Publications by authors named "Candace Gunnarsson"

77 Publications

Use of iso-osmolar contrast media during endovascular revascularization is associated with a lower incidence of major adverse renal, cardiac, or limb events.

Catheter Cardiovasc Interv 2021 Nov 12. Epub 2021 Nov 12.

Center for Complex Coronary Interventions, Minneapolis Heart Institute, Minneapolis, Minnesota, USA.

Objective: We examined the association of iso-osmolar contrast media (IOCM) versus low-osmolar contrast media (LOCM) with major adverse renal, cardiovascular, or limb events in patients at high-risk of acute kidney injury (AKI) undergoing peripheral endovascular procedures.

Background: Procedural characteristics including iodinated contrast type and volume have been associated with adverse renal and cardiovascular outcomes in patients undergoing angiographic interventions.

Methods: Patients at high-risk of AKI, undergoing peripheral endovascular procedures were identified using the Premier Healthcare Database and separated into claudication and critical limb ischemia (CLI) cohorts. For each cohort, we compared IOCM versus LOCM for the primary endpoint of MARCE (major adverse renal or cardiovascular events) and secondary endpoints of major adverse renal events (MARE) and major adverse renal and limb events (MARLE). These outcomes were captured within the indexed hospitalization via adjusted multivariable regression analyses.

Results: Two procedure-based cohorts of high-risk patients were formed: claudication (N = 11,976) and CLI (N = 8713). Use of IOCM was associated with a significant absolute risk reduction (ARR) of 2.2% (p < 0.0001) for MARCE overall and in each cohort (claudication, 1.8%, p = 0.0070; CLI, 2.7%, p = 0.0054). The incidence of MARE and MARLE in the overall cohort was also lower with the use of IOCM: MARE (ARR = 1.4%, p = 0.0072) and MARLE (ARR = 2.0%, p = 0.0043).

Conclusions: Using IOCM versus LOCM in patients at high-risk of adverse renal events undergoing peripheral endovascular procedures was independently associated with lower risk of MARCE, MARE, and MARLE.
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http://dx.doi.org/10.1002/ccd.30006DOI Listing
November 2021

Temporal Changes in Mortality After Transcatheter and Surgical Aortic Valve Replacement: Retrospective Analysis of US Medicare Patients (2012-2019).

J Am Heart Assoc 2021 10 28;10(20):e021748. Epub 2021 Sep 28.

Sunnybrook Health Sciences University of Toronto Canada.

Background The treatment of aortic stenosis is evolving rapidly. Pace of change in the care of patients undergoing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differs. We sought to determine differences in temporal changes in 30-day mortality, 30-day readmission, and length of stay after TAVR and SAVR. Methods and Results We conducted a retrospective cohort study of patients treated in the United States between 2012 and 2019 using data from the Medicare Data Set Analytic File 100% Fee for Service database. We included consecutive patients enrolled in Medicare Parts A and B and aged ≥65 years who had SAVR or transfemoral TAVR. We defined 3 study cohorts, including all SAVR, isolated SAVR (without concomitant procedures), and elective isolated SAVR and TAVR. The primary end point was 30-day mortality; secondary end points were 30-day readmission and length of stay. Statistical models controlled for patient demographics, frailty measured by the Hospital Frailty Risk Score, and comorbidities measured by the Elixhauser Comorbidity Index (ECI). Cox proportional hazard models were developed with TAVR versus SAVR as the main covariates with a 2-way interaction term with index year. We repeated these analyses restricted to full aortic valve replacement hospitals offering both SAVR and TAVR. The main study cohort included 245 269 patients with SAVR and 188 580 patients with TAVR, with mean±SD ages 74.3±6.0 years and 80.7±6.9 years, respectively, and 36.5% and 46.2% female patients, respectively. Patients with TAVR had higher ECI scores (6.4±3.6 versus 4.4±3) and were more frail (55.4% versus 33.5%). Total aortic valve replacement volumes increased 61% during the 7-year span; TAVR volumes surpassed SAVR in 2017. The magnitude of mortality benefit associated with TAVR increased until 2016 in the main cohort (2012: hazard ratio [HR], 0.76 [95% CI, 0.67-0.86]; 2016: HR, 0.39 [95% CI, 0.36-0.43]); although TAVR continued to have lower mortality rates from 2017 to 2019, the magnitude of benefit over SAVR was attenuated. A similar pattern was seen with readmission, with a lower risk of readmission from 2012 to 2016 for patients with TAVR (2012: HR, 0.68 [95% CI, 0.63-0.73]; 2016: HR, 0.43 [95% CI, 0.41-0.45]) followed by a lesser difference from 2017 to 2019. Year over year, TAVR was associated with increasingly shorter lengths of stay compared with SAVR (2012: HR, 1.91 [95% CI, 1.84-1.98]; 2019: HR, 5.34 [95% CI, 5.22-5.45]). These results were consistent in full aortic valve replacement hospitals. Conclusions The rate of improvement in TAVR outpaced SAVR until 2016, with the recent presence of U-shaped phenomena suggesting a narrowing gap between outcomes. Future longitudinal research is needed to determine the long-term implications of lowering risk profiles across treatment options to guide case selection and clinical care.
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http://dx.doi.org/10.1161/JAHA.120.021748DOI Listing
October 2021

Mortality and guideline-directed medical therapy in real-world heart failure patients with reduced ejection fraction.

Clin Cardiol 2021 Sep 3;44(9):1192-1198. Epub 2021 Aug 3.

Scripps Clinic, La Jolla, California, USA.

Objective: To estimate the prevalence of guideline-directed medical therapy (GDMT) in commercially insured US patients with heart failure with reduced ejection fraction (HFrEF) and examine the effect of GDMT on all-cause mortality. GDMT for HFrEF includes pharmacologic therapies such as β-blockers (BB), angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin (ARNI), mineralocorticoid receptor antagonists (MRA), and sodium-glucose cotransporter inhibitors to reduce morbidity and mortality.

Methods: Patients in the Optum Integrated File from 2007 to 2019Q3, ≥18 years, with history of HFrEF, were identified. Patients prescribed both a BB and either an ACE-I, ARB, or ARNI during 6-month post-diagnosis were assigned to the GDMT cohort. All others were assigned to the not on GDMT cohort. The GDMT cohort was further classified by those patients with a record of prescription fills for both classes of medications concurrently (GDMT concurrent medication fills). Mortality at 2 years was assessed with a Cox regression model accounting for baseline demographics, comorbidities, and diuretic use.

Results: This study identified 14 880 HFrEF patients, of which 70% had a record of GDMT, and 57% had a record of concurrent prescriptions. Patients in the not on GDMT cohort had 29% increased risk of mortality versus GDMT (hazard ratio 1.29; 95% CI (1.19-1.40); p < .0001). As a sensitivity analysis, the effect of patients not on GDMT compared to GDMT with concurrent medication fills was more pronounced, with a 37% increased mortality risk.

Conclusion: In a real-world population of HFrEF patients, inadequate GDMT confers a 29% excess mortality risk over the 2-year follow-up.
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http://dx.doi.org/10.1002/clc.23664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8427999PMC
September 2021

Association of Iso-Osmolar vs Low-Osmolar Contrast Media With Major Adverse Renal or Cardiovascular Events in Patients at High Risk for Acute Kidney Injury Undergoing Endovascular Abdominal Aortic Aneurysm Repair.

J Invasive Cardiol 2021 Aug 16;33(8):E640-E646. Epub 2021 Jul 16.

Interventional Cardiology, Dartmouth-Hitchcock Medical Center, Associate Professor of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756 USA.

Objective: The purpose of this analysis was to examine the association of iso-osmolar contrast media (IOCM) vs low-osmolar contrast media (LOCM) with major adverse renal or cardiovascular events (MARCE) in patients at high risk of acute kidney injury (AKI), undergoing endovascular abdominal aortic aneurysm repair (EVAR).

Methods: Patients at high risk of AKI (defined as age ≥75 years, or one or more of the following comorbidities: diabetes, anemia, chronic kidney disease (CKD stages 1-4) or congestive heart failure), undergoing EVAR from September 2012 to June 2018 were identified using the Premier Hospital Database. We compared the primary endpoint of MARCE (composite of AKI, AKI requiring dialysis, acute myocardial infarction [AMI], stroke/transient ischemic attack [TIA], and death) with IOCM vs LOCM via adjusted multivariable regression analyses.

Results: Among 15,777 high-risk patients undergoing EVAR, the occurrence of in-hospital MARCE was 6.8%, including renal events (4.5%), AMI (0.8%), stroke/TIA (0.4%), and death (1.9%), IOCM was used in 7360 patients (47%). Multivariable modeling found IOCM was associated with 1.8% (95% confidence interval [CI], 0.4-3.3; P=.01) lower absolute risk for MARCE (23.9% relative risk reduction; 95% CI, 5.2%-44.2%).

Conclusions: Use of IOCM vs LOCM in patients at high risk of AKI undergoing EVAR procedures was associated with a lower risk of MARCE. As prevention of AKI or cardiovascular events after EVAR procedures may lead to reduced morbidity and mortality, this finding may have important clinical implications and should be confirmed through randomized controlled clinical studies.
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August 2021

The need for future coronary access following surgical or transcatheter aortic valve replacement.

Catheter Cardiovasc Interv 2021 11 6;98(5):950-956. Epub 2021 Jul 6.

Department of Surgery, East Carolina University, Greenville, North Carolina, USA.

The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.
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http://dx.doi.org/10.1002/ccd.29841DOI Listing
November 2021

Healthcare utilization and guideline-directed medical therapy in heart failure patients with reduced ejection fraction.

J Comp Eff Res 2021 10 6;10(14):1055-1063. Epub 2021 Jul 6.

Scripps Clinic, La Jolla, CA, USA.

This study examines the effect of guideline-directed medical therapy (GDMT) on healthcare utilization in patients with heart failure with reduced ejection fraction from Optum Integrated File from 1 January 2007 to 30 June 2020. Patients with both a beta blocker and either an ACE inhibitor (ACE-I), angiotensin receptor blocker (ARB) or angiotensin receptor neprilysin inhibitor were assigned to the GDMT cohort. All others were not on GDMT. Estimated annual all cause hospitalizations and emergency department visits per 100 patients was 29% (80 vs 62 patients) and 26% higher (54 vs 43 patients; p < 0.0001) and annualized hospital days were longer (1.88 vs 1.64; p = 0.0020) for patients not on GDMT. In a real-world population, heart failure with reduced ejection fraction, patients not optimally managed on GDMT had higher annualized healthcare utilization when compared with patients on GDMT.
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http://dx.doi.org/10.2217/cer-2021-0118DOI Listing
October 2021

Comparison of Survival in Patients With Clinically Significant Tricuspid Regurgitation With and Without Heart Failure (From the Optum Integrated File).

Am J Cardiol 2021 04 30;144:125-130. Epub 2020 Dec 30.

Edwards Lifesciences, Irvine, California.

This study aimed to quantify survival rates for patients with tricuspid regurgitation (TR) using real-world data. Several clinical conditions are associated with TR, including heart failure (HF), other valve disease (OVD), right-sided heart disease (RSHD), and others that impact mortality. Optum data from January 1, 2007, through December 31, 2018 included patients age ≥18 years with TR and 12 months of continuous health plan enrollment before TR. Exclusion criteria were end-stage renal disease or known/primary organ pathology. Cohorts were created hierarchically: (1) TR with HF; (2) TR with OVD (no HF); (3) TR with RSHD only (no OVD or HF); (4) TR only. Survival was estimated using a Cox hazard model with an interaction term for TR severity and adjusted for patient demographics and Elixhauser co-morbidities. A total of 33,686 met study inclusion (1) TR with HF (26.6%); (2) TR with OVD (36.7%); (3) TR with RSHD only (17.1%); (4) TR only (19.6%). TR patients (regardless of severity) with HF, OVD or RSHD had an increased risk of mortality compared with patients with TR alone. TR severity was also significantly associated (hazard ratio = 1.33; p = 0.0002) with an increased risk of all-cause mortality. In conclusion, TR severity is significantly associated with an increased risk of all-cause mortality, independent of associated conditions including HF, OVD, or RSHD. In patients with severe TR, the mortality risk is most pronounced for patients who had RSHD without HF or OVD before their TR diagnosis.
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http://dx.doi.org/10.1016/j.amjcard.2020.12.070DOI Listing
April 2021

Healthcare utilization in clinically significant tricuspid regurgitation patients with and without heart failure.

J Comp Eff Res 2021 01 11;10(1):29-37. Epub 2020 Nov 11.

Edwards Lifesciences, Irvine, CA, USA.

This study evaluated how the presence of right-sided heart disease (RSHD), other valve disease (OVD) and heart failure (HF) impacts healthcare utilization in patients with tricuspid valve disease (tricuspid regurgitation [TR]). Of the 33,686 patients with TR: 6618 (19.6%) had TR-only; 8952 (26.6%) had TR with HF; 12,367 (36.7%) had TR with OVD but no HF; and 5749 (17.1%) had TR with RSHD only. The presence of RSHD, OVD or HF in patients with TR was independently associated with increased annualized hospitalizations, hospital days and costs relative to patients with TR alone. All three co-morbidities were associated with increased healthcare utilization, with HF showing the greatest impact across all measures.
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http://dx.doi.org/10.2217/cer-2020-0198DOI Listing
January 2021

Long-term Healthcare Expenditures Over Time for Tissue and Mechanical Aortic Valve Replacement.

Ann Thorac Surg 2021 08 2;112(2):526-531. Epub 2020 Nov 2.

Health Finance & Access Initiative, Bryn Mawr, Pennsylvania.

Background: Guidelines currently indicate the use of surgical aortic valve replacement (SAVR) to treat severe cases of aortic stenosis, particularly for low- to medium-risk patients. Although several studies have compared health outcomes of tissue and mechanical SAVR, this economic simulation model estimates the difference in long-term healthcare costs associated with tissue relative to mechanical SAVR.

Methods: The deterministic and Monte Carlo simulation models used literature-based epidemiologic and cost inputs to calculate annual expenditures related to SAVR for up to 25 years after initial surgery. A series of 3 cohort studies across different age groups provided the health outcome probabilities for tissue valve patients. Outcome probabilities for mechanical valve patients were based on relative risks reported in comparative meta-analyses or large cohort studies.

Results: Relative to mechanical SAVR the expected net discounted savings for a patient receiving tissue SAVR at ages 45, 55, and 65 years were $12,266, $15,462, and $16,008, respectively (based on 2018 US dollars) over a 25-year horizon (95% confidence intervals exceed $0). For a 45-year-old tissue SAVR patient, the estimated per-patient cost difference (relative to mechanical SAVR) of reoperation over 25 years ($16,201) were offset by expected savings on anticoagulation monitoring ($26,257) over the same period. In a sensitivity analysis in which mortality risk was assumed equal, significant long-term savings associated with tissue SAVR still accrued in each of the 3 age cohorts.

Conclusions: Payers, providers, and the healthcare system may financially benefit from the use of tissue valves because significant savings were associated with the use of tissue valves relative to mechanical valves for SAVR.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.106DOI Listing
August 2021

Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments.

J Vasc Surg Venous Lymphat Disord 2021 03 11;9(2):383-392. Epub 2020 Aug 11.

University of Pennsylvania Wharton School, Philadelphia, Pa.

Objective: To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments.

Methods: Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments.

Results: Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing.

Conclusions: Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.
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http://dx.doi.org/10.1016/j.jvsv.2020.08.003DOI Listing
March 2021

Impact of mitral regurgitation on cardiovascular hospitalization and death in newly diagnosed heart failure patients.

ESC Heart Fail 2020 08 29;7(4):1502-1509. Epub 2020 May 29.

Edwards Lifesciences, Irvine, CA, 92614, USA.

Aims: Heart failure (HF) carries a poor prognosis, and the impact of concomitant mitral regurgitation (MR) is not well understood. This analysis aimed to estimate the incremental effect of MR in patients newly diagnosed with HF.

Methods And Results: Data from the IBM® MarketScan® Research Databases were analysed. Included patients had at least one inpatient or two outpatient HF claims. A 6 month post-period after HF index was used to capture MR diagnosis and severity. HF patients were separated into three cohorts: without MR (no MR), not clinically significant MR (nsMR), and significant MR (sMR). Time-to-event analyses were modelled to estimate the clinical burden of disease. The primary outcome was a composite endpoint of death or cardiovascular (CV)-related admission. Secondary outcomes were death and CV hospitalization alone. All models controlled for baseline demographics and co-morbidities. Patients with sMR were at significantly higher risk of either death or CV admission compared with patients with no MR [hazard ratio (HR) 1.26; 95% confidence interval (CI) 1.15-1.39]. When evaluating death alone, patients with sMR had significantly higher risk of death (HR 1.24; 95% CI 1.08-1.43) compared with patients with no MR. When evaluating CV admission alone, patients with MR were at higher risk of hospital admission vs. patients with no MR, and the magnitude was dependent upon the MR severity: sMR (HR 1.55; 95% CI 1.38-1.74) and nsMR (HR 1.23; 95% CI 1.08-1.40).

Conclusions: Evidence of MR in retrospective claims significantly increases the clinical burden of incident HF patients. Time to death and CV hospitalizations are increased when MR is clinically significant.
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http://dx.doi.org/10.1002/ehf2.12653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373926PMC
August 2020

The economic impact of clinically significant tricuspid regurgitation in a large, administrative claims database.

J Med Econ 2020 May 2;23(5):521-528. Epub 2020 Mar 2.

Edwards Lifesciences, Irvine, CA, USA.

This study aimed to quantify the healthcare burden of clinically significant tricuspid regurgitation (TR) in patients with and without heart failure (HF). Data were from the IBM MarketScan Research Databases from October 2011 to September 2016. Eligible patients met the following inclusion criteria: age ≥18 with a TR diagnosis, 12 months pre (baseline), and 6 months post (landmark) medical enrollment. The landmark period was used to categorize TR severity, defined as a record of pulmonary hypertension with ascites, lower extremity edema or hepatic insufficiency, or tricuspid valve surgery. Cohorts were defined based on TR etiology and severity: (1) no HF and no clinically significant TR; (2) HF with no clinically significant TR; (3) no HF with clinically significant TR; and (4) HF with clinically significant TR. Outcomes of interest were all-cause hospitalizations, hospital days, and expenditures. Multivariable models were fit for each of the annualized outcomes and adjusted for patient demographics, comorbidities, and other concomitant valve diseases. There were 92,994 patients eligible for analysis. Patients with no HF and no clinically significant TR had the annualized healthcare burden of 0.20 all-cause hospitalizations (approximately one inpatient hospitalization every 5 years), 1.07 hospital days, and $17,478 in expenditures. The presence of clinically significant TR, alone or with HF, significantly increased healthcare utilization and expenditures. For patients with no HF with clinically significant TR, the annualized economic burden increased to 0.41 all-cause hospitalizations, 3.13 hospital days, and $29,985 in expenditures. For patients with HF and clinically significant TR, the annualized economic burden was even greater with 0.59 all-cause hospitalizations, 4.31 hospital days, and $42,255 in expenditures. The presence of clinically significant TR is associated with an increase in healthcare utilization and expenditures, irrespective of the presence of HF.
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http://dx.doi.org/10.1080/13696998.2020.1718681DOI Listing
May 2020

Twelve-month healthcare utilization and expenditures in Medicare fee-for-service patients with clinically significant mitral regurgitation.

J Comp Eff Res 2019 10 7;8(13):1089-1098. Epub 2019 Oct 7.

San Diego Cardiac Center, SHARP Memorial Hospital, San Diego, CA, USA.

This study sought to quantify the healthcare burden of Medicare patients with clinically significant mitral regurgitation (sMR). Proxy definitions were used for sMR, including MR surgery, atrial fibrillation, pulmonary hypertension or >2 echocardiograms. In this study, 11,173 patients had significant degenerative MR (sDMR); 25,402 had significant functional MR (sFMR); and 12,232 had significant uncharacterized MR (sUMR). Patients with sFMR (18,880) were more likely to be hospitalized and present to the emergency department compared with patients with sDMR (9,795) or sUMR (10,587). Annual healthcare expenditures for sMR patients were: US$29,328 for sFMR; US$17,112 for sUMR; and US$12,870 for sDMR. Novel therapeutic interventions merit further evaluation to reduce the substantial healthcare burden of sMR in the Medicare population.
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http://dx.doi.org/10.2217/cer-2019-0026DOI Listing
October 2019

The Economic Impact of Mitral Regurgitation on Patients With Medically Managed Heart Failure.

Am J Cardiol 2019 10 30;124(8):1226-1231. Epub 2019 Jul 30.

Edwards Lifesciences, Irvine, California.

The objective of this study was to quantify the financial healthcare burden of mitral regurgitation (MR) on medically managed heart failure (HF) patients. Data from the Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases were analyzed. Included patients had a minimum of 1 inpatient or 2 outpatient claims for HF with a 6-month preperiod (baseline). A 6-month postperiod (landmark) after HF index was used to capture MR diagnosis and severity. Following the landmark period, patients had to have 12 months of continuous medical and prescription drug plan enrollment with at least 2 records of HF medication refills. A therapeutic intensity score was calculated based on HF medication usage. Medically managed HF patients were separated into 3 cohorts: without MR (no MR), insignificant MR (iMR), and significant MR (sMR). Healthcare utilization and all-cause expenditures were modeled to quantify the burden of MR. All models controlled for baseline demographics, co-morbid conditions, and HF therapeutic intensity. Medically managed incident HF patients with sMR had significantly more hospital days (1.91 vs 1.72 days; p = 0.0096) and annual expenditures ($23,988 vs $21,530; p < 0.0001) compared with no MR patients. No differences were identified when comparing iMR and no MR. When evaluating HF admissions, sMR patients had an estimated 50% greater HF admissions rate (0.036 vs 0.024; p < 0.0001) compared with no MR patients. Additionally, HF admits for iMR were 23% more than those with no MR (0.029 vs 0.024; p = 0.0064). In conclusion, evidence of MR in retrospective claims significantly increases the healthcare impact of medically managed HF patients. Both utilization and financial burden is more pronounced when MR is clinically significant.
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http://dx.doi.org/10.1016/j.amjcard.2019.07.033DOI Listing
October 2019

Incremental direct healthcare expenditures of valvular heart disease in the USA.

J Comp Eff Res 2019 08 21;8(11):879-887. Epub 2019 Aug 21.

Stony Brook University, Department of Family, Population & Preventive Medicine & Department of Economics, Stony Brook, NY 11790, USA.

To quantify the healthcare expenditures for valvular heart disease (VHD) in the USA. Direct annual incremental healthcare expenditures were estimated using multiple logistic and linear regression models. Results were stratified by age cohorts (18-64 years, ≥65 and ≥75 years) and disease status: symptomatic aortic valve disease (AVD), asymptomatic AVD, symptomatic mitral valve disease (MVD) and asymptomatic MVD. A total of 1463 VHD patients were identified. The overall aggregated incremental direct expenditures were $56.62 billion ($26.48 billion for patients ≥75 years). Individuals ≥75 years with symptomatic AVD had the largest incremental effect on annual, per-patient healthcare expenditure of $30,949. The annualized incremental costs of VHD were greatest for individuals ≥75 years with AVD. Identification of VHD at an earlier stage may reduce the economic burden.
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http://dx.doi.org/10.2217/cer-2019-0007DOI Listing
August 2019

The healthcare burden of disease progression in medicare patients with functional mitral regurgitation.

J Med Econ 2019 Sep 7;22(9):909-916. Epub 2019 Jun 7.

e GHER, Edwards Lifesciences , Irvine , CA , USA.

This retrospective database analysis estimated the incremental effect that disease progression from non-clinically significant functional mitral regurgitation (nsFMR) to clinically significant FMR (sFMR) has on clinical outcomes and costs. Medicare Fee for Service beneficiaries with nsFMR were examined, defined as those with a heart failure diagnosis prior to MR. Patients were classified as ischemic if there was a history of: CAD, AMI, PCI, or CABG. The primary outcome was time to sFMR, defined as pulmonary hypertension, atrial fibrillation, mitral valve surgery, serial echocardiography, or death, using a Cox hazard regression model. Annualized hospitalizations, inpatient hospital days, and healthcare expenditures were also modeled. Patients with IHD had higher risk (Hazard Ratio = 1.22 [1.14-1.30]) for disease progression compared to patients without. The progression cohort had significantly more annual inpatient hospitalizations (non-IHD = 1.32; IHD = 1.40) than the non-progression cohort (non-IHD = 0.36; IHD = 0.34), and significantly more annual inpatient hospital days (non-IHD = 13.07; IHD = 13.52) than the non-progression cohort (non-IHD = 2.29; with IHD = 2.08). The progression cohort had over 3.5-times higher costs vs the non-progression cohort, independent of IHD (non-IHD = $12,798 vs $46,784; IHD = $12,582 vs $49,348). Treating FMR patients earlier in their clinical trajectory may prevent disease progression and reduce high rates of healthcare utilization and expenditures.
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http://dx.doi.org/10.1080/13696998.2019.1621325DOI Listing
September 2019

Incidence and distribution of lower extremity reflux in patients with pelvic venous insufficiency.

Phlebology 2020 Feb 3;35(1):10-17. Epub 2019 Apr 3.

Center for Vein Restoration, Greenbelt, MD, USA.

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http://dx.doi.org/10.1177/0268355519840846DOI Listing
February 2020

Hospital costs associated with intraoperative hypotension among non-cardiac surgical patients in the US: a simulation model.

J Med Econ 2019 Jul 25;22(7):645-651. Epub 2019 Mar 25.

e Cleveland Clinic , Cleveland , OH , USA.

Recent studies indicate intraoperative hypotension, common in non-cardiac surgical patients, is associated with myocardial injury, acute kidney injury, and mortality. This study extends on these findings by quantifying the association between intraoperative hypotension and hospital expenditures in the US. Monte Carlo simulations (10,000 trial per simulation) based on current epidemiological and cost outcomes literature were developed for both acute kidney injury (AKI) and myocardial injury in non-cardiac surgery (MINS). For AKI, three models with different epidemiological assumptions (two models based on observational studies and one model based on a randomized control trial [RCT]) estimate the marginal probability of AKI conditional on intraoperative hypotension status. Similar models are also developed for MINS (except for the RCT case). Marginal probabilities of AKI and MINS sequelae (myocardial infarction, congestive heart failure, stroke, cardiac catheterization, and percutaneous coronary intervention) are multiplied by marginal cost estimates for each outcome to evaluate costs associated with intraoperative hypotension. The unadjusted (adjusted) model found hypotension control lowers the absolute probability of AKI by 2.2% (0.7%). Multiplying these probabilities by the marginal cost of AKI, the unadjusted (adjusted) AKI model estimated a cost reduction of $272 [95% CI = $223-$321] ($86 [95% CI = $47-$127]) per patient. The AKI model based on relative risks from the RCT had a mean cost reduction estimate of $281 (95% CI = -$346-$750). The unadjusted (adjusted) MINS model yielded a cost reduction of $186 [95% CI = $73-$393] ($33 [95% CI = $10-$77]) per patient. The model results suggest improved intraoperative hypotension control in a hospital with an annual volume of 10,000 non-cardiac surgical patients is associated with mean cost reductions ranging from $1.2-$4.6 million per year. Since the magnitude of the RCT mean estimate is similar to the unadjusted observational model, the institutional costs are likely at the upper end of this range.
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http://dx.doi.org/10.1080/13696998.2019.1591147DOI Listing
July 2019

A Monte Carlo simulation estimating US hospital cost reductions associated with hypotension control in septic ICU patients.

J Med Econ 2019 Apr 19;22(4):383-389. Epub 2019 Feb 19.

e Cleveland Clinic , Cleveland , OH , USA.

Objective: This economic analysis extends upon a recent epidemiological study to estimate the association between hypotension control and hospital costs for septic patients in US intensive care units (ICUs).

Methods: A Monte Carlo simulation decision analytic model was developed that accounted for the probability of complications-acute kidney injury and mortality-in septic ICU patients and the cost of each health outcome from the hospital perspective. Probabilities of complications were calculated based on observational data from 110 US hospitals for septic ICU patients (n = 8,782) with various levels of hypotension exposure as measured by mean arterial pressure (MAP, units: mmHg). Costs for acute kidney injury (AKI) and mortality were derived from published literature. Each simulation calculated mean hospital cost reduction and 95% confidence intervals based on 10,000 trials.

Results: In the base-case analysis hospital costs for a hypothetical "control" cohort (MAP of 65 mmHg) were $699 less per hospitalization (95% CI: $342-$1,116) relative to a "case" cohort (MAP of 60 mmHg). In the most extreme case considered (45 mmHg vs 65 mmHg), the associated cost reduction was $4,450 (95% CI: $2,020-$7,581). More than 99% of the simulated trials resulted in cost reductions. A conservative institution-level analysis for a hypothetical hospital (which assumes no benefit for increasing MAP above 65 mmHg) estimated a cost decline of $417 for a 5 mmHg increase in MAP per ICU septic patient. These results are applicable to the US only.

Conclusions: Hypotension control (via MAP increases) for patients with sepsis in the ICU is associated with lower hospitalization cost.
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http://dx.doi.org/10.1080/13696998.2019.1576695DOI Listing
April 2019

Use of echocardiograms in the Medicare population: a diagnostic tool in the fight against severe aortic stenosis.

J Comp Eff Res 2019 03 14;8(4):265-272. Epub 2019 Jan 14.

Gunnarsson Consulting, Jupiter, FL 33477, USA.

Aim: To estimate undiagnosed aortic stenosis (AS) in the Medicare population.

Methods: Patients enrolled (2011-2014) were eligible. After criteria were applied, time zero was the first record of an echocardiogram (ECHO) for the ECHO-AS cohort and randomly assigned for the no-ECHO cohort. The ECHO-AS cohort was propensity matched to patients in the no-ECHO cohort, and survival analysis was performed.

Results: Of the 854,493 (25%) patients who received an ECHO, 1 in 4 were diagnosed with AS. After propensity matching, the no-ECHO cohort who died, almost half (49%) had a record of a cardiovascular event prior to their death. The no-ECHO cohort had statistically significant (p = 0.003) higher risk of death than their ECHO-AS counterparts.

Conclusion: In the Medicare population, patients aged 65 years or older, with increased risk factors for and symptoms common in AS patients, should be considered for diagnostic ECHOs.
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http://dx.doi.org/10.2217/cer-2018-0071DOI Listing
March 2019

Rate of major adverse renal or cardiac events with iohexol compared to other low osmolar contrast media during interventional cardiovascular procedures.

Catheter Cardiovasc Interv 2019 02 2;93(2):E90-E97. Epub 2018 Oct 2.

Real World Evidence, CTI Clinical Trial & Consulting Services, Covington, Kentucky.

Objective: This study assessed the rate of major adverse renal or cardiac events (MARCE) when iohexol is used during interventional cardiovascular procedures compared to other low osmolar contrast media (LOCMs).

Background: Interventional cardiovascular procedures are often essential for diagnosis and treatment, the risk of MARCE should be considered.

Methods: Data were derived from the Premier Hospital Database January 1, 2010 through September 30, 2015. Patient encounters with an inpatient primary interventional cardiovascular procedure with a single LOCM (iohexol, ioversol, ioxilan, ioxaglate, or iopamidol) were included. The primary outcome was a composite endpoint of MARCE, which included: renal failure with dialysis, acute kidney injury (AKI) with or without dialysis, contrast induced AKI, acute myocardial infarction, angina, stent occlusion/thrombosis, stroke, transient ischemic attack, or death. Multivariable regression analysis was performed using the hospital fixed-effects specification to assess the relationship between MARCE and iohexol compared to other LOCMs, while controlling for patient demographics, comorbid conditions and reason for hospitalization. As a sensitivity analysis, direct comparisons of iohexol were made to other LOCMs.

Results: A total of 458,091 inpatient encounters met inclusion criteria of which 26% used iohexol and 74% used other LOCMs. Results of multivariable modeling revealed no differences in MARCE rates between iohexol and other LOCMs. When direct comparisons of iohexol vs. ioversol and iopamidol were modeled, no differences in MARCE nor the renal component of MARCE were found.

Conclusions: In this retrospective multicenter study, there were no differences in MARCE events with iohexol compared to other LOCMs during inpatient interventional cardiovascular procedures.
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http://dx.doi.org/10.1002/ccd.27807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585608PMC
February 2019

Risk of renal events following intravenous iodinated contrast material administration among inpatients admitted with cancer a retrospective hospital claims analysis.

Cancer Imaging 2018 Aug 24;18(1):30. Epub 2018 Aug 24.

University of California San Diego 0892 UCSD Medical Center, 9500 Gilman Drive, La Jolla, CA, 92037, USA.

Background: There is little published evidence examining the use of contrast material (CM) and the risk of acute renal adverse events (AEs) in individuals with increasingly common risk factors including cancer and chronic kidney disease (CKD). The objective of this study was to use real world hospital data to test the hypothesis that inpatients with cancer having CT procedures with iodinated CM would have higher rates of acute renal AEs in comparison to inpatients without cancer.

Methods: Inpatient hospital visits in the Premier Hospital Database from January 1, 2010 through September 30, 2015 were eligible for inclusion. The outcome of interest was a composite of acute renal AEs including: acute kidney injury, acute renal failure requiring dialysis, contrast induced-acute kidney injury and renal failure. Multivariable models, adjusted for differences in patient demographics and comorbid conditions, were used to estimate the incremental risk of acute renal AEs by CT (with or without iodinated CM), CKD stage and type of cancer.

Results: Among 29,850,475 inpatient visits across 611 hospitals, 7.4% had record of a CT scan, 5.9% had CKD, and 3.4% had the primary diagnosis of cancer. The baseline risk for an acute renal AE in patients without cancer or CKD and no CT or CM was 0.5%. The absolute risk increases from baseline by 0.2% with a CT and by 0.8% with iodinated CM. Patients with CKD having a CT scan with iodinated CM have an absolute risk of 4.1 to 9.7% depending on the stage of CKD. For patients with cancer, the absolute risk increases, varying from 0.3 to 2.3% depending on the type of cancer.

Conclusions: Inpatients with cancer are at higher likelihood of developing acute renal AEs following CT with iodinated CM compared to those without a cancer. Understanding the underlying risks of acute renal AEs among complex inpatient admissions is an important consideration in treatment choices for oncology patients.
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http://dx.doi.org/10.1186/s40644-018-0159-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109283PMC
August 2018

Racial Disparities in PAD-Related Amputation Rates among Native Americans and non-Hispanic Whites: An HCUP Analysis.

J Health Care Poor Underserved 2018 ;29(2):782-800

Introduction: This study analyzed the impact of sociodemographic characteristics, patient comorbidities, risk factors for critical limb ischemia and hospital characteristics on racial disparities in amputation rates for Native American patients with peripheral artery disease (PAD).

Methods: The study used the Healthcare Cost and Utilization Program inpatient discharge data from 2006-2013 for patients with a primary diagnosis of PAD. Multivariable models using the Blinder-Oaxaca decomposition method were estimated to isolate the impact of individual covariates to identify determinants of amputation rates for Native Americans compared with non-Hispanic Whites.

Results: Region of the country made a difference in this analysis with Native Americans residing in the West Census Region being twice as likely to undergo amputation as non-Hispanic Whites.

Conclusions: After adjusting for sociodemographic characteristics, patient comorbidities, and hospital characteristics, Native Americans with PAD who reside in the West Census Region are substantially more likely to undergo amputation than are non-Hispanic Whites.
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http://dx.doi.org/10.1353/hpu.2018.0058DOI Listing
March 2019

Clinical and economic benefits of advanced microplegia delivery system in cardiac surgery: evidence from 250 hospitals.

J Comp Eff Res 2018 07 23;7(7):673-683. Epub 2018 Apr 23.

CTI Clinical Trial & Consulting Services Inc., Consulting Services 100 E. Rivercenter Blvd, Covington, KY 41011, USA.

Aim: Determine the impact of a second generation microplegia delivery system (MPS2) compared with traditional cardioplegia. Materials &  methods: Multivariable difference-in-differences analysis using fixed effects was performed for each outcome: adverse event (AE) composite, total visit cost, medication cost, length of stay (LOS) and  intensive care unit (ICU) days.

Results: A 2.25% absolute risk reduction in AE composite was found with MPS2 compared with traditional cardioplegia, which equates to relative risk reduction of 5.25%. Significant reductions in LOS and ICU days (0.1 α level). Per case reduction of US$1231 total visit and US$192 medication costs were found in MPS2 hospitals.

Conclusion: For hospitals with MPS2, significant reductions were seen in AEs, LOS and ICU days, which lead to reductions in total visit and medication costs.
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http://dx.doi.org/10.2217/cer-2018-0011DOI Listing
July 2018

Health Care Burden in Patients With Adrenal Insufficiency.

J Endocr Soc 2017 May 12;1(5):512-523. Epub 2017 Apr 12.

Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114.

Objective: This study aimed to estimate the annual health care burden for patients with adrenal insufficiency [AI; primary (PAI), secondary to pituitary disorder (PIT), and congenital adrenal hyperplasia (CAH)] using real-world data.

Methods: Using a US-based payer database comprising >108 million members, strict inclusion criteria with diagnostic codes and pharmacy records were used to identify 10,383 patients with AI. This included 1014 patients with PAI, 8818 with PIT, and 551 with CAH, followed for >12 months. Patients were matched 1:1 to controls, based on age (±5 years), sex, insurance, and region. Multivariable expenditure models were estimated for each AI cohort vs controls as well as subsets by glucocorticoid therapy (hydrocortisone, dexamethasone, prednisone, or multiple therapies). A separate multivariable model was estimated to assess the association between adherence and expenditures.

Results: Total annual health care expenditure estimates were significantly higher ( < 0.0001) in all AI cohorts compared with matched controls (PAI $18,624 vs $4320, PIT $32,218 vs $6956, CAH $7677 vs $4203). Patients with AI have more frequent inpatient hospital stays with up to eight to 10 times more days in the hospital per year than their matched controls. In each AI cohort, patients on multiple steroid therapies had higher expenditures in comparison with patients using hydrocortisone therapy alone. In PAI and PIT cohorts taking hydrocortisone only, fewer expenditures were found in higher adherence subsets.

Conclusion: Patients with AI demonstrate a substantial annual health care burden. Expenditures vary by underlying cause and treatment and are reduced in patients with higher adherence to glucocorticoid replacement.
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http://dx.doi.org/10.1210/js.2016-1064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686625PMC
May 2017

The effect of major adverse renal cardiovascular event (MARCE) incidence, procedure volume, and unit cost on the hospital savings resulting from contrast media use in inpatient angioplasty.

J Med Econ 2018 Apr 15;21(4):356-364. Epub 2017 Dec 15.

a CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA.

Objective: To determine the net economic impact of switching from low-osmolar contrast media (LOCM) to iso-osmolar contrast media (IOCM; iodixanol) in patients undergoing inpatient coronary or peripheral angioplasty in the United States (US).

Methods: A budget impact model (BIM) was developed from a hospital perspective. Nationally representative procedural and contrast media prevalence rates, along with MARCE (major adverse renal cardiovascular event) incidence and episode-related cost data were derived from Premier Hospital Data (October 2014 to September 2015). A previously estimated relative risk reduction in MARCE associated with IOCM usage (9.3%) was applied. The higher cost of IOCM was included when calculating the net impact estimates at the aggregate, hospital type, and per hospital levels. One-way (±25%) and probabilistic sensitivity analyses identified the model's most important inputs.

Results: Based on weighted analysis, 513,882 US inpatient angioplasties and 35,610 MARCE cases were estimated annually. Switching to an "IOCM only" strategy from a "LOCM only" strategy increases contrast media cost, but prevents 2,900 MARCE events. The annual budget impact was an estimated saving of $30.71 million, aggregated across all US hospitals, $6,316 per hospital, or $60 per procedure. Net savings were maintained across all univariate sensitivity analyses. While MARCE/event-free cost differential was the most important factor driving total net savings for hospitals in the Northeast and West, procedural volume was important in the Midwest and rural locations.

Conclusions: Switching to an "IOCM only" strategy from a "LOCM only" approach yields substantial net global savings to hospitals, both at the national level and within hospital sub-groups. Hospital administrators should maintain awareness of the factors that are likely to be more influential for their hospital and recognize that purchasing on the basis of lower contrast media cost may result in higher overall costs for patients undergoing inpatient angioplasty.
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http://dx.doi.org/10.1080/13696998.2017.1415912DOI Listing
April 2018

Iso-osmolar contrast media and adverse renal and cardiac events after percutaneous cardiovascular intervention.

J Comp Eff Res 2018 04 9;7(4):331-341. Epub 2017 Nov 9.

CTI Clinical Trial & Consulting Services, 100 E RiverCenter Blvd, Covington, KY 41011, USA.

Aim: To assess the relationship between type of contrast media (CM), iso-osmolar contrast media (IOCM) or low-osmolar contrast media (LOCM), and major adverse renal and cardiovascular events (MARCE).

Materials & Methods: Coronary or peripheral angioplasty visits were stratified into CM cohorts: IOCM or LOCM. Multivariable regression analysis used hospital fixed effects to assess the relationship between MARCE events and type of CM.

Results: Among 333,533 visits (357 hospitals), the incidence of MARCE was 7.41%. After controlling for observable and unobservable time invariant within-hospital characteristics, administration of IOCM versus LOCM was associated with a 0.69% absolute and 9.32% relative risk reduction in MARCE rate.

Conclusion: Our study indicates that as compared with LOCM, IOCM may be associated with reduction of MARCE events in coronary or peripheral angioplasty patients.
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http://dx.doi.org/10.2217/cer-2017-0052DOI Listing
April 2018

Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management.

J Med Econ 2017 Nov 16;20(11):1148-1154. Epub 2017 Aug 16.

b CTI Clinical Trial and Consulting Services, Inc. , Covington , KY , USA.

Aims: Patients with critical limb ischemia (CLI) have an increased risk of major amputation. The initial treatment approach for CLI may significantly impact the subsequent risk of major amputation or death. The objective of this study was to describe the initial treatment approaches of patients with CLI and the limb outcomes associated with each approach.

Methods: Data from MarketScan Commercial and Medicare Supplemental Databases from January 2006-December 2014 was utilized. Cohorts of CLI patients were defined as follows: (1) peripheral vascular intervention (PVI); (2) peripheral vascular surgery (PVS); (3) minor amputation without concomitant PVI or PVS (MinAMP); and (4) Patients without PVI, PVS, or MinAMP (conservative therapy). The odds of major amputation or inpatient death were estimated using the Cox proportional hazards model. For those patients requiring a major amputation, the incremental expenditures per member per month (PMPM) were estimated using a gamma log-link model.

Results: Conservative therapy was associated with significantly higher odds of major amputation or inpatient death compared to patients who underwent minor amputation (1.59-times), PVI (2.08-times), or PVS (2.12-times). Patients treated with an initial strategy of minor amputation also had higher odds of major amputation or inpatient death compared to PVS (1.31-times) or PVI (1.33-times). The estimated incremental expenditures PMPM for patients with a major amputation was $5,165.

Conclusions: Revascularization reduces the risk of a major amputation or inpatient death for patients with CLI when compared to conservative therapy. Major amputation is also associated with significantly higher healthcare expenditures.
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http://dx.doi.org/10.1080/13696998.2017.1361961DOI Listing
November 2017

The economic value of rapid deployment aortic valve replacement via full sternotomy.

J Comp Eff Res 2017 Jun 4;6(4):293-302. Epub 2017 Apr 4.

New York University School of Medicine, New York, NY, USA.

Aim: To compare the economic value of EDWARDS INTUITY Elite™ (EIE) valve system for rapid-deployment aortic valve replacement (RDAVR) in a full sternotomy (FS) approach (EIE-FS-RDAVR) versus FS-AVR using conventional stented bioprosthesis.

Data & Methods: A simulation model to compare each treatment's 30-day inpatient utilization and complication rates utilized: clinical end points obtained from the TRANSFORM trial patient subset (EIE-FS-RDAVR) and a best evidence review of the published literature (FS-AVR); and costs from the Premier database and published literature.

Results: EIE-FS-RDAVR costs $800 less than FS-AVR per surgery episode attributable to lowered complication rates and utilization. Combined with the lower mortality, EIE-FS-RDAVR was a superior (dominant) technology versus FS-AVR.

Conclusion: This preliminary investigation of EIE-FS-RDAVR versus conventional FS-AVR found the EIE valve offered superior economic value over a 30-day period. Real-world analyses with additional long-term follow-up are needed to evaluate if this result can be replicated over a longer timeframe.
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http://dx.doi.org/10.2217/cer-2016-0064DOI Listing
June 2017

Explaining Racial Disparities in Amputation Rates for the Treatment of Peripheral Artery Disease (PAD) Using Decomposition Methods.

J Racial Ethn Health Disparities 2017 Feb 15. Epub 2017 Feb 15.

CTI Clinical Trials and Consulting Services, Inc., 1775 Lexington Avenue, Suite 200, Cincinnati, OH, 45212, USA.

Introduction: While studies have documented racial and ethnic disparities in amputation rates for patients with peripheral artery disease (PAD), the importance of specific factors has not been quantified. This research seeks to provide such evidence and to quantify how much of the difference reflects observable versus unexplained factors.

Methods: This study used the nationally representative HCUP inpatient database from 2006 to 2013 for patients with a primary diagnosis of PAD who were either Caucasian, African-American, or Hispanic. Multivariable logistic regression models were estimated to identify the determinants of amputation rates.

Results: Multivariable results revealed that African-Americans and Hispanics are approximately twice as likely to be amputated as are Caucasians. Observed factors in the models collectively account for 51 to 55 % of the disparities for African-Americans and 64 to 69 % for Hispanics. The results suggest that African-Americans and Hispanics have less access to care, because they are being admitted when sicker and more likely on an emergent basis.

Conclusions: Racial and ethnic disparities in amputation rates are substantial, with disease severity and hospital admission source being key factors.
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http://dx.doi.org/10.1007/s40615-016-0261-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626799PMC
February 2017
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