable numbers of life-years lost attributable to smoking. As age at AMI increased, the magnitude of life-years lost due to smoking decreased. After full risk adjustment, the differences in life expectancy between current smokers and non-smokers persisted at all ages.Conclusions: Current smoking is associated with lower life expectancy and large numbers of life-years lost after AMI. Our findings lend additional support to smoking cessation efforts after AMI. [ABSTRACT FROM AUTHOR]

• Qatar's COVID-19 mortality was driven by infection among vulnerable persons. • There was excess mortality in short-term and deficit mortality in medium-term. • Observed pattern was particularly evident in clinically vulnerable individuals. • Vaccination prevented early deaths, regardless of vulnerability status. We assessed short-, medium-, and long-term all-cause mortality risks after a primary SARS-CoV-2 infection. A national, matched, retrospective cohort study was conducted in Qatar to assess risk of all-cause mortality in the national SARS-CoV-2 primary infection cohort compared with the national infection-naïve cohort. Associations were estimated using Cox proportional-hazards regression models. Analyses were stratified by vaccination status and clinical vulnerability status. Among unvaccinated persons, within 90 days after primary infection, the adjusted hazard ratio (aHR) comparing mortality incidence in the primary-infection cohort with the infection-naïve cohort was 1.19 (95% confidence interval 1.02-1.39). aHR was 1.34 (1.11-1.63) in persons more clinically vulnerable to severe COVID-19 and 0.94 (0.72-1.24) in those less clinically vulnerable. Beyond 90 days after primary infection, aHR was 0.50 (0.37-0.68); aHR was 0.41 (0.28-0.58) at 3-7 months and 0.76 (0.46-1.26) at ≥8 months. The aHR was 0.37 (0.25-0.54) in more clinically vulnerable persons and 0.77 (0.48-1.24) in less clinically vulnerable persons. Among vaccinated persons, mortality incidence was comparable in the primary-infection versus infection-naïve cohorts, regardless of clinical vulnerability status. COVID-19 mortality was primarily driven by an accelerated onset of death among individuals who were already vulnerable to all-cause mortality, but vaccination prevented these accelerated deaths. [ABSTRACT FROM AUTHOR]

Objective: To characterize hospitals based on patterns of their combined financial and clinical outcomes for heart failure hospitalizations longitudinally.Data Source: Detailed cost and administrative data on hospitalizations for heart failure from 424 hospitals in the 2005-2011 Premier database.Study Design: Using a mixture modeling approach, we identified groups of hospitals with distinct joint trajectories of risk-standardized cost (RSC) per hospitalization and risk-standardized in-hospital mortality rate (RSMR), and assessed hospital characteristics associated with the distinct patterns using multinomial logistic regression.Principal Findings: During 2005-2011, mean hospital RSC decreased from $12,003 to $10,782, while mean hospital RSMR declined from 3.9 to 3.2 percent. We identified five distinct hospital patterns: highest cost and low mortality (3.2 percent of the hospitals), high cost and low mortality (20.4 percent), medium cost and low mortality (34.6 percent), medium cost and high mortality (6.2 percent), and low cost and low mortality (35.6 percent). Longer hospital stay and greater use of intensive care unit and surgical procedures were associated with phenotypes with higher costs or greater mortality.Conclusions: Hospitals vary substantially in the joint longitudinal patterns of cost and mortality, suggesting marked difference in value of care. Understanding determinants of the variation will inform strategies for improving the value of hospital care. [ABSTRACT FROM AUTHOR]

Background: Sex differences in clinical characteristics and in-hospital outcomes among patients with non-ST-segment-elevation myocardial infarction have been described in Western countries, but whether these differences exist in China is unknown.Methods: We used a 2-stage random sampling design to create a nationally representative sample of patients admitted to 151 Chinese hospitals for non-ST-segment-elevation myocardial infarction in 2006, 2011, and 2015 and examined sex differences in clinical profiles, treatments, and in-hospital outcomes over this time. Multivariable logistic regression models adjusting for age or other potentially confounding clinical covariates were used to estimate these sex-specific differences.Results: Among 4611 patients, the proportion of women (39.8%) was unchanged between 2006 and 2015. Women were older with higher rates of hypertension, diabetes, and dyslipidemia. Among patients without contraindications, women were less likely to receive treatments than men, with significant differences for aspirin in 2015 (90.3% versus 93.9%) and for invasive strategy in 2011 (28.7% versus 45.7%) and 2015 (34.0% versus 48.4%). After adjusting for age, such differences in aspirin and invasive strategy in 2015 were not significant, but the difference in invasive strategy in 2011 persisted. The sex gaps in the use of invasive strategy did not narrow. From 2006 to 2015, a significant decrease in in-hospital mortality was observed in men (from 16.9% to 8.7%), but not in women (from 11.8% to 12.0%), with significant interaction between sex and study year (P=0.023). After adjustment, in-hospital mortality in women was significantly lower than men in 2006, but not in 2011 or 2015.Conclusions: Sex differences in cardiovascular risk factors and invasive strategy after non-ST-segment-elevation myocardial infarction were observed between 2011 and 2015 in China. Although sex gaps in in-hospital mortality were largely explained by age differences, efforts to narrow sex-related disparities in quality of care should remain a focus.Registration: URL: http://www.Clinicaltrials: gov; Unique identifier: NCT01624883. [ABSTRACT FROM AUTHOR]

Background: The epidemiology of aortic dissection (AD) has not been well described among older persons in the United States. It is not known whether advancements in AD care over the last decade have been accompanied by changes in outcomes.Methods and Results: The Inpatient Medicare data from 2000 to 2011 were used to determine trends in hospitalization rates for AD. Mortality rates were ascertained through corresponding vital status files. A total of 32 057 initial AD hospitalizations were identified. The overall hospitalization rate for AD remained unchanged at 10 per 100 000 person-years. For 30-day and 1-year mortality associated with AD, the observed rate decreased from 31.8% to 25.4% (difference, 6.4%; 95% confidence interval [CI], 6.2-6.5; adjusted, 6.4%; 95% CI, 5.7-6.9) and from 42.6% to 37.4% (difference, 5.2%; 95% CI, 5.1-5.2; adjusted, 6.2%; 95% CI, 5.3-6.7), respectively. For patients undergoing surgical repair for type A dissections, the observed 30-day mortality decreased from 30.7% to 21.4% (difference, 9.3%; 95% CI, 8.3-10.2; adjusted, 7.3%; 95% CI, 5.8-7.8) and the observed 1-year mortality decreased from 39.9% to 31.6% (difference, 8.3%; 95% CI, 7.5-9.1%; adjusted, 8.2%; 95% CI, 6.7-9.1). The 30-day mortality decreased from 24.9% to 21% (difference, 3.9%; 95% CI, 3.5-4.2; adjusted, 2.9%; 95% CI, 0.7-4.4) and 1-year decreased from 36.4% to 32.5% (difference, 3.9%; 95% CI, 3.3-4.3; adjusted, 3.9%; 95% CI, 2.5-6.3) for surgical repair of type B dissection.Conclusions: Although AD hospitalization rates remained stable, improvement in mortality was noted, particularly in patients undergoing surgical repair. [ABSTRACT FROM AUTHOR]

Background: Recent studies show an association between neighborhood-level measures of socioeconomic status (SES) and outcomes for patients with heart failure. We do not know whether neighborhood SES has a primary effect or is a marker for individual SES.Methods and Results: We used the data from participants of the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) trial, recruited from 33 US internal medicine and cardiology practices and examined the association between neighborhood SES and outcomes of patients with heart failure. We used census tracts as proxies for neighborhoods and constructed summary SES scores that included information about wealth and income, education, and occupation. The primary end points were readmission and all-cause mortality at 6 months. We conducted patient interviews and medical chart reviews to obtain demographic information, clinical factors, therapies, and individual SES. We included 1557 patients: 524, 516, and 517 from low, medium, and high SES neighborhoods, respectively (mean age, 61.1±15.2 years; 42.2% women).Overall, 745 patients (47.8%) had ≥1 readmission and 179 patients (11.5%) died. When compared with patients in high SES neighborhoods, those living in low-SES neighborhoods were more likely to be readmitted (odds ratio, 1.35; 95% confidence interval, 1.01-1.82), but the mortality rates were not significantly different (odds ratio, 0.78; 95% confidence interval, 0.50-1.18). The results were consistent after multivariable adjustments for individual demographics, clinical factors, and individual SES.Conclusions: Among patients with heart failure, neighborhood SES was significantly associated with 6-month all-cause readmission even after adjusting for other patient-level factors, including individual SES. Greater number of events and longer follow-up is required to ascertain the potential effect of neighborhood SES on mortality.Clinical Trial Registration Url: http://clinicaltrials.gov/. Unique identifier: NCT00303212. [ABSTRACT FROM AUTHOR]

Although noninvasive positive pressure ventilation (NIPPV) for patients with acute decompensated heart failure was introduced almost 20 years ago, the variation in its use among hospitals remains unknown. We sought to define hospital practice patterns of NIPPV use for acute decompensated heart failure and their relationship with intubation and mortality.We conducted a cross-sectional study using a database maintained by Premier, Inc., that includes a date-stamped log of all billed items for hospitalizations at >400 hospitals. We examined hospitalizations for acute decompensated heart failure in this database from 2005 to 2010 and included hospitals with annual average volume of >25 such hospitalizations. We identified 384 hospitals that encompassed 524 430 hospitalizations (median annual average volume: 206). We used hierarchical logistic regression models to calculate hospital-level outcomes: risk-standardized NIPPV rate, risk-standardized intubation rate, and in-hospital risk-standardized mortality rate. We grouped hospitals into quartiles by risk-standardized NIPPV rate and compared risk-standardized mortality rates and risk-standardized intubation rates across quartiles. Median risk-standardized NIPPV rate was 6.2% (interquartile range, 2.8%-9.3%; 5th percentile, 0.2%; 95th percentile, 14.8%). There was no clear pattern of risk-standardized mortality rates across quartiles. The bottom quartile of hospitals had higher risk-standardized intubation rate (11.4%) than each of the other quartiles (9.0%, 9.7%, and 9.1%; P<0.02 for all comparisons).Substantial variation exists among hospitals in the use of NIPPV for acute decompensated heart failure without evidence for differences in mortality. There may be a threshold effect in relation to intubation rates, with the lowest users of NIPPV having higher intubation rates. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Cardiologists are distributed unevenly across regions of the United States. It is unknown whether patients in regions with fewer cardiologists have worse outcomes after hospitalization for acute myocardial infarction (AMI) or heart failure (HF).Methods and Results: Using Medicare administrative claims data from 2010, we examined the relationship between regional density of cardiologists and risk of death after hospitalization for AMI and HF using hospitalizations for pneumonia as a comparison. We defined density as the number of cardiologists divided by population aged≥65 years within hospital referral regions, categorized into quintiles. Among 171 126 admissions for AMI, 352 853 admissions for HF, and 343 053 admissions for pneumonia, we tested associations between density of cardiologists and 30-day and 1-year mortality for each condition. We used 2-level hierarchical logistic regression models that adjusted for characteristics of patients and hospital referral regions. Patients hospitalized for AMI (odds ratios [OR], 1.13; 95% confidence interval [CI], 1.06-1.21) and HF (OR, 1.19; 95% CI, 1.12-1.27) in the lowest quintile of density had modestly higher 30-day mortality risk compared with patients in the highest quintile, unlike patients hospitalized for pneumonia (OR, 1.02; 95% CI, 0.96-1.09). Patients hospitalized for AMI (OR, 1.06; 95% CI, 1.00-1.12) and HF (OR, 1.09; 95% CI, 1.04-1.13) in the lowest quintile had slightly higher 1-year mortality risk, unlike patients hospitalized for pneumonia (OR, 1.00; 95% CI, 0.95-1.05).Conclusions: Patients hospitalized for AMI and HF in regions with a low density of cardiologists experienced modestly higher 30-day and 1-year mortality risk, unlike patients with pneumonia. [ABSTRACT FROM AUTHOR]

The article presents a research study that developed models of percutaneous coronary interventions (PCI) mortality using merged clinical data from the CathPCI Registry and administrative claims to produce hospital-specific risk standardized 30-day PCI mortality rates. Methods are presented involving data sources, outcome and candidate and final variables. Results of the analysis are discussed indicating the registry-based models produce estimates of hospital risk-standardized mortality rates.

The article analyzes whether hospitals that perform more invasive cardiovascular procedures for patients with heart failure (HF) also had a bigger tendency to provide higher-cost care to the larger subset of these patients who did not receive procedures. In-hospital mortality outcomes between hospital groups is also examined.