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Okeke N, Hennessey KC, Sitapati AM, Weisshaar D, Shah NP, Alicki R, Haft H. Sustainable Approach to Justice, Equity, Diversity, and Inclusion Through Better Quality Measurement. Circ Cardiovasc Qual Outcomes 2024; 17:e010791. [PMID: 38618717 DOI: 10.1161/circoutcomes.123.010791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
The US health care industry has broadly adopted performance and quality measures that are extracted from electronic health records and connected to payment incentives that hope to improve declining life expectancy and health status and reduce costs. While the development of a quality measurement infrastructure based on electronic health record data was an important first step in addressing US health outcomes, these metrics, reflecting the average performance across diverse populations, do not adequately adjust for population demographic differences, social determinants of health, or ecosystem vulnerability. Like society as a whole, health care must confront the powerful impact that social determinants of health, race, ethnicity, and other demographic variations have on key health care performance indicators and quality metrics. Tools that are currently available to capture and report the health status of Americans lack the granularity, complexity, and standardization needed to improve health and address disparities at the local level. In this article, we discuss the current and future state of electronic clinical quality measures through a lens of equity.
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Affiliation(s)
- Nkem Okeke
- Medicalincs, Silver Spring, MD (N.O.)
- Harvard Medical School, Center for Primary Care, Boston, MA (N.O.)
| | - Kerrilynn C Hennessey
- Department of Medicine, Section of Cardiovascular Medicine, Dartmouth Hitchcock Health, Lebanon, NH (K.C.H.)
| | - Amy M Sitapati
- Division of Biomedical Informatics, Department of Medicine, University of California San Diego Health (A.M.S.)
| | - Dana Weisshaar
- Institute of Medical Educators, Kaiser Permanente Santa Clara, CA (D.W.)
| | - Nishant P Shah
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC (N.P.S)
| | - Rebecca Alicki
- American Heart Association, Department of Quality, Outcomes Research and Analytics, Dallas, TX (R.A.)
| | - Howard Haft
- University of Maryland School of Medicine, Division of Health Sciences and Human Services, Baltimore (H.H.)
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Zhang RS, Alviar CL, Yuriditsky E, Alam U, Zhang PS, Elbaum L, Grossman K, Singh A, Maqsood MH, Greco AA, Postelnicu R, Mukherjee V, Horowitz J, Keller N, Bangalore S. Percutaneous mechanical thrombectomy in acute pulmonary embolism: Outcomes from a safety-net hospital. Catheter Cardiovasc Interv 2024. [PMID: 38577945 DOI: 10.1002/ccd.31024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 02/23/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.
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Affiliation(s)
- Robert S Zhang
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Carlos L Alviar
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Eugene Yuriditsky
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Usman Alam
- Department of Medicine, New York University, New York City, New York, USA
| | - Peter S Zhang
- Department of Medicine, New York University, New York City, New York, USA
| | - Lindsay Elbaum
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Kelsey Grossman
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Arushi Singh
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Muhammad H Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Allison A Greco
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Radu Postelnicu
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - James Horowitz
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Norma Keller
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
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Minhas AMK, Kobo O, Mamas MA, Al-Kindi SG, Abushamat LA, Nambi V, Michos ED, Ballantyne C, Abramov D. Social Vulnerability and Cardiovascular-Related Mortality Among Older Adults in the United States. Am J Med 2024; 137:122-127.e1. [PMID: 37879590 DOI: 10.1016/j.amjmed.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The association of social vulnerability and cardiovascular disease-related mortality in older adults has not been well characterized. METHODS The Centers for Disease Control and Prevention database was evaluated to examine the relationship between county-level Social Vulnerability Index (SVI) and age-adjusted cardiovascular disease-related mortality rates (AAMRs) in adults aged 65 and above in the United States between 2016 and 2020. RESULTS A total of 3139 counties in the United States were analyzed. Cardiovascular disease-related AAMRs increased in a stepwise manner from first (least vulnerable) to fourth SVI quartiles; (AAMR of 2423, 95% CI [confidence interval] 2417-2428; 2433, 95% CI 2429-2437; 2516, 95% CI 2513-2520; 2660, 95% CI 2657-2664). Similar trends among AAMRs were noted based on sex, all race and ethnicity categories, and among urban and rural regions. Higher AAMR ratios between the highest and lowest SVI quartiles, implying greater relative associations of SVI on mortality rates, were seen among Hispanic individuals (1.52, 95% CI 1.49-1.55), Non-Hispanic-Asian and Pacific Islander individuals (1.32, 95% CI 1.29-1.52), Non-Hispanic- American Indian or Alaskan Native individuals (1.43, 95% CI 1.37-1.50), and rural counties (1.21, 95% CI 1.20-1.21). CONCLUSION Social vulnerability as measures by the SVI was associated with cardiovascular disease-related mortality in older adults, with the association being particularly prominent in ethnic minority patients and rural counties.
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Affiliation(s)
| | - Ofer Kobo
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel; Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Sadeer G Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, Ohio
| | - Layla A Abushamat
- Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Baylor College of Medicine, Houston, Tex
| | - Vijay Nambi
- Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Baylor College of Medicine, Houston, Tex
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Christie Ballantyne
- Department of Medicine, Baylor College of Medicine, Houston, Tex; Section of Cardiovascular Research, Baylor College of Medicine, Houston, Tex
| | - Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda University Medical Center, Calif.
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Minhas AMK, Kewcharoen J, Hall ME, Warraich HJ, Greene SJ, Shapiro MD, Michos ED, Sauer AJ, Abramov D. Temporal Trends in Substance Use and Cardiovascular Disease-Related Mortality in the United States. J Am Heart Assoc 2024; 13:e030969. [PMID: 38197601 PMCID: PMC10926834 DOI: 10.1161/jaha.123.030969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/25/2023] [Indexed: 01/11/2024]
Abstract
BACKGROUND There are limited data on substance use (SU) and cardiovascular disease (CVD)-related mortality trends in the United States. We aimed to evaluate SU+CVD-related deaths in the United States using the Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research database. METHODS AND RESULTS The Multiple Cause-of-Death Public Use record death certificates were used to identify deaths related to both SU and CVD. Crude, age-adjusted mortality rates, annual percent change, and average annual percent changes with a 95% CI were analyzed. Between 1999 and 2019, there were 636 572 SU+CVD-related deaths (75.6% men, 70.6% non-Hispanic White individuals, 65% related to alcohol). Age-adjusted mortality rates per 100 000 population were pronounced in men (22.5 [95% CI, 22.6-22.6]), American Indian or Alaska Native individuals (37.7 [95% CI, 37.0-38.4]), nonmetropolitan/rural areas (15.2 [95% CI, 15.1-15.3]), and alcohol-related death (9.09 [95% CI, 9.07 to 9.12]). The overall SU+CVD-related age-adjusted mortality rates increased from 9.9 (95% CI, 9.8-10.1) in 1999 to 21.4 (95% CI, 21.2-21.6) in 2019 with an average annual percent change of 4.0 (95% CI, 3.7-4.3). Increases in SU+CVD-related average annual percent change were noted across all subgroups and were pronounced among women (4.8% [95% CI, 4.5-5.1]), American Indian or Alaska Native individuals, younger individuals, nonmetropolitan areas, and cannabis and psychostimulant users. CONCLUSIONS There was a prominent increase in SU+CVD-related mortality in the United States between 1999 and 2019. Women, non-Hispanic American Indian or Alaska Native individuals, younger individuals, nonmetropolitan area residents, and users of cannabis and psychostimulants had pronounced increases in SU+CVD mortality.
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Affiliation(s)
| | - Jakrin Kewcharoen
- Division of CardiologyLoma Linda University Medical CenterLoma LindaCA
| | - Michael E. Hall
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMS
| | | | | | - Michael D. Shapiro
- Cardiovascular MedicineWake Forest University School of MedicineWinston SalemNC
| | - Erin D. Michos
- Division of CardiologyJohns Hopkins School of MedicineBaltimoreMD
| | | | - Dmitry Abramov
- Division of CardiologyLoma Linda University Medical CenterLoma LindaCA
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Kewcharoen J, Basharat SA, Fobb-Mitchell I, Chatta P, Diep B, Ramsingh D, Bhardwaj R, Contractor T, Mandapati R, Garg J. Racial and Ethnic Disparities in Patients Who Underwent Leadless Pacemaker Implantation. Am J Cardiol 2023; 208:153-155. [PMID: 37839459 DOI: 10.1016/j.amjcard.2023.09.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023]
Abstract
Evidence regarding racial disparities in leadless pacemaker (LP) utilization and outcomes is limited. We aimed to explore ethnicity-based disparities in LP utilization and clinical outcomes of patients who underwent LP implantation. All consecutive patients who underwent LP between January 2019 and January 2023 at our institution were included. Charts were reviewed for baseline characteristics and clinical outcomes. The primary outcomes were procedure-related complications, cardiac rehospitalization, worsening heart failure (HF) or HF hospitalization, and all-cause mortality. All statistical analyses were performed using SPSS Statistics 22 (IBM Corp., Armonk, NY). The p <0.05 was considered statistically significant. A total of 196 adult patients underwent LP implantation during the study period (48% Caucasians, 36.2% Hispanic, 8.2% Asians, and 7.7% African-American). The groups were balanced with respect to baseline demographics, clinical characteristics, and procedure-related complications. During the median follow-up of 104 days (interquartile range 24 to 382), no statistically significant differences were observed in worsening HF or HF hospitalization or all-cause mortality among the ethnic groups. After multivariable logistic regression, Asian individuals had higher odds of cardiac readmissions (odds ratio 4.1, 95% confidence interval 1.4 to 12.3, p = 0.01). Patients from racial and ethnic minorities face significant inequities in arrhythmia care, including patients who have undergone LP implantation. Awareness and a system-based approach (understanding cultural preferences, effective application of evidence-based guidelines, and population-based policies) are crucial to lessen disparities in health care among minorities.
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Affiliation(s)
- Jakrin Kewcharoen
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Sohaib A Basharat
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Ingrid Fobb-Mitchell
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Payush Chatta
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Brian Diep
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Health, Loma Linda, California
| | - Rahul Bhardwaj
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Tahmeed Contractor
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Ravi Mandapati
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California.
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Vasan RS, Rao S, van den Heuvel E. Race as a Component of Cardiovascular Disease Risk Prediction Algorithms. Curr Cardiol Rep 2023; 25:1131-1138. [PMID: 37581773 DOI: 10.1007/s11886-023-01938-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 08/16/2023]
Abstract
PURPOSE OF REVIEW Several prediction algorithms include race as a component to account for race-associated variations in disease frequencies. This practice has been questioned recently because of the risk of perpetuating race as a biological construct and diverting attention away from the social determinants of health (SDoH) for which race might be a proxy. We evaluated the appropriateness of including race in cardiovascular disease (CVD) prediction algorithms, notably the pooled cohort equations (PCE). RECENT FINDINGS In a recent investigation, we reported substantial and biologically implausible differences in absolute CVD risk estimates upon using PCE for predicting CVD risk in Black and White persons with identical risk factor profiles, which might result in differential treatment decisions based solely on their race. We recommend the development of raceless CVD risk prediction algorithms that obviate race-associated risk misestimation and racializing treatment practices, and instead incorporate measures of SDoH that mediate race-associated risk differences.
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Affiliation(s)
- Ramachandran S Vasan
- University of Texas School of Public Health and University of Texas Health Sciences Center, 8403 Floyd Curl Drive, Mail Code 7992, San Antonio, TX 78229, USA.
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.
| | - Shreya Rao
- University of Texas School of Public Health and University of Texas Health Sciences Center, 8403 Floyd Curl Drive, Mail Code 7992, San Antonio, TX 78229, USA
| | - Edwin van den Heuvel
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
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Brandt EJ, Kirch M, Patel N, Chennareddy C, Murthy VL, Goonewardena SN. The Impact of Social Determinants of Health and Lifestyle on the Association of Lipoprotein(a) with Myocardial Infarction and Stroke. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.01.23294968. [PMID: 37693416 PMCID: PMC10491356 DOI: 10.1101/2023.09.01.23294968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Background In European cohorts, a higher Mediterranean diet or Life's Simple 7 (LS7) score abolished or attenuated the risk associated with increasing Lipoprotein(a) [Lp(a)] on cardiovascular outcomes. This is unstudied in US cohorts. The impact of social determinants of health (SDOH) on the association of Lp(a) with cardiovascular outcomes remains unstudied. We sought to test if a SDOH score and LS7 score impacts the association of Lp(a) with myocardial infarction (MI) or stroke. Methods Observational Cohort of US Adults from the Atherosclerosis Risk in Communities (ARIC) and Multi-Ethnic Study of Atherosclerosis (MESA) cohorts. We performed sequential multivariable Cox proportional hazard analysis, first adjusting for age, gender, non-HDL-C, race and ethnicity, then added SDOH and LS7 scores sequentially. The primary outcomes were time until first fatal or nonfatal MI or stroke. Results ARIC (n=15,072; median Lp(a)=17.3 mg/dL) had 16.2 years average follow up. MESA (n=6,822; median Lp(a)=18.3 mg/dL had 12.3 years average follow-up. In multivariable analyses adjusted for age, gender, race and ethnicity, and non-HDL-C, Lp(a) was associated (HR, p-value) with MI in ARIC (1.10, <0.001) and MESA (1.09, <0.001), and stroke in ARIC (1.08, <0.001) but not MESA (0.97, 0.50). With SDOH and LS7 added to the model associations remained similar (association of Lp(a) with MI in ARIC 1.09, <0.001 and in MESA 1.10, 0.001, with stroke in ARIC 1.06, <0.003 and in MESA 0.96, 0.39). In models with all covariates, each additional SDOH correlated positively with MI (ARIC 1.13, <0.001; MESA 1.11, <0.001) and stroke (ARIC 1.17, <0.001; HR 1.07, p=0.11) and each additional LS7 score point correlated negatively with MI (ARIC 0.81, <0.001; MESA 0.84, <0.001) and stroke (ARIC 0.82, <0.001; MESA 0.84, <0.001). Conclusions and Relevance SDOH and lifestyle factors were predictors for MI and stroke that did not impact the association between Lp(a) and cardiovascular events. Our findings support that Lp(a) is an independent risk factor for MI and possibly stroke.
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Affiliation(s)
- Eric J Brandt
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Matthias Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Nimai Patel
- Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX
| | | | - Venkatesh L Murthy
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Divisions of Nuclear Medicine and Cardiothoracic Imaging, Department of Radiology, University of Michigan, Ann Arbor, MI
| | - Sascha N Goonewardena
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Brandt EJ. Social determinants of racial health inequities. Lancet Public Health 2023; 8:e396-e397. [PMID: 37244668 PMCID: PMC11104490 DOI: 10.1016/s2468-2667(23)00100-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Eric J Brandt
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA; Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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