Faculty Bibliography

BACKGROUND:Coding of systolic function in heart failure is important but the accuracy is uncertain. METHODS:We used data from chart review of VA heart failure hospitalizations between 2006 and 2013. Trained abstractors determined the documented diagnosis of heart failure and the left ventricular ejection fraction (LVEF). We compared this LVEF to the primary and secondary International Classification of Disease (ICD)-9 codes for heart failure for the same hospitalization. RESULTS:Among 43,044 hospitalizations for heart failure, the primary discharge diagnosis was coded as systolic heart failure in 18%, diastolic heart failure in 17% and other heart failure codes in 65%. For an LVEF less than 40%, a systolic heart failure code had a sensitivity of 29% and a positive predictive value of 76%. The code for systolic heart failure was used more frequently over time with sensitivity increasing from 16% to 37% but at the expense of the positive predictive value which decreased from 80% to 74%. The overall area under the receiver operating curve for the relationship between LVEF and the systolic heart failure code was 0.71. Using a LVEF > 50% to define diastolic heart failure, led to a sensitivity of 29% for a diastolic heart failure code with a positive predictive value of 78%. In multivariate analysis, a systolic heart failure code had an odds ratio for 1-year mortality of 1.1 (95% CI 1.03-1.17) compared to not having a systolic heart failure code. CONCLUSION/CONCLUSIONS:Coding for systolic and diastolic heart failure is associated with LVEF but the accuracy is too poor to substitute for the documented LVEF in performance measurement.

Background: Amputation dramatically lowers quality of life and increases risk of mortality in peripheral arterial disease (PAD) or diabetes. Some studies report an increased lower extremity amputation (LEA) risk for black patients compared to white patients, though others report no disparity, particularly in persons with diabetes. We conducted a meta-analysis using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines to examine the risk of LEA in black and white adults with PAD and/or diabetes.
Method(s): We systematically searched PubMed and EMBASE databases for cohort or case-cohort studies that included blacks and whites with PAD and/or diabetes and reported risks for LEA. A quality assessment was conducted using the Newcastle-Ottawa Scale (NOS). In addition to presenting the overall risks for amputation attributed to blacks, we conducted a meta-analysis of patients who had a previous amputation and examined the odds that the amputation was primary, defined as an amputation without any previous attempt at revascularization. A Jackknife sensitivity analysis evaluated the effect of individual articles on the estimate.
Result(s): After the database search, we identified 570 articles. 13 articles met the inclusion criteria, 9 of which were pooled in the metaanalysis. Among diabetic patients, the unadjusted odds ratio (OR) for black patients (n= 6 studies) receiving a LEA was 1.35 (95%CI, 1.05-1.75) compared to white patients [Figure below]. The Goldberg and Helmer articles had the greatest effect on the pooled estimate. The adjusted risks among black diabetic patients also suggested an increased risk but the large heterogeneity prevented pooling. Similarly, while the risk for LEA among PAD patients could not be quantified, the forest plot indicated an increased risk among blacks. The pooled unadjusted risk for primary amputation (n = 3 studies) among black patients was high (OR, 1.86; 95% CI, 1.35-2.56). Even when using the adjusted OR, the risk was attenuated but remained significant (OR 1.17; 95% CI, 1.09-1.26).
Conclusion(s): Black patients with PAD or diabetes are at an increased risk for a LEA as well as for primary amputation. Future studies should evaluate mediators of this disparity and examine ways to eliminate it. [Figure Presented]

United States Veterans are at excess risk for type 2 diabetes, but population differentials in risk have not been characterized. We determined risk of type 2 diabetes in relation to prediabetes and dyslipidemic profiles in Veterans at the VA New York Harbor (VA NYHHS) during 2004-2014. Prediabetes was based on American Diabetes Association hemoglobin A1c (HbA1c) testing cut-points, one of several possible criteria used to define prediabetes. We evaluated transition to type 2 diabetes in 4,297 normoglycemic Veterans and 7,060 Veterans with prediabetes. Cox proportional hazards regression was used to relate HbA1c levels, lipid profiles, demographic, anthropometric and comorbid cardiovascular factors to incident diabetes (Hazard Ratio [HR] and 95% confidence intervals). Compared to normoglycemic Veterans (HbA1c: 5.0-5.6%; 31-38 mmol/mol), risks for diabetes were >2-fold in the moderate prediabetes risk group (HbA1c: 5.7-5.9%; 39-41 mmol/mol) (HR 2.37 [1.98-2.85]) and >5-fold in the high risk prediabetes group (HbA1c: 6.0-6.4%; 42-46 mmol/mol) (HR 5.59 [4.75-6.58]). Risks for diabetes were increased with elevated VLDL (≥40mg/dl; HR 1.31 [1.09-1.58]) and TG/HDL (≥1.5mg/dl; HR 1.34 [1.12-1.59]), and decreased with elevated HDL (≥35mg/dl; HR 0.80 [0.67-0.96]). Transition to diabetes in Veterans was related in age-stratified risk score analyses to HbA1c, VLDL, HDL and TG/HDL, BMI, hypertension and race, with 5-year risk differentials of 62% for the lowest (5-year risk, 13.5%) vs. the highest quartile (5-year risk, 21.9%) of the risk score. This investigation identified substantial differentials in risk of diabetes in Veterans, based on a readily-derived risk score suitable for risk stratification for type 2 diabetes prevention.

BACKGROUND: Ischemic heart disease (IHD) is the most potent risk factor for heart failure (HF). Our study aims to evaluate the incremental impact of diabetes on the incidence of HF in individuals with IHD. METHODS: Data from the NHANES Epidemiologic Follow-Up Study (Baseline: 1971 to 1974) were linked to the facility and mortality files up to 1992. Our analyses were restricted to patients with IHD without prevalent HF at baseline. The cumulative incidence of HF in patients with diabetes and IHD versus those with IHD alone was assessed using failure curves. Cox proportional hazards models were used to control for important covariates. All analyses incorporated the complex sample design by including the weights and clustering variables. RESULTS: Out of the 14,407 participants, 497 had IHD without prevalent HF and had information about diabetes status. Among these participants, the cumulative incidence of HF was 38.1% for those with diabetes (n=63) and 26.5% in those without diabetes (n=434) (log-rank p-value<0.005). The multivariate hazard ratio (adjusted for age, BMI, alcohol consumption, hypertension, high cholesterol, and smoking) for incident HF for people who had myocardial infarction (MI) and diabetes compared to people who had MI alone was 2.98 (95% CI 1.51, 5.88). CONCLUSION: Among participants with MI, those with diabetes had a substantially higher incidence of HF than those without diabetes. Based on these findings, practitioners should focus greater attention on patients with diabetes and previous MI in order to potentially prevent incident HF.