RESUMO
BACKGROUND: Due to the high cost of left ventricular assist device (LVAD) therapy, payer type may be an important factor in determining eligibility. How payer type influences outcomes after LVAD implantation is unclear. We, therefore, aimed to study the association of health insurance payer type with outcomes after durable LVAD implantation. METHODS: Using STS-INTERMACS (Society of Thoracic Surgeons-Interagency Registry for Mechanically Assisted Circulatory Support), we studied nonelderly adults receiving a durable LVAD from 2016 to 2018 and compared all-cause mortality and postindex hospitalization adverse event episode rate by payer type. Multivariable Fine-Gray and generalized linear models were used to compare the outcomes. RESULTS: Of the 3251 patients included, 26.0% had Medicaid, 24.9% had Medicare alone, and 49.1% had commercial insurance. Compared with commercially insured patients, mortality did not differ for patients with Medicaid (subdistribution hazard ratio, 1.00 [95% CI, 0.75-1.34], P=0.99) or Medicare (subdistribution hazard ratio, 1.09 [95% CI, 0.84-1.41], P=0.52). Medicaid was associated with a significantly lower adjusted incidence rate (incidence rate ratio, 0.88 [95% CI, 0.78-0.99], P=0.041), and Medicare was associated with a significantly higher adjusted incidence rate (incidence rate ratio, 1.16 [95% CI, 1.03-1.30], P=0.011) of adverse event episodes compared with commercially insured patients. CONCLUSIONS: All-cause mortality after durable LVAD implantation did not differ significantly by payer type. Payer type was associated with the rate of adverse events, with Medicaid associated with a significantly lower rate, and Medicare with a significantly higher rate of adverse event episodes compared with commercially insured patients.
Assuntos
Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Coração Auxiliar/economia , Seguro Saúde , Medicare/economia , Adulto , Idoso , Feminino , Insuficiência Cardíaca/fisiopatologia , Hospitalização/economia , Humanos , Incidência , Seguro Saúde/economia , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Scientific statements have championed the measurement of clinical outcomes after cardiac stress testing to better define their value. Using contemporary national data, we sought to describe the characteristics of patients who experience outcomes after stress testing. METHODS AND RESULTS: Using administrative claims from a large national private insurer, we conducted an observational cohort study of patients without cardiovascular disease aged 25 to 64 years who underwent stress testing from 2006 to 2011 and had at least 1 year of membership in the insurance company before and after testing. We used Kaplan-Meier time-to-event analyses to determine rates of acute myocardial infarction (AMI), elective coronary revascularization, and coronary angiography without revascularization in the year following testing. We used logistic regression to determine factors associated with outcomes, and stratified the cohort into quintiles based on likelihood of experiencing AMI and/or revascularization to describe the characteristics of patients at highest and lowest risk. Among 553 027 patients who underwent stress testing (mean age 50 years, 49% women, 73% white), 0.8% were hospitalized for AMI, 1.8% underwent elective coronary revascularization, and 2.5% underwent coronary angiography without revascularization within 1 year. Patients who were older, male, and white were more likely to undergo subsequent revascularization. Patients in the lowest likelihood quintile were young (mean age 40 years), frequently women (84.7%), had a low incidence of coexisting conditions (5.2% with diabetes mellitus), and had a 0.5% rate of AMI and/or revascularization. CONCLUSIONS: The proportion of US patients younger than 65 who had AMI and/or coronary revascularization after stress testing was low. Assessing risk of subsequent outcomes may be useful in improving patient referrals for stress testing.
Assuntos
Ecocardiografia sob Estresse/métodos , Eletrocardiografia/métodos , Teste de Esforço , Cardiopatias/diagnóstico por imagem , Imagem de Perfusão do Miocárdio/métodos , Tomografia Computadorizada de Emissão de Fóton Único , Demandas Administrativas em Assistência à Saúde , Adulto , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/terapia , Bases de Dados Factuais , Feminino , Cardiopatias/epidemiologia , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Admissão do Paciente , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Transcatheter aortic valve replacement (TAVR) received US regulatory approval for treatment of severe symptomatic aortic stenosis (AS) in November 2011. After subsequent approvals for expanded indications, it is now performed throughout Michigan but the distribution of these providers and their impact on access is uncertain. As the number of providers and utilization for TAVR grows, how procedural volume is distributed among providers may significantly impact patient outcomes. METHODS: We determined geographic access to TAVR in Michigan as of October 2014, and compared it to access of other invasive cardiac services; namely, percutaneous coronary intervention (PCI), non-transplant cardiac surgery, and cardiac transplant surgery. A geographic information systems analysis was performed using recent U.S. Census Survey data and statewide inpatient data to construct maps of service areas around hospitals providing TAVR, PCI, non-transplant cardiac surgery, and cardiac transplant surgery. Service areas ranging across multiple driving distances were included in the analysis. Geographic access was calculated as percentage of the population living within the hospital service areas providing invasive cardiac services. RESULTS: In October 2014, 15 hospitals provide TAVR in Michigan. For TAVR sites, the mean number of beds, annual discharges, and annual patient days are 571, 28,946, and 140,859, respectively. Compared to hospitals not offering TAVR, TAVR facilities were more likely to be non-profit (86.7% vs 71.0%), a teaching hospital (93.3% vs 87.1%), and rural (12.1% vs 6.5%). Of the 9,883,640 persons in Michigan, 4,492,941 (45.5%) live within 10 miles, 7,856,455 (79.5%) live within 30 miles, and 9,004,943 (91.1%) live within 50 miles driving distance of TAVR sites. These proportions compare favorably with hospitals providing PCI (8,857,148 [89.6%] living within 30 miles) and non-transplant cardiac surgery (8,814,143 [89.2%] living within 30 miles) as opposed to cardiac transplant surgery (5,481,122 [55.5%] living within 30 miles). For Michigan patients who underwent surgical valve replacement (SAVR) in 2010-2011, the median driving distance to a TAVR site was under 15 miles and under 10 miles to a hospital providing non-transplant cardiac surgery. CONCLUSIONS: Nearly 4 of 5 Michigan residents lived within 30 miles of TAVR services early after its approval, suggesting its wide availability despite initial regulations on its use. These findings may encourage growth in TAVR utilization and limit the development of expertise as procedural volume is distributed among more providers. Given procedural volume tends to relate positively with outcomes, increased access to TAVR may have negative effects on patient outcomes.