Switching warfarin to direct oral anticoagulants in atrial fibrillation: Insights from the NCDR PINNACLE registry

BACKGROUND: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin. HYPOTHESIS: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC. METHODS: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed. RESULTS: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P \u3c .001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA CONCLUSIONS: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement

Oral diabetes medication monotherapy and short-term mortality in individuals with type 2 diabetes and coronary artery disease

Objective To determine whether sulfonylurea use, compared with non-sulfonylurea oral diabetes medication use, was associated with 2-year mortality in individuals with well-controlled diabetes and coronary artery disease (CAD). Research design and methods We studied 5352 US veterans with type 2 diabetes, obstructive CAD on coronary angiography, hemoglobin A1c ≤7.5% at the time of catheterization, and taking zero or one oral diabetes medication (categorized as no medications, non-sulfonylurea medication, or sulfonylurea). We estimated the association between medication category and 2-year mortality using inverse probability of treatment-weighted (IPW) standardized mortality differences and IPW multivariable Cox proportional hazards regression. Results 49%, 35%, and 16% of the participants were on no diabetes medications, non-sulfonylurea medications, and sulfonylureas, respectively. In individuals on no medications, non-sulfonylurea medications, and sulfonylureas, the unadjusted mortality rates were 6.6%, 5.2%, and 11.9%, respectively, and the IPW-standardized mortality rates were 5.9%, 6.5%, and 9.7%, respectively. The standardized absolute 2-year mortality difference between non-sulfonylurea and sulfonylurea groups was 3.2% (95% CI 0.7 to 5.7) (p=0.01). In Cox proportional hazards models, the point estimate suggested that sulfonylurea use might be associated with greater hazard of mortality than non-sulfonylurea medication use, but this finding was not statistically significant (HR 1.38 (95% CI 1.00 to 1.93), p=0.05). We did not observe significant mortality differences between individuals on no diabetes medications and non-sulfonylurea users. Conclusions Sulfonylurea use was common (nearly one-third of those taking medications) and was associated with increased 2-year mortality in individuals with obstructive CAD. The significance of the association between sulfonylurea use and mortality was attenuated in fully adjusted survival models. Caution with sulfonylurea use may be warranted for patients with well-controlled diabetes and CAD, and metformin or newer diabetes medications with cardiovascular safety data could be considered as alternatives when individualizing therapy

Characteristics of U.S. acute care hospitals that have implemented telemedicine critical care

OBJECTIVES: Telemedicine critical care is associated with improved efficiency, quality, and cost-effectiveness. As of 2010, fewer than 5% of U.S. hospitals had telemedicine critical care, and fewer than 10% of ICU beds were covered. We evaluated recent telemedicine critical care implementation and bed coverage rates in the United States and compared characteristics of hospitals with and without telemedicine critical care. DESIGN: Cross-sectional study of 2018 American Hospital Association Annual Survey Database. SETTING: U.S. hospitals. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained data regarding telemedicine critical care implementation, ICU capability (defined as ≥ 1 ICU bed), other hospital characteristics, and the Herfindahl-Hirschman Index, a measure of ICU market competition based on hospital referral regions. Among 4,396 hospitals (response rate 71%), 788 (17.9%) had telemedicine critical care, providing potential coverage to 27,624 (28% of total) ICU beds. Among 306 hospital referral regions, 197 (64%) had a respondent hospital with telemedicine critical care. Telemedicine critical care implementation was associated with being a nonprofit (odds ratio, 7.75; 95% CI, 5.18-11.58) or public (odds ratio, 4.16 [2.57-6.73]) compared with for-profit hospital; membership in a health system (odds ratio, 3.83 [2.89-5.08]; stroke telemedicine presence (odds ratio, 6.87 [5.35-8.81]); ICU capability (odds ratio, 1.68 [1.25-2.26]); and more competitive ICU markets (odds ratio per 1,000-point decrease in Herfindahl-Hirschman Index 1.11 [1.01-1.22]). Notably, rural critical access hospitals had lower odds of telemedicine critical care implementation (odds ratio, 0.49 [0.34-0.70]). Teaching status, geographic region, and rurality were not associated with telemedicine critical care implementation. CONCLUSIONS: About one fifth of respondent hospitals had telemedicine critical care by 2018, providing potential coverage of nearly one third of reported ICU beds. This represents a substantial increase in telemedicine critical care implementation over the last decade. Future expansion to include more rural hospitals that could benefit most may be aided by addressing hospital financial and market barriers to telemedicine critical care implementation

Impaired heart rate recovery is associated with new-onset atrial fibrillation: a prospective cohort study

<p>Abstract</p> <p>Background</p> <p>Autonomic dysfunction appears to play a significant role in the development of atrial fibrillation (AF), and impaired heart rate recovery (HRR) during exercise treadmill testing (ETT) is a known marker for autonomic dysfunction. However, whether impaired HRR is associated with incident AF is unknown. We studied the association of impaired HRR with the development of incident AF, after controlling for demographic and clinical confounders.</p> <p>Methods</p> <p>We studied 8236 patients referred for ETT between 2001 and 2004, and without a prior history of AF. Patients were categorized by normal or impaired HRR on ETT. The primary outcome was the development of AF. Cox proportional hazards modeling was used to control for demographic and clinical characteristics. Secondary analyses exploring a continuous relationship between impaired HRR and AF, and exploring interactions between cardiac medication use, HRR, and AF were also conducted.</p> <p>Results</p> <p>After adjustment, patients with impaired HRR were more likely to develop AF than patients with normal HRR (HR 1.43, 95% confidence interval (CI) 1.06, 1.93). In addition, there was a linear trend between impaired HRR and AF (HR 1.05 for each decreasing BPM in HRR, 95% CI 0.99, 1.11). No interactions between cardiac medications, HRR, and AF were noted.</p> <p>Conclusion</p> <p>Patients with impaired HRR on ETT were more likely to develop new-onset AF, as compared to patients with normal HRR. These findings support the hypothesis that autonomic dysfunction mediates the development of AF, and suggest that interventions known to improve HRR, such as exercise training, may delay or prevent AF.</p

Management practices and the quality of care in cardiac units

Importance:- To improve the quality of health care, many researchers have suggested that health care institutions adopt management approaches that have been successful in the manufacturing and technology sectors. However, relatively little information exists about how these practices are disseminated in hospitals and whether they are associated with better performance. Objectives:- To describe the variation in management practices among a large sample of hospital cardiac care units; assess association of these practices with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches. Design:- We adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units. We scored performance in 18 practices using the following 4 dimensions: standardizing care, tracking of key performance indicators, setting targets, and incentivizing employees. We used multivariate analyses to assess the relationship of management practices with process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI). Setting:- Cardiac units in US hospitals. Participants_ Five hundred ninety-seven cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges. Main Outcome Measures:- Process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for AMI. Results:- We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a 4 or a 5 (best practice) on more than 9 measures. In multivariate analyses, management practices were significantly correlated with mortality (P = .01) and 6 of 6 process measures (P < .05). No statistically significant association was found between management and 30-day readmissions. Conclusions and Relevance:- The use of management practices adopted from manufacturing sectors is associated with higher process-of-care measures and lower 30-day AMI mortality. Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high-quality outcomes. Interest in quality improvement in health care during the past 10 years has been associated with a handful of important successes.1- 3 However, improvements in the quality of care have been slower than many would have hoped for,4- 8 and quality is still highly variable across organizations.9 Although significant effort has been focused on the use of evidence-based medicine—clinical practices that lead to better care—an interest in organizational strategies and management practices that enable and incentivize high-quality health care is emerging.10- 15 One of the most active areas of interest is in the use of management practices with origins in manufacturing, including, for example, “Lean” methodologies developed at Toyota16 or the use of balanced scorecard approaches that originated in the technology sector.17 These management approaches can be characterized as a set of formalized tools, the use of which is intended to improve quality through multiple pathways, such as eliminating inefficient and variable practices; engaging providers in a collaborative, team-based approach; and structuring mechanisms for setting targets and tracking progress. However, the evidence on the potential effectiveness of these approaches in health care is relatively weak13,18 and consists primarily of single-site studies.19- 21 To address this gap in knowledge, we present a new framework and instrument for defining key management dimensions and for measuring them on a large scale in health care organizations. We describe the variation in management practices among a large sample of hospitals; assess its association with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches

The Apparent and Intrinsic Shape of the APM Galaxy Clusters

We estimate the distribution of intrinsic shapes of APM galaxy clusters from the distribution of their apparent shapes. We measure the projected cluster ellipticities using two alternative methods. The first method is based on moments of the discrete galaxy distribution while the second is based on moments of the smoothed galaxy distribution. We study the performance of both methods using Monte Carlo cluster simulations covering the range of APM cluster distances and including a random distribution of background galaxies. We find that the first method suffers from severe systematic biases, whereas the second is more reliable. After excluding clusters dominated by substructure and quantifying the systematic biases in our estimated shape parameters, we recover a corrected distribution of projected ellipticities. We use the non-parametric kernel method to estimate the smooth apparent ellipticity distribution, and numerically invert a set of integral equations to recover the corresponding distribution of intrinsic ellipticities under the assumption that the clusters are either oblate or prolate spheroids. The prolate spheroidal model fits the APM cluster data best.Comment: 8 pages, including 7 figures, accepted for publication in MNRA

Extragalactic Foregrounds of the Cosmic Microwave Background: Prospects for the MAP Mission

(Abridged) While the major contribution to the Cosmic Microwave Background (CMB) anisotropies are the sought-after primordial fluctuations produced at the surface of last scattering, other effects produce secondary fluctuations at lower redshifts. Here, we study the extragalactic foregrounds of the CMB in the context of the upcoming MAP mission. We first survey the major extragalactic foregrounds and show that discrete sources, the Sunyaev-Zel'dovich (SZ) effect, and gravitational lensing are the most dominant ones for MAP. We then show that MAP will detect (>5 sigma) about 46 discrete sources and 10 SZ clusters directly with 94 GHz fluxes above 2 Jy. The mean SZ fluxes of fainter clusters can be probed by cross-correlating MAP with cluster positions extracted from existing catalogs. For instance, a MAP-XBACs cross-correlation will be sensitive to clusters with S(94GHz)>200mJy, and will thus provide a test of their virialization state and a measurement of their gas fraction. Finally, we consider probing the hot gas on supercluster scales by cross-correlating the CMB with galaxy catalogs. Assuming that galaxies trace the gas, we show that a cross-correlation between MAP and the APM catalog should yield a marginal detection, or at least a four-fold improvement on the COBE upper limits for the rms Compton y-parameter.Comment: 27 LaTeX pages, including 5 ps figures and 2 tables. To appear in ApJ. Minor revisions to match accepted version. Color figures and further links available at http://www.astro.princeton.edu/~refreg

Implementation of a non-emergent medical transportation programme at an integrated health system

OBJECTIVES: To implement a unified non-emergency medical transportation (NEMT) service across a large integrated healthcare delivery network. METHODS: We assessed needs among key organisational stakeholders, then reviewed proposals. We selected a single NEMT vendor best aligned with organisational priorities and implemented this solution system-wide. RESULTS: Our vendor\u27s hybrid approach combined rideshares with contracted vehicles able to serve patients with equipment and other needs. After 6195 rides in the first year, we observed shorter wait times and lower costs compared with our prior state. DISCUSSION: Essential lessons included (1) understanding user and patient needs, (2) obtaining complete, accurate and comprehensive baseline data and (3) adapting existing workflows-rather than designing de novo-whenever possible. CONCLUSIONS: Our implementation of a single-vendor NEMT solution validates the need for NEMT at large healthcare organisations, geographical challenges to establishing NEMT organisation-wide, and the importance of baseline data and stakeholder engagement