Alex Sandhu, MD, MS is a cardiologist with a special interest in the care of patients with advanced heart failure. He graduated from the seven-year combined BA-MD program at Northwestern Feinberg School of Medicine. He completed an internal medicine residency at Stanford University, spending 16 weeks at Makerere Hospital in Uganda as part of the Global Health track. He subsequently obtained completed a Masters in Health Services Research at Stanford while acting as a fellow in health services research at the VA and Stanford's Center for Health Policy/Primary Care and Outcomes Research. He then completed fellowships in cardiology and advanced heart failure and transplant at Stanford before joining the faculty.
He is an active heart failure researcher who focuses on health economics, the implementation of high-value care strategies, and comparative effectiveness. He is currently funded by a K23 career development award. In his free time, he enjoys playing soccer and teaching his son Kyle to play soccer (but not to head the ball).
- Heart Failure
- Cardiovascular Disease
Residency: Stanford University Internal Medicine Residency (2014) CA
Fellowship, Stanford University, Advanced Heart Failure & Transplant (2020)
Fellowship: Stanford University Advanced Heart Failure and Transplant Fellowship (2020) CA
Medical Education: Northwestern University Feinberg School of Medicine (2011) IL
Fellowship: Stanford University Cardiovascular Medicine Fellowship (2019) CA
Board Certification: National Board of Echocardiography, Echocardiography (2019)
Board Certification: American Board of Internal Medicine, Cardiovascular Disease (2019)
Board Certification: American Board of Internal Medicine, Internal Medicine (2014)
Internship: Stanford University Internal Medicine Residency (2012) CA
Fellowship, Stanford University, Cardiovascular Medicine (2019)
Residency, Stanford University, Internal Medicine (2014)
Master of Science, Stanford University, Health Services Research (2016)
Incidental Coronary Calcification Quality Improvement Project
This is a multi-center, randomized quality improvement project. At least 200 statin-naïve patients without a history of atherosclerotic cardiovascular disease with incidental coronary artery calcium (CAC) on a prior non-gated chest CT will be enrolled across the Stanford Healthcare System and the Palo Alto Veteran's Affairs Healthcare System. Patients will be randomized in a 1:1 fashion to notification or usual care arms. The primary aim of this project is to estimate the increase in 6-month statin prescription among statin-naïve patients without a history of atherosclerotic cardiovascular disease with incidental CAC on a non-gated chest CT who are randomized to receive notification of their findings vs. usual care.
Patient-Reported Outcome Measurement in Heart Failure Clinic
This is a randomized study evaluating the effect of routinely collecting a standardized questionnaire of heart failure health status during heart failure clinic visits. Participants will be randomized to early or delayed implementation of a validated health-related quality of life survey (the Kansas City Cardiomyopathy Questionnaire). Participants randomized to early implementation will be given this 12-question survey at each heart failure clinic visit at the beginning of the study; their heart failure clinician will have access to survey results but will continue to manage participants based on standard treatment practice. Patients randomized to delayed implementation will start receiving the survey at each clinic visit one year later. By comparing the health status and treatment rates between early and delayed implementation, this study will determine the impact of standardized health status assessment on patient outcomes and clinician decision-making.
Development of a Knee Arthroplasty Episode-Based Cost Measure for Evaluating Cost in the Merit-Based Incentive Payment System.
The Journal of bone and joint surgery. American volume
BACKGROUND: Under the Merit-based Incentive Payment System (MIPS), the U.S. Centers for Medicare and Medicaid Services (CMS) evaluate clinicians who manage Medicare patients on the basis of cost and quality outcomes. CMS contractor Acumen, LLC, convened an expert panel to develop a knee arthroplasty episode-based cost measure (EBCM) for use in the MIPS.METHODS: A Clinical Subcommittee of 28 clinician experts affiliated with 27 specialty societies provided guidance in developing the knee arthroplasty EBCM. The Clinical Subcommittee specified all aspects of the EBCM including triggering of the episode, services within the episode, risk adjustment, subgrouping, and exclusions. Services were counted only if the Clinical Subcommittee deemed them under the influence of the clinician assigned to the EBCM (selective service assignment; SSA). We assessed the reliability of the EBCM and compared it with an alternative population-based cost measure constructed without SSA.RESULTS: We identified 249,301 knee arthroplasty episodes from June 1, 2016, to May 31, 2017, with 10,681 clinicians having at least 10 attributed episodes. The mean episode cost was $19,321 with a standard deviation of $1,816. SSA increased the reliability score from 0.71 to 0.81 relative to an alternative measure that counted all patient costs. SSA also led to reclassification of 41.8% of clinicians into different quintiles of performance.CONCLUSIONS: We found that the use of SSA in the creation of the EBCM substantially reduces random noise (i.e., unrelated medical procedures or costs) and offers a tool for assessing clinicians' costs of management that is focused on care directly related to knee arthroplasty.
View details for DOI 10.2106/JBJS.20.02221
View details for PubMedID 34609983
Disparity in the Setting of Incident Heart Failure Diagnosis.
Circulation. Heart failure
BACKGROUND: Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.METHODS: We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.RESULTS: Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.CONCLUSIONS: A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.
View details for DOI 10.1161/CIRCHEARTFAILURE.121.008538
View details for PubMedID 34311559
DISPARITIES IN VIRTUAL CARDIOLOGY VISITS AMONG VETERANS HEALTH ADMINISTRATION PATIENTS DURING THE COVID-19 PANDEMIC
SPRINGER. 2021: S168
View details for Web of Science ID 000679443300404
- High-Deductible Health Plans and Emergency Care for Chest Pain: To Go or Not to Go? Circulation 2021
Renin-Angiotensin-Aldosterone System Inhibitors and SARS-CoV-2 Infection: An Analysis from the Veteran's Affairs Healthcare System: Sandhu. ACEI, ARB, and Association with COVID.
American heart journal
BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear.OBJECTIVES: The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system.METHODS: We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values.RESULTS: Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes.CONCLUSIONS: Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.
View details for DOI 10.1016/j.ahj.2021.06.004
View details for PubMedID 34126079
Availability of Cost-effectiveness Studies for Drugs With High Medicare Part D Expenditures.
JAMA network open
2021; 4 (6): e2113969
Importance: Prescription drug spending in the US requires policy intervention to control costs and improve the value obtained from pharmaceutical spending. One such intervention is to apply cost-effectiveness evidence to decisions regarding drug coverage and pricing, but this intervention depends on the existence of such evidence to guide decisions.Objective: To characterize the availability and quality of cost-effectiveness studies for prescription drugs with the greatest Medicare Part D spending.Design, Setting, and Participants: In this national cross-sectional analysis, publicly available 2016 Medicare drug spending records were merged with 2016 US Food & Drug Administration Orange Book data and the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. All studies published through 2015 that evaluated the cost-effectiveness of the 250 drugs for which Medicare Part D spending was the greatest in US-based adult patient populations were included. Data were analyzed from September 2018 to June 2020.Main Outcomes and Measures: The presence and quality of published cost-effectiveness analyses for the 250 drugs for which Medicare Part D spending was greatest in 2016 were assessed based on the inclusion of key cost-effectiveness analysis elements and global ratings by independent reviewers for the Tufts CEA Registry.Results: Medicare Part D spending on the 250 drugs in the sample totaled $122.8 billion in 2016 (84.1% of total spending). Of these 250 drugs, 91 (36.4%) had a generic equivalent and 159 (63.6%) retained some patent exclusivity. There were 280 unique cost-effectiveness analyses for these drugs, representing data on 135 (54.0%) of the 250 drugs included and 67.0% of Part D spending on the top 250 drugs. The 115 drugs (46.0%) without cost-effectiveness studies accounted for 33.0% of Part D spending on the top 250 drugs. Of the 280 available studies, 128 (45.7%) were industry sponsored. A large proportion of the studies (250 [89.3%]) did not meet the minimum quality requirements.Conclusions and Relevance: In this cross-sectional study, a substantial proportion of 2016 Medicare Part D spending was for drugs with absent or low-quality cost-effectiveness analyses. The lack of quality analyses may present a challenge in efforts to develop policies addressing drug spending in terms of value.
View details for DOI 10.1001/jamanetworkopen.2021.13969
View details for PubMedID 34143189
Automated coronary calcium scoring using deep learning with multicenter external validation.
NPJ digital medicine
2021; 4 (1): 88
Coronary artery disease (CAD), the most common manifestation of cardiovascular disease, remains the most common cause of mortality in the United States. Risk assessment is key for primary prevention of coronary events and coronary artery calcium (CAC) scoring using computed tomography (CT) is one such non-invasive tool. Despite the proven clinical value of CAC, the current clinical practice implementation for CAC has limitations such as the lack of insurance coverage for the test, need for capital-intensive CT machines, specialized imaging protocols, and accredited 3D imaging labs for analysis (including personnel and software). Perhaps the greatest gap is the millions of patients who undergo routine chest CT exams and demonstrate coronary artery calcification, but their presence is not often reported or quantitation is not feasible. We present two deep learning models that automate CAC scoring demonstrating advantages in automated scoring for both dedicated gated coronary CT exams and routine non-gated chest CTs performed for other reasons to allow opportunistic screening. First, we trained a gated coronary CT model for CAC scoring that showed near perfect agreement (mean difference in scores=-2.86; Cohen's Kappa=0.89, P<0.0001) with current conventional manual scoring on a retrospective dataset of 79 patients and was found to perform the task faster (average time for automated CAC scoring using a graphics processing unit (GPU) was 3.5±2.1s vs. 261s for manual scoring) in a prospective trial of 55 patients with little difference in scores compared to three technologists (mean difference in scores=3.24, 5.12, and 5.48, respectively). Then using CAC scores from paired gated coronary CT as a reference standard, we trained a deep learning model on our internal data and a cohort from the Multi-Ethnic Study of Atherosclerosis (MESA) study (total training n=341, Stanford test n=42, MESA test n=46) to perform CAC scoring on routine non-gated chest CT exams with validation on external datasets (total n=303) obtained from four geographically disparate health systems. On identifying patients with any CAC (i.e., CAC≥1), sensitivity and PPV was high across all datasets (ranges: 80-100% and 87-100%, respectively). For CAC≥100 on routine non-gated chest CTs, which is the latest recommended threshold to initiate statin therapy, our model showed sensitivities of 71-94% and positive predictive values in the range of 88-100% across all the sites. Adoption of this model could allow more patients to be screened with CAC scoring, potentially allowing opportunistic early preventive interventions.
View details for DOI 10.1038/s41746-021-00460-1
View details for PubMedID 34075194
Cost-effectiveness of Dapagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction.
Importance: In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, dapagliflozin was shown to reduce cardiovascular mortality and hospitalizations due to heart failure while improving patient-reported health status. However, the cost-effectiveness of adding dapagliflozin therapy to standard of care (SOC) is unknown.Objective: To estimate the cost-effectiveness of dapagliflozin therapy among patients with chronic heart failure with reduced ejection fraction (HFrEF).Design, Setting, and Participants: This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, and utilities from the DAPA-HF trial and other published literature. Costs were derived from published sources. Patients with HFrEF included subgroups based on diabetes status and health status impairment due to heart failure. We compiled parameters from the literature including DAPA-HF, on which our model is based, and many other sources from December 2019 to February 27, 2021. We performed our analysis in February 2021.Exposures: Dapagliflozin or SOC.Main Outcomes and Measures: Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), costs, and the cost per QALY gained (incremental cost-effectiveness ratio).Results: In the model, dapagliflozin therapy yielded a mean of 0.78 additional life-years and 0.46 additional QALYs compared with SOC at an incremental cost of $38 212, resulting in a cost per QALY gained of $83 650. The cost per QALY was similar for patients with or without diabetes and for patients with mild or moderate impairment of health status due to heart failure. The cost-effectiveness was most sensitive to estimates of the effect on mortality and duration of therapy effectiveness. If the cost of dapagliflozin decreased from $474 to $270 (43% decline), the cost per QALY gained would drop below $50 000.Conclusions and Relevance: These findings suggest that dapagliflozin provides intermediate value compared with SOC, based on American College of Cardiology/American Heart Association benchmarks. Additional data regarding the magnitude of mortality reduction would improve the precision of cost-effectiveness estimates.
View details for DOI 10.1001/jamacardio.2021.1437
View details for PubMedID 34037681
COST-EFFECTIVENESS AND SYSTEM-WIDE IMPACT OF USING HEPATITIS C-VIREMIC DONORS FOR HEART TRANSPLANT
ELSEVIER SCIENCE INC. 2021: 3417
View details for Web of Science ID 000647487503438
STATIN ADHERENCE AFTER HEART TRANSPLANTATION: AN OUTCOMES ANALYSIS
ELSEVIER SCIENCE INC. 2021: 569
View details for Web of Science ID 000647487500568
PREDICTORS OF SETTING OF HEART FAILURE DIAGNOSIS
ELSEVIER SCIENCE INC. 2021: 676
View details for Web of Science ID 000647487500675
- Correspondence to European Heart Journal - Quality of Care and Clinical Outcomes in response to letter by Dalal H. et al. European heart journal. Quality of care & clinical outcomes 2021
- Development of a Cost Measure for Screening/Surveillance Colonoscopy for the Merit-Based Incentive Payment System. Gastroenterology 2021
Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure.
Circulation. Cardiovascular quality and outcomes
BACKGROUND: The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI.METHODS: Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures.RESULTS: We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs.CONCLUSIONS: The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.
View details for DOI 10.1161/CIRCOUTCOMES.119.006461
View details for PubMedID 33653117
- The Affordability of Guideline-Directed Medical Therapy: Cost Sharing is a Critical Barrier to Therapy Adoption. Circulation 2021; 143 (11): 1073–75
Cost-effectiveness and system-wide impact of using Hepatitis C-viremic donors for heart transplant.
The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation
The advent of direct-acting antiviral therapy for Hepatitis C (HCV) has made using HCV-viremic donors a viable strategy to address the donor shortage in heart transplantation. We employed a large-scale simulation to evaluate the impact and cost-effectiveness of using HCV-viremic donors for heart transplant.We simulated detailed histories from time of listing until death for the real-world cohort of all adults listed for heart transplant in the United States from July 2014 to June 2019 (n = 19,346). This population was imputed using historical data and captures "real-world" heterogeneity in geographic and clinical characteristics. We estimated the impact of an intervention in which all candidates accept HCV+ potential donors (n = 472) on transplant volume, waitlist outcomes, and lifetime costs and quality-adjusted life years (QALYs).The intervention produced 232 more transplants, 132 fewer delistings due to deterioration, and 50 fewer waitlist deaths within this 5-year cohort and reduced wait times by 3% to 11% (varying by priority status). The intervention was cost-effective, adding an average of 0.08 QALYs per patient at a cost of $124 million ($81,892 per QALY). DAA therapy and HCV care combined account for 11% this cost, with the remainder due to higher costs of transplant procedures and routine post-transplant care. The impact on transplant volume varied by blood type and region and was correlated with donor-to-candidate ratio (ρ = 0.71).Transplanting HCV+ donor hearts is likely to be cost-effective and improve waitlist outcomes, particularly in regions and subgroups experiencing high donor scarcity.
View details for DOI 10.1016/j.healun.2021.09.002
View details for PubMedID 34635381
Risk of Covid-19-Related Hospitalization and More Severe Outcomes in Medicare Beneficiaries Treated with Renin-Angiotensin-Aldosterone System Inhibitors for Hypertension.
Journal of general internal medicine
There are theoretical concerns that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) could increase the risk of severe Covid-19.To determine if ACEIs and ARBs are associated with an increased risk of Covid-19 hospitalization overall, or hospitalization involving intensive care unit (ICU) admission, invasive mechanical ventilation, or death.Observational case-control study.Medicare beneficiaries aged ≥ 66 years with hypertension, treated with ACEIs, ARBs, calcium channel blockers (CCBs), or thiazide diuretics.Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the outcomes of Covid-19 hospitalization, or hospitalization involving ICU admission, invasive mechanical ventilation, or death.A total of 35,300 cases of hospitalized Covid-19 were matched to 228,228 controls on calendar date and neighborhood of residence. The median age of cases was 79 years, 57.4% were female, and the median duration of hospitalization was 8 days (interquartile range 5-12). ACEIs and ARBs were associated with a slight reduction in Covid-19 hospitalization risk compared with treatment with other first-line antihypertensives (OR for ACEIs 0.95, 95% CI 0.92-0.98; OR for ARBs 0.94, 95% CI 0.90-0.97). Similar results were obtained for hospitalizations involving ICU admission, invasive mechanical ventilation, or death. There were no meaningful differences in risk for ACEIs compared with ARBs. In an analysis restricted to monotherapy with a first-line agent, CCBs were associated with a small increased risk of Covid-19 hospitalization compared with ACEIs (OR 1.09, 95% CI 1.04-1.14), ARBs (OR 1.10, 95% CI 1.05-1.15), or thiazide diuretics (OR 1.11, 95% CI 1.03-1.19).ACEIs and ARBs were not associated with an increased risk of Covid-19 hospitalization or with hospitalization involving ICU admission, invasive mechanical ventilation, or death. The finding of a small increased risk of Covid-19 hospitalization with CCBs was unexpected and could be due to residual confounding.
View details for DOI 10.1007/s11606-021-07155-z
View details for PubMedID 34599472
Predicting the EQ-5D from the Kansas City Cardiomyopathy Questionnaire (KCCQ) in Patients with Heart Failure.
European heart journal. Quality of care & clinical outcomes
Evaluation of health status benefits, cost-effectiveness, and value of new heart failure therapies is critical for supporting their use. The Kansas City Cardiomyopathy Questionnaire (KCCQ) measures patients' heart failure-specific health status, but does not provide utilities needed for cost-effectiveness analyses. We mapped the KCCQ scores to EQ-5D scores so that estimates of societal-based utilities can be generated to support economic analyses.Using data from two U.S. cohort studies, we developed models for predicting EQ-5D utilities (3L and 5L versions) from the KCCQ (23- and 12-item versions). In addition to predicting scores directly, we considered predicting the five EQ-5D health state items and deriving utilities from the predicted responses, allowing different countries' health state valuations to be used. Model validation was performed internally via bootstrap and externally using data from two clinical trials. Model performance was assessed using R2, mean prediction error, mean absolute prediction error, and calibration of observed versus predicted values.The EQ-5D-3L models were developed from 1,000 health status assessments in 547 patients with heart failure and reduced ejection fraction (HFrEF), while the EQ-5D-5L model was developed from 3,925 patients with HFrEF. For both versions, models predicting individual EQ-5D items performed as well as those predicting utilities directly. The selected models for the 3L had internally validated R-squares of 48.4-50.5% and 33.7-45.6% on external validation. The 5L version had validated R-square of 57.7%.Mappings from the KCCQ to the EQ-5D can yield estimates of societal-based utilities to support cost-effectiveness analyses when EQ-5D data are not available.
View details for DOI 10.1093/ehjqcco/qcab014
View details for PubMedID 33724402
Association of Diagnostic Coding-Based Frailty and Outcomes in Patients With Heart Failure: A Report From the Veterans Affairs Health System.
Journal of the American Heart Association
Background The aim of this study was to determine whether frailty is associated with increased admission and mortality risk in the setting of heart failure. Methods and Results This retrospective cohort analysis included patients treated within the Veterans Affairs Health System who had International Classification of Diseases, Ninth Revision (ICD-9) codes for heart failure on 2 or more dates over a 2-year period. The clinical variables identifiable in claims data, such as demographic variables and markers of physical and cognitive dysfunction, were used to identify patients meeting the frailty phenotype. Of 388785 extracted patients with coding of heart failure between 2015 and 2018, 163085 patients (41.9%) with ejection fraction (EF) measurement were included in the present analysis (38.3% with reduced EF and 61.7% with preserved EF). There were 16660 patients (10.2%) who were identified as frail (9.1% in heart failure with reduced EF and 10.9% in heart failure with preserved EF). Frail patients were older, more often depressed, and were likely to have been admitted in the previous year. One-year all-cause mortality rate was 9.7% and 28.1%, and admission rate was 58.1% and 79.5% for nonfrail and frail patients, respectively. Frailty was associated with mortality and admission risk compared with the nonfrail group (adjusted odds ratio [OR], 1.71; 95% CI, 1.65-1.77 for mortality; adjusted OR, 1.29; 95% CI, 1.24-1.34 for admission) independent of EF. Conclusions Frailty based on diagnostic coding was associated with particularly higher risk of mortality despite adjustment for known clinical variables. Our findings underscore the importance of nontraditional parameters in the prognostic assessment.
View details for DOI 10.1161/JAHA.120.016502
View details for PubMedID 33283587
Interpreting the Kansas City Cardiomyopathy Questionnaire in ClinicalTrials and Clinical Care: JACC State-of-the-Art Review.
Journal of the American College of Cardiology
2020; 76 (20): 2379–90
To improve the patient-centeredness of care, patient-reported outcomes have been increasingly used to quantify patients' symptoms, function, and quality of life. In heart failure, the Kansas City Cardiomyopathy Questionnaire (KCCQ) has been qualified by the U.S. Food and Drug Administration as a Clinical Outcome Assessment and recommended as a performance measure for quantifying the quality of care. By systematically asking the same questions reproducibly over time, the KCCQ can validly and sensitively capture the impact of heart failure on patients' lives and is strongly associated with clinical events over time. This review describes how to interpret the KCCQ, how it should be analyzed in clinical trials to maximize the interpretability of results, and how it can be used in clinical practice and population health. By providing a deeper understanding of the KCCQ, it is hoped that its use can further improve the patient-centeredness of heart failure care.
View details for DOI 10.1016/j.jacc.2020.09.542
View details for PubMedID 33183512
- Evaluation of variation in insurance payor mix among heart transplant centers. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation 2020
- Association Between Neighborhood Social Risk and Hospital Readmission Reduction Penalties Under the New Stratified Approach: Is Dual Eligibility Adjustment Enough? Circulation. Cardiovascular quality and outcomes 2020: CIRCOUTCOMES119006353
Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017.
Importance: The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.Objectives: To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).Design, Setting, and Participants: This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.Exposures: Admission for a primary diagnosis of heart failure at discharge.Main Outcomes and Measures: Thirty-day all-cause readmission and mortality rates.Results: A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.Conclusions and Relevance: In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.
View details for DOI 10.1001/jamacardio.2020.2028
View details for PubMedID 32584921
Ischemic and Bleeding Events Among Patients With Acute Coronary Syndrome Associated With Low-Dose Prasugrel vs Standard-Dose Clopidogrel Treatment.
JAMA network open
2020; 3 (4): e202004
Importance: Prasugrel was approved at a lower dose in 2014 in Japan than in the West because East Asian patients are considered more susceptible to bleeding than Western patients. However, real-world outcomes with low-dose prasugrel treatment remain unclear.Objective: To investigate the association of low-dose prasugrel vs standard-dose clopidogrel administration with short-term outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).Design, Setting, and Participants: This study used data from the Japan Cardiovascular Database-Keio Interhospital Cardiovascular Studies registry, a large, ongoing, multicenter, retrospective cohort of consecutive patients who underwent PCI. The present cohort study evaluated 2770 patients with acute coronary syndrome who underwent PCI and received either low-dose prasugrel (loading dose, 20 mg; maintenance dose, 3.75 mg) or clopidogrel (loading dose, 300 mg; maintenance dose, 75 mg) in combination with aspirin between 2014 and 2018. Propensity score-matching analysis was conducted to balance the baseline characteristics of patients receiving low-dose prasugrel and those receiving clopidogrel. Data analysis was conducted in June 2019.Exposures: Prescription of either low-dose prasugrel or standard-dose clopidogrel prior to PCI.Main Outcomes and Measures: Primary ischemic events (in-hospital death, recurrent myocardial infarction, and ischemic stroke) and primary bleeding events, defined as bleeding complications within 72 hours after PCI consistent with the National Cardiovascular Data Registry CathPCI Registry definition.Results: Of 2559 patients included in the study, the mean (SD) age was 67.8 (12.7) years, and 78.2% were male. In total, 1297 patients (50.7%) received low-dose prasugrel, and 1262 patients (49.3%) received clopidogrel. After propensity score matching, primary ischemic events among patients receiving low-dose prasugrel and those receiving clopidogrel were comparable (odds ratio [OR], 1.42; 95% CI, 0.90-2.23), but primary bleeding events were significantly higher among patients receiving prasugrel (OR, 2.91; 95% CI, 1.63-5.18). This increase in bleeding events was associated with the presence of a profile of high-bleeding risk (≥75 years of age, body weight <60 kg, or history of stroke or transient ischemic attack) (OR, 4.08; 95% CI, 1.86-8.97), being female (OR, 3.84; 95% CI, 1.05-14.0), or the presence of ST-segment elevation myocardial infarction (OR, 2.07; 95% CI, 1.05-4.09) or chronic kidney disease (OR, 4.78; 95% CI, 1.95-11.7).Conclusions and Relevance: Since its approval, low-dose prasugrel has been used by nearly 80% of patients who undergo PCI. Despite the modified dose, bleeding events were higher among patients receiving low-dose prasugrel than among patients receiving clopidogrel, with no difference in ischemic events between the 2 groups. These results suggest the importance of a risk assessment of bleeding prior to selecting a P2Y12 inhibitor, even for the use of a lower approved dose, when treating patients of East Asian descent.
View details for DOI 10.1001/jamanetworkopen.2020.2004
View details for PubMedID 32239221
INCIDENTAL CORONARY ARTERY CALCIFICATION IN NON-GATED CT SCANS
ELSEVIER SCIENCE INC. 2020: 1806
View details for Web of Science ID 000522979101793
Adjustment For Social Risk Factors Does Not Meaningfully Affect Performance On Medicare's MIPS Clinician Cost Measures.
Health affairs (Project Hope)
2020; 39 (9): 1495–1503
Medicare's Merit-based Incentive Payment System (MIPS) includes episode-based cost measures that evaluate Medicare expenditures for specific conditions and procedures. These measures compare clinicians' cost performance and, along with other MIPS category scores, determine Medicare Part B clinician payment adjustments. The measures do not include risk adjustment for social risk factors. We found that adjusting for individual and community social risk did not have a meaningful impact on clinicians' cost measure performance. Across eight cost measures, 1.4 percent of clinician groups, on average, had an absolute change in their cost measure performance percentile of 10 percent or more (range, 0.4-3.4 percent). Prior analyses have generally found higher health care costs for patients with increased social risk. MIPS episode-based cost measures are distinct from previous cost measures because they only include costs related to the specific condition being evaluated. This unique approach may explain why costs were similar for patients with high and low social risk before any risk adjustment. MIPS episode-based cost measures do not appear to penalize clinicians who primarily care for patients with increased social risk.
View details for DOI 10.1377/hlthaff.2020.00440
View details for PubMedID 32897780
Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017.
2020; 5 (9): 1042–47
The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.Admission for a primary diagnosis of heart failure at discharge.Thirty-day all-cause readmission and mortality rates.A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.
View details for DOI 10.1001/jamacardio.2020.2028
View details for PubMedID 32936253
- Association Between Current and Future Annual Hospital Percutaneous Coronary Intervention Mortality Rates JAMA CARDIOLOGY 2019; 4 (11): 1077–83
Engaging Cardiology Providers in Quality Measurement.
Journal of the American Heart Association
2019; 8 (9): e012519
See Article Segal etal.
View details for PubMedID 31020894
EVALUATION OF TRENDS IN READMISSION AND MORTALITY RATES AFTER HEART FAILURE HOSPITALIZATION IN THE VETERANS AFFAIRS HEALTH CARE SYSTEM BETWEEN 2007 AND 2017
ELSEVIER SCIENCE INC. 2019: 737
View details for Web of Science ID 000460565900737
- Comparison of the change in heart failure readmission and mortality rates between hospitals subject to hospital readmission reduction program penalties and critical access hospitals AMERICAN HEART JOURNAL 2019; 209: 63–67
Coronary CT Angiography and Subsequent Risk of Myocardial Infarction
NEW ENGLAND JOURNAL OF MEDICINE
2019; 380 (3): 299
View details for Web of Science ID 000455806200019
- Optimizing the Use of Heart Transplant in the United States. JAMA 2019; 322 (18): 1772–74
Validity of Performance and Outcome Measures for Heart Failure.
Circulation. Heart failure
2018; 11 (9): e005035
Background Numerous quality metrics for heart failure (HF) care now exist based on process and outcome. What remains unclear, however, is if the correct quality metrics are being emphasized. To determine the validity of certain measures, we compared correlations between measures and reliability over time. Measures assessed include guideline-recommended beta-blocker (BB), any BB, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, mineralocorticoid receptor antagonist, and hydralazine/isosorbide dinitrate (in blacks) use among candidates, 30-day mortality, 1-year mortality, and 30-day readmission. Methods and Results This was an observational cohort analysis using chart review and electronic resources for 55735 patients from 102 Veterans Affairs medical centers hospitalized with HF from 2008 to 2013. Assessments of convergent validity and reliability were performed. Significant correlations were found between in-hospital rates of ACE inhibitor use and the following measures: BB use, 30-day mortality, and 1-year mortality. Guideline-recommended BB use was also significantly correlated with mineralocorticoid receptor antagonists, 30-day mortality, and 1-year mortality. There was no correlation between 30-day readmission rates and any therapy or mortality. Measure reliability over time was seen for guideline-recommended BBs ( r=0.57), mineralocorticoid receptor antagonists ( r=0.50), 30-day mortality ( r=0.29), and 1-year mortality ( r=0.31). ACE inhibitor and readmission rates were not reliable measures over time. Conclusions BB use, ACE inhibitor use, mortality, and mineralocorticoid receptor antagonist use are valid measures of HF quality. Thirty-day readmission rate did not seem to be a valid measure of HF quality of care. If the goal is to identify high-quality HF care, the emphasis on decreasing readmission rates might be better directed towards improving usage of the recommended therapies.
View details for PubMedID 30354367
- Association Between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography JAMA INTERNAL MEDICINE 2018; 178 (9): 1270-+
Association Between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography.
JAMA internal medicine
View details for PubMedID 30039163
- Heart failure management with ambulatory pulmonary artery pressure monitoring TRENDS IN CARDIOVASCULAR MEDICINE 2018; 28 (3): 212–19
- Cost-Effectiveness of Sacubitril-Valsartan in Patients Who Have Heart Failure With Reduced Ejection Fraction. Annals of internal medicine 2017; 166 (8): 607-608
Determinants of Raised Blood Pressure in Urban Uganda: A Community-Based Case-Control Study.
Ethnicity & disease
2017; 27 (1): 15-20
Rapid urbanization is changing the epidemiology of non-communicable diseases in sub-Saharan Africa. We aimed to identify the determinants of raised blood pressure in urban Uganda to highlight targets for preventive interventions.Case-control.Three community-based sites in Kampala, the capital of Uganda.Participants were eligible to enroll if they were aged ≥18 years and not pregnant.450 cases with raised blood pressure were frequency matched by sex and age to 412 controls. Unconditional logistic regression was used to evaluate the association of socio-demographic, lifestyle, anthropometric, and laboratory variables with the outcome of raised blood pressure. Cases currently treated with antihypertensive medication and cases not treated with antihypertensive medication were analyzed separately.Significantly increased odds of raised blood pressure were associated with overweight body mass index (BMI) (25 kg/m(2) ≤ BMI < 30 kg/m(2)), obese BMI (BMI ≥ 30 kg/m(2)) and hemoglobin A1c ≥ 6.5%. Significantly decreased odds of raised blood pressure were associated with moderate-to-vigorous work-related physical activity of >4 hours/week. No significant associations were found between raised blood pressure and marital status, education level, car or flush toilet ownership, dietary habits, alcohol consumption, smoking habits, moderate-to-vigorous leisure-related physical activity > 4 hours/week, waist-to-hip ratio, or total cholesterol levels.Targeted interventions are needed to address the key modifiable risk factors for raised blood pressure identified in this study, namely elevated BMI and regular physical activity, in order to reduce the burden of cardiovascular disease in urban Uganda.
View details for DOI 10.18865/ed.27.1.15
View details for PubMedID 28115817
Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain.
JAMA internal medicine
Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.To determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.Noninvasive testing or coronary angiography within 2 days or 30 days of presentation.The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.
View details for PubMedID 28654959
Using Commercial Programs for Lifestyle Intervention: Not Reinventing the Wheel.
Journal of the American College of Cardiology
2017; 70 (3): 328–30
View details for PubMedID 28705313
Cost-Effectiveness of Sacubitril-Valsartan in Patients With Heart Failure With Reduced Ejection Fraction
ANNALS OF INTERNAL MEDICINE
2016; 165 (10): 681-?
Sacubitril-valsartan therapy reduces cardiovascular mortality compared with enalapril therapy in patients with heart failure with reduced ejection fraction.To evaluate the cost-effectiveness of sacubitril-valsartan versus angiotensin-converting enzyme inhibitor therapy in patients with chronic heart failure.Markov decision model.Clinical trials, observational analyses, reimbursement data from the Centers for Medicare & Medicaid Services, drug pricing databases, and Centers for Disease Control and Prevention life tables.Patients at an average age of 64 years, New York Heart Association (NYHA) class II to IV heart failure, and left ventricular ejection fraction of 0.40 or less.Lifetime.Societal.Treatment with sacubitril-valsartan or lisinopril.Life-years, quality-adjusted life-years (QALYs), costs, heart failure hospitalizations, and incremental cost-effectiveness ratios.The sacubitril-valsartan group experienced 0.08 fewer heart failure hospitalization, 0.69 additional life-year, 0.62 additional QALY, and $29 203 in incremental costs, equating to a cost per QALY gained of $47 053. The cost per QALY gained was $44 531 in patients with NYHA class II heart failure and $58 194 in those with class III or IV heart failure.Sacubitril-valsartan treatment was most sensitive to the duration of improved outcomes, with a cost per QALY gained of $120 623 if the duration was limited to the length of the trial (median, 27 months). No variations in other parameters caused the cost to exceed $100 000 per QALY gained.The benefit of sacubitril-valsartan is based on a single clinical trial.Treatment with sacubitril-valsartan provides reasonable value in reducing cardiovascular mortality and morbidity in patients with NYHA class II to IV heart failure.U.S. Department of Veterans Affairs and Institute for Clinical and Economic Review.
View details for DOI 10.7326/M16-0057
View details for Web of Science ID 000387970500012
View details for PubMedID 27571284
- CardioMEMS HF for the Management of Heart Failure-Effectiveness and Value JAMA INTERNAL MEDICINE 2016; 176 (10): 1551-1552
Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure
2016; 4 (5): 368-375
This study aimed to evaluate the cost-effectiveness of the CardioMEMS (CardioMEMS Heart Failure System, St Jude Medical Inc, Atlanta, Georgia) device in patients with chronic heart failure.The CardioMEMS device, an implantable pulmonary artery pressure monitor, was shown to reduce hospitalizations for heart failure and improve quality of life in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial.We developed a Markov model to determine the hospitalization, survival, quality of life, cost, and incremental cost-effectiveness ratio of CardioMEMS implantation compared with usual care among a CHAMPION trial cohort of patients with heart failure. We obtained event rates and utilities from published trial data; we used costs from literature estimates and Medicare reimbursement data. We performed subgroup analyses of preserved and reduced ejection fraction and an exploratory analysis in a lower-risk cohort on the basis of the CHARM (Candesartan in Heart failure: Reduction in Mortality and Morbidity) trials.CardioMEMS reduced lifetime hospitalizations (2.18 vs. 3.12), increased quality-adjusted life-years (QALYs) (2.74 vs. 2.46), and increased costs ($176,648 vs. $156,569), thus yielding a cost of $71,462 per QALY gained and $48,054 per life-year gained. The cost per QALY gained was $82,301 in patients with reduced ejection fraction and $47,768 in those with preserved ejection fraction. In the lower-risk CHARM cohort, the device would need to reduce hospitalizations for heart failure by 41% to cost <$100,000 per QALY gained. The cost-effectiveness was most sensitive to the device's durability.In populations similar to that of the CHAMPION trial, the CardioMEMS device is cost-effective if the trial effectiveness is sustained over long periods. Post-marketing surveillance data on durability will further clarify its value.
View details for DOI 10.1016/j.jchf.2015.12.015
View details for PubMedID 26874380
- Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program RESPONSE ANNALS OF INTERNAL MEDICINE 2016; 164 (8): 571-572
- Sacubitril-Valsartan for the Treatment of Heart Failure: Effectiveness and Value. JAMA internal medicine 2016; 176 (2): 249-250
Hospital Medicine Clinics
2016; 6 (1): 53-66
View details for DOI 10.1016/j.ehmc.2016.07.005
A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program
ANNALS OF INTERNAL MEDICINE
2015; 163 (6): 401-?
In 2014, the American Board of Internal Medicine (ABIM) substantially increased the requirements and fees for its maintenance-of-certification (MOC) program. Faced with mounting criticism, the ABIM suspended certain content requirements in February 2015 but retained the increased fees and number of modules. An objective appraisal of the cost of MOC would help inform upcoming consultations about MOC reform.To estimate the total cost of the 2015 version of the MOC program ("2015 MOC") and the incremental cost relative to the 2013 version ("2013 MOC").Decision analytic model.Published literature.All ABIM-certified U.S. physicians.10 years (2015 to 2024).Societal.2015 MOC.Testing costs (ABIM fees) and time costs (monetary value of physician time).Internists will incur an average of $23 607 (95% CI, $5380 to $66 383) in MOC costs over 10 years, ranging from $16 725 for general internists to $40 495 for hematologists-oncologists. Time costs account for 90% of MOC costs. Cumulatively, 2015 MOC will cost $5.7 billion over 10 years, $1.2 billion more than 2013 MOC. This includes $5.1 billion in time costs (resulting from 32.7 million physician-hours spent on MOC) and $561 million in testing costs.Costs are sensitive to time spent on MOC and MOC credits obtainable from current continuing education activities.Precise estimates of time required for MOC are not available.The ABIM MOC program will generate considerable costs, predominantly due to demands on physician time. A rigorous evaluation of its effect on clinical and economic outcomes is warranted to balance potential gains in health care quality and efficiency against the high costs identified in this study.University of California, San Francisco, and the U.S. Department of Veterans Affairs.
View details for DOI 10.7326/M15-1011
View details for Web of Science ID 000361365900014
View details for PubMedID 26216046
Telomere length in patients with systemic lupus erythematosus and its associations with carotid plaque
2013; 52 (6): 1101-1108
To evaluate telomere length (TL) between patients with SLE and healthy controls and to test if TL is associated with carotid plaque.A pilot study of 154 patients with SLE and 152 controls was performed from the SOLVABLE (Study of Lupus Vascular and Bone Long-Term Endpoints) cohort. Demographic and cardiovascular disease (CVD) factors were collected at baseline. The presence or absence of plaque was evaluated by B-mode US. Genomic DNA was isolated from whole peripheral blood. TL was quantified using real-time quantitative PCR.SLE women had a short TL compared with healthy controls (4.57 vs 5.44 kb, P = 0.03). SLE women showed shorter TL than controls across all age groups: <35 years (4.38 vs 6.37 kb), 35-44 years (4.52 vs 5.30 kb), 45-54 years (4.77 vs 5.68 kb) and ≥55 years (4.60 vs 4.71 kb). Among patients with SLE and carotid plaque there was a trend towards shorter TL at a younger age and it was significantly lower in the 35- to 44-year age group when compared with controls (P = 0.025). Multiple logistic regression analysis indicated a risk of carotid plaque with older age [odds ratio (OR) 1.09; 95% CI 1.06, 1.12] but not with TL (OR 1.05; 95% CI 0.97, 1.13).SLE women had significantly shorter TL than controls. SLE women trended towards shorter TL at a younger age. When carotid plaque was identified, the younger SLE women had shorter TL. Only older age but not shorter TL was independently associated with carotid plaque. Additional studies are needed to confirm if TL is a novel biomarker for cardiovascular disease in SLE.
View details for DOI 10.1093/rheumatology/kes424
View details for Web of Science ID 000319460000018
View details for PubMedID 23382361