Socioeconomically disadvantaged veterans experience treatment delays for pulmonary arterial hypertension

Abstract Prompt initiation of therapy after pulmonary arterial hypertension (PAH) diagnosis is critical to improve outcomes; yet delays in PAH treatment are common. Prior research demonstrates that individuals with PAH belonging to socially disadvantaged groups experience worse clinical outcomes. Whether these poor outcomes are mediated by delays in care or other factors is incompletely understood. We sought to examine the association between race/ethnicity and socioeconomic status and time‐to‐PAH treatment. We conducted a retrospective cohort study of Veterans diagnosed with incident PAH between 2006 and 2019 and treated with PAH therapy. Our outcome was time‐to‐PAH treatment. Our primary exposures were race/ethnicity, annual household income, health insurance status, education, and housing insecurity. We calculated time‐to‐treatment using multivariable mixed‐effects Cox proportional hazard models. Of 1827 Veterans with PAH, 27% were Black, 4% were Hispanic, 22.1% had an income < $20,000, 53.3$20,000 vs. ≥ $100,000) and those without non‐VA insurance (HR 0.90, 95% CI 0.82–1.00). Race/ethnicity, education, and housing insecurity were not associated with time‐to‐treatment. Veterans with PAH experienced substantial and potentially harmful treatment delays, with median time‐to‐treatment of 16 weeks after diagnosis. Those with lower income and those without non‐VA health insurance experienced even greater treatment delays. Additional research is urgently needed to develop interventions to improve timely PAH treatment and mitigate economic disparities in treatment

Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to COVID-19.

ObjectivesTo describe hospital variation in use of "guideline-based care" for acute respiratory distress syndrome (ARDS) due to COVID-19.DesignRetrospective, observational study.SettingThe Society of Critical Care Medicine's Discovery Viral Infection and RESPIRATORY ILLNESS UNIVERSAL STUDY COVID-19 REGISTRY.PatientsAdult patients with ARDS due to COVID-19 between February 15, 2020, and April 12, 2021.InterventionsHospital-level use of "guideline-based care" for ARDS including low-tidal-volume ventilation, plateau pressure less than 30 cm H2O, and prone ventilation for a Pao2/Fio2 ratio less than 100.Measurements and main resultsAmong 1,495 adults with COVID-19 ARDS receiving care across 42 hospitals, 50.4% ever received care consistent with ARDS clinical practice guidelines. After adjusting for patient demographics and severity of illness, hospital characteristics, and pandemic timing, hospital of admission contributed to 14% of the risk-adjusted variation in "guideline-based care." A patient treated at a randomly selected hospital with higher use of guideline-based care had a median odds ratio of 2.0 (95% CI, 1.1-3.4) for receipt of "guideline-based care" compared with a patient receiving treatment at a randomly selected hospital with low use of recommended therapies. Median-adjusted inhospital mortality was 53% (interquartile range, 47-62%), with a nonsignificantly decreased risk of mortality for patients admitted to hospitals in the highest use "guideline-based care" quartile (49%) compared with the lowest use quartile (60%) (odds ratio, 0.7; 95% CI, 0.3-1.9; p = 0.49).ConclusionsDuring the first year of the COVID-19 pandemic, only half of patients received "guideline-based care" for ARDS management, with wide practice variation across hospitals. Strategies that improve adherence to recommended ARDS management strategies are needed