Faculty Bibliography

Background Results of trials and registry studies have shown lower long-term mortality after coronary-artery bypass grafting (CABG) than after percutaneous coronary intervention (PCI) among patients with multivessel disease. These previous analyses did not evaluate PCI with second-generation drug-eluting stents. Methods In an observational registry study, we compared the outcomes in patients with multivessel disease who underwent CABG with the outcomes in those who underwent PCI with the use of everolimus-eluting stents. The primary outcome was all-cause mortality. Secondary outcomes were the rates of myocardial infarction, stroke, and repeat revascularization. Propensity-score matching was used to assemble a cohort of patients with similar baseline characteristics. Results Among 34,819 eligible patients, 9223 patients who underwent PCI with everolimus-eluting stents and 9223 who underwent CABG had similar propensity scores and were included in the analyses. At a mean follow-up of 2.9 years, PCI with everolimus-eluting stents, as compared with CABG, was associated with a similar risk of death (3.1% per year and 2.9% per year, respectively; hazard ratio, 1.04; 95% confidence interval [CI], 0.93 to 1.17; P=0.50), higher risks of myocardial infarction (1.9% per year vs. 1.1% per year; hazard ratio, 1.51; 95% CI, 1.29 to 1.77; P<0.001) and repeat revascularization (7.2% per year vs. 3.1% per year; hazard ratio, 2.35; 95% CI, 2.14 to 2.58; P<0.001), and a lower risk of stroke (0.7% per year vs. 1.0% per year; hazard ratio, 0.62; 95% CI, 0.50 to 0.76; P<0.001). The higher risk of myocardial infarction with PCI than with CABG was not significant among patients with complete revascularization but was significant among those with incomplete revascularization (P=0.02 for interaction). Conclusions In a contemporary clinical-practice registry study, the risk of death associated with PCI with everolimus-eluting stents was similar to that associated with CABG. PCI was associated with a higher risk of myocardial infarction (among patients with incomplete revascularization) and repeat revascularization but a lower risk of stroke. (Funded by Abbott Vascular.).

BACKGROUND: Evidence concerning the association of anger-proneness with incidence of heart failure is lacking. METHODS: Anger proneness was ascertained among 13,171 black and white participants of the Atherosclerosis Risk in Communities (ARIC) Study cohort using the Spielberger Trait Anger Scale. Incident heart failure events, defined as occurrence of ICD-9-CM code 428.x, were ascertained from participants' medical records during follow-up 1990-2010. Relative hazard of heart failure across categories of trait anger was estimated from Cox proportional hazard models. RESULTS: Study participants (mean age 56.9 (SD 5.7) years) experienced 1,985 incident HF events during 18.5 (SD 4.9) years of follow-up. Incidence of HF was greater among those with high, as compared to those with low or moderate trait anger, with higher incidence observed for men as compared to women. The relative hazard of incident HF was modestly high among those with high trait anger, as compared to those with low or moderate trait anger (age-adjusted HR for men=1.44 (95% CI 1.23, 1.69). Adjustment for comorbidities and depressive symptoms attenuated the estimated age-adjusted relative hazard in men to 1.26 (95% CI 1.00, 1.60). CONCLUSION: Assessment of anger proneness may be necessary in successful prevention and clinical management of heart failure, especially in men.

BACKGROUND: Treatment of acute heart failure in the emergency department (ED) or observation unit is an alternative to hospitalization. Both ED management and observation unit management have been associated with reduced costs and may be used to avoid penalties related to rehospitalizations. The purpose of this study was to examine trends in ED visits for heart failure and disposition following such visits. METHODS: We used the National Hospital Ambulatory Medical Care Survey, a representative sample of ED visits in the United States, to estimate rates and characteristics of ED visits for heart failure between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit. RESULTS: The number of ED visits for heart failure remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%, 95% CI -3.7% to +2.5%). Of these visits, 74.2% led to hospitalization, wheras 3.1% led to observation unit admission. The likelihood of hospitalization did not change during the period (adjusted prevalence ratio 1.00, 95% CI 0.99-1.01 for each additional year), whereas admission to the observation unit increased annually (adjusted prevalence ratio 1.12, 95% CI 1.01-1.25). We observed significant regional differences in likelihood of hospitalization and observation admission. CONCLUSIONS: The number of ED visits for heart failure and the high proportion of ED visits with subsequent inpatient hospitalization have not changed in the last decade. Opportunities may exist to reduce hospitalizations by increasing short-term management of heart failure in the ED or observation unit.

BACKGROUND: Cardiac stress testing, particularly with imaging, has been the focus of debates about rising health care costs, inappropriate use, and patient safety in the context of radiation exposure. OBJECTIVE: To determine whether U.S. trends in cardiac stress test use may be attributable to population shifts in demographics, risk factors, and provider characteristics and evaluate whether racial/ethnic disparities exist in physician decision making. DESIGN: Analyses of repeated cross-sectional data. SETTING: National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (1993 to 2010). PATIENTS: Adults without coronary heart disease. MEASUREMENTS: Cardiac stress test referrals and inappropriate use. RESULTS: Between 1993 to 1995 and 2008 to 2010, the annual number of U.S. ambulatory visits in which a cardiac stress test was ordered or performed increased from 28 per 10,000 visits to 45 per 10,000 visits. No trend was found toward more frequent testing after adjustment for patient characteristics, risk factors, and provider characteristics (P = 0.134). Cardiac stress tests with imaging comprised a growing portion of all tests, increasing from 59% in 1993 to 1995 to 87% in 2008 to 2010. At least 34.6% were probably inappropriate, with associated annual costs and harms of $501 million and 491 future cases of cancer. Authors found no evidence of a lower likelihood of black patients receiving a cardiac stress test (odds ratio, 0.91 [95% CI, 0.69 to 1.21]) than white patients, although some evidence of disparity in Hispanic patients was found (odds ratio, 0.75 [CI, 0.55 to 1.02]). LIMITATION: Cross-sectional design with limited clinical data. CONCLUSION: National growth in cardiac stress test use can largely be explained by population and provider characteristics, but use of imaging cannot. Physician decision making about cardiac stress test use does not seem to contribute to racial/ethnic disparities in cardiovascular disease. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute and the National Center for Advancing Translational Sciences.

OBJECTIVE: The purpose of this study was to evaluate the association of physician continuity of care with length of stay, likelihood of weekend discharge, in-hospital mortality and 30-day readmission. DESIGN: A cohort study of hospitalized medical patients. The primary exposure was the weekend usual provider continuity (UPC) over the initial weekend of care. This metric was adapted from an outpatient continuity of care index. Regression models were developed to determine the association between UPC and outcomes. SETTING: An academic medical center. MAIN OUTCOME MEASURE: Length of stay which was calculated as the number of days from the first Saturday of the hospitalization to the day of discharge. RESULTS: Of the 3391 patients included in this study, the prevalence of low, moderate and high UPC for the initial weekend of hospitalization was 58.7, 22.3 and 19.1%, respectively. When compared with low continuity of care, both moderate and high continuity of care were associated with reduced length of stay, with adjusted rate ratios of 0.92 (95% CI 0.86-1.00) and 0.64 (95% CI 0.53-0.76), respectively. High continuity of care was associated with likelihood of weekend discharge (adjusted odds ratio 2.84, 95% CI 2.11-3.83) but was not significantly associated with mortality (adjusted odds ratio 0.72, 95% CI 0.29-1.80) or readmission (adjusted odds ratio 0.88, 95% CI 0.68-1.14) when compared with low continuity of care. CONCLUSIONS: Increased weekend continuity of care is associated with reduced length of stay. Improvement in weekend cross-coverage and patient handoffs may be useful to improve clinical outcomes.

Background: Appropriate use criteria (AUC) for imaging stress testing address concerns about utilization growth, high costs, and radiation safety. However, differences in test use over time between primary care physicians (PCPs) and cardiologists have not been examined. Methods: We analyzed 164,569 ambulatory visits from the National Ambulatory Medical Care Survey from 1993-2010. Patients with CAD were excluded. The main outcome was survey-weighted incidence of referrals for imaging stress. Referrals were considered inappropriate in patients with neither ischemic equivalents (chest pain, anginal equivalent, or ischemic ECG abnormalities) nor CAD risk equivalents. Logistic regressions examined time trends and adjusted for clinical characteristics. Results: Ambulatory visits resulting in an inappropriate imaging stress referral increased from 523,000 in 1993-1995 to 1.63 million in 2008- 2010. PCP referral increased until 2008-2010 when referrals fell; P=0.33 for time trend. However, among cardiologists, inappropriate testing rates rose during each period, including 2008-2010 when AUC were well accepted, rising from 260 to 710 per 10,000 visits (P<0.01). The portion of inappropriate tests was stable over time: 50% for cardiologists; 55-65% for PCPs. Conclusion: Growth in inappropriate imaging stress tests is driven on the margin by cardiologists, and PCPs have reduced utilization in recent years. Payers and policy makers designing quality metrics should consider these patterns