Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity

BACKGROUND: Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. METHODS AND RESULTS: Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early-adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013–2014). Estimates of change in census-adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi-Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early-adopter states (1.07 [95% CI, 0.78–1.48]) or nonadopter states (0.79 [95% CI, 0.57–1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early-adopter states (0.99 [95% CI, 0.70–1.38]) or nonadopter states (1.01 [95% CI, 0.65–1.57]). There was a 34% increase in CRT rates among White individuals from early-adopter states (1.34 [95% CI, 1.05–1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59–1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation (P=0.003). CONCLUSIONS: Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients. © 2022 The Authors.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

The association between heart rate behavior and gait performance: The moderating effect of frailty

Introduction Research suggests that frailty not only influence individual systems, but also it affects the interconnection between them. However, no study exists to show how the interplay between cardiovascular and motor performance is compromised with frailty. Aim To investigate the effect of frailty on the association between heart rate (HR) dynamics and gait performance. Methods Eighty-five older adults (≥65 years and able to walk 9.14 meters) were recruited (October 2016-March 2018) and categorized into 26 non-frail (age = 78.65±7.46 years) and 59 pre-frail/frail individuals (age = 81.01±8.17) based on the Fried frailty phenotype. Participants performed gait tasks while equipped with a wearable electrocardiogram (ECG) sensor attached to the chest, as well as wearable gyroscopes for gait assessment. HR dynamic parameters were extracted, including time to peak HR and percentage increase in HR in response to walking. Using the gyroscope sensors gait parameters were recorded including stride length, stride velocity, mean swing velocity, and double support. Results Among the pre-frail/frail group, time to peak HR was significantly correlated with all gait parameters (p0.45, r = 0.03-0.15). The moderation analysis of time to peak HR, demonstrated a significant interaction effect of HR dynamics and frailty status on walking velocity (p0.10). Conclusions Current findings, for the first time, suggest that a compromised motor and cardiac autonomic interaction exist among pre-frail/frail older adults; an impaired HR performance (i.e., slower increase of HR in response to stressors) may lead to a slower walking performance. Assessing physical performance and its corresponding HR behavior should be studied as a tool for frailty screening and providing insights about the underlying cardiovascular-related mechanism leading to physical frailty. © 2022 Ruberto et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Sex disparities in organ donation: Finding an equitable donor pool

BACKGROUND: The majority of living organ donors are women, but few are deceased organ donors, which increases risks associated with sex mismatched organs. We sought to identify reasons for sex disparities in organ donation and strategies for equity. METHODS AND RESULTS: Using Amazon’s Mechanical Turk, we examined US adults’ perceptions regarding donation in a mixed-methods survey study. Results were compared by sex with Fisher’s exact test and T-tests for quantitative results and qualitative descriptive analyses for write-in responses. Among 667 participants (55% women), the majority of men (64.8%) and women (63.4%) self-identified as registered donors. Women’s willingness to donate their own organs to family members (P=0.03) or strangers (P=0.03) was significantly higher than men. Donors from both sexes were guided by: desire to help, personal experience, and believing organs would be useless to deceased donors. Non-donors from both sexes were guided by: no reason, medical mistrust, contemplating donation. When considering whether to donate organs of a deceased family member, women were equally guided by a family member’s wishes and believing the family member had no further use for or-gans. Men had similar themes but valued the family member’s wishes more. Among non-donors, both sexes would consider donation if more information was provided. CONCLUSIONS: In a national survey, both sexes had similar reasons for becoming and not becoming an organ donor. However, compared with men, women were more willing to donate their organs to family members and strangers. Improving educa-tion and communicating wishes regarding organ donation with direct relatives may increase sex equity in deceased organ donation. © 2021 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

A novel approach for assessing bias during team-based clinical decision-making

Many clinical processes include multidisciplinary group decision-making, yet few methods exist to evaluate the presence of implicit bias during this collective process. Implicit bias negatively impacts the equitable delivery of evidence-based interventions and ultimately patient outcomes. Since implicit bias can be difficult to assess, novel approaches are required to detect and analyze this elusive phenomenon. In this paper, we describe how the de Groot Critically Reflective Diagnoses Protocol (DCRDP) can be used as a data analysis tool to evaluate group dynamics as an essential foundation for exploring how interactions can bias collective clinical decision-making. The DCRDP includes 6 distinct criteria: challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Based on the strength and frequency of codes in the form of exemplar quotes, each criterion was given a numerical score of 1–4 with 1 representing teams that are interactive, reflective, higher functioning, and more equitable. When applied as a coding scheme to transcripts of recorded decision-making meetings, the DCRDP was revealed as a practical tool for examining group decision-making bias. It can be adapted to a variety of clinical, educational, and other professional settings as an impetus for recognizing the presence of team-based bias, engaging in reflexivity, informing the design and testing of implementation strategies, and monitoring long-term outcomes to promote more equitable decision-making processes in healthcare. Copyright © 2023 Pool, Hebdon, de Groot, Yee, Herrera-Theut, Yee, Allen, Hasan, Lindenfeld, Calhoun, Carnes, Sweitzer and Breathett.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Group Dynamics and Allocation of Advanced Heart Failure Therapies—Heart Transplants and Ventricular Assist Devices—By Gender, Racial, and Ethnic Group

BACKGROUND: US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. METHODS AND RESULTS: We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experi-mentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. CONCLUSIONS: Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation. © 2023 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Coronary Artery Calcification (CAC) and Post‐Trial Cardiovascular Events and Mortality Within the Women's Health Initiative (WHI) Estrogen‐Alone Trial

Background: Among women aged 50 to 59 years at baseline in the Women's Health Initiative (WHI) Estrogen‐Alone (E‐Alone) trial, randomization to conjugated equine estrogen‐alone versus placebo was associated with lower risk of myocardial infarction and mortality, and, in an ancillary study, the WHI‐CACS (WHI Coronary Artery Calcification Study) with lower CAC, measured by cardiac computed tomography ≈8.7 years after baseline randomization. We hypothesized that higher CAC would be related to post‐trial coronary heart disease (CHD), cardiovascular disease (CVD), and total mortality, independent of baseline randomization or risk factors. Methods and Results: WHI‐CACS participants (n=1020) were followed ≈8 years from computed tomography scan in 2005 (mean age=64.4) through 2013 for incident CHD (myocardial infarction and fatal CHD, n=17), CVD (n=69), and total mortality (n=55). Incident CHD and CVD analyses excluded women with CVD before scan (n=89). Women with CAC=0 (n=54%) had very low age‐adjusted rates/1000 person‐years of CHD (0.91), CVD (5.56), and mortality (3.45). In comparison, rates were ≈2‐fold higher for women with any CAC (>0). Associations were not modified by baseline randomization to conjugated equine estrogen–alone versus placebo. Adjusted for baseline randomization and risk factors, the hazard ratio (95% confidence interval) for CAC >100 (19%) was 4.06 (2.11, 7.80) for CVD and 2.70 (1.26, 5.79) for mortality. Conclusions: Among a subset of postmenopausal women aged 50 to 59 years at baseline in the WHI E‐Alone Trial, CAC at mean age of 64 years was strongly related to incident CHD, CVD, and to total mortality over ≈8 years, independent of baseline randomization to conjugated equine estrogen–alone versus placebo or CVD risk factors. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00000611