Banning open carry of unloaded handguns decreases firearm-related fatalities and hospital utilization.

BackgroundSince 1967, in California it has been illegal to openly carry a loaded firearm in public except when engaged in hunting or law enforcement. However, beginning January 1, 2012, public open carry of unloaded handguns also became illegal. Fatal and non-fatal (NF) firearm injuries were examined before and after adoption of the 2012 ban to quantify the effect of the new law on public health.MethodsState-level data were obtained directly from California and nine other US state inpatient and emergency department (ED) discharge databases, and the Centers for Disease Control Web-Based Injury Statistics Query and Reporting System. Case numbers of firearm fatalities, NF hospitalizations, NF ED visits, and state-level population estimates were extracted. Each incident was classified as unintentional, self-inflicted, or assault. Crude incidence rates were calculated. The strength of gun laws was quantified using the Brady grade. There were no changes to open carry in these nine states during the study. Using a difference-in-difference technique, the rate trends 3 years preban and postban were compared.ResultsThe 2012 open carry ban resulted in a significantly lower incident rate of both firearm-related fatalities and NF hospitalizations (p<0.001). The effect of the law remained significant when controlling for baseline state gun laws (p<0.001). Firearm incident rate drops in California were significant for male homicide (p=0.023), hospitalization for NF assault (p=0.021  male; p=0.025 female), and ED NF assault visits (p=0.04). No significant decreases were observed by sex for suicides or unintentional injury. Changing the law saved an estimated 337 lives (3.6% fewer deaths) and 1285 NF visits in California during the postban period.DiscussionOpen carry ban decreases fatalities and healthcare utilization even in a state with baseline strict gun laws. The most significant impact is from decreasing firearm-related fatal and NF assaults.Level of evidenceIII, epidemiology

Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries

ObjectiveAbdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA.MethodsData were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination.ResultsOf 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5 ± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P < .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P < .0001) and for women compared with men (66.3% vs 59.0%; P < .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery.ConclusionsDespite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs

Cost-effectiveness of genotype-guided and dual antiplatelet therapies in acute coronary syndrome.

BackgroundThe choice of antiplatelet therapy after acute coronary syndrome (ACS) is complicated: Ticagrelor and prasugrel are novel alternatives to clopidogrel, patients with some genotypes may not respond to clopidogrel, and low-cost generic formulations of clopidogrel are available.ObjectiveTo determine the most cost-effective strategy for dual antiplatelet therapy after percutaneous coronary intervention for ACS.DesignDecision-analytic model.Data sourcesPublished literature, Medicare claims, and life tables.Target populationPatients having percutaneous coronary intervention for ACS.Time horizonLifetime.PerspectiveSocietal.InterventionFive strategies were examined: generic clopidogrel, prasugrel, ticagrelor, and genotyping for polymorphisms of CYP2C19 with carriers of loss-of-function alleles receiving either ticagrelor (genotyping with ticagrelor) or prasugrel (genotyping with prasugrel) and noncarriers receiving clopidogrel.Outcome measuresDirect medical costs, quality-adjusted life years(QALYs), and incremental cost-effectiveness ratios (ICERs).Results of base-case analysisThe clopidogrel strategy produced$179 301 in costs and 9.428 QALYs. Genotyping with prasugrel was superior to prasugrel alone, with an ICER of$35 800 per QALY relative to clopidogrel. Genotyping with ticagrelor was more effective than genotyping with prasugrel ($30 200 per QALY relative to clopidogrel). Ticagrelor was the most effective strategy($52 600 per QALY relative to genotyping with ticagrelor).Results of sensitivity analysisStronger associations between genotype and thrombotic outcomes rendered ticagrelor substantially less cost-effective ($104 800 per QALY). Genotyping with prasugrel was the preferred therapy among patients who could not tolerate ticagrelor.LimitationNo randomized trials have directly compared genotyping strategies or prasugrel with ticagrelor.ConclusionGenotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings

Evaluation of regional variations in length of stay after elective, uncomplicated carotid endarterectomy in North America

ObjectiveThe objective of this study was to evaluate factors affecting regional variation in length of stay (LOS) after elective, uncomplicated carotid endarterectomy (CEA).MethodsData were obtained from the Vascular Quality Initiative database and included patients with complete data who received elective CEA without complications between 2012 and 2017 across 18 regions in North America and 294 centers. The main outcome measure was LOS &gt;1&nbsp;day after surgery (LOS &gt;1 postoperative day [POD]). Using least absolute shrinkage and selection operator regression, multivariable modeling, and mixed-effects general linear modeling, we evaluated whether regional variations in LOS were independent of demographic, clinical, or center-related factors and to what extent these factors accounted for postoperative variation in LOS.ResultsA total of 36,004 patients were included. Mean postprocedure LOS was 1.6&nbsp;± 6.6&nbsp;days. Overall, 24% of patients had an LOS &gt;1 POD. After adjustment for important demographic, clinical, and center-related factors, the region in which a patient was treated independently and significantly affected LOS after elective, uncomplicated CEA. Region and center of treatment accounted for 18% of LOS variation. Demographic, clinical, and surgical factors accounted for another 32% of variation in LOS. Of these factors, postoperative discharge to a facility other than home (odds ratio [OR], 6.3; confidence interval [CI], 5.2-7.6), use of intravenous (IV) vasoactive agents (OR, 3.2; CI, 3-3.4), intraoperative drain placement (OR, 1.4; CI, 1.3-1.55), and female sex (OR, 1.4; CI, 1.3-1.5) were associated with longer LOS. Factors associated with LOS ≤1 POD included preoperative aspirin (OR, 0.88; CI, 0.8-0.96) and statin use (OR, 0.9; CI, 0.83-0.98), high surgeon volume (highest quartile: OR, 0.68; CI, 0.5-0.87), and completion evaluation after CEA (eg, Doppler, ultrasound; OR, 0.87; CI, 0.8-0.95). We also found that use of IV vasoactive medications varied significantly across regions, independent of demographic and clinical factors.ConclusionsSignificant regional variation in LOS exists after elective, uncomplicated CEA even after controlling for a wide range of important factors, indicating that there remain unmeasured causes of longer LOS in some regions. Even so, modification of certain clinical practices may reduce overall LOS. Regional differences in use of IV vasoactive medications not driven by clinical factors warrant further analysis, given the strong association with longer LOS

Predictors of surgical site infection after open lower extremity revascularization

ObjectivesSurgical site infection (SSI) after open surgery for lower extremity revascularization is a serious complication that may lead to graft infection, prolonged hospitalization, and increased cost. Rates of SSI after revascularization vary widely, with most studies reported from single institutions. The objective of this study was to describe the rate and predictors of SSI after surgery for arterial occlusive disease using national data, and to identify any association between SSI and length of hospital stay, reoperation, graft loss, and mortality.MethodsPatients who underwent lower extremity arterial bypass or thromboendarterectomy from 2005-2008 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use files. Multivariate logistic regression identified predictors of SSI. Odds ratios were adjusted for patient demographics, comorbidities, preoperative laboratory values, and operative factors. The association between SSI and other 30-day outcomes such as mortality and graft failure was determined.ResultsOf 12,330 patients who underwent revascularization, 1367 (11.1%) were diagnosed with an SSI within 30 days. Multivariate predictors of SSI included female gender (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.3-1.6), obesity (OR, 2.1; 95% CI, 1.8-2.4), chronic obstructive pulmonary disease (OR, 1.2; 95% CI, 1.0-1.5), dialysis (OR, 1.5; 95% CI, 1.1-2.1), preoperative hyponatremia (OR, 1.2; 95% CI, 1.0-1.4), and length of operation >4 hours (OR, 1.4; 95% CI, 1.2-1.6). SSI was associated with prolonged (>10 days) hospital stay (OR, 1.8; 95% CI, 1.4-2.1) and higher rates of 30-day graft loss (OR, 2.3; 95% CI, 1.7-3.1) and reoperation (OR, 3.7; 95% CI, 3.1-4.6). SSI was not associated with increased 30-day mortality.ConclusionSSI is a common complication after open revascularization and is associated with a more than twofold increased risk of early graft loss and reoperation. Several patient and operation-related risk factors that predict postoperative SSI were identified, suggesting that targeted improvements in perioperative care may decrease complications and improve outcomes in this patient population

Impact of office-based laboratories on physician practice patterns and outcomes after percutaneous vascular interventions for peripheral artery disease

BackgroundPercutaneous vascular interventions (PVIs) for peripheral artery disease have shifted from hospital-based facilities to office-based laboratories (OBLs). The transition to OBLs is due to a variety of factors such as technology advancement, increased efficiency, and financial incentives. We evaluated the impact of physicians switching to OBLs use from hospital-based facilities on procedure volume, procedure type, and patient outcomes.MethodsWe identified patients with PVI for lower extremity peripheral artery disease from 2006 to 2013 in a 20% Medicare sample and identified physicians who transitioned from predominantly hospital-based facilities to OBLs (switch physicians) and compared them with those who did not use OBLs (control physicians). The main outcomes investigated were average number of PVIs at 30&nbsp;days and 1&nbsp;year and atherectomy usage. Patient outcomes included above-ankle amputation, major adverse limb events, and death. We used a difference-in-difference model to control for time effects in a multivariate regression model, reported as an odds ratio (OR) and 95% confidence interval (CI).ResultsThe cohort comprised 292 switch physicians, who treated 7134 patients (3888 before OBL use and 3246 after transitioning to OBLs), and 3715 control physicians treating 54,213 patients (36,327 in the preperiod and 17,886 in the postperiod). Switch and control physicians both treated more patients with lower extremity wounds during the study period; however, this increase was greater for control physician (0.7% vs 5.5%, P&nbsp;&lt; .001). On average, patients treated by switch physicians had 0.05 (95% CI, 0.03-0.07; P&nbsp;&lt; .001) underwent more PVIs within 30&nbsp;days and 0.12 more PVIs (95% CI, 0.08-0.16; P&nbsp;&lt; .001) within 1&nbsp;year of the initial revascularization procedure after the physician transitioned to an OBL. Similarly, patients treated by switch physicians underwent 0.02 (95% CI, 0.01-0.03; P&nbsp;= .002) more atherectomy procedures at 30&nbsp;days and 0.03 (95% CI, 0.01-0.05; P&nbsp;= .008) more atherectomy procedures at 1&nbsp;year. Transitioning to OBLs was also associated with a decreased risk in above-ankle amputation at 30&nbsp;days (OR, 0.58; 95% CI, 0.38-0.97; P&nbsp;= .009) and 1&nbsp;year (OR, 0.75; 95% CI, 0.60-0.95; P&nbsp;= .01). However, no statistical difference was observed for major adverse limb events and mortality rates at 30&nbsp;days and 1&nbsp;year because patients treated by switch and control physicians experienced similar decreases.ConclusionsTransitioning to OBLs was associated higher 30-day and 1-year PVI rates and atherectomy rates. Although transitioning to OBLs was associated with lower rates of above-ankle amputations, switch physicians treated a lower number of patients with lower extremity wounds

Forearm loop arteriovenous grafts preserve and may create new upper arm access sites

IntroductionThis study evaluated the mid-term patency of forearm loop arteriovenous grafts and the dilation of previously inadequate upper arm basilic and cephalic veins after failed forearm loop arteriovenous graft.MethodsAll access procedures from September 2009 to December 2015 were reviewed. Vein mapping measurements were used to determine whether there was "adequate" upper arm cephalic and/or basilic vein, defined as ⩾3 mm by duplex ultrasound, at the time of forearm loop arteriovenous graft creation. Outcomes of forearm loop arteriovenous graft were compared with upper arm arteriovenous fistula, and primary and cumulative patencies were evaluated.ResultsThirty-eight forearm loop arteriovenous grafts and 278 upper arm arteriovenous fistulas were created. In the forearm loop arteriovenous graft cohort, nine were inserted with adequate upper arm vein, group A, and 29 were inserted with inadequate upper arm vein, group B. Cumulative patency was lower for forearm loop arteriovenous graft compared with upper arm arteriovenous fistula at 6 months, 1 year, and 2 years (67% vs 91%, 61% vs 85%, and 49% vs 80%, respectively, P &lt; .01). Comparison of group A forearm loop arteriovenous graft and upper arm arteriovenous fistula did not show a statistical difference in cumulative patency at 6 months, 1 year, and 2 years (P = .80, .62, and .70, respectively). Of group B with failed forearm loop arteriovenous graft, 36% became candidates for upper arm arteriovenous fistula with dilation of ipsilateral upper arm cephalic or basilic vein to ⩾3 mm.ConclusionIn this study, forearm loop arteriovenous graft with adequate upper arm vein did not show a statistical difference in mid-term patencies compared with upper arm arteriovenous fistula. For those forearm loop arteriovenous grafts with inadequate upper arm vein, approximately one-third of patients became candidates for upper arm arteriovenous fistula demonstrating the benefits forearm loop arteriovenous graft