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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.

ObjectivesThis study sought to analyze recent trends over time in heart failure (HF) hospital stay rates, length of stay (LOS), and in-hospital mortality by age groups with a large national dataset of U.S. hospital discharges.BackgroundHeart failure hospital stay rates, LOS, and mortality have fallen over the past decade for older Medicare beneficiaries, but whether this holds true for younger adults is unknown.MethodsFrom the National Inpatient Sample, we calculated HF hospital stay rates, LOS, and in-hospital mortality from 2001 to 2009 with survey data analysis techniques.ResultsHospital stays (n = 1,686,089) with a primary discharge diagnosis of HF were identified from National Inpatient Sample data between 2001 and 2009. The overall national hospital stay rate decreased from 633 to 463 hospital stays/100,000 persons, (−26.9%, p-for-trend

Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.Hospital penalty status or target condition under the HRRP.Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.The study included 48 137 102 hospitalizations of 20 351 161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -1.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P .001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 [95% CI, -0.81 to -0.16] percentage points per year relative to nontarget conditions [P = .004]; for HF, -0.90 [95% CI, -1.18 to -0.62; P .001]; and for pneumonia, -0.57 [95% CI, -0.92 to -0.23; P .001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P = .05]; for HF, 0.08 [95% CI, -0.30 to 0.46; P = .67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P = .01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P .05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty.Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.

Objectives To characterize the magnitude and duration of risk of rehospitalization according to age after hospitalization for heart failure (HF), acute myocardial infarction (AMI), or pneumonia. Design Retrospective cohort study. Setting U.S. hospitals (n = 4,767). Participants All Medicare fee-for-service beneficiaries aged 65 and older surviving hospitalization for HF, AMI, or pneumonia between October 2012 and December 2013. Measurements Daily risk of first rehospitalization for 1 year after hospital discharge was calculated according to age category (65–74, 75–84, ≥85) after adjustment for sex, race, comorbidities, and median ZIP code income. Time required for adjusted rehospitalization risk to decline 50% from maximum value after discharge, time required for adjusted risk to approach a plateau period of minimal day-to-day change, and degree to which adjusted risk was higher in recently hospitalized individuals than in the general elderly population were identified. Results There were 414,720 hospitalizations for HF, 177,752 for AMI, and 568,304 for pneumonia. The adjusted risk of rehospitalization declined with increasing age after HF hospitalization (P < .001), rose with increasing age after AMI hospitalization (P < .001), and was slightly lower with increasing age after pneumonia hospitalization (P = .002). Adjusted risks of rehospitalization were high beyond 30 days after hospitalization for all ages. Conclusion Although older age has heterogeneous relationships with rehospitalization risk, risk of readmission remains high for an extended time after discharge regardless of age or admitting condition. Condition-specific data on risk can be used to guide discussions on advanced care planning and strategies for longitudinal follow-up after hospitalization.

Background: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI. Methods: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction. Results: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12−1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08−1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96−1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women. Conclusions: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Objectives To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions. Design Retrospective cohort study. Setting 368 U.S. hospitals in the Premier research database. Participants Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010. Measurements Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days. Results Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both). Conclusion Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.

Background— The current ability to predict readmissions in patients with heart failure is modest at best. It is unclear whether machine learning techniques that address higher dimensional, nonlinear relationships among variables would enhance prediction. We sought to compare the effectiveness of several machine learning algorithms for predicting readmissions. Methods and Results— Using data from the Telemonitoring to Improve Heart Failure Outcomes trial, we compared the effectiveness of random forests, boosting, random forests combined hierarchically with support vector machines or logistic regression (LR), and Poisson regression against traditional LR to predict 30- and 180-day all-cause readmissions and readmissions because of heart failure. We randomly selected 50% of patients for a derivation set, and a validation set comprised the remaining patients, validated using 100 bootstrapped iterations. We compared C statistics for discrimination and distributions of observed outcomes in risk deciles for predictive range. In 30-day all-cause readmission prediction, the best performing machine learning model, random forests, provided a 17.8% improvement over LR (mean C statistics, 0.628 and 0.533, respectively). For readmissions because of heart failure, boosting improved the C statistic by 24.9% over LR (mean C statistic 0.678 and 0.543, respectively). For 30-day all-cause readmission, the observed readmission rates in the lowest and highest deciles of predicted risk with random forests (7.8% and 26.2%, respectively) showed a much wider separation than LR (14.2% and 16.4%, respectively). Conclusions— Machine learning methods improved the prediction of readmission after hospitalization for heart failure compared with LR and provided the greatest predictive range in observed readmission rates.

OBJECTIVES/SPECIFIC AIMS: Determine timing of risk of readmissions within 30 days among patients first discharged to a skilled nursing facilities (SNF) after heart failure hospitalization and subsequently discharged home. METHODS/STUDY POPULATION: This was a retrospective cohort study of patients with SNF stays of 30 days or less following discharge from a heart failure hospitalization. Patients were followed for 30 days following discharge from SNF. We categorized patients based on SNF length of stay (LOS): 1–6 days, 7–13 days, 14–30 days. We then fit a piecewise exponential Bayesian model with the outcome as time to readmission after discharge from SNF for each group. Our event of interest was unplanned readmission; death and planned readmissions were considered as competing risks. Our model examined 2 different time intervals following discharge from SNF: 0–3 days post SNF discharge and 4–30 days post SNF discharge. We reported the hazard rate (credible interval) of readmission for each time interval. We examined all Medicare fee-for-service (FFS) patients 65 and older admitted from July 2012 to June 2015 with a principal discharge diagnosis of HF, based on methods adopted by the Centers for Medicare and Medicaid Services (CMS) for hospital quality measurement. RESULTS/ANTICIPATED RESULTS: Our study included 67,585 HF hospitalizations discharged to SNF and subsequently discharged home [median age, 84 years (IQR; 78–89); female, 61.0%]; 13,257 (19.2%) were discharged with home care, 54,328 (80.4%) without. Median length of SNF admission was 17 days (IQR; 11–22). In total, 16,333 (24.2%) SNF discharges to home were readmitted within 30 days of SNF discharge; median time to readmission was 9 days (IQR; 3–18). The hazard rate of readmission for each group was significantly increased on days 0–3 after discharge from SNF compared with days 4–30 after discharge from SNF. In addition, the hazard rate of readmission during the first 0–3 days after discharge from SNF decreased as the LOS in SNF increased. DISCUSSION/SIGNIFICANCE OF IMPACT: The hazard rate of readmission after SNF discharge following heart failure hospitalization is highest during the first 6 days home. Length of stay at SNF also has an effect on risk of readmission immediately after discharge from SNF; patients with a longer length of stay in SNF were less likely to be readmitted in the first 3 days after discharge from SNF.

Background— Patients with an unused or malfunctioning implantable cardioverter–defibrillator (ICD) lead may have the lead either abandoned or explanted; yet there are limited data on the comparative acute and longer-term safety of these 2 approaches. Methods and Results— We examined in-hospital events among 24 908 subject encounters using propensity score 1:1 matching for ICD lead abandonment or explantation in the National Cardiovascular Data Registry (NCDR) ICD Registry (April 2010 to June 2014). Relative to patients undergoing lead abandonment, patients undergoing lead explantation had more in-hospital procedure-related complications: 2.19% (n=273) versus 3.77% (n=469; P P P =0.06). In the Medicare subset analyzed for postprocedure complications, there was no difference with respect to 6-month bleeding (4.80% in both the groups), tamponade (0.38% versus 0.58%), infection (1.34% versus 3.07%), upper extremity thrombosis (0.77% versus 0.96%), pulmonary embolism (0.38% versus 0.96%), or urgent surgery (1.15% for both the groups; P >0.05 for all). Conclusions— After matching, patients undergoing removal of an unused or malfunctioning ICD lead had slightly higher in-hospital complications and deaths than those with a lead abandonment strategy. Although the 1-year mortality risk was slightly higher in the lead explantation group, this difference was not statistically significant and may be explained by chance.

Background The risk of rehospitalization is elevated in the immediate post-discharge period and declines over time. It is not known if the extent and timing of risk vary across readmission diagnoses, suggesting that recovery and vulnerability after discharge differ by physiologic system. Objective We compared risk trajectories for major readmission diagnoses in the year after discharge among all Medicare fee-for-service beneficiaries hospitalized with heart failure (HF), acute myocardial infarction (AMI), or pneumonia from 2008–2010. Methods We estimated the daily risk of rehospitalization for 12 major readmission diagnostic categories after accounting for the competing risk of death after discharge. For each diagnostic category, we identified (1) the time required for readmission risk to peak and then decline 50% from maximum values after discharge; (2) the time required for readmission risk to approach plateau periods of minimal day-to-day change; and (3) the extent to which hospitalization risks are higher among patients recently discharged from the hospital compared with the general elderly population. Results Among >3,000,000 hospitalizations, the yearly rate of rehospitalization was 67.0%, 49.5%, and 55.3% after hospitalization for HF, AMI, and pneumonia, respectively. The extent and timing of risk varied by readmission diagnosis and initial admitting condition. Risk of readmission for gastrointestinal bleeding/anemia peaked particularly late after hospital discharge, occurring 10, 6, and 7 days after hospitalization for HF, AMI, and pneumonia, respectively. Risk of readmission for trauma/injury declined particularly slowly, requiring 38, 20, and 38 days to decline by 50% after hospitalization for HF, AMI, and pneumonia, respectively. Conclusions Patterns of vulnerability to different conditions that cause rehospitalization vary by time after hospital discharge. This finding suggests that recovery of various physiologic systems occurs at different rates and that post-discharge interventions to minimize vulnerability to specific conditions should be tailored to their underlying risks.

Introduction: While implantable cardioverter defibrillator (ICD) systems are lifesaving, leads often require replacement over time. When ICD leads require replacement, the existing lead can either be left in (abandoned) or be extracted, yet there are insufficient comparative data between these 2 strategies. Methods: We examined in-hospital events among propensity matched subjects undergoing lead replacement where the existing lead was either abandoned or extracted from National Cardiovascular Data Registry (NCDR) ICD Registry (2010 - 2011). Six month complication and 90-day and 1-year mortality rates were examined in a subset of Medicare subjects. We excluded those procedures involving infection and those performed by a cardiothoracic surgeon (extraction predetermined). Results: After 1:1 matching, we had 41744 subjects with in hospital outcomes, of which 2362 were Medicare aged and had 6-month complications and survival information. About 1/4 were women; average age was 66 yrs overall and 75 yrs in the Medicare cohort. In hospital events included 2.22% (n=463) and 3.63% (n=758) procedure related complications, and death in 0.21% (n=44) and 0.45% (n=94) in abandonment and extraction patients, respectively (p0.05 for all). At 90 days and 1 year, there was no difference in survival (p=0.55) (See Figure). Conclusion: Among propensity-matched patients undergoing ICD lead replacement, there were more in-hospital complications and deaths among extraction versus abandonment subjects. Among a Medicare subset, there were no differences in longer term outcomes. Thus, abandonment may be a reasonable alternative to extraction for sterile lead revision in some cases.

Two articles in this issue explore the clinical epidemiology and predictors of hospital revisits. The editorialists raise questions about the preventability of revisits from Duseja and colleagues' ...

Background The treatment for patients with acute myocardial infarction (AMI) was transformed by the introduction of intensive care units (ICUs), yet we know little about how contemporary hospitals use this resource-intensive setting and whether higher use is associated with better outcomes. Methods We identified 114,136 adult hospitalizations for AMI from 307 hospitals in the 2009 to 2010 Premier database using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification . Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. Across quartiles, we examined in-hospital risk-standardized mortality rates and usage rates of critical care therapies for these patients. Results Rates of ICU admission for AMI patients varied markedly among hospitals (median 48%, Q1-Q4 20%-71%, range 0%-98%), and there was no association with in-hospital risk-standardized mortality rates (6% all quartiles, P = .7). However, hospitals admitting more AMI patients to the ICU were more likely to use critical care therapies overall (mechanical ventilation [from Q1 with lowest rate of ICU use to Q4 with highest rate 13%-16%], vasopressors/inotropes [17%-21%], intra-aortic balloon pumps [4%-7%], and pulmonary artery catheters [4%-5%]; P for trend Conclusions Rates of ICU admission for patients with AMI vary substantially across hospitals and were not associated with differences in mortality, but were associated with greater use of critical care therapies. These findings suggest uncertainty about the appropriate use of this resource-intensive setting and a need to optimize ICU triage for patients who will truly benefit.

Background During a myocardial infarction, no single best approach of systemic anticoagulation is recommended, likely due to a lack of comparative effectiveness studies and trade‐offs between treatments. Methods and Results We investigated the patterns of use and site‐level variability in anticoagulant strategies (unfractionated heparin [ UFH ] only, low‐molecular‐weight heparin [ LMWH ] only, UFH + LMWH , any bivalirudin) of 63 796 patients with a principal diagnosis of myocardial infarction treated with an early invasive strategy with percutaneous coronary intervention at 257 hospitals. About half (47%) of patients received UFH only, 6% UFH + LMWH , 7% LMWH only, and 40% bivalirudin. Compared with UFH , the median odds ratio was 2.90 for LMWH + UFH , 4.70 for LMWH only, and 3.09 for bivalirudin, indicating that 2 “identical” patients would have a 3‐ to 4‐fold greater likelihood of being treated with anticoagulants other than UFH at one hospital compared with another. We then categorized hospitals as low‐ or high‐users of LMWH and bivalirudin. Using hierarchical, multivariate regression models, we found that low bivalirudin‐using hospitals had higher unadjusted bleeding rates, but the risk‐adjusted and anticoagulant‐adjusted bleeding rates did not differ across the hospital anticoagulation phenotypes. Risk‐standardized mortality and risk‐standardized length of stay also did not differ across hospital phenotypes. Conclusions We found substantial site‐level variability in the choice of anticoagulants for invasively managed acute myocardial infarction patients, even after accounting for patient factors. No single hospital‐use pattern was found to be clinically superior. More studies are needed to determine which patients would derive the greatest benefit from various anticoagulants and to support consistent treatment of patients with the optimal anticoagulant strategy.

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

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

Objective To characterize the absolute risks for older patients of readmission to hospital and death in the year after hospitalization for heart failure, acute myocardial infarction, or pneumonia. Design Retrospective cohort study. Setting 4767 hospitals caring for Medicare fee for service beneficiaries in the United States, 2008-10. Participants More than 3 million Medicare fee for service beneficiaries, aged 65 years or more, surviving hospitalization for heart failure, acute myocardial infarction, or pneumonia. Main outcome measures Daily absolute risks of first readmission to hospital and death for one year after discharge. To illustrate risk trajectories, we identified the time required for risks of readmission to hospital and death to decline 50% from maximum values after discharge; the time required for risks to approach plateau periods of minimal day to day change, defined as 95% reductions in daily changes in risk from maximum daily declines after discharge; and the extent to which risks are higher among patients recently discharged from hospital compared with the general elderly population. Results Within one year of hospital discharge, readmission to hospital and death, respectively, occurred following 67.4% and 35.8% of hospitalizations for heart failure, 49.9% and 25.1% for acute myocardial infarction, and 55.6% and 31.1% for pneumonia. Risk of first readmission had declined 50% by day 38 after hospitalization for heart failure, day 13 after hospitalization for acute myocardial infarction, and day 25 after hospitalization for pneumonia; risk of death declined 50% by day 11, 6, and 10, respectively. Daily change in risk of first readmission to hospital declined 95% by day 45, 38, and 45; daily change in risk of death declined 95% by day 21, 19, and 21. After hospitalization for heart failure, acute myocardial infarction, or pneumonia, the magnitude of the relative risk for hospital admission over the first 90 days was 8, 6, and 6 times greater than that of the general older population; the relative risk of death was 11, 8, and 10 times greater. Conclusions Risk declines slowly for older patients after hospitalization for heart failure, acute myocardial infarction, or pneumonia and is increased for months. Specific risk trajectories vary by discharge diagnosis and outcome. Patients should remain vigilant for deterioration in health for an extended time after discharge. Health providers can use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest risk periods for patients.

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.

Background: Admissions among ambulatory patients with heart failure (HF) is a key quality metric for Accountable Care Organizations (ACOs). Yet HF patients are at risk for many acute illnesses, HF and non-HF related, and it is unknown whether specific types of admissions explain lower or higher ACO

Background— Young women ( Methods and Results— We included patients aged 18 to 64 years with a principal diagnosis of acute myocardial infarction. Data were used from the Healthcare Cost and Utilization Project-State Inpatient Database for California (07–09). Readmission diagnoses were categorized by using an aggregated version of the Centers for Medicare and Medicaid Services’ Condition Categories, and readmission timing was determined from the day after discharge. Of 42 518 younger patients with acute myocardial infarction (26.4% female), 4775 (11.2%) had at least 1 readmission. The 30-day all-cause readmission rate was higher for women (15.5% versus 9.7%, P P =0.01). Female sex was associated with a higher rate of 30-day readmission, which persisted after adjustment (hazard ratio, 1.22; 95% confidence interval, 1.15–1.30). There was no significant interaction between age and sex on readmission. Conclusions— In comparison with men, younger women have a higher risk for readmission, even after the adjustment for confounders. The timing of 30-day readmission was similar in women and men, and both sexes were susceptible to a wide range of causes for readmission.

Background: It is currently unknown whether young women (≤55 yrs) have a greater risk of all cause-re-hospitalization following AMI than similarly aged men. This is an important subgroup to study considering younger women’s higher post-AMI mortality compared with age-matched men. We determined if there are sex differences in the 1-year re-hospitalization rate, including factors associated with this outcome. Methods: Young AMI patients (N=1414, 28% women) were identified from the 24-center prospective, observational TRIUMPH study. Patient data was abstracted from medical records and health status was collected through interviews at the time of the AMI [Short Form 12 (SF-12), and the Seattle Angina Questionnaire (SAQ)]. Physicians adjudicated each re-hospitalization the year after discharge. We compared sexes using t-test/x2 and Cox proportional hazards analysis, sequentially adjusting for important covariates. Results: The crude 1-yr re-hospitalization rate was higher in women vs. men (32% vs. 23%, P Conclusion: Young women have a higher crude rate of 1-year re-hospitalization post AMI compared with men, however this effect was attenuated following adjustment. In addition to conventional risk factors, health status/psychosocial issues may be contributing factors in the risk of re-hospitalization among these young patients.

Background There are few data characterizing temporal changes in hospitalization for recurrent acute myocardial infarction ( AMI ) after AMI . Methods and Results Using a national sample of 2 305 441 Medicare beneficiaries hospitalized for AMI from 1999 to 2010, we evaluated changes in the incidence of 1‐year recurrent AMI hospitalization and mortality using Cox proportional hazards models. The observed recurrent AMI hospitalization rate declined from 12.1% (95% CI 11.9 to 12.2) in 1999 to 8.9% (95% CI 8.8 to 9.1) in 2010, a relative decline of 26.4%. The observed recurrent AMI hospitalization rate declined by a relative 27.7% in whites, from 11.9% (95% CI 11.8 to 12.1) to 8.6% (95% CI 8.5 to 8.8) versus a relative decline in blacks of 13.6% from 13.2% (95% CI 12.6 to 13.8) to 11.4% (95% CI 10.9 to 12.0). The risk‐adjusted rate of annual decline in recurrent AMI hospitalizations was 4.1% ( HR 0.959; 95% CI 0.958 to 0.961), and whites experienced a higher rate of decline ( HR 0.957, 95% CI 0.956 to 0.959) than blacks ( HR 0.974, 95% CI 0.970 to 0.979).The overall, observed 1‐year mortality rate after hospitalization for recurrent AMI declined from 32.4% in 1999 to 29.7% in 2010, a relative decline of 8.3% ( P AMI hospitalization declined 1.8% per year ( HR , 0.982; 95% CI 0.980 to 0.985). Conclusions In a national sample of Medicare beneficiaries hospitalized for AMI from 1999 to 2010, hospitalization for recurrent AMI decreased, as did subsequent mortality, albeit to a lesser extent. The risk of recurrent AMI hospitalization declined less in black patients than in whites, increasing observed racial disparities by the end of the study period.

Isuru Ranasinghe and colleagues compare readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia in adults aged 18 to 64 years with readmissions in those aged 65 and older. Please see later in the article for the Editors' Summary, Background Patients aged ≥65 years are vulnerable to readmissions due to a transient period of generalized risk after hospitalization. However, whether young and middle-aged adults share a similar risk pattern is uncertain. We compared the rate, timing, and readmission diagnoses following hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among patients aged 18–64 years with patients aged ≥65 years. Methods and Findings We used an all-payer administrative dataset from California consisting of all hospitalizations for HF (n = 206,141), AMI (n = 107,256), and pneumonia (n = 199,620) from 2007–2009. The primary outcomes were unplanned 30-day readmission rate, timing of readmission, and readmission diagnoses. Our findings show that the readmission rate among patients aged 18–64 years exceeded the readmission rate in patients aged ≥65 years in the HF cohort (23.4% vs. 22.0%, p, Editors' Summary Background Many elderly people who are admitted to hospital, successfully treated, and discharged are readmitted soon after, often for an unrelated illness. In the US, for example, nearly a fifth of Medicare beneficiaries are readmitted to hospital within 30 days of discharge (Medicare is a national insurance program that primarily pays for health care services for Americans aged 65 and older). Experts have recently coined the term “post-hospital syndrome” for the transient period of increased susceptibility to a range of adverse health events that elderly patients seem to experience and have suggested that exposure to stress during hospital stays may underlie the syndrome. For example, hospital patients frequently have their sleep disrupted because of hospital routines, they are often in pain, they may have insufficient food intake (sometimes because they are waiting for an operation), and they may lose physical conditioning because they are confined to bed. These and other stressors can reduce individuals' natural reserves and increase their vulnerability to a range of illnesses and conditions. Why Was This Study Done? Although stress is one possible determinant of the post-hospital syndrome, the underlying causes and patterns of hospital readmission are generally poorly understood. In particular, it is not known whether the post-hospital syndrome affects young and middle-aged patients as well as elderly patients. Importantly, a better understanding of the post-hospital syndrome is needed before effective strategies to reduce hospital readmissions can be developed. In this retrospective observational cohort study, the researchers compare readmission rates, timing, and diagnoses after hospitalization for heart failure (HF), acute myocardial infarction (AMI; heart attack), and pneumonia among patients aged 18–64 years living in California with readmission rates, timing, and diagnoses among patients aged 65 years or older hospitalized for the same conditions. A retrospective observational cohort study analyzes data that has been already been collected for a group (cohort) of people. Readmission is common among people of all ages who are admitted to hospital for HF, AMI, and pneumonia, and readmissions after hospitalization for these conditions among elderly Medicare patients are used in the US as a measure of hospital quality; hospitals with high readmission rates are subject to a Medicare reimbursement penalty. What Did the Researchers Do and Find? The researchers used the Healthcare Cost and Utilization Project inpatient dataset for California to identify all the hospitalizations for HF, AMI, and pneumonia in California in 2007–2009 and to obtain data on the 30-day unplanned rehospitalization rate, timing of readmission, and readmission diagnoses for the identified patients (more than half a million patients). Nearly 30% of all hospital readmissions after hospitalization for HF, AMI, and pneumonia in California occurred among patients aged 18–64. After hospitalization for AMI, pneumonia, and HF, 11.2%, 14.4%, and 23.4%, respectively, of young and middle-aged patients were readmitted. Notably, the 30-day readmission rate among patients aged 18–64 admitted for HF exceeded the readmission rate among elderly patients admitted for the same condition. After allowing for other factors likely to affect the risk of readmission such as other illnesses, the 30-day readmission risk in patients aged 18–64 was similar to that in patients aged 65 years or older admitted for HF and pneumonia and only marginally lower among patients admitted for AMI. Finally, the timing of readmission was similar in both age groups and diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions in both age groups. What Do These Findings Mean? This study shows that after adjusting for differences in patient characteristics, the 30-day hospital readmission rates among young and middle-aged patients after hospitalization for HF, AMI, and pneumonia were similar to those among elderly patients. Moreover, the timing of readmission and the reasons for readmission among young and middle-aged patients were similar to those among elderly patients. These findings may not apply to other US states or to other countries and may not reflect the pattern of hospital readmissions following conditions other than HF, AMI, and pneumonia. Nevertheless, these findings suggest that the post-hospital syndrome affects young and middle-aged as well as elderly patients. Hospital readmission should therefore be considered as a potential problem for people of all ages and broad-based, multidisciplinary strategies that target patients of all ages should be developed to mitigate the risk of hospital readmissions. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001737. The Institute for Healthcare Improvement provides information about reducing avoidable hospital readmissions Information about the US Centers for Medicare & Medicaid Services readmissions reduction program is available An article written by one of the study authors about the post-hospital syndrome is available

Mortality rates after aortic valve replacement have declined, but little is known about the risk of hospitalization among survivors and how that has changed with time.Among Medicare patients who underwent aortic valve replacement from 1999 to 2010 and survived to 1 year, we assessed trends in 1-year hospitalization rates, mean cumulative length of stay (average number of hospitalization days per patient in the entire year), and adjusted annual Medicare payments per patient toward hospitalizations. We characterized hospitalizations by principal diagnosis and mean length of stay.Among 1-year survivors of aortic valve replacement, 43% of patients were hospitalized within that year, of whom 44.5% were hospitalized within 30 days (19.2% for overall cohort). Hospitalization rates were higher for older (50.3% for85 years), female (45.1%), and black (48.9%) patients. One-year hospitalization rate decreased from 44.2% (95% confidence interval, 43.5 to 44.8) in 1999 to 40.9% (95% confidence interval, 40.3 to 41.4) in 2010. Mean cumulative length of stay decreased from 4.8 days to 4.0 days (p0.05 for trend); annual Medicare payments per patient were unchanged ($5,709 to $5,737; p = 0.32 for trend). The three most common principal diagnoses in hospitalizations were heart failure (12.7%), arrhythmia (7.9%), and postoperative complications (4.4%). Mean length of stay declined from 6.0 days to 5.3 days (p0.05 for trend).Among Medicare beneficiaries who survived 1 year after aortic valve replacement, 3 in 5 remained free of hospitalization; however, certain subgroups had higher rates of hospitalization. After the 30-day period, the hospitalization rate was similar to that of the general Medicare population. Hospitalization rates and cumulative days spent in hospital decreased with time.

Substantial hospital-level variation has been documented for readmission rates after hospitalization for heart failure.1 The factors causing this variation, however, have not been well characterized. A recent study of Medicare beneficiaries over a 14-year period revealed a trend of shortening lengths of stay accompanied by increasing readmission rates for patients hospitalized with heart failure,2 suggesting premature discharge may be playing a role in readmission. Guidelines recommend that adults hospitalized for heart failure be transitioned from intravenous diuretics to an oral regimen on which they are stable before hospital discharge.3,4 This practice is intended to ensure that patients remain stable on the oral drug regimen with which they are discharged. We evaluated the extent to which hospitals complied with this recommendation by calculating the proportion of patients hospitalized for heart failure who had orders for intravenous diuretics on the day of discharge. We also evaluated the association between this proportion and length of stay for heart failure among hospitals. We conducted a cross-sectional study using data from Perspective, a voluntary, fee-supported database developed by Premier, Inc. (Charlotte, NC) for measuring quality and health care use. As of 2011, Perspective contained data from more than 400 hospitals in the United States and represented approximately 20% of all acute care inpatient hospitalizations nationwide. We included hospitalizations for which the principal discharge diagnosis was heart failure (International Classification of Diseases, 9th revision, clinical modification codes 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 428.xx). Hospitalizations were excluded if patients were

Stroke is a common and important adverse event after acute myocardial infarction (AMI) in the elderly. It is unclear whether the risk of stroke after AMI has changed with improvements in treatments and outcomes for AMI in the last decade.To assess trends in risk of stroke after AMI, we used a national sample of Medicare data to identify Fee-for-Service patients (n = 2,305,441) aged ≥65 years who were discharged alive after hospitalization for AMI from 1999 to 2010.We identified 57,848 subsequent hospitalizations for ischemic stroke and 4,412 hospitalizations for hemorrhagic stroke within 1 year after AMI. The 1-year rate of ischemic stroke decreased from 3.4% (95% CI 3.3%-3.4%) to 2.6% (2.5%-2.7%; P.001). The risk-adjusted annual decline was 3% (hazard ratio, 0.97; [0.97-0.98]) and was similar across all age and sex-race groups. The rate of hemorrhagic stroke remained stable at 0.2% and did not differ by subgroups. The 30-day mortality for patients admitted with ischemic stroke after AMI decreased from 19.9% (18.8%-20.9%) to 18.3% (17.1%-19.6%) and from 48.3% (43.0%-53.6%) to 45.7% (40.3%-51.2%) for those admitted with hemorrhagic stroke. We observed a decrease in 1-year mortality from 37.8% (36.5%-39.1%) to 35.3% (33.8%-36.8%) for ischemic stroke and from 66.6% (61.4%-71.5%) to 60.6% (55.1%-65.9%) for hemorrhagic stroke.From 1999 to 2010, the 1-year risk for ischemic stroke after AMI declined, whereas the risk of hemorrhagic stroke remained unchanged. However, 30-day and 1-year mortality continued to be high.

Young women (≤55 years) experience a 2-3 fold greater mortality following acute myocardial infarction (AMI), yet it is unknown if they have an increased risk of 30-day all cause readmission, compared with similarly aged men. We sought to (a) examine sex differences in patient characteristics (i.e

Background— 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. Methods and Results— 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 Conclusions— 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.

Skeletal muscle adapts to decreases in activity and load by undergoing atrophy. To identify candidate molecular mediators of muscle atrophy, we performed transcript profiling. Although many genes were up-regulated in a single rat model of atrophy, only a small subset was universal in all atrophy models. Two of these genes encode ubiquitin ligases:Muscle RING Finger 1(MuRF1), and a gene we designateMuscle Atrophy F-box(MAFbx), the latter being a member of the SCF family of E3 ubiquitin ligases. Overexpression ofMAFbxin myotubes produced atrophy, whereas mice deficient in eitherMAFbxorMuRF1were found to be resistant to atrophy. These proteins are potential drug targets for the treatment of muscle atrophy.

This commentary discusses how patients in adult hospitals could benefit from the health care approach found in pediatric wards, which includes being sensitive to stressinducing procedures and offer...

Each year in the United States, approximately 800 000 men and women are affected by stroke, which equates to one incident of stroke every 40 seconds.1 Stroke is the fourth leading cause of death nationally and is one of the foremost contributors to functional disability.2 The cost to the US healthcare system is substantial. Specifically, in 2010 medical treatment for stroke cost approximately $54 billion and is expected to exceed $1 trillion by 2050.3 The burden of stroke is not limited to US alone; mortality from stroke is responsible for ~9% of all deaths worldwide and is the second most common cause of death following ischemic heart disease.4 While the overall risk of stroke has declined by 25% in the last decade,5 disability from stroke is now emerging as a major public health problem, particularly in the elderly, as we observe an increase in aging of the population. Accordingly, in this month’s topic review in Circulation: Cardiovascular Quality and Outcomes , we concentrate on contemporary issues around stroke and transient ischemic attack (TIA). Significant knowledge and practice gaps continue to exist across the continuum of stroke care. First, risk factor modification for stoke remains suboptimal. The most important modifiable risk factor for prevention of stroke is hypertension (HTN), with the lowering of blood pressure associated with a more than 25% reduction in the relative risk (RR) of stroke.6,7 Modification of other risk factors such as diabetes, hypercholesterolemia, smoking cessation and atrial fibrillation (AF),8 have also been shown to reduce the incidence of stroke.9 However, appropriate identification of patients at risk and ensuring adherence to prevention strategies presents many challenges. For example, numerous patients with HTN are not on therapy and many of those who are treated have suboptimal blood pressure …

Previous studies have reported conflicting findings regarding how the incidence of heart failure (HF) after acute myocardial infarction (AMI) has changed over time, and data on contemporary national trends are sparse.Using a complete national sample of 2 789 943 AMI hospitalizations of Medicare fee-for-service beneficiaries from 1998 through 2010, we evaluated annual changes in the incidence of subsequent HF hospitalization and mortality using Poisson and survival analysis models. The number of patients hospitalized for HF within 1 year after AMI declined modestly from 16.1 per 100 person-years in 1998 to 14.2 per 100 person years in 2010 (P0.001). After adjusting for demographic factors, a relative 14.6% decline for HF hospitalizations after AMI was observed over the study period (incidence risk ratio, 0.854; 95% confidence interval, 0.809-0.901). Unadjusted 1-year mortality following HF hospitalization after AMI was 44.4% in 1998, which decreased to 43.2% in 2004 to 2005, but then increased to 45.5% by 2010. After adjusting for demographic factors and clinical comorbidities, this represented a 2.4% relative annual decline (hazard ratio, 0.976; 95% confidence interval, 0.974-0.978) from 1998 to 2007, but a 5.1% relative annual increase from 2007 to 2010 (hazard ratio, 1.051; 95% confidence interval, 1.039-1.064).In a national sample of Medicare beneficiaries, HF hospitalization after AMI decreased from 1998 to 2010, which may indicate improvements in the management of AMI. In contrast, survival after HF following AMI remains poor, and has worsened from 2007 to 2010, demonstrating that challenges still remain for the treatment of this high-risk condition after AMI.

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

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

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

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

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

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

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

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

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

Many patients are discharged to a skilled nursing facility (SNF) after hospitalization for heart failure (HF) or acute myocardial infarction (AMI). Yet relatively little is known about the long term outcomes of these patients, including whether outcomes vary by state rates of discharge to a SNF.

Importance To better guide strategies intended to reduce high rates of 30-day readmission after hospitalization for heart failure (HF), acute myocardial infarction (MI), or pneumonia, further information is needed about readmission diagnoses, readmission timing, and the relationship of both to patient age, sex, and race. Objective To examine readmission diagnoses and timing among Medicare beneficiaries readmitted within 30 days after hospitalization for HF, acute MI, or pneumonia. Design, Setting, and Patients We analyzed 2007-2009 Medicare fee-for-service claims data to identify patterns of 30-day readmission by patient demographic characteristics and time after hospitalization for HF, acute MI, or pneumonia. Readmission diagnoses were categorized using an aggregated version of the Centers for Medicare & Medicaid Services' Condition Categories. Readmission timing was determined by day after discharge. Main Outcome Measures We examined the percentage of 30-day readmissions occurring on each day (0-30) after discharge; the most common readmission diagnoses occurring during cumulative periods (days 0-3, 0-7, 0-15, and 0-30) and consecutive periods (days 0-3, 4-7, 8-15, and 16-30) after hospitalization; median time to readmission for common readmission diagnoses; and the relationship between patient demographic characteristics and readmission diagnoses and timing. Results From 2007 through 2009, we identified 329 308 30-day readmissions after 1 330 157 HF hospitalizations (24.8% readmitted), 108 992 30-day readmissions after 548 834 acute MI hospitalizations (19.9% readmitted), and 214 239 30-day readmissions after 1 168 624 pneumonia hospitalizations (18.3% readmitted). The proportion of patients readmitted for the same condition was 35.2% after the index HF hospitalization, 10.0% after the index acute MI hospitalization, and 22.4% after the index pneumonia hospitalization. Of all readmissions within 30 days of hospitalization, the majority occurred within 15 days of hospitalization: 61.0%, HF cohort; 67.6%, acute MI cohort; and 62.6%, pneumonia cohort. The diverse spectrum of readmission diagnoses was largely similar in both cumulative and consecutive periods after discharge. Median time to 30-day readmission was 12 days for patients initially hospitalized for HF, 10 days for patients initially hospitalized for acute MI, and 12 days for patients initially hospitalized for pneumonia and was comparable across common readmission diagnoses. Neither readmission diagnoses nor timing substantively varied by age, sex, or race. Conclusion and Relevance Among Medicare fee-for-service beneficiaries hospitalized for HF, acute MI, or pneumonia, 30-day readmissions were frequent throughout the month after hospitalization and resulted from a similar spectrum of readmission diagnoses regardless of age, sex, race, or time after discharge.

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