Bio


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 with a focus on economics and mathematics. 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 earned a Masters in Health Services Research at Stanford while acting as a fellow in health services research at the Palo Alto VA and Stanford's Center for Health Policy/Primary Care and Outcomes Research. Next, he completed fellowships in cardiology and advanced heart failure and transplant at Stanford before joining the faculty.

Alex is now an active clinician and heart failure researcher who focuses on health economics, the implementation of high-value care strategies, comparative effectiveness, and innovative clinical trial design. He is passionate about patient care and finding ways to bring meaningful improvements to patients’ lives. He is involved in several clinical trials including the K-23 funded PRO-HF (patient centered quality of life assessments), DOT-HF (mobile device based implementation trial), and a CAC notification pilot trial (patient centered coronary artery calcification notification).

In his free time, he enjoys playing soccer as well as entertaining and being entertained by his joyful sons, Kyle and Tyler.

Clinical Focus


  • Cardiology
  • Heart Failure
  • Advanced Heart Failure and Transplant Cardiology

Academic Appointments


Honors & Awards


  • Residency Research Award for Outstanding Mentorship, Stanford Internal Medicine Residency (2024)
  • Wilkerson Award for the best clinical paper published in Circulation, American Heart Association (2023)
  • Hearst Health Prize for excellence in data science in Healthcare, UCLA Center for SMART Health (2023)
  • Clinical Research Award, Stanford Cardiology Fellowship (2019)

Professional Education


  • Board Certification: American Board of Internal Medicine, Advanced Heart Failure and Transplant Cardiology (2022)
  • Board Certification: National Board of Echocardiography, Adult Echocardiography (2019)
  • Residency: Stanford University Internal Medicine Residency (2014) CA
  • 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: 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
  • Master of Science, Stanford University, Health Services Research (2016)

Clinical Trials


  • A Comparative Study on the Effectiveness of Video vs Text-Based Education in Heart Failure Recruiting

    This is a study seeking to compare the change in overall heart failure (HF) knowledge score and participant preference between video-based and text-based HF education modules. Participants will be randomized to watching and reading different combinations of video-based education modules and text-based education modules. Participants will be asked to answer questions about their familiarity with heart failure medications and management before and after the said education modules.

    View full details

  • Incidental Coronary Calcification Quality Improvement Project Not Recruiting

    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.

    Stanford is currently not accepting patients for this trial.

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  • Mobile Technology-Based System for Patient Engagement and Physician-Directed Remote Management of Heart Failure Not Recruiting

    This pilot study is to assess the feasibility, preliminary utility and acceptance of a digital technology-based system for heart failure management.

    Stanford is currently not accepting patients for this trial.

    View full details

  • Patient-Reported Outcome Measurement in Heart Failure Clinic Not Recruiting

    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.

    Stanford is currently not accepting patients for this trial. For more information, please contact Alexander T Sandhu, MD, MS, (650) 498-5522.

    View full details

2023-24 Courses


All Publications


  • How adoption of new pharmaceuticals can impact US health system reimbursement under alternative payment models: An economic model measuring the impact of sotagliflozin among patients with heart failure and diabetes. Journal of managed care & specialty pharmacy Shafrin, J., Wang, S., Kim, J., Sikirica, S., Sandhu, A. T. 2024: 1-11

    Abstract

    Heart failure (HF) is among the leading causes of death in the United States. Further, patients hospitalized because of HF with comorbid diabetes mellitus (DM) are at a significantly increased risk of death and rehospitalization. Results from the SOLOIST-WHF trial show that sotagliflozin lowered rates of readmission among hospitalized patients with HF and comorbid DM. However, it is unclear what the economic impact of the use of sotagliflozin would be on hospitals and health systems, particularly in an age where provider reimbursement is increasingly tied to value.To quantify the 1-year financial impact on US provider health systems of adopting sotagliflozin relative to standard of care (SoC) across different alternative payment models.This study created a 3-part decision tree model to quantify the financial impact of using sotagliflozin to treat patients hospitalized with HF in a US hospital setting. The model first estimated the clinical and economic outcomes of health systems with current SoC (no sotagliflozin) to treat US patients hospitalized for HF with comorbid DM. Then, using the results from the SOLOIST trial, the changes in clinical and economic outcomes with sotagliflozin adoption were modeled. Finally, the differences in health care utilization between sotagliflozin and SoC arms were translated to differences in health system reimbursement in the context of 3 common alternative payment models (APMs) in addition to the baseline fee-for-service (FFS) model: FFS with the Hospital Readmissions Reduction Program, the Bundled Payments for Care Improvement-Advanced program, and Accountable Care Organizations.A typical community hospital would have 83.4 patients per year on average with an index HF hospitalization with comorbid DM. The model predicted that sotagliflozin would reduce the probability of hospitalization, emergency department visits, and deaths by 29.3%, 38.5%, and 17.8%, respectively, compared with SoC. For hospitals not participating in APM programs, sotagliflozin resulted in a net loss of $92.94 per person ($7,754 per health system). Conversely, when accounting for provider health system participation in APMs, sotagliflozin adoption increased financial returns by $4,720 per person ($305,604 per health system) under the Hospital Readmissions Reduction Program, $1,200 per person ($100,106 per health system) for the Bundled Payments for Care Improvement-Advanced program, and $1,078 per person ($31,029 per health system) for Accountable Care Organizations. Based on the national average composition of APM reimbursement, sotagliflozin adoption resulted in a $1,576 increase in margin per patient with HF ($105,454 per health system).Although sotagliflozin adoption reduced health system revenue in an FFS payment model, it led to a net positive financial impact after accounting for APM bonus payments.

    View details for DOI 10.18553/jmcp.2024.23236

    View details for PubMedID 38989709

  • Using large language models to assess public perceptions around glucagon-like peptide-1 receptor agonists on social media. Communications medicine Somani, S., Jain, S. S., Sarraju, A., Sandhu, A. T., Hernandez-Boussard, T., Rodriguez, F. 2024; 4 (1): 137

    Abstract

    The prevalence of obesity has been increasing worldwide, with substantial implications for public health. Obesity is independently associated with cardiovascular morbidity and mortality and is estimated to cost the health system over $200 billion dollars annually. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have emerged as a practice-changing therapy for weight loss and cardiovascular risk reduction independent of diabetes.We used large language models to augment our previously reported artificial intelligence-enabled topic modeling pipeline to analyze over 390,000 unique GLP-1 RA-related Reddit discussions.We find high interest around GLP-1 RAs, with a total of 168 topics and 33 groups focused on the GLP-1 RA experience with weight loss, comparison of side effects between differing GLP-1 RAs and alternate therapies, issues with GLP-1 RA access and supply, and the positive psychological benefits of GLP-1 RAs and associated weight loss. Notably, public sentiment in these discussions was mostly neutral-to-positive.These findings have important implications for monitoring new side effects not captured in randomized control trials and understanding the public health challenge of drug shortages.

    View details for DOI 10.1038/s43856-024-00566-z

    View details for PubMedID 38987347

    View details for PubMedCentralID PMC11237093

  • Sodium-Glucose Cotransporter Inhibitors in Heart Failure: Access, Economics, and Clinical Promise. JACC. Heart failure Sandhu, A. T., Zheng, J. 2024

    View details for DOI 10.1016/j.jchf.2024.05.011

    View details for PubMedID 38970589

  • Equity in the Setting of Heart Failure Diagnosis: An Analysis of Differences Between and Within Clinician Practices. Circulation. Heart failure Gupta, A., Tisdale, R. L., Calma, J., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A. P., Heidenreich, P. A., Sandhu, A. T. 2024: e010718

    Abstract

    BACKGROUND: Timely heart failure (HF) diagnosis can lead to earlier intervention and reduced morbidity. Among historically marginalized patients, new-onset HF diagnosis is more likely to occur in acute care settings (emergency department or inpatient hospitalization) than outpatient settings. Whether inequity within outpatient clinician practices affects diagnosis settings is unknown.METHODS: We determined the setting of incident HF diagnosis among Medicare fee-for-service beneficiaries between 2013 and 2017. We identified sociodemographic and medical characteristics associated with HF diagnosis in the acute care setting. Within each outpatient clinician practice, we compared acute care diagnosis rates across sociodemographic characteristics: female versus male sex, non-Hispanic White versus other racial and ethnic groups, and dual Medicare-Medicaid eligible (a surrogate for low income) versus nondual-eligible patients. Based on within-practice differences in acute diagnosis rates, we stratified clinician practices by equity (high, intermediate, and low) and compared clinician practice characteristics.RESULTS: Among 315 439 Medicare patients with incident HF, 173 121 (54.9%) were first diagnosed in acute care settings. Higher adjusted acute care diagnosis rates were associated with female sex (6.4% [95% CI, 6.1%-6.8%]), American Indian (3.6% [95% CI, 1.1%-6.1%]) race, and dual eligibility (4.1% [95% CI, 3.7%-4.5%]). These differences persisted within clinician practices. With clinician practice adjustment, dual-eligible patients had a 4.9% (95% CI, 4.5%-5.4%) greater acute care diagnosis rate than nondual-eligible patients. Clinician practices with greater equity across dual eligibility also had greater equity across sex and race and ethnicity and were more likely to be composed of predominantly primary care clinicians.CONCLUSIONS: Differences in HF diagnosis rates in the acute care setting between and within clinician practices highlight an opportunity to improve equity in diagnosing historically marginalized patients.

    View details for DOI 10.1161/CIRCHEARTFAILURE.123.010718

    View details for PubMedID 38847082

  • Applying natural language processing to identify emergency department and observation encounters for worsening heart failure. ESC heart failure Hamilton, S. A., Ambrosy, A. P., Parikh, R. V., Tan, T. C., Fitzpatrick, J. K., Avula, H. R., Sandhu, A. T., Ku, I. A., Go, A. S., Sax, D., Bhatt, A. S. 2024

    Abstract

    Worsening heart failure (WHF) events occurring in non-inpatient settings are becoming increasingly recognized, with implications for prognostication. We evaluate the performance of a natural language processing (NLP)-based approach compared with traditional diagnostic coding for non-inpatient clinical encounters and left ventricular ejection fraction (LVEF).We compared characteristics for encounters that did vs. did not meet WHF criteria, stratified by care setting [i.e. emergency department (ED) and observation stay]. Overall, 8407 (22%) encounters met NLP-based criteria for WHF (3909 ED visits and 4498 observation stays). The use of an NLP-derived definition adjudicated 3983 (12%) of non-primary HF diagnoses as meeting consensus definitions for WHF. The most common diagnosis indicated in these encounters was dyspnoea. Results were primarily driven by observation stays, in which 2205 (23%) encounters with a secondary HF diagnosis met the WHF definition by NLP.The use of standard claims-based adjudication for primary diagnosis in the non-inpatient setting may lead to misclassification of WHF events in the ED and overestimate observation stays. Primary diagnoses alone may underestimate the burden of WHF in non-hospitalized settings.

    View details for DOI 10.1002/ehf2.14829

    View details for PubMedID 38741373

  • Sex-Based Differences in the Epidemiology, Clinical Characteristics, and Outcomes Associated with Worsening Heart Failure Events in a Learning Health System. Journal of cardiac failure Leung, C. J., Bhatt, A. S., Go, A. S., Parikh, R. V., Garcia, E. A., Le, K. C., Low, D., Allen, A. R., Fitzpatrick, J. K., Adatya, S., Sax, D. R., Goyal, P., Varshney, A. S., Sandhu, A. T., Gustafson, S. E., Ambrosy, A. P. 2024

    Abstract

    Differences in demographics, risk factors, and clinical characteristics may contribute to variation in men and women in terms of prevalence, clinical setting, and outcomes associated with worsening heart failure (WHF) events.To describe sex-based differences in the epidemiology, clinical characteristics, and outcomes associated with WHF events across clinical settings.We examined adults diagnosed with HF from 2010-2019 within a large, integrated healthcare delivery system. Electronic health record data were accessed for hospitalizations, emergency department (ED) visits/observation stays, and outpatient encounters. WHF was identified using validated natural language processing algorithms and defined as ≥1 symptom, ≥2 objective findings (including ≥1 sign), and ≥1 change in HF-related therapy. Incidence rates and associated outcomes for WHF were compared across care setting by sex.We identified 1,122,368 unique clinical encounters with a diagnosis code for HF, with 124,479 meeting WHF criteria. These WHF encounters existed among 102,116 patients, of which 48,543 (47.5%) were women and 53,573 (52.5%) were men. Women experiencing WHF were older and more likely to have HF with preserved ejection fraction compared to men. The clinical settings of WHF were similar among women and men: hospitalizations (36.8% vs. 37.7%), ED visits or observation stays (11.8% vs. 13.4%), and outpatient encounters (4.4% vs. 4.9%). Women had lower odds of 30-day mortality following an index hospitalization (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.83-0.93) or ED visit/observation stay (aOR 0.86, 95% 0.75-0.98) for WHF.Women and men contribute similarly to WHF events across diverse clinical settings despite marked differences in age and left ventricular ejection fraction.

    View details for DOI 10.1016/j.cardfail.2024.01.019

    View details for PubMedID 38697466

  • Atherosclerosis evaluation and cardiovascular risk estimation using coronary computed tomography angiography. European heart journal Nurmohamed, N. S., van Rosendael, A. R., Danad, I., Ngo-Metzger, Q., Taub, P. R., Ray, K. K., Figtree, G., Bonaca, M. P., Hsia, J., Rodriguez, F., Sandhu, A. T., Nieman, K., Earls, J. P., Hoffmann, U., Bax, J. J., Min, J. K., Maron, D. J., Bhatt, D. L. 2024

    Abstract

    Clinical risk scores based on traditional risk factors of atherosclerosis correlate imprecisely to an individual's complex pathophysiological predisposition to atherosclerosis and provide limited accuracy for predicting major adverse cardiovascular events (MACE). Over the past two decades, computed tomography scanners and techniques for coronary computed tomography angiography (CCTA) analysis have substantially improved, enabling more precise atherosclerotic plaque quantification and characterization. The accuracy of CCTA for quantifying stenosis and atherosclerosis has been validated in numerous multicentre studies and has shown consistent incremental prognostic value for MACE over the clinical risk spectrum in different populations. Serial CCTA studies have advanced our understanding of vascular biology and atherosclerotic disease progression. The direct disease visualization of CCTA has the potential to be used synergistically with indirect markers of risk to significantly improve prevention of MACE, pending large-scale randomized evaluation.

    View details for DOI 10.1093/eurheartj/ehae190

    View details for PubMedID 38606889

  • Advances in management of heart failure BMJ-BRITISH MEDICAL JOURNAL Heidenreich, P., Sandhu, A. 2024; 385
  • Contemporary Decongestion Strategies in Patients Hospitalized for Heart Failure: A National Community-Based Cohort Study. JACC. Heart failure Zheng, J., Ambrosy, A. P., Bhatt, A. S., Collins, S. P., Flint, K. M., Fonarow, G. C., Fudim, M., Greene, S. J., Lala, A., Testani, J. M., Varshney, A. S., Wi, R. S., Sandhu, A. T. 2024

    Abstract

    Heart failure (HF) is a leading cause of hospitalization in the United States. Decongestion remains a central goal of inpatient management, but contemporary decongestion practices and associated weight loss have not been well characterized nationally.This study aimed to describe contemporary inpatient diuretic practices and clinical predictors of weight loss in patients hospitalized for HF.The authors identified HF hospitalizations from 2015 to 2022 in a U.S. national database aggregating deidentified patient-level electronic health record data across 31 geographically diverse community-based health systems. The authors report patient characteristics and inpatient weight change as a primary indicator of decongestion. Predictors of weight loss were evaluated using multivariable models. Temporal trends in inpatient diuretic practices, including augmented diuresis strategies such as adjunctive thiazides and continuous diuretic infusions, were assessed.The study cohort included 262,673 HF admissions across 165,482 unique patients. The median inpatient weight loss was 5.3 pounds (Q1-Q3: 0.0-12.8 pounds) or 2.4 kg (Q1-Q3: 0.0-5.8 kg). Discharge weight was higher than admission weight in 20% of encounters. An increase of ≥0.3 mg/dL in serum creatinine from admission to inpatient peak occurred in >30% of hospitalizations and was associated with less weight loss. Adjunctive diuretic agents were utilized in <20% of encounters but were associated with greater weight loss.In a large-scale U.S. community-based cohort study of HF hospitalizations, estimated weight loss from inpatient decongestion remains highly variable, with weight gain observed across many admissions. Augmented diuresis strategies were infrequently used. Comparative effectiveness trials are needed to establish optimal strategies for inpatient decongestion for acute HF.

    View details for DOI 10.1016/j.jchf.2024.04.002

    View details for PubMedID 38678466

  • Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic. Circulation Sandhu, A. T., Calma, J., Skye, M., Kalwani, N. M., Zheng, J., Schirmer, J., Din, N., Brown Johnson, C., Gupta, A., Lan, R., Yu, B., Spertus, J. A., Heidenreich, P. A. 2024

    Abstract

    The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year.PRO-HF was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 Overall Summary Score (OSS) between 12-15 months post-randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates.Across 17 clinicians, 1,248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 (interquartile range [IQR] 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care [p=0.16]) median OSS scores were 87.5 (IQR 68.8-96.9) in the PRO arm and 87.6 (IQR 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 (95% CI: -1.7 to 2.0; p=0.85). The results were consistent across pre-specified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with baseline KCCQ-12 OSS scores of 60-80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, ED visits, medication therapy, clinic follow-up, or testing rates between arms.Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested.

    View details for DOI 10.1161/CIRCULATIONAHA.124.069624

    View details for PubMedID 38583147

  • Healthcare utilization and left ventricular ejection fraction distribution in methamphetamine use associated heart failure hospitalizations. American heart journal Manja, V., Sandhu, A. T., Asch, S., Frayne, S., McGovern, M., Chen, C., Heidenreich, P. 2024; 270: 156-160

    Abstract

    Although methamphetamine use associated heart failure (MU-HF) is increasing, data on its clinical course are limited due to a preponderance of single center studies and significant heterogeneity in the definition of MU-HF in the published literature. Our objective was to evaluate left ventricular ejection fraction (LVEF) distribution, methamphetamine use treatment engagement and postdischarge healthcare utilization among Veterans with heart failure hospitalization in the department of Veterans Affairs (VA) medical centers for MU-HF versus HF not associated with methamphetamine use (other-HF).Observational study including a cohort of Veterans with a first heart failure hospitalization during 2007 - 2020 using data in the VA Corporate Data Warehouse. MU-HF was identified based on the presence of an ICD-code for methamphetmaine use or positive toxicology results within 1-year of heart failure hospitalization. LVEF values entered in the medical record were identified using a validated natural language processing algorithm. Healthcare utilization data was obtained using clinic stop-codes and hosptilaization records.Of 203,005 first-time heart failure hospitlaizations, 4080 were categorized as MU-HF. Median (interquartile range) of LVEF was 30 (20-45) % for MU-HF versus 40 (25-55)% for other-HF (P < .0001). Eighteen percent of MU-HF had LVEF ≥ 50% compared to 28% in other-HF. Discharge against medical advice was higher in MU-HF (8% vs 2%). Among Veterans with MU-HF, post hospital discharge methamphetamine use treatment engagement was low (18% at 30 days post discharge), with higher follow-up in primary care (76% at 30 days). Post discharge emergency department visits (33% versus 22% at 30 days) and rehospitalizations (24% versus 18% at 30 days) were higher in MU-HF compared to other-HF.While the majority of MU-HF hospitalizations are HFrEF, a sizeable minority have HFpEF. This finding has implications for accurate MU-HF classification, treatment, and prognosis. Patients with MU-HF have low addiction treatment receipt and high postdischarge unplanned healthcare utilization. Increasing substance use disorder treatment in this population must be a priority to improve health outcomes. Care-coordination and linkage interventions are urgently needed to increase post-hospitalization addiction treatment and follow-up in an effort to increase evidence-base care and mitigate unplanned healthcare utilization.

    View details for DOI 10.1016/j.ahj.2023.12.014

    View details for PubMedID 38492945

  • Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals. Journal of the American Heart Association Wei, C., Paranjpe, I., Sharma, P., Milligan, M., Lam, M., Heidenreich, P. A., Kalwani, N., Schulman, K., Sandhu, A. 2024: e031982

    Abstract

    Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care.Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating.There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

    View details for DOI 10.1161/JAHA.123.031982

    View details for PubMedID 38362880

  • Uptake of sodium-glucose cotransporter-2 inhibitors in hospitalized patients with heart failure: insights from the veterans affairs healthcare system. Journal of cardiac failure Varshney, A. S., Calma, J., Kalwani, N. M., Hsiao, S., Sallam, K., Cao, F., Din, N., Schirmer, J., Bhatt, A. S., Ambrosy, A. P., Heidenreich, P., Sandhu, A. T. 2024

    Abstract

    The use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) in Veteran Affairs (VA) patients hospitalized with heart failure (HF) has not been previously reported.VA electronic health record data were used to identify patients hospitalized for HF (primary or secondary diagnosis) from 01/2019-11/2022. Patients with SGLT2i allergy, advanced/end-stage chronic kidney disease (CKD), or advanced HF therapies were excluded. We identified factors associated with discharge SGLT2i prescription among hospitalizations in 2022. We also compared SGLT2i and angiotensin receptor-neprilysin inhibitor (ARNI) prescription rates. Hospital-level variation in SGLT2i prescription was assessed via the median odds ratio.A total of 69,680 patients were hospitalized for HF; 10.3% were prescribed SGLT2i at discharge (4.4% newly prescribed, 5.9% continued pre-admission therapy). SGLT2i prescription increased over time and was higher in patients with HFrEF and primary HF. Among 15,762 patients hospitalized in 2022, SGLT2i prescription was more likely in patients with diabetes (adjusted odds ratio [aOR] 2.27; 95% confidence interval [CI]: 2.09-2.47) and ischemic heart disease (aOR 1.14; 95% CI: 1.03-1.26). Patients with increased age (aOR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (aOR 0.94 per 10mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i, and SGLT2i prescription was not more likely in patients with CKD (aOR 1.07; 95% CI 0.98-1.16). The adjusted median odds ratio suggested a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i (range 0%-21.0%). In patients with EF ≤40%, 30.9% were prescribed SGLT2i while 26.9% were prescribed ARNI (p<0.01).One-tenth of VA patients hospitalized for HF were prescribed SGLT2i at discharge. Opportunities exist to reduce variation in SGLT2i prescription across hospitals and promote use in patients with CKD and older age.

    View details for DOI 10.1016/j.cardfail.2023.12.018

    View details for PubMedID 38281540

  • The economics of heart failure care. Progress in cardiovascular diseases Wei, C., Heidenreich, P. A., Sandhu, A. T. 2024

    Abstract

    Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.

    View details for DOI 10.1016/j.pcad.2024.01.010

    View details for PubMedID 38244828

  • Patient Representativeness With Virtual Enrollment in the PRO-HF Trial. Journal of the American Heart Association Gupta, A., Skye, M., Calma, J., Din, N., Azizi, Z., Hernandez, M. F., Zheng, J., Kalwani, N. M., Malunjkar, S., Schirmer, J., Wang, P., Rodriguez, F., Heidenreich, P., Sandhu, A. T. 2024; 13 (2): e030903

    View details for DOI 10.1161/JAHA.123.030903

    View details for PubMedID 38226522

  • Challenge of Optimizing Medical Therapy in Heart Failure: Unlocking the Potential of Digital Health and Patient Engagement. Journal of the American Heart Association Azizi, Z., Golbus, J. R., Spaulding, E. M., Hwang, P. H., Ciminelli, A. L., Lacar, K., Hernandez, M. F., Gilotra, N. A., Din, N., Brant, L. C., Au, R., Beaton, A., Nallamothu, B. K., Longenecker, C. T., Martin, S. S., Dorsch, M. P., Sandhu, A. T. 2024; 13 (2): e030952

    View details for DOI 10.1161/JAHA.123.030952

    View details for PubMedID 38226520

  • American Heart Association Focusing Research Rigor on Digital Health. Journal of the American Heart Association Weyhenmeyer, J. A., Peterson, E. D., Beam, C., Wayte, P., Marvel, F. A., Bakken, S., Sandhu, A., Nallamothu, B., Martin, S., Beaton, A., Au, R., Brown, N. A. 2024; 13 (2): e032870

    View details for DOI 10.1161/JAHA.123.032870

    View details for PubMedID 38226508

  • Design and Implementation of an Electronic Health Record-Integrated Hypertension Management Application. Journal of the American Heart Association Funes Hernandez, M., Babakhanian, M., Chen, T. P., Sarraju, A., Seninger, C., Ravi, V., Azizi, Z., Tooley, J., Chang, T. I., Lu, Y., Downing, N. L., Rodriguez, F., Li, R. C., Sandhu, A. T., Turakhia, M., Bhalla, V., Wang, P. J. 2024; 13 (2): e030884

    Abstract

    High blood pressure affects approximately 116 million adults in the United States. It is the leading risk factor for death and disability across the world. Unfortunately, over the past decade, hypertension control rates have decreased across the United States. Prediction models and clinical studies have shown that reducing clinician inertia alone is sufficient to reach the target of ≥80% blood pressure control. Digital health tools containing evidence-based algorithms that are able to reduce clinician inertia are a good fit for turning the tide in blood pressure control, but careful consideration should be taken in the design process to integrate digital health interventions into the clinical workflow.We describe the development of a provider-facing hypertension management platform. We enumerate key steps of the development process, including needs finding, clinical workflow analysis, treatment algorithm creation, platform design and electronic health record integration. We interviewed and surveyed 5 Stanford clinicians from primary care, cardiology, and their clinical care team members (including nurses, advanced practice providers, medical assistants) to identify needs and break down the steps of clinician workflow analysis. The application design and development stage were aided by a team of approximately 15 specialists in the fields of primary care, hypertension, bioinformatics, and software development.Digital monitoring holds immense potential for revolutionizing chronic disease management. Our team developed a hypertension management platform at an academic medical center to address some of the top barriers to adoption and achieving clinical outcomes. The frameworks and processes described in this article may be used for the development of a diverse range of digital health tools in the cardiovascular space.

    View details for DOI 10.1161/JAHA.123.030884

    View details for PubMedID 38226516

  • Digital Health Interventions for Heart Failure Management in Underserved Rural Areas of the United States: A Systematic Review of Randomized Trials. Journal of the American Heart Association Azizi, Z., Broadwin, C., Islam, S., Schenk, J., Din, N., Hernandez, M. F., Wang, P., Longenecker, C. T., Rodriguez, F., Sandhu, A. T. 2024; 13 (2): e030956

    Abstract

    Heart failure disproportionately affects individuals residing in rural areas, leading to worse health outcomes. Digital health interventions have been proposed as a promising approach for improving heart failure management. This systematic review aims to identify randomized trials of digital health interventions for individuals living in underserved rural areas with heart failure.We conducted a systematic review by searching 6 databases (CINAHL, EMBASE, MEDLINE, Web of Science, Scopus, and PubMed; 2000-2023). A total of 30 426 articles were identified and screened. Inclusion criteria consisted of digital health randomized trials that were conducted in underserved rural areas of the United States based on the US Census Bureau's classification. Two independent reviewers screened the studies using the National Heart, Lung, and Blood Institute tool to evaluate the risk of bias. The review included 5 trials from 6 US states, involving 870 participants (42.9% female). Each of the 5 studies employed telemedicine, 2 studies used remote monitoring, and 1 study used mobile health technology. The studies reported improvement in self-care behaviors in 4 trials, increased knowledge in 2, and decreased cardiovascular mortality in 1 study. However, 3 trials revealed no change or an increase in health care resource use, 2 showed no change in cardiac biomarkers, and 2 demonstrated an increase in anxiety.The results suggest that digital health interventions have the potential to enhance self-care and knowledge of patients with heart failure living in underserved rural areas. However, further research is necessary to evaluate their impact on clinical outcomes, biomarkers, and health care resource use.URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022366923.

    View details for DOI 10.1161/JAHA.123.030956

    View details for PubMedID 38226517

  • Cataract Surgery in the Medicare Merit-Based Incentive Payment System: Episode-Based Cost Measure Development and Evaluation. Ophthalmology science Pershing, S., Sandhu, A. T., Uwilingiyimana, A. S., Glasser, D. B., Morgenstern, A. S., Do, R., Choradia, N., Lin, E., Leoung, J., Shah, M., Liu, A., Lee, J., Fairchild, A., Lam, J., MaCurdy, T. E., Nagavarapu, S., Bhattacharya, J. 2023; 3 (4): 100315

    Abstract

    To characterize the development and performance of a cataract surgery episode-based cost measure for the Medicare Quality Payment Program.Claims-based analysis.Medicare clinicians with cataract surgery claims between June 1, 2016, and May 31, 2017.We limited the analysis to claims with procedure code 66984 (routine cataract surgery), excluding cases with relevant ocular comorbidities. We divided episodes into subgroups by surgery location (Ambulatory Surgery Center [ASC] or Hospital Outpatient Department [HOPD]) and laterality (bilateral when surgeries were within 30 days apart). For the episode-based cost measure, we calculated costs occurring between 60 days before surgery and 90 days after surgery, limited to services identified by an expert committee as related to cataract surgery and under the influence of the cataract surgeon. We attributed costs to the clinician submitting the cataract surgery claim, categorized costs into clinical themes, and calculated episode cost distribution, reliability in detecting clinician-dependent cost variation, and costs with versus without complications. We compared episode-based cost scores with hypothetical "nonselective" cost scores (total Medicare beneficiary costs between 60 days before surgery and 90 days after surgery).Episode costs with and without complications, clinician-dependent variation (proportion of total cost variance), and proportion of costs from cataract surgery-related clinical themes.We identified 583 356 cataract surgery episodes attributed to 10 790 clinicians and 8189 with ≥ 10 episodes during the measurement period. Most surgeries were performed in an ASC (71%) and unilateral (66%). The mean episode cost was $2876. The HOPD surgeries had higher costs; geography and episodes per clinician did not substantially affect costs. The proportion of cost variation from clinician-dependent factors was higher in episode-based compared with nonselective cost measures (94% vs. 39%), and cataract surgery-related clinical themes represented a higher proportion of total costs for episode-based measures. Episodes with complications had higher costs than episodes without complications ($3738 vs. $2276).The cataract surgery episode-based cost measure performs better than a comparable nonselective measure based on cost distribution, clinician-dependent variance, association with cataract surgery-related clinical themes, and quality alignment (higher costs in episodes with complications). Cost measure maintenance and refinement will be important to maintain clinical validity and reliability.Proprietary or commercial disclosure may be found after the references.

    View details for DOI 10.1016/j.xops.2023.100315

    View details for PubMedID 37274014

    View details for PubMedCentralID PMC10232885

  • Opportunistic assessment of ischemic heart disease risk using abdominopelvic computed tomography and medical record data: a multimodal explainable artificial intelligence approach. Scientific reports Zambrano Chaves, J. M., Wentland, A. L., Desai, A. D., Banerjee, I., Kaur, G., Correa, R., Boutin, R. D., Maron, D. J., Rodriguez, F., Sandhu, A. T., Rubin, D., Chaudhari, A. S., Patel, B. N. 2023; 13 (1): 21034

    Abstract

    Current risk scores using clinical risk factors for predicting ischemic heart disease (IHD) events-the leading cause of global mortality-have known limitations and may be improved by imaging biomarkers. While body composition (BC) imaging biomarkers derived from abdominopelvic computed tomography (CT) correlate with IHD risk, they are impractical to measure manually. Here, in a retrospective cohort of 8139 contrast-enhanced abdominopelvic CT examinations undergoing up to 5 years of follow-up, we developed multimodal opportunistic risk assessment models for IHD by automatically extracting BC features from abdominal CT images and integrating these with features from each patient's electronic medical record (EMR). Our predictive methods match and, in some cases, outperform clinical risk scores currently used in IHD risk assessment. We provide clinical interpretability of our model using a new method of determining tissue-level contributions from CT along with weightings of EMR features contributing to IHD risk. We conclude that such a multimodal approach, which automatically integrates BC biomarkers and EMR data, can enhance IHD risk assessment and aid primary prevention efforts for IHD. To further promote research, we release the Opportunistic L3 Ischemic heart disease (OL3I) dataset, the first public multimodal dataset for opportunistic CT prediction of IHD.

    View details for DOI 10.1038/s41598-023-47895-y

    View details for PubMedID 38030716

    View details for PubMedCentralID 7734661

  • Use of Human-Centered Design Methodology to Develop a Digital Toolkit to Optimize Heart Failure Guideline-Directed Medical Therapy. The Journal of cardiovascular nursing Spaulding, E. M., Isakadze, N., Molello, N., Khoury, S. R., Gao, Y., Young, L., Antonsdottir, I. M., Azizi, Z., Dorsch, M. P., Golbus, J. R., Ciminelli, A., Brant, L. C., Himmelfarb, C. R., Coresh, J., Marvel, F. A., Longenecker, C. T., Commodore-Mensah, Y., Gilotra, N. A., Sandhu, A., Nallamothu, B., Martin, S. S. 2023

    Abstract

    Guideline-directed medical therapies (GDMTs) improve quality of life and health outcomes for patients with heart failure (HF). However, GDMT utilization is suboptimal among patients with HF.The aims of this study were to engage key stakeholders in semistructured, virtual human-centered design sessions to identify challenges in GDMT optimization posthospitalization and inform the development of a digital toolkit aimed at optimizing HF GDMTs.For the human-centered design sessions, we recruited (a) clinicians who care for patients with HF across 3 hospital systems, (b) patients with HF with reduced ejection fraction (ejection fraction ≤ 40%) discharged from the hospital within 30 days of enrollment, and (c) caregivers. All participants were 18 years or older, English speaking, with Internet access.A total of 10 clinicians (median age, 37 years [interquartile range, 35-41], 12 years [interquartile range, 10-14] of experience caring for patients with HF, 80% women, 50% White, 50% nurse practitioners) and three patients and one caregiver (median age 57 years [IQR: 53-60], 75% men, 50% Black, 75% married) were included. Five themes emerged from the clinician sessions on challenges to GDMT optimization (eg, barriers to patient buy-in). Six themes on challenges (eg, managing medications), 4 themes on motivators (eg, regaining independence), and 3 themes on facilitators (eg, social support) to HF management arose from the patient and caregiver sessions.The clinician, patient, and caregiver insights identified through human-centered design will inform a digital toolkit aimed at optimizing HF GDMTs, including a patient-facing smartphone application and clinician dashboard. This digital toolkit will be evaluated in a multicenter, clinical trial.

    View details for DOI 10.1097/JCN.0000000000001051

    View details for PubMedID 37855732

  • Phased target trial design and meta-analysis in a head-to-head treatment comparison Singh, J. P., Wieloch, M., Reynolds, S. L., Blomstrom-Lundqvist, C., Sandhu, A. T., Camm, A., Kabadi, S. M., Pundi, K., Turakhia, M., Boiron, R., Coudert, M., Din, N., Fan, J., Heller, C. G., Leeming, R. C., McKindley, D., Sajedian, R. M., Kowey, P. R. WILEY. 2023: 444
  • Developing Clinical Risk Prediction Models for Worsening Heart Failure Events and Death by Left Ventricular Ejection Fraction. Journal of the American Heart Association Parikh, R. V., Go, A. S., Bhatt, A. S., Tan, T. C., Allen, A. R., Feng, K. Y., Hamilton, S. A., Tai, A. S., Fitzpatrick, J. K., Lee, K. K., Adatya, S., Avula, H. R., Sax, D. R., Shen, X., Cristino, J., Sandhu, A. T., Heidenreich, P. A., Ambrosy, A. P. 2023: e029736

    Abstract

    Background There is a need to develop electronic health record-based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1-year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all-cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF <40%), HF with mildly reduced EF (LVEF 40%-49%), and HF with preserved EF (LVEF ≥50%). Model discrimination was evaluated using area under the curve and calibration using mean squared error. We identified 338 426 adults with HF: 61 045 (18.0%) had HF with reduced EF, 49 618 (14.7%) had HF with mildly reduced EF, and 227 763 (67.3%) had HF with preserved EF. The 1-year risks of any WHF event and death were, respectively, 22.3% and 13.0% for HF with reduced EF, 17.0% and 10.1% for HF with mildly reduced EF, and 16.3% and 10.3% for HF with preserved EF. The WHF model displayed an area under the curve of 0.76 and mean squared error of 0.13, whereas the model for death displayed an area under the curve of 0.83 and mean squared error of 0.076. Performance and predictors were similar across WHF encounter types and LVEF categories. Conclusions We developed risk prediction models for 1-year WHF events and death across the LVEF spectrum using structured and unstructured electronic health record data and observed no substantial differences in model performance or predictors except for death, despite differences in underlying HF cause.

    View details for DOI 10.1161/JAHA.122.029736

    View details for PubMedID 37776209

  • Association of Coronary Artery Calcium Detected by Routine Ungated CT Imaging With Cardiovascular Outcomes. Journal of the American College of Cardiology Peng, A. W., Dudum, R., Jain, S. S., Maron, D. J., Patel, B. N., Khandwala, N., Eng, D., Chaudhari, A. S., Sandhu, A. T., Rodriguez, F. 2023; 82 (12): 1192-1202

    Abstract

    Coronary artery calcium (CAC) is a strong predictor of cardiovascular events across all racial and ethnic groups. CAC can be quantified on nonelectrocardiography (ECG)-gated computed tomography (CT) performed for other reasons, allowing for opportunistic screening for subclinical atherosclerosis.The authors investigated whether incidental CAC quantified on routine non-ECG-gated CTs using a deep-learning (DL) algorithm provided cardiovascular risk stratification beyond traditional risk prediction methods.Incidental CAC was quantified using a DL algorithm (DL-CAC) on non-ECG-gated chest CTs performed for routine care in all settings at a large academic medical center from 2014 to 2019. We measured the association between DL-CAC (0, 1-99, or ≥100) with all-cause death (primary outcome), and the secondary composite outcomes of death/myocardial infarction (MI)/stroke and death/MI/stroke/revascularization using Cox regression. We adjusted for age, sex, race, ethnicity, comorbidities, systolic blood pressure, lipid levels, smoking status, and antihypertensive use. Ten-year atherosclerotic cardiovascular disease risk was calculated using the pooled cohort equations.Of 5,678 adults without ASCVD (51% women, 18% Asian, 13% Hispanic/Latinx), 52% had DL-CAC >0. Those with DL-CAC ≥100 had an average 10-year ASCVD risk of 24%; yet, only 26% were on statins. After adjustment, patients with DL-CAC ≥100 had increased risk of death (HR: 1.51; 95% CI: 1.28-1.79), death/MI/stroke (HR: 1.57; 95% CI: 1.33-1.84), and death/MI/stroke/revascularization (HR: 1.69; 95% CI: 1.45-1.98) compared with DL-CAC = 0.Incidental CAC ≥100 was associated with an increased risk of all-cause death and adverse cardiovascular outcomes, beyond traditional risk factors. DL-CAC from routine non-ECG-gated CTs identifies patients at increased cardiovascular risk and holds promise as a tool for opportunistic screening to facilitate earlier intervention.

    View details for DOI 10.1016/j.jacc.2023.06.040

    View details for PubMedID 37704309

  • Lifting the Veil on Advanced HeartFailure. JACC. Heart failure Sandhu, A. T., Khera, R. 2023

    View details for DOI 10.1016/j.jchf.2023.07.031

    View details for PubMedID 37737760

  • Heart Failure Medical Therapy Prior to Mitral Transcatheter Edge-to-Edge Repair: The STS/ACC Transcatheter Valve Therapy Registry. European heart journal Varshney, A. S., Shah, M., Vemulapalli, S., Kosinski, A., Bhatt, A. S., Sandhu, A. T., Hirji, S., DeFilippis, E. M., Shah, P. B., Fiuzat, M., O'Gara, P. T., Bhatt, D. L., Kaneko, T., Givertz, M. M., Vaduganathan, M. 2023

    Abstract

    Guideline-directed medical therapy (GDMT) is recommended prior to mitral valve transcatheter edge-to-edge repair (MTEER) in patients with heart failure (HF) and severe functional mitral regurgitation (FMR). Whether MTEER is being performed on the background of optimal GDMT in clinical practice is unknown.Patients with left ventricular ejection fraction (LVEF) < 50% who underwent MTEER for FMR from July 23, 2019 to March 31, 2022 in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry were identified. Pre-procedure GDMT utilization was assessed. Cox proportional hazards models were constructed to evaluate associations between pre-MTEER therapy (no/single, double, or triple therapy) and risk of one-year mortality or HF hospitalization (HFH).Among 4,199 patients across 449 sites, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitor were used in 85.1%, 44.4%, 28.6%, and 19.9% prior to MTEER, respectively. Triple therapy was prescribed for 19.2%, double therapy for 38.2%, single therapy for 36.0%, and 6.5% were on no GDMT. Significant center-level variation in the proportion of patients on pre-intervention triple therapy was observed (0-61%; adjusted median odds ratio 1.48 [95% confidence interval (CI) 1.25-3.88]; P < 0.001). In patients eligible for one-year follow-up (n = 2,014; 341 sites), the composite rate of one-year mortality or HFH was lowest in patients prescribed triple therapy (23.1%) compared with double (24.8%), single (35.7%), and no (41.1%) therapy (P < 0.01 comparing across groups). Associations persisted after accounting for relevant clinical characteristics, with lower risk in patients prescribed triple therapy (adjusted hazard ratio [aHR] 0.73, 95% CI 0.55-0.97) and double therapy (aHR 0.69, 95% CI 0.56-0.86) prior to MTEER compared with no/single therapy.Under one-fifth of patients with LVEF <50% who underwent MTEER for FMR in this US nationwide registry were prescribed comprehensive GDMT, with substantial variation across sites. Compared with no/single therapy, triple and double therapy prior to MTEER were independently associated with reduced risk of mortality or HFH one year after intervention.

    View details for DOI 10.1093/eurheartj/ehad584

    View details for PubMedID 37632738

  • Variation in Methamphetamine-Associated Heart Failure Hospitalizations Across the United States. Journal of cardiac failure Manja, V., Sandhu, A. T., Frayne, S., Asch, S., McGovern, M., Chen, C., Heidenreich, P. 2023

    View details for DOI 10.1016/j.cardfail.2023.07.015

    View details for PubMedID 37611844

  • Implementation of evidence-based heart failure management: Regional variations between Japan and the USA. Journal of cardiology Ichihara, Y. K., Kohsaka, S., Kisanuki, M., Sandhu, A. T., Kawana, M. 2023

    Abstract

    The implementation of optimal medical therapy is a crucial step in the management of heart failure with reduced ejection fraction (HFrEF). Over the prior three decades, there have been substantial advancements in this field. Early and accurate detection and diagnosis of the disease allow for the appropriate initiation of optimal therapies. The initiation and uptitration of optimal medical therapy including renin-angiotensin system inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter 2 inhibitor in the early stage would prevent the progression and morbidity of HF. Concurrently, individualized surveillance to recognize and treat signs of disease progression is critical given the progressive nature of HF, even among stable patients on optimal therapy. However, there remains a wide variation in regional practice regarding the initiation, titration, and long-term monitoring of this therapy. To cover the differences in approaches toward HFrEF management and the implementation of guideline-based medical therapy, we discuss the current evidence in this arena, differences in present guideline recommendations, and compare practice patterns in Japan and the USA using a case of new-onset HF as an example. We will discuss pros and cons of the way HF is managed in each region, and highlight potential areas for improvement in care.

    View details for DOI 10.1016/j.jjcc.2023.07.019

    View details for PubMedID 37543194

  • Response by Sandhu et al to Letter Regarding Article, "Incidental Coronary Artery Calcium: Opportunistic Screening of Previous Nongated Chest Computed Tomography Scans to Improve Statin Rates (NOTIFY-1 Project)". Circulation Sandhu, A. T., Rodriguez, F., Maron, D. J. 2023; 148 (5): 441

    View details for DOI 10.1161/CIRCULATIONAHA.123.065360

    View details for PubMedID 37523759

  • Dronedarone Versus Sotalol in Antiarrhythmic Drug-Naive Veterans With Atrial Fibrillation. Circulation. Arrhythmia and electrophysiology Pundi, K., Fan, J., Kabadi, S., Din, N., Blomström-Lundqvist, C., John Camm, A., Kowey, P., Singh, J. P., Rashkin, J., Wieloch, M., Turakhia, M. P., Sandhu, A. T. 2023: e011893

    Abstract

    Sotalol and dronedarone are both used for maintenance of sinus rhythm for patients with atrial fibrillation. However, while sotalol requires initial monitoring for QT prolongation and proarrhythmia, dronedarone does not. These treatments can be used in comparable patients, but their safety and effectiveness have not been compared head to head. Therefore, we retrospectively evaluated the effectiveness and safety using data from a large health care system.Using Veterans Health Administration data, we identified 11 296 antiarrhythmic drug-naive patients with atrial fibrillation prescribed dronedarone or sotalol in 2012 or later. We excluded patients with prior conduction disease, pacemakers or implantable cardioverter-defibrillators, ventricular arrhythmia, cancer, renal failure, liver disease, or heart failure. We used natural language processing to identify and compare baseline left ventricular ejection fraction between treatment arms. We used 1:1 propensity score matching, based on patient demographics, comorbidities, and medications, and Cox regression to compare strategies. To evaluate residual confounding, we performed falsification analysis with nonplausible outcomes.The matched cohort comprised 6212 patients (3106 dronedarone and 3106 sotalol; mean [±SD] age, 71±10 years; 2.5% female; mean [±SD] CHA2DS2-VASC, 2±1.3). The mean (±SD) left ventricular ejection fraction was 55±11 and 58±10 for dronedarone and sotalol users, correspondingly. Dronedarone, compared with sotalol, did not demonstrate a significant association with risk of cardiovascular hospitalization (hazard ratio, 1.03 [95% CI, 0.88-1.21]) or all-cause mortality (hazard ratio, 0.89 [95% CI, 0.68-1.16]). However, dronedarone was associated with significantly lower risk of ventricular proarrhythmic events (hazard ratio, 0.53 [95% CI, 0.38-0.74]) and symptomatic bradycardia (hazard ratio, 0.56 [95% CI, 0.37-0.87]). The primary findings were stable across sensitivity analyses. Falsification analyses were not significant.Dronedarone, compared with sotalol, was associated with a lower risk of ventricular proarrhythmic events and conduction disorders while having no difference in risk of incident cardiovascular hospitalization and mortality. These observational data provide the basis for prospective efficacy and safety trials.

    View details for DOI 10.1161/CIRCEP.123.011893

    View details for PubMedID 37485722

  • Risk of severe Covid-19 in prevalent users of α-1 adrenergic receptor antagonists: a national case-control study of Medicare beneficiaries. The American journal of medicine Graham, D. J., Izurieta, H. S., Zhang, D., Avagyan, A., Lyu, H., Wiederhorn, R., Lu, Y., Mosholder, A. D., Smith, E. R., Zhao, Y., Shangguan, S., Tsai, H. T., Pennap, D., Sandhu, A. T., Wernecke, M., MaCurdy, T. E., Kelman, J. A., Forshee, R. A. 2023

    Abstract

    α-1 adrenergic receptor antagonists prevent cytokine storm in mouse sepsis models. This led to the hypothesis that α-1 blockers might prevent severe Covid-19, which is characterized by hypercytokinemia and progressive respiratory failure.We performed an observational case-control study in male Medicare beneficiaries age ≥65 years, with or without benign prostatic hyperplasia (BPH), and treated with α-1 receptor blockers or 5-α reductase inhibitors. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated for outcomes of uncomplicated and severe Covid-19 hospitalization (intensive care unit admission, invasive mechanical ventilation, or death).20,963 cases of hospitalized Covid-19 were matched to 101,161 controls on calendar date and neighborhood of residence. In the primary analysis (males with BPH), there was no difference in risk of uncomplicated Covid-19 hospitalization (aOR 1.08, 95% CI 0.996-1.17) or hospitalization with severe complications (aOR 0.97, 95% CI 0.88-1.08). In the secondary analysis (males with or without BPH), the corresponding aORs were 1.02, 95% CI 0.96-1.09 (uncomplicated), and 0.99, 95% CI 0.91-1.07 (complicated), respectively. Subgroup and sensitivity analyses yielded similar results. Of note, there was no difference in risk of severe Covid-19 hospitalization when comparing non-selective vs. selective α-1 blocker use (aOR 0.98, 95% CI 0.86-1.10), higher vs. lower dose α-1 blocker use (aOR 0.96, 95% CI 0.86-1.08), or current vs. remote α-1 blocker use (aOR 1.04, 95% CI 0.91-1.18).Prevalent use of α-1 receptor blockers was not associated with a protective or harmful effect on risk of uncomplicated or severe hospitalized Covid-19.

    View details for DOI 10.1016/j.amjmed.2023.07.003

    View details for PubMedID 37454868

  • Evaluating Recommendations About Atrial Fibrillation for Patients and Clinicians Obtained From Chat-Based Artificial Intelligence Algorithms. Circulation. Arrhythmia and electrophysiology Azizi, Z., Alipour, P., Gomez, S., Broadwin, C., Islam, S., Sarraju, A., Rogers, A. J., Sandhu, A. T., Rodriguez, F. 2023: e012015

    View details for DOI 10.1161/CIRCEP.123.012015

    View details for PubMedID 37334705

  • The Inflation Reduction Act Expands Prescription Drug Affordability: Decades in the Making. Journal of the American College of Cardiology Zheng, J., Sandhu, A. T. 2023; 81 (21): 2112-2114

    View details for DOI 10.1016/j.jacc.2023.03.415

    View details for PubMedID 37225365

  • Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure. Circulation. Heart failure Zheng, J., Heidenreich, P. A., Kohsaka, S., Fearon, W. F., Sandhu, A. T. 2023: e010426

    Abstract

    BACKGROUND: Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF.METHODS: We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment.RESULTS: Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that 70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant.CONCLUSIONS: Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.

    View details for DOI 10.1161/CIRCHEARTFAILURE.122.010426

    View details for PubMedID 37212148

  • How to Make the Transplantation Allocation System Better. JACC. Heart failure Khush, K. K., Sandhu, A. T., Parker, W. F. 2023; 11 (5): 516-519

    View details for DOI 10.1016/j.jchf.2022.11.029

    View details for PubMedID 37137658

  • Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment. Circulation. Cardiovascular quality and outcomes Brown-Johnson, C., Calma, J., Amano, A., Winget, M., Harris, S. R., Vilendrer, S., Asch, S. M., Heidenreich, P., Sandhu, A. T., Kalwani, N. M. 2023: e009677

    Abstract

    Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.URL: https://clinicaltrials.gov; Unique identifier: NCT04164004.

    View details for DOI 10.1161/CIRCOUTCOMES.122.009677

    View details for PubMedID 37114990

  • Pursuing Equity in Performance Measurement. Circulation Heidenreich, P., Sandhu, A. 2023; 147 (15): 1134-1136

    View details for DOI 10.1161/CIRCULATIONAHA.123.064123

    View details for PubMedID 37036909

  • Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. Journal of cardiac failure Zheng, J., Mednick, T., Heidenreich, P. A., Sandhu, A. T. 2023

    Abstract

    Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in heart failure. This study sought to characterize alternative models of care involving non-physician provider-led GDMT interventions and their associations with therapy utilization and clinical outcomes.We performed a systematic review and meta-analysis of randomized controlled trials (RCT) and observational studies comparing non-physician provider-led GDMT initiation and/or uptitration interventions versus usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target doses by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations.33 studies were reviewed, of which 17 (52%) were randomized controlled trials with median follow-up of 6 months. 14 (82%) trials evaluated nurse interventions, while the remainder assessed pharmacist interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5,268 patients. Pooled risk ratios (RR) for RASI and BB initiation were 2.09 (95% CI 1.05-4.16; I2=68%) and 1.91 (95% CI 1.35-2.70; I2=37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2=77%) and BB (RR 2.22, 95% CI 1.29-3.83; I2=66%). No association was found with MRA initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2=12%) and HF hospitalization (RR 0.80, 95% CI 0.63-1.01; I2=25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification.Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.

    View details for DOI 10.1016/j.cardfail.2023.03.012

    View details for PubMedID 37004867

  • Updating the Accuracy of Administrative Claims for Identifying Left Ventricular Ejection Fraction Among Patients With Heart Failure. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Zheng, J., Skye, M., Heidenreich, P. A. 2023: e008919

    View details for DOI 10.1161/CIRCOUTCOMES.122.008919

    View details for PubMedID 36924223

  • OPPORTUNISTIC SCREENING OF INCIDENTAL CORONARY ARTERY CALCIUM WITH DEEP-LEARNING ALGORITHM ON NON-ECG GATED CHEST CT IMAGING AND ASSOCIATION WITH CARDIOVASCULAR EVENTS AND MORTALITY Peng, A., Dudum, R., Maron, D., Sandhu, A., Rodriguez, F. ELSEVIER SCIENCE INC. 2023: 2123
  • PREVALENCE AND PROGNOSTIC VALUE OF VENTRICULAR TACHYCARDIA ON AMBULATORY ECG MONITORING Pundi, K., Fan, J., Din, N., Sandhu, A., Heidenreich, P. A., Turakhia, M. ELSEVIER SCIENCE INC. 2023: 125
  • METHAMPHETAMINE ASSOCIATED HEART FAILURE HOSPITALIZATIONS AMONG VETERANS IN THE UNITED STATES Manja, V., Sandhu, A., Chen, C., Asch, S., Frayne, S., Heidenreich, P. A. ELSEVIER SCIENCE INC. 2023: 492
  • Cost-effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors for Patients With Heart Failure and Preserved Ejection Fraction-Living on the Edge. JAMA cardiology Sandhu, A. T., Cohen, D. J. 2023

    View details for DOI 10.1001/jamacardio.2023.0087

    View details for PubMedID 36870043

  • Frailty and subsequent adverse outcomes in older patients with atrial fibrillation treated with oral anticoagulants: The Shizuoka study. Research and practice in thrombosis and haemostasis Nishimura, S., Kumamaru, H., Shoji, S., Nakatani, E., Yamamoto, H., Ichihara, N., Sandhu, A. T., Miyachi, Y., Miyata, H., Kohsaka, S. 2023; 7 (3): 100129

    Abstract

    In older patients with atrial fibrillation (AF), frailty is frequently prevalent. However, the prognostic value of frailty for adverse events after initiation of oral anticoagulants (OACs) is unclear.We assessed whether frailty at the time of OAC initiation is associated with subsequent bleeding or embolic events.We extracted patients aged ≥65 years with nonvalvular AF in whom OACs were initiated from a universal administrative claims database incorporating primary and hospital care records in Shizuoka, Japan, between 2012 and 2018. Frailty was assessed using the electronic frailty index (eFI). The association of frailty with bleeding events and ischemic stroke/transient ischemic attack were evaluated using the Fine-Gray model and restricted cubic spline model.Among 12,585 patients with AF, 7.8% were categorized as fit, 31.5% as mildly frail, 34.8% as moderately frail, and 25.9% as severely frail. The risk of bleeding was associated with a higher eFI (adjusted subdistribution hazard ratio [95% CI] for fit or mild frailty: 1.15 [1.02-1.30]; moderate frailty: 1.42 [1.24-1.61]; and severe frailty: 1.86 [1.61-2.15]), whereas the association was weaker for ischemic stroke/transient ischemic attack. The spline models demonstrated that the relative hazard for bleeding increased steeply with increasing eFI.Patients with frailty in whom OAC therapy is initiated have higher risk of bleeding, highlighting the importance of discussing this increased risk with patients with AF who have frailty and assessing frailty at the time of OAC initiation.

    View details for DOI 10.1016/j.rpth.2023.100129

    View details for PubMedID 37168397

    View details for PubMedCentralID PMC10165150

  • Variation in Cost of Echocardiography Within and Across US Hospitals. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Wei, C., Milligan, M., Lam, M., Heidenreich, P. A., Sandhu, A. 2023

    Abstract

    BACKGROUND: While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated US hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices.METHODS: We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked this price data to hospital and regional characteristics using Medicare Facility IDs.RESULTS: 1949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93- and 3.06-times greater than the median Medicare price ($1313 and $1422, respectively, versus $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (IQR 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 2.47 (IQR 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (p=0.04), teaching (p<0.01), investor-owned (P<0.01), and higher-rated hospitals (p<0.01) charged higher prices, whereas rural referral centers (p=0.01) and disproportionate share hospitals (DSH) (p<0.01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except investor ownership and rural referral centers.CONCLUSIONS: Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. Better understanding the relationship between this cost variation and quality of care is critical given the impact of cost on healthcare access and affordability.

    View details for DOI 10.1016/j.echo.2023.01.002

    View details for PubMedID 36638930

  • Predictors of Incident HeartFailure Diagnosis Setting: Insights From the Veterans Affairs Healthcare System. JACC. Heart failure Tisdale, R. L., Fan, J., Calma, J., Cyr, K., Podchiyska, T., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A., Heidenreich, P. A., Sandhu, A. T. 2022

    Abstract

    BACKGROUND: Early recognition of heart failure (HF) can reduce morbidity, yet HF is often diagnosed only after symptoms require urgent treatment.OBJECTIVES: The authors sought to describe predictors of HF diagnosis in the acute care vs outpatient setting within the Veterans Health Administration (VHA).METHODS: The authors estimated whether incident HF diagnoses occurred in acute care (inpatient hospital or emergency department) vs outpatient settings within the VHA between 2014 and 2019. After excluding new-onset HF potentially caused by acute concurrent conditions, they identified sociodemographic and clinical variables associated with diagnosis setting and assessed variation across 130 VHA facilities using multivariable regression analysis.RESULTS: The authors identified 303,632 patients with new HF, with 160,454 (52.8%) diagnosed in acute care settings. In the prior year, 44% had HF symptoms and 11% had a natriuretic peptide tested, 88% of which were elevated. Patients with housing insecurity and high neighborhood social vulnerability had higher odds of acute care diagnosis (adjusted odds ratio: 1.22 [95%CI: 1.17-1.27] and 1.17 [95%CI: 1.14-1.21], respectively) adjusting for medical comorbidities. Better outpatient quality of care (blood pressure control and cholesterol and diabetes monitoring within the prior 2 years) predicted a lower odds of acute care diagnosis. Likelihood of acute care HF diagnosis varied from 41% to 68% across facilities after adjusting for patient-level risk factors.CONCLUSIONS: Many first HF diagnoses occur in the acute care setting, especially among socioeconomically vulnerable populations. Better outpatient care was associated with lower rates of an acute care diagnosis. These findings highlight opportunities for timelier HF diagnosis that may improve patient outcomes.

    View details for DOI 10.1016/j.jchf.2022.11.013

    View details for PubMedID 36881392

  • Disparities in Adoption of New Diabetic Therapies with Cardiovascular Benefits. Diabetes research and clinical practice Vasti, E. C., Basina, M., Calma, J., Maron, D. J., Rodriguez, F., Sandhu, A. T. 2022: 110233

    Abstract

    Sodium-glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 agonists (GLP1a) have cardiovascular benefit, but adoption into clinical practice has been lagging. We aim to evaluate use of SGLT2i and GLP1a across socioeconomic strata (SES), medical risk as well as provider type.We conducted a retrospective cohort study of the prescription of SGLT2i or GLP1a within 12 months of clinic visit between January 1, 2018 and January 1, 2019 using de-identified claims data. The primary outcome was the composite of a medication fill of either an SGLT2i and/or GLP1a within 180 days of the index visit.Of the total cohort, 125,636 (15.8%) received either a GLP-1a or SGLT2i.The odds of prescription of either medication was 0.64 [p=0.006)] in patients with heart failure. Patients who identified as Black, Hispanic or Asian had lower odds of the primary outcome [Black: (AOR 0.81, p<0.000); Hispanic: (AOR 0.87, p<0.000); Asian: (AOR 0.83, p<0.000). The odds was higher for those treated by an endocrinologist versus primary care clinician [AOR 2.12, p<0.000)].Prescriptionof SGLT2i or GLP1a was lower among patients with cardiovascular co-morbidities and those who identified as Black, Hispanic or Asian. Further efforts to minimize these disparities should be pursued.

    View details for DOI 10.1016/j.diabres.2022.110233

    View details for PubMedID 36581144

  • Use of lipid-lowering therapy preceding first hospitalization for acute myocardial infarction or stroke. American journal of preventive cardiology Sandhu, A. T., Rodriguez, F., Maron, D. J., Heidenreich, P. A. 2022; 12: 100426

    View details for DOI 10.1016/j.ajpc.2022.100426

    View details for PubMedID 36304918

  • Methamphetamine-associated heart failure: a systematic review of observational studies. Heart (British Cardiac Society) Manja, V., Nrusimha, A., Gao, Y., Sheikh, A., McGovern, M., Heidenreich, P. A., Sandhu, A. T., Asch, S. 2022

    Abstract

    To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

    View details for DOI 10.1136/heartjnl-2022-321610

    View details for PubMedID 36456204

  • Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic. JAMIA open Tisdale, R. L., Ferguson, J., Van Campen, J., Greene, L., Sandhu, A. T., Heidenreich, P. A., Zulman, D. M. 2022; 5 (4): ooac103

    Abstract

    Objective: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.Materials and Methods: Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.Results: 416587 Veterans with 1689595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92).Conclusion: The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.

    View details for DOI 10.1093/jamiaopen/ooac103

    View details for PubMedID 36531138

  • Cardiovascular vs. non-cardiovascular deaths after heart failure hospitalization in young, older, and very old patients. ESC heart failure Nakamaru, R., Shiraishi, Y., Sandhu, A. T., Heidenreich, P. A., Shoji, S., Kohno, T., Takei, M., Nagatomo, Y., Nakano, S., Kohsaka, S., Yoshikawa, T. 2022

    Abstract

    AIMS: The long-term outcome in patients with heart failure (HF) after hospitalization may vary substantially depending on their age and left ventricular ejection fraction (LVEF). We aimed to assess the relative rates of cardiovascular death (CVD) and non-CVD based on the age and how the rates differ under the updated LVEF classification system.METHODS AND RESULTS: Consecutively registered hospitalized patients with HF (N=3558; 39.7% women with a mean age of 73.9±13.3years) were followed for a median of 2 (interquartile range, 0.8-3.1) years. The CVDs and non-CVDs were evaluated based on age [young (<65years), older (65-84years), and very old (≥85years)] and LVEF classification [HF with preserved EF (HFpEF; LVEF ≥50%) and non-HFpEF (LVEF <50%)]. The adverse clinical events were adjudicated independently by a central committee. Overall, 1505 (42.3%) had HFpEF [young: n=182 (12.1%), older: n=894 (59.4%), very old: n=429 (28.5%)], and 2053 (57.7%) had non-HFpEF [young: n=575 (28.0%), older: n=1159 (56.5%), very old: n=319 (15.5%)]. During the follow-up, the crude incidence of all-cause death was higher in non-HFpEF than in HFpEF across all age groups (non-HFpEF vs. HFpEF, young: 10.4% vs. 5.5%, log-rank P=0.10; older: 26.6% vs. 20.9%, log-rank P=0.002; very old: 36.7% vs. 31.7%, log-rank P=0.043). CVDs accounted for more than half of all deaths in non-HFpEF (young 65.0%, older 64.2%, and very old 55.6%), whereas the proportion of CVDs remained less than half in HFpEF (young 50.0%, older 41.2%, very old 38.2%). HF readmission was associated with subsequent all-cause death in non-HFpEF [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.41-2.09, P<0.001], but not in HFpEF (HR: 1.12, 95% CI: 0.87-1.43, P=0.39).CONCLUSIONS: The probability of a non-CVD increases in both LVEF categories with advancing age, but that it is greater in the HFpEF category. The findings indicate that mitigating CV-related outcomes alone may be insufficient for treating HF in older population, particularly in the HFpEF category.

    View details for DOI 10.1002/ehf2.14245

    View details for PubMedID 36436825

  • Incidental Coronary Artery Calcium: Opportunistic Screening of Prior Non-gated Chest CTs to Improve Statin Rates (NOTIFY-1 Project). Circulation Sandhu, A. T., Rodriguez, F., Ngo, S., Patel, B. N., Mastrodicasa, D., Eng, D., Khandwala, N., Balla, S., Sousa, D., Maron, D. J. 2022

    Abstract

    BACKGROUND: Coronary artery calcium (CAC) can be identified on non-gated chest CTs, but this finding is not consistently incorporated into care. A deep learning algorithm enables opportunistic CAC screening of non-gated chest CTs. Our objective was to evaluate the impact of notifying clinicians and patients of incidental CAC on statin initiation.METHODS: NOTIFY-1 was a randomized quality improvement project in the Stanford healthcare system. Patients without known atherosclerotic cardiovascular disease (ASCVD) or prior statin prescription were screened for CAC on a prior non-gated chest CT from 2014-2019 using a validated deep learning algorithm with radiologist confirmation. Patients with incidental CAC were randomized to notification of the primary care clinician and patient versus usual care. Notification included a patient-specific image of CAC and guideline recommendations regarding statin use. The primary outcome was statin prescription within 6 months.RESULTS: Among 2,113 patients who met initial clinical inclusion criteria, CAC was identified by the algorithm in 424 patients. After additional exclusions following chart review, a radiologist confirmed CAC among 173 of 194 patients (89.2%) who were randomized to notification or usual care. At 6 months, the statin prescription rate was 51.2% (44/86) in the notification arm versus 6.9% (6/87) with usual care (p<0.001). There was also more coronary artery disease testing in the notification arm (15.1% [13/86] vs. 2.3% [2/87], p=0.008).CONCLUSIONS: Opportunistic CAC screening of prior non-gated chest CTs followed by clinician and patient notification led to a significant increase in statin prescriptions. Further research is needed to determine whether this approach can reduce ASCVD events.

    View details for DOI 10.1161/CIRCULATIONAHA.122.062746

    View details for PubMedID 36342823

  • Cost-effectiveness of Empagliflozin in Patients With Heart Failure With Preserved Ejection Fraction. JAMA internal medicine Zheng, J., Parizo, J. T., Spertus, J. A., Heidenreich, P. A., Sandhu, A. T. 2022

    Abstract

    Importance: In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear.Objective: To estimate the cost-effectiveness of empagliflozin in patients with HFpEF.Design, Setting, and Participants: This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure-specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients.Exposures: Empagliflozin or standard of care.Main Outcomes and Measures: Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio.Results: A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations.Conclusions and Relevance: In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.

    View details for DOI 10.1001/jamainternmed.2022.5010

    View details for PubMedID 36342696

  • Impact of Patient-Reported Outcome Measurement in Heart Failure Clinic on Clinician Health Status Assessment and Patient Experience: A Sub-Study of the PRO-HF Trial. Circulation. Heart failure Sandhu, A. T., Zheng, J., Kalwani, N., Gupta, A., Calma, J., Skye, M., Lan, R., Yu, B., Spertus, J., Heidenreich, P. 2022

    Abstract

    Background: Clinicians typically estimate heart failure (HF) health status using the New York Heart Association (NYHA) class, which is often discordant with patient-reported health status. It is unknown if collecting patient-reported health status improves the accuracy of clinician assessments. Methods: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a randomized, non-blinded trial evaluating routine Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) collection in HF clinic. Patients with a scheduled visit to Stanford HF clinic between August 30, 2021, and June 30, 2022 were enrolled and randomized to KCCQ-12 assessment or usual care. In this prespecified sub-study, we evaluated whether access to the KCCQ-12 improved the accuracy of clinicians' NYHA assessment or patients' perspectives on their clinician interaction. We surveyed clinicians regarding their patients' NYHA class, quality of life, and symptom frequency. Clinician responses were compared with patients' KCCQ-12 responses. We surveyed patients regarding their clinician interactions. Results: Of the 1,248 enrolled patients, 1,051 (84.2%) attended a visit during the sub-study. KCCQ-12 results were given to the clinicians treating the 528 patients in the KCCQ-12 arm; the 523 patients in the usual care arm completed the KCCQ-12 without the results being shared. The correlation between NYHA class and KCCQ-12 Overall Summary Score was stronger when clinicians had access to the KCCQ-12 (r=-0.73 vs. r=-0.61, p<0.001). More patients in the KCCQ-12 arm strongly agreed that their clinician understood their symptoms (95.2% vs. 89.7% of respondents; [OR 2.27; 95% CI: 1.32-3.87)]. However, patients in both arms reported similar quality of clinician communication and therapeutic alliance. Conclusions: Collecting the KCCQ-12 in HF clinic improved clinicians' accuracy of health status assessment; correspondingly, patients believed their clinicians better understood their symptoms. Registration: URL: ClinicalTrials.gov; Unique Identifier: NCT04164004.

    View details for DOI 10.1161/CIRCHEARTFAILURE.122.010280

    View details for PubMedID 36334312

  • Disparities in Hospital Length of Stay Across Race and Ethnicity Among Patients With Heart Failure. Circulation. Heart failure Zheng, J., Tisdale, R. L., Heidenreich, P. A., Sandhu, A. T. 2022; 15 (11): e009362

    Abstract

    Reducing hospital length of stay (LOS) has been identified as an important lever for minimizing the burden of heart failure hospitalization, yet the impact of social and structural determinants of health on LOS has received little attention. We investigated disparities in LOS across race/ethnicity and their possible drivers.We analyzed patients hospitalized for heart failure from 2017 to 2020 using the Get With The Guidelines-Heart Failure registry. We characterized LOS differences across race/ethnicity by insurance and disposition, adjusting for demographics, comorbidities, and clinical severity. Effects of hospital-level clustering on LOS across race/ethnicity were assessed using hierarchical mixed-effects models. We evaluated the association between LOS and discharge rates of guideline-directed medical therapy.Three thousand three seven hundred thirty patients hospitalized for heart failure were identified. After excluding inpatient deaths, the adjusted LOS for Black (5.72 days [95% CI, 5.62-5.82]), Hispanic (5.94 days [95% CI, 5.79-6.08]), and Indigenous American/Pacific Islander (6.06 days [95% CI, 5.85-6.27]) patients remained significantly longer compared with non-Hispanic White patients (5.32 days [95% CI, 5.25-5.39]). This pattern was driven by LOS differences among patients discharged to hospice or nursing facilities. After accounting for variability between hospitals, associations of race/ethnicity with LOS either were attenuated or reversed in direction. Guideline-directed medical therapy rates on discharge did not differ significantly across race/ethnicity despite longer LOS for Black, Hispanic, and Indigenous American/Pacific Islander patients.Differences between hospitals drive LOS disparities across race/ethnicity. Longer LOS among Black, Hispanic, and Indigenous American/Pacific Islander patients was not associated with improved quality of care.

    View details for DOI 10.1161/CIRCHEARTFAILURE.121.009362

    View details for PubMedID 36378760

  • The Patient-Reported Outcome Measurement in Heart Failure Clinic Trial: Rationale and Methods of The PRO-HF Trial. American heart journal Kalwani, N. M., Calma, J., Varghese, G. M., Gupta, A., Zheng, J., Brown-Johnson, C., Amano, A., Vilendrer, S., Winget, M., Asch, S. M., Heidenreich, P., Sandhu, A. 2022

    Abstract

    BACKGROUND: Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.STUDY DESIGN: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and healthcare utilization, including clinic visits, testing, hospitalizations, and emergency department (ED) visits. As a sub-study, PRO-HF also evaluated the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.CONCLUSIONS: PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

    View details for DOI 10.1016/j.ahj.2022.10.081

    View details for PubMedID 36309127

  • Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups. JACC. Heart failure Witting, C., Zheng, J., Tisdale, R. L., Shannon, E., Kohsaka, S., Lewis, E. F., Heidenreich, P., Sandhu, A. 2022

    Abstract

    There are sociodemographic disparities in outcomes of heart failure with reduced ejection fraction (HFrEF), but disparities in guideline-directed medical therapy (GDMT) remain poorly characterized.This study aimed to analyze GDMT treatment rates in eligible patients with recently diagnosed HFrEF, and to determine how rates vary by sociodemographic characteristics.This retrospective cohort study included patients diagnosed with HFrEF at Veterans Affairs (VA) hospitals from 2013 to 2019. The authors analyzed GDMT treatment rates and doses, excluding patients with contraindications. Therapies of interest were evidence-based beta-blockers (BBs), renin-angiotensin system inhibitors (RASIs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid antagonists (MRAs). The authors compared adjusted treatment rates by race and ethnicity, neighborhood social vulnerability, rurality, distance to medical care, and sex.The cohort comprised 126,670 VA patients with recently diagnosed HFrEF. The study found that racial and ethnic minorities had similar or higher treatment rates than White patients. Patients residing in socially vulnerable neighborhoods had 3.4% lower ARNI (95% CI: 1.9%-5.0%) treatment rates. Patients residing farther from specialty care had similar rates of GDMT therapy overall, but were less likely to be taking at least 50% of the target doses of either BBs (4.0% less likely; 95% CI: 3.1%-5.0%) or RASIs (5.0% less likely; 95% CI: 4.1%-6.0%) compared with those closer to care.Among VA patients with recently diagnosed HFrEF, the authors did not find that racial and ethnic minority patients were less likely to receive GDMT. However, appropriate dose up-titration may occur less frequently in more remote patients.

    View details for DOI 10.1016/j.jchf.2022.08.023

    View details for PubMedID 36647925

  • Medical therapy for patients with recent-onset heart failure with reduced ejection fraction during the COVID-19 pandemic: Insights from the Veteran's affairs healthcare system. American heart journal plus : cardiology research and practice Sandhu, A., Zheng, J., Tisdale, R., Kohsaka, S., Turakhia, M. P., Heidenreich, P. 2022: 100210

    Abstract

    This study aims to evaluate trends in guideline-directed medical therapy (GDMT) for patients with recent-onset heart failure with reduced ejection fraction (HFrEF) following the onset of the COVID-19 pandemic using an interrupted time series analysis in the Veteran's Affairs Healthcare System. Among 71,428 patients with recent-onset HFrEF between 1/1/2018 and 2/28/2021, we found the pandemic was not associated with differences in treatment rates for beta-blockers, renin-angiotensin-aldosterone system inhibitors, or mineralocorticoid receptor antagonists; there was a 2.6 % absolute decrease (95 % CI: 0.5 %-4.7 %) in ARNI rates in April 2020; which decreased over the pandemic. Despite the changes to healthcare delivery, the COVID-19 pandemic was associated with minimal changes in GDMT rates among patients with recent-onset HFrEF.

    View details for DOI 10.1016/j.ahjo.2022.100210

    View details for PubMedID 36156887

  • alpha-1 Adrenergic receptor antagonists and risk of severe COVID-19 Smith, E., Graham, D., Izurieta, H., Zhang, D., Avagyan, A., Lyu, H., Wiederhorn, A., Lu, Y., Mosholder, A., Zhao, Y., Shangguan, S., Tsai, H., Pennap, D., Sandhu, A., Wernecke, M., MaCurdy, T. E., Kelman, J., Forshee, R. A. WILEY. 2022: 163-164
  • Potential association with malnutrition and allocation of combination medical therapies in hospitalized heart failure patients with reduced ejection fraction. Scientific reports Kawakubo, Y., Shiraishi, Y., Kohsaka, S., Kohno, T., Goda, A., Nagatomo, Y., Nishihata, Y., Saji, M., Takei, M., Ikegami, Y., Niimi, N., Sandhu, A. T., Nakano, S., Yoshikawa, T., Fukuda, K., West Tokyo Heart Failure Registry, Shiraishi, Y., Kohsaka, S., Kohno, T., Goda, A., Nagatomo, Y., Nishihata, Y., Saji, M., Takei, M., Ikegami, Y., Nakano, S., Yoshikawa, T. 2022; 12 (1): 8318

    Abstract

    Malnutrition is common in patients with heart failure with reduced ejection fraction (HFrEF) and may influence the long-term prognosis and allocation of combination medical therapy. We reviewed 1231 consecutive patient-level records from a multicenter Japanese registry of hospitalized HFrEF patients. Nutritional status was assessed using geriatric nutritional risk index (GNRI). Combination medical therapy were categorized based on the use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists. The composite outcome of all-cause death and HF rehospitalization was assessed. The mean age was 72.0±14.2years and 42.6% patients were malnourished (GNRI<92). At discharge, 43.6% and 33.4% of patients were receiving two and three agents, respectively. Malnourished patients had lower rates of combination medical therapy use. The standardized GNRI score was independently associated with the occurrence of adverse events (hazard ratio [HR]: 0.88, 95% confidence interval [CI] 0.79-0.98). Regardless of the GNRI score, referenced to patients receiving single agent, risk of adverse events were lower with those receiving three (HR: 0.70, 95% CI 0.55-0.91) or two agents (HR: 0.70, 95% CI 0.56-0.89). Malnutrition assessed by GNRI score predicts long-term adverse outcomes among hospitalized HFrEF patients. However, its prognosis may be modified with combination medical therapy.

    View details for DOI 10.1038/s41598-022-12357-4

    View details for PubMedID 35585128

  • Regional variations in the process of care for patients undergoing percutaneous coronary intervention in Japan. The Lancet regional health. Western Pacific Shoji, S., Yamaji, K., Sandhu, A. T., Ikemura, N., Shiraishi, Y., Inohara, T., Heidenreich, P. A., Amano, T., Ikari, Y., Kohsaka, S. 2022; 22: 100425

    Abstract

    Background: Measuring the quality of care has been central for improving the outcomes of patients undergoing percutaneous coronary intervention (PCI). This study described the performance rates and regional variations in quality metrics for PCI using a representative national Japanese registry.Methods: Overall, 760,854 patients across 714 institutions (2016-2018) were analysed. Quality metrics included preprocedural antiplatelet therapy use, door-to-balloon time ≤90min for ST-elevation myocardial infarction, transradial approach, and preprocedural noninvasive stress testing for elective cases in 47 Japanese prefectures. Coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) were also evaluated. Factors associated with preprocedural testing rates were evaluated using multivariable linear regression.Findings: Rates of preprocedural antiplatelet therapy use were high with low variations (96·4% [94·7-97·2%]), but there was still substantial room for improvement in the rates of door-to-balloon time (74·7% [71·2-78·9%]) and transradial approach use (70·9% [65·1-73·4%]). Rates of preprocedural noninvasive stress testing were low with substantial variation (36·6% [27·1-49·7%]). Additionally, we found substantial variations in CCTA (50·0% [39·5-55·1%]) and FFR measurement (15·7% [113·-18·3%]) rates. The number of scintigraphy scanners/ prefecture was associated with the performance of noninvasive stress testing (13·4% [95% CI, 2·45-24·4%] increase for every 1/100,000 population increase in scanners).Interpretations: We observed substantial regional variation in the use of preprocedural testing, and its performance was directly related to nuclear-scanner availability. These findings suggest the need for targeted efforts in improving testing rates, whether by optimising resource allocation or additional education or feedback mechanisms.Funding: This study was funded by the Japan Society for the Promotion of Science (Grant Nos. 20H03915, 16H05215, 16KK0186, and 20K22883) and by the Ministry of Health, Labor and Welfare Grants-in-Aid for Scientific Research Program (Grant No. 21FA1015).The J-PCI registry is led and supported by the Japanese Association of Cardiovascular Intervention and Therapeutics.

    View details for DOI 10.1016/j.lanwpc.2022.100425

    View details for PubMedID 35308578

  • 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022: 101161CIR0000000000001063

    Abstract

    The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

    View details for DOI 10.1161/CIR.0000000000001063

    View details for PubMedID 35363499

  • 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022: 101161CIR0000000000001062

    Abstract

    The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

    View details for DOI 10.1161/CIR.0000000000001062

    View details for PubMedID 35363500

  • 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

    Abstract

    The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

    View details for DOI 10.1016/j.jacc.2021.12.012

    View details for PubMedID 35379503

  • 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

    Abstract

    The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

    View details for DOI 10.1016/j.jacc.2021.12.011

    View details for PubMedID 35379504

  • 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of cardiac failure Heidenreich, P. A., BozkurtChair, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

    Abstract

    The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

    View details for DOI 10.1016/j.cardfail.2022.02.009

    View details for PubMedID 35378259

  • Assessment of coding-based frailty algorithms for long-term outcome prediction among older people in community settings: a cohort study from the Shizuoka Kokuho Database. Age and ageing Nishimura, S., Kumamaru, H., Shoji, S., Nakatani, E., Yamamoto, H., Ichihara, N., Miyachi, Y., Sandhu, A. T., Heidenreich, P. A., Yamauchi, K., Watanabe, M., Miyata, H., Kohsaka, S. 2022; 51 (3)

    Abstract

    OBJECTIVES: To assess the applicability of Electronic Frailty Index (eFI) and Hospital Frailty Risk Score (HFRS) algorithms to Japanese administrative claims data and to evaluate their association with long-term outcomes.STUDY DESIGN AND SETTING: A cohort study using a regional government administrative healthcare and long-term care (LTC) claims database in Japan 2014-18.PARTICIPANTS: Plan enrollees aged ≥50years.METHODS: We applied the two algorithms to the cohort and assessed the scores' distributions alongside enrollees' 4-year mortality and initiation of government-supported LTC. Using Cox regression and Fine-Gray models, we evaluated the association between frailty scores and outcomes as well as the models' discriminatory ability.RESULTS: Among 827,744 enrollees, 42.8% were categorised by eFI as fit, 31.2% mild, 17.5% moderate and 8.5% severe. For HFRS, 73.0% were low, 24.3% intermediate and 2.7% high risk; 35 of 36 predictors for eFI, and 92 of 109 codes originally used for HFRS were available in the Japanese system. Relative to the lowest frailty group, the highest frailty group had hazard ratios [95% confidence interval (CI)] of 2.09 (1.98-2.21) for mortality and 2.45 (2.28-2.63) for LTC for eFI; those for HFRS were 3.79 (3.56-4.03) and 3.31 (2.87-3.82), respectively. The area under the receiver operating characteristics curves for the unadjusted model at 48months was 0.68 for death and 0.68 for LTC for eFI, and 0.73 and 0.70, respectively, for HFRS.CONCLUSIONS: The frailty algorithms were applicable to the Japanese system and could contribute to the identifications of enrollees at risk of long-term mortality or LTC use.

    View details for DOI 10.1093/ageing/afac009

    View details for PubMedID 35231096

  • Economic Issues in Heart Failure in the United States. Journal of cardiac failure Heidenreich, P. A., Fonarow, G. C., Opsha, Y., Sandhu, A. T., Sweitzer, N. K., Warraich, H. J. 1800

    Abstract

    The cost of heart failure care is high due to cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost-effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in one year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failurefor patientsand the health care system in the UnitedStates. It also provides a summary of the cost-effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out of pocket expenses for patients.

    View details for DOI 10.1016/j.cardfail.2021.12.017

    View details for PubMedID 35085762

  • Perks and Pitfalls of Performance-Linked Reimbursement for Novel Drugs: The Case of Sacubitril-Valsartan. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Heidenreich, P. A., Lin, J., Parizo, J., Bhattacharya, J., Goldhaber-Fiebert, J. D. 1800; 15 (1): e007993

    Abstract

    BACKGROUND: Rising drug costs have increased interest in performance-linked reimbursement (PLR) contracts that tie payment to patient outcomes. PLR is theoretically attractive to payers interested in reducing the risk of overpaying for expensive drugs, to manufacturers working to improve early drug adoption, and to patients seeking improved access. Multiple PLR contracts were developed for sacubitril-valsartan. We evaluated how the characteristics of a PLR contract influence its performance.METHODS: We used a published cost-effectiveness model of sacubitril-valsartan. We evaluated hypothetical PLR contracts that adjusted drug payment based on observed therapy effectiveness. Ideally, these contracts reduce the uncertainty around the value obtained with purchasing sacubitril-valsartan. By reducing the financial risk in covering an ineffective therapy, PLR incentivizes insurers to increase patient access. We measured the uncertainty in value as the SD of the incremental net monetary benefit (INMB), an estimate of therapy value incorporating costs and clinical benefits. We evaluated the change in INMB SD under a variety of different assumptions regarding contract design, therapy effectiveness, and population characteristics.RESULTS: Over 2 years, sacubitril-valsartan led to 0.042 additional quality-adjusted life-years at an incremental cost of $4916. Using a willingness-to-pay of $150000 per quality-adjusted life-year, this led to a mean INMB across simulations of $1416 (SD, $1720). A PLR contract that adjusted payment based on cardiovascular mortality reduced the INMB SD moderately by 20.7% while a contract based on all-cause mortality was more effective (INMB SD reduction of 27.3%). A contract based on heart failure hospitalization reduction was ineffective. PLR effectiveness increased with greater uncertainty regarding therapy effectiveness or in sicker cohorts (eg, New York Heart Association Class III/IV heart failure). Contracts required precise estimates of treatment effect in addition to trust or verifiability between manufacturers and payers concerning patient selection.CONCLUSIONS: The development of accurate prospective estimates of treatment effectiveness using actual enrollee characteristics will be critical for successful PLR. If able to meet these requirements, PLRs could incentivize insurers to expand access to expensive treatments by reducing financial risk.

    View details for DOI 10.1161/CIRCOUTCOMES.121.007993

    View details for PubMedID 35041480

  • Variability in Coronary Artery Disease Testing for Patients With New-Onset Heart Failure. Journal of the American College of Cardiology Zheng, J., Heidenreich, P. A., Kohsaka, S., Fearon, W. F., Sandhu, A. T. 2022; 79 (9): 849-860

    Abstract

    Coronary artery disease (CAD) is the most common cause of new-onset heart failure (HF). Although guidelines recommend ischemic evaluation in this population, testing has historically been underutilized.This study aimed to identify contemporary trends in CAD testing for patients with new-onset HF, particularly after publication of the STICHES (Surgical Treatment for Ischemic Heart Failure Extension Study), and to characterize geographic and clinician-level variability in testing patterns.We determined the proportion of patients with incident HF who received CAD testing from 2004 to 2019 using an administrative claims database covering commercial insurance and Medicare. We identified demographic and clinical predictors of CAD testing during the 90 days before and after initial diagnosis. Patients were grouped by their county of residence to assess national variation. Patients were then linked to their primary care physician and/or cardiologist to evaluate variation across clinicians.Among 558,322 patients with new-onset HF, 34.8% underwent CAD testing and 9.3% underwent revascularization. After multivariable adjustment, patients who underwent CAD testing were more likely to be younger, male, diagnosed in an acute care setting, and have systolic dysfunction or recent cardiogenic shock. Incidence of CAD testing remained flat without significant change post-STICHES. Covariate-adjusted testing rates varied from 20% to 45% across counties. The likelihood of testing was higher among patients co-managed by a cardiologist (adjusted OR: 5.12; 95% CI: 4.98-5.27) but varied substantially across cardiologists (IQR: 50.9%-62.4%).Most patients with new-onset HF across inpatient and outpatient settings did not receive timely testing for CAD. Substantial variability in testing persists across regions and clinicians.

    View details for DOI 10.1016/j.jacc.2021.11.061

    View details for PubMedID 35241218

  • Opportunistic Incidence Prediction of Multiple Chronic Diseases from Abdominal CT Imaging Using Multi-task Learning Blankemeier, L., Gallegos, I., Chaves, J., Maron, D., Sandhu, A., Rodriguez, F., Rubin, D., Patel, B., Willis, M., Boutin, R., Chaudhari, A. S., Wang, L., Dou, Q., Fletcher, P. T., Speidel, S., Li, S. SPRINGER INTERNATIONAL PUBLISHING AG. 2022: 309-318
  • Utilization of Generic Cardiovascular Drugs in Medicare's Part D Program. Circulation. Cardiovascular quality and outcomes Ma, I., Tisdale, R. L., Vail, D., Heidenreich, P. A., Sandhu, A. T. 2021: CIRCOUTCOMES120007559

    Abstract

    BACKGROUND: Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications.METHODS: This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution.RESULTS: Of $22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, $11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings.CONCLUSIONS: There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.

    View details for DOI 10.1161/CIRCOUTCOMES.120.007559

    View details for PubMedID 34879702

  • Seasonal influenza vaccination is associated with reduced risk of death among Medicare beneficiaries☆. Vaccine Buchman, T. G., Simpson, S. Q., Sciarretta, K. L., Finne, K. P., Sowers, N., Collier, M., Chavan, S., Do, R., Lin, C., Oke, I., Rhodes, K. E., Santhosh, A., Sandhu, A. T., Chu, S., Patel, S. A., Disbrow, G. L., Bright, R. A., MaCurdy, T. E., Kelman, J. A. 2021

    Abstract

    BACKGROUND: Influenza causes substantial mortality, especially among older persons. Influenza vaccines are rarely more than 50% effective and rarely reach more than half of the US Medicare population, which is primarily an aged population. We wished to estimate the association between vaccination and mortality reduction.METHOD: We used the US Center for Medicare and Medicaid Services (CMS) DataLink Project to determine vaccination status and timing during the 2017-2018 influenza season for more than 26 million Medicare enrollees. Patient-level demographic, health, co-morbidity, hospitalization, vaccination, and healthcare utilization claims data were supplied as covariates to general linear models in order to isolate and estimate the association between participation in the vaccination program and relative risk of death.FINDINGS: The 2017-2018 seasonal influenza vaccine reduced (Relative Risk Ratio [RRR] 0.936 [95% CI = 0.918-0.954]) the risk of all-cause death among beneficiaries following a hospitalization for sepsis and moreover the risk of death without a prior hospitalization during the 2.5-month outcome window (RRR 0.870 [95% CI = 0.853-0.887]). We estimate the number needed to vaccinate (NNV) to prevent a death in the ten-week outcome window is between 1,515 beneficiaries (95% CI = 1,351-1,754; derived from the average treatment effect of augmented inverse probability weighting) and 1,960 beneficiaries (95% CI = 1,695-2,381; derived from the average marginal effect of logistic regression). Among beneficiaries requiring hospitalization, the greatest death risk reduction accrued to those 85+years of age who were hospitalized with sepsis, RRR 0.92 [95% CI = 0.89-0.95]. No apparent benefit was realized by beneficiaries who required custodial (nursing home) care.INTERPRETATION: Seasonal influenza immunization is associated with relative reduction of death risk among non-institutionalized Medicare beneficiaries.FUNDING: All authors are full-time or contractual employees of the United States Federal Government, Department of Health and Human Services, the funding agency.

    View details for DOI 10.1016/j.vaccine.2021.11.016

    View details for PubMedID 34836659

  • 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 Choradia, N., Lam, J., Luo, B., Bounds, S., Yates, A. J., Quintana, J., Do, R., Feinberg, L., Sandhu, A., Vail, D., MaCurdy, T., Nagavarapu, S., Bhattacharya, J., Knee Arthroplasty Workgroup 2021

    Abstract

    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 Sandhu, A. T., Tisdale, R. L., Rodriguez, F., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Lewis, E., Heidenreich, P. A. 2021: CIRCHEARTFAILURE121008538

    Abstract

    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 Tisdale, R. L., Ferguson, J. M., Van Campen, J., Greene, L., Sandhu, A., Heidenreich, P., Zulman, D. SPRINGER. 2021: S168
  • High-Deductible Health Plans and Emergency Care for Chest Pain: To Go or Not to Go? Circulation Kalwani, N. M., Sandhu, A. T. 2021

    View details for DOI 10.1161/CIRCULATIONAHA.121.055368

    View details for PubMedID 34176296

  • 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 Sandhu, A. T., Kohsaka, S., Lin, S., Woo, C. Y., Goldstein, M. K., Heidenreich, P. A. 2021

    Abstract

    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 Tisdale, R. L., Ma, I., Vail, D., Bhattacharya, J., Goldhaber-Fiebert, J. D., Heidenreich, P. A., Sandhu, A. T. 2021; 4 (6): e2113969

    Abstract

    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 Eng, D., Chute, C., Khandwala, N., Rajpurkar, P., Long, J., Shleifer, S., Khalaf, M. H., Sandhu, A. T., Rodriguez, F., Maron, D. J., Seyyedi, S., Marin, D., Golub, I., Budoff, M., Kitamura, F., Takahashi, M. S., Filice, R. W., Shah, R., Mongan, J., Kallianos, K., Langlotz, C. P., Lungren, M. P., Ng, A. Y., Patel, B. N. 2021; 4 (1): 88

    Abstract

    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. JAMA cardiology Parizo, J. T., Goldhaber-Fiebert, J. D., Salomon, J. A., Khush, K. K., Spertus, J. A., Heidenreich, P. A., Sandhu, A. T. 2021

    Abstract

    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

  • Development of Episode-Based Cost Measures for the US Medicare Merit-based Incentive Payment System JAMA HEALTH FORUM Duseja, R., Andress, J., Sandhu, A. T., Bhattacharya, J., Lam, J., Nagavarapu, S., Nilasena, D., Choradia, N., Do, R., Feinberg, L., Bounds, S., Leoung, J., Luo, B., Swygard, A., Uwilingiyimana, A., MaCurdy, T. 2021; 2 (5)
  • COST-EFFECTIVENESS AND SYSTEM-WIDE IMPACT OF USING HEPATITIS C-VIREMIC DONORS FOR HEART TRANSPLANT Wayda, B., Sandhu, A., Parizo, J., Teuteberg, J., Khush, K. ELSEVIER SCIENCE INC. 2021: 3417
  • STATIN ADHERENCE AFTER HEART TRANSPLANTATION: AN OUTCOMES ANALYSIS Li, K., Kalwani, N., Sandhu, A., Khush, K., Fearon, W. ELSEVIER SCIENCE INC. 2021: 569
  • PREDICTORS OF SETTING OF HEART FAILURE DIAGNOSIS Tisdale, R., Stafford, R., Maron, D., Hernandez-Boussard, T., Rodriguez, F., Heidenreich, P., Sandhu, A. ELSEVIER SCIENCE INC. 2021: 676
  • Development of Episode-Based Cost Measures for the US Medicare Merit-based Incentive Payment System. JAMA health forum Duseja, R., Andress, J., Sandhu, A. T., Bhattacharya, J., Lam, J., Nagavarapu, S., Nilasena, D., Choradia, N., Do, R., Feinberg, L., Bounds, S., Leoung, J., Luo, B., Swygard, A., Uwilingiyimana, A. S., MaCurdy, T. 2021; 2 (5): e210451

    Abstract

    The Merit-based Incentive Payment System (MIPS), established as part of the Quality Payment Program, is a Medicare value-based payment program that evaluates clinicians' performance across 4 categories: quality, cost, promoting interoperability, and improvement activities. The cost category includes novel episode-based measures designed for targeted evaluation of the resource use of specific conditions. This report describes the development of episode-based cost measures and their role in the shift from volume-based to value-based purchasing.Episode-based cost measures focus on resource use related to the treatment of a specific condition or procedure. The measures exclude health care costs unrelated to the condition or procedure of focus. The episode-based cost measures provide a nuanced examination of resource use that can be used alongside quality metrics to identify opportunities to improve the value by capturing costs that are clinically related to the care being delivered within a given patient-clinician relationship of care delivered to patients. These measures were developed with the input of clinical committees composed of over 320 clinicians from 127 specialty societies and stakeholder organizations. The MIPS program currently evaluates clinician cost category performance based on 2 population-based cost measures (Medicare spending per beneficiary and total per capita costs) in addition to 18 episode-based cost measures. Additional episode-based cost measures are currently under development.The transition to value-based payment requires an accurate assessment of clinician effect on health care quality and cost. The use of episode-based cost measures to assess clinician influence on health care costs for high-priority conditions and procedures is an important step. The Centers for Medicare & Medicaid Services is introducing MIPS Value Pathways that will align episode-based cost measures with related quality measures to further incentivize the transition from fee-for-service to value-based care.

    View details for DOI 10.1001/jamahealthforum.2021.0451

    View details for PubMedID 36218674

  • 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 Thomas, M., Jones, P. G., Cohen, D. J., Arnold, S. V., Magnuson, E. A., Thourani, V. H., Fonarow, G. C., Sandhu, A. T., Spertus, J. A. 2021

    View details for DOI 10.1093/ehjqcco/qcab034

    View details for PubMedID 33914883

  • Development of a Cost Measure for Screening/Surveillance Colonoscopy for the Merit-Based Incentive Payment System. Gastroenterology Park, W. G., Sandhu, A., MaCurdy, T., collaborators of the Clinical Subcommittee for Screening/Surveillance Colonoscopy, U. A., Choradia, N., Schmitt, C., Koscheski, C., Lam, J., Bounds, S., Do, R., Feinberg, L., Vail, D., Nagavarapu, S., Bhattacharya, J. 2021

    View details for DOI 10.1053/j.gastro.2021.03.040

    View details for PubMedID 33798526

  • Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Do, R., Lam, J., Blankenship, J., Van Decker, W., Rich, J., Gonzalez, O., Wu, X., Pershing, S., Lin, E., MaCurdy, T. E., Bhattacharya, J., Nagavarapu, S. 2021: CIRCOUTCOMES119006461

    Abstract

    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

  • 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 Graham, D. J., Izurieta, H. S., Muthuri, S. G., Zhang, D., Sandhu, A. T., Lu, Y., Zhao, Y., Feng, Y., Eworuke, E., Lyu, H., Gandotra, C., Smith, E. R., Avagyan, A., Wernecke, M., Kelman, J. A., Forshee, R. A., MaCurdy, T. E. 2021

    Abstract

    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

  • Evaluation of Quality of Care for US Veterans With Recent-Onset Heart Failure With Reduced Ejection Fraction. JAMA cardiology Sandhu, A. T., Kohsaka, S., Turakhia, M. P., Lewis, E. F., Heidenreich, P. A. 2021

    Abstract

    Multiple guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF) are available and promoted by performance measures. However, contemporary data on the use of these therapies are limited.To evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among patients with recent-onset HFrEF.This cohort study analyzed claims and electronic health record data of patients with recent-onset HFrEF diagnosed at US Department of Veterans Affairs (VA) health care system facilities from July 1, 2013, through June 30, 2019. Veterans who had a history of heart transplant or used a ventricular assist device were among the patients who were excluded.Guideline-directed medical therapy (any β-blocker, guideline-recommended β-blocker [bisoprolol, carvedilol, or metoprolol succinate], angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and hydralazine plus nitrate) and ICD.Treatment rates for guideline-directed medical therapies and ICDs were calculated within 6 months of the index HFrEF date using medication fills, procedural codes for implantation and monitoring, and diagnosis codes. Risk-adjusted mortality was calculated after adjusting for baseline patient characteristics. For both treatment rates and risk-adjusted mortality, we evaluated the change over 3 periods (period 1: July 1, 2013, to June 30, 2015; period 2: July 1, 2015, to June 30, 2017; and period 3: July 1, 2017, to June 30, 2019) and variation across VA facilities.The final cohort comprised 144 074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. The cohort had a mean (SD) age of 71.0 (11.4) years and was mostly composed of men (140 765 [97.7%]). Overall, changes in medical therapy rates were minimal over time, with the use of a guideline-recommended β-blocker increasing from 64.2% in 2013 to 72.0% in 2019. Rates for mineralocorticoid receptor antagonist therapy increased from 23.9% in 2013 to 26.9% in 2019, and rates for hydralazine plus nitrate therapy remained stable at 24.2% over the study period. Rates for angiotensin receptor-neprilysin inhibitor therapy increased since its introduction in 2015 but only to 22.6% in 2019. Among patients with an ICD indication, early use rates decreased over time. Substantial variation in medical therapy rates persisted across VA facilities. Risk-adjusted mortality decreased over the study period from 19.9% (95% CI, 19.6%-20.2%) in July 1, 2013, to June 30, 2015, to 18.4% (95% CI, 18.0%-18.7%) in July 1, 2017, to June 30, 2019 (OR, 0.96 per additional year; 95% CI, 0.96-0.97).This study found only marginal improvement between 2013 and 2019 in the guideline-recommended therapy and mortality rates among patients with recent-onset HFrEF. New approaches to increase the uptake of evidence-based HFrEF treatment are urgently needed and could lead to larger reductions in mortality.

    View details for DOI 10.1001/jamacardio.2021.4585

    View details for PubMedID 34757380

  • 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 Wayda, B., Sandhu, A. T., Parizo, J., Teuteberg, J. J., Khush, K. K. 2021

    Abstract

    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

  • Predicting the EQ-5D from the Kansas City Cardiomyopathy Questionnaire (KCCQ) in Patients with Heart Failure. European heart journal. Quality of care & clinical outcomes Thomas, M. n., Jones, P. G., Cohen, D. J., Arnold, S. V., Magnuson, E. A., Wang, K. n., Thourani, V. H., Fonarow, G. C., Sandhu, A. T., Spertus, J. A. 2021

    Abstract

    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

  • The Affordability of Guideline-Directed Medical Therapy: Cost Sharing is a Critical Barrier to Therapy Adoption. Circulation Sandhu, A. T., Heidenreich, P. A. 2021; 143 (11): 1073–75

    View details for DOI 10.1161/CIRCULATIONAHA.120.053291

    View details for PubMedID 33720777

  • 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 Kohsaka, S., Sandhu, A. T., Parizo, J. T., Shoji, S., Kumamamru, H., Heidenreich, P. A. 2020: e016502

    Abstract

    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 Spertus, J. A., Jones, P. G., Sandhu, A. T., Arnold, S. V. 2020; 76 (20): 2379–90

    Abstract

    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 Parizo, J. T., Desai, M., Rodriguez, F., Sandhu, A. T., Khush, K. K. 2020

    View details for DOI 10.1016/j.healun.2020.09.017

    View details for PubMedID 33229249

  • 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 Sandhu, A. T., Tisdale, R., Joynt Maddox, K. E., Heidenreich, P. A. 2020: CIRCOUTCOMES119006353

    View details for DOI 10.1161/CIRCOUTCOMES.119.006353

    View details for PubMedID 32600063

  • Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017. JAMA cardiology Parizo, J. T., Kohsaka, S., Sandhu, A. T., Patel, J., Heidenreich, P. A. 2020

    Abstract

    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 Shoji, S., Sawano, M., Sandhu, A. T., Heidenreich, P. A., Shiraishi, Y., Ikemura, N., Ueno, K., Suzuki, M., Numasawa, Y., Fukuda, K., Kohsaka, S. 2020; 3 (4): e202004

    Abstract

    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 Sanders, M., Balla, S., Rodriguez, F., Patel, B., Eng, D., Khandwala, N., Sandhu, A., Maron, D. ELSEVIER SCIENCE INC. 2020: 1806
  • Adjustment For Social Risk Factors Does Not Meaningfully Affect Performance On Medicare's MIPS Clinician Cost Measures. Health affairs (Project Hope) Sandhu, A. T., Bhattacharya, J. n., Lam, J. n., Bounds, S. n., Luo, B. n., Moran, D. n., Uwilingiyimana, A. S., Fenson, D. n., Choradia, N. n., Do, R. n., Feinberg, L. n., MaCurdy, T. n., Nagavarapu, S. n. 2020; 39 (9): 1495–1503

    Abstract

    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. JAMA cardiology Parizo, J. T., Kohsaka, S. n., Sandhu, A. T., Patel, J. n., Heidenreich, P. A. 2020; 5 (9): 1042–47

    Abstract

    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 Sandhu, A. T., Kohsaka, S., Bhattacharya, J., Fearon, W. F., Harrington, R. A., Heidenreich, P. A. 2019; 4 (11): 1077–83
  • Engaging Cardiology Providers in Quality Measurement. Journal of the American Heart Association Heidenreich, P., Sandhu, A., Schofield, R. 2019; 8 (9): e012519

    Abstract

    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 Parizo, J., Kohsaka, S., Sandhu, A., Patel, J., Heidenreich, P. ELSEVIER SCIENCE INC. 2019: 737
  • 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 Sandhu, A. T., Heidenreich, P. A. 2019; 209: 63–67
  • Coronary CT Angiography and Subsequent Risk of Myocardial Infarction NEW ENGLAND JOURNAL OF MEDICINE Sandhu, A. T., Maron, D. J. 2019; 380 (3): 299
  • Optimizing the Use of Heart Transplant in the United States. JAMA Sandhu, A. T., Woo, Y. J., Khush, K. K. 2019; 322 (18): 1772–74

    View details for DOI 10.1001/jama.2019.16002

    View details for PubMedID 31714972

  • Validity of Performance and Outcome Measures for Heart Failure. Circulation. Heart failure Patel, J., Sandhu, A., Parizo, J., Moayedi, Y., Fonarow, G. C., Heidenreich, P. A. 2018; 11 (9): e005035

    Abstract

    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 Sandhu, A. T., Parizo, J., Moradi-Ragheb, N., Heidenreich, P. A. 2018; 178 (9): 1270-+
  • Association Between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography. JAMA internal medicine Sandhu, A. T., Parizo, J., Moradi-Ragheb, N., Heidenreich, P. A. 2018

    View details for PubMedID 30039163

  • Heart failure management with ambulatory pulmonary artery pressure monitoring TRENDS IN CARDIOVASCULAR MEDICINE Sandhu, A. T., Heidenreich, P. A. 2018; 28 (3): 212–19
  • Cost-Effectiveness of Sacubitril-Valsartan in Patients Who Have Heart Failure With Reduced Ejection Fraction. Annals of internal medicine Sandhu, A. T., Ollendorf, D. A., Chapman, R. H., Pearson, S. D., Heidenreich, P. A. 2017; 166 (8): 607-608

    View details for DOI 10.7326/L17-0044

    View details for PubMedID 28418550

  • Determinants of Raised Blood Pressure in Urban Uganda: A Community-Based Case-Control Study. Ethnicity & disease Chin, J. H., Twinobuhungiro, A., Sandhu, A., Hootsmans, N., Kayima, J., Kalyesubula, R. 2017; 27 (1): 15-20

    Abstract

    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 Sandhu, A. T., Heidenreich, P. A., Bhattacharya, J. n., Bundorf, M. K. 2017

    Abstract

    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 Maron, D. J., Sandhu, A. T. 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 Sandhu, A. T., Ollendorf, D. A., Chapman, R. H., Pearson, S. D., Heidenreich, P. A. 2016; 165 (10): 681-?

    Abstract

    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 Ollendorf, D. A., Sandhu, A. T., Pearson, S. D. 2016; 176 (10): 1551-1552
  • Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure JACC-HEART FAILURE Sandhu, A. T., Goldhaber-Fiebert, J. D., Owens, D. K., Turakhia, M. P., Kaiser, D. W., Heidenreich, P. A. 2016; 4 (5): 368-375

    Abstract

    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 Sandhu, A. T., Dudley, R. A., Kazi, D. S. 2016; 164 (8): 571-572

    View details for DOI 10.7326/L16-0007

    View details for Web of Science ID 000374257900024

    View details for PubMedID 27089078

  • Sacubitril-Valsartan for the Treatment of Heart Failure: Effectiveness and Value. JAMA internal medicine Ollendorf, D. A., Sandhu, A. T., Pearson, S. D. 2016; 176 (2): 249-250

    View details for DOI 10.1001/jamainternmed.2015.7661

    View details for PubMedID 26720832

  • Immune thrombocytopenia Hospital Medicine Clinics Ma, I., Sandhu, A. T. 2016; 6 (1): 53-66
  • A Cost Analysis of the American Board of Internal Medicine's Maintenance-of-Certification Program ANNALS OF INTERNAL MEDICINE Sandhu, A. T., Dudley, R. A., Kazi, D. S. 2015; 163 (6): 401-?

    Abstract

    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 RHEUMATOLOGY Skamra, C., Romero-Diaz, J., Sandhu, A., Huang, Q., Lee, J., Pearce, W., McPherson, D. D., Sutton-Tyrrell, K., Pope, R., Ramsey-Goldman, R. 2013; 52 (6): 1101-1108

    Abstract

    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