The use of large-scale databases in medical research is increasing due to advancements in computing power and ease of execution; however, their practical application in dermatology remains incompletely characterized. We reviewed the number of overall dermatology publications and the use of 14 large-scale databases in dermatology publications during recent decades. We also discuss the ethical implications of the growing use of large-scale databases in medical research, specifically dermatology. Structural issues within large-scale databases potentially introduce bias and risk exacerbating existing disparities. There are also concerns surrounding data transparency, reproducibility, and integrity. Finally, protection of patient privacy, autonomy, and informed consent remain major ethical concerns in large-scale database research. While these database resources allow for expanded research capabilities, there remains limited long-term validation of their findings along with questions regarding their general limitations.
Use of digital communication tools (e.g., telehealth, patient portals) is increasing in outpatient palliative care (OPC). Assess patient/caregiver experiences with digital communication tools. Qualitative. Inclusion criteria were age ≥18 years, English/Spanish/Cantonese-speaking, and ≥1 telehealth OPC visit in the prior year. If patients could not converse by phone, we interviewed their caregivers. We developed an interview guide using the Capability-Opportunity-Motivation-Behavior framework. We analyzed semi-structured interviews using thematic analysis. Among 32 participants, 10 were caregivers, 11 Spanish-speaking, 9 Cantonese-speaking. Theme 1: Video and in-person visits have important and distinct roles. Theme 2: Establishing a trusting rapport over video is possible. Theme 3: Engagement can be high with the patient portal despite poor usability. A flexible approach offering both video and in-person visits is ideal. Usability is a key factor in patient portal engagement. Our findings underscore the need to advocate for a permanent Medicare telehealth extension.
Race and ethnicity measures in administrative data can vary geographically. The extent of this challenge in US nursing homes is not well described. To describe geographic variation in missing race and ethnicity data in the Minimum Data Set (MDS) 3.0 and Medicare claims, and to compare discrepancies across data sources. Cross-sectional study. Medicare beneficiaries with MDS 3.0 records between 2014 and 2018. The Medicare Beneficiary Summary File provided demographic information. Missingness of MDS race and ethnicity data by state, and misclassification of Medicare race and ethnicity enrollment database (EDB) and Research Triangle Institute (RTI) variables compared with MDS. We calculate the sensitivity, specificity, and positive predictive value of the EDB and RTI variables relative to the MDS. Among 18.1 million nursing home residents pooled across 2014-2018, geographic variation in missing race and ethnicity in the MDS 3.0 ranged from 1.2% to 14.7%. Compared with MDS, misclassification of residents classified as Hispanic in MDS ranged from 48.1% to 89.2% for EDB and 0.5% to 44.8% for RTI. Misclassification of residents classified as Asian American/Pacific Islander in MDS ranged from 29.4% to 77.2% for EDB and 12.7% to 65.4% for RTI. Misclassification of residents classified as Black ranged from 0% to 14.2% for EDB and 0% to 16.2% for RTI. Overall, the RTI variables provided better sensitivity and specificity of race and ethnicity than the EDB. Missing race and ethnicity data in the MDS varies geographically, as do discrepancies between MDS and EDB and RTI variables. Thoughtful consideration of these issues is recommended when handling missing MDS race and ethnicity data.
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To determine how hospitalized cancer patients were impacted by the pandemic. Inpatients with a primary or secondary cancer diagnosis in the United States were identified using International Classification of Diseases, Tenth Revision, codes. Over 414,000 (210,000 weighted) cancer admissions were reported on the National Inpatient Sample database from 2019 to 2021 and used for analysis. Patients were stratified by COVID-19 status and sociodemographic factors. Primary outcomes included in-hospital complications, discharge disposition, and in-hospital mortality. Key subgroups included income quartiles and insurance type. Cancer patient admissions declined by 10.2% (75,150) from 2019 to 2020, whereas odds of in-hospital mortality decreased 9% (OR, 0.91; 95% CI, 0.87-0.94; P<.001). Drug-induced hematologic complications increased from 9.56% (70,207/734,385) to 10.2% (69,338/679,780; P<.001) and adverse effects and poisoning increased from 6.18% (45,385/734,385) to 6.86% (46,633/679,780; P<.001). COVID-19 patients experienced more drug-induced hematologic complications (9.87% [203,709/2,063,920] vs 16.3% [1545/9480]; P<.001), infectious (3.08% [63,569/2,063,920] vs 6.70% [635/9480]; P<.001), and thromboembolic events (2.79% [57,583/2,063,920] vs 5.01% [475/9480]; P<.001). The highest income quartile had 11% lower odds of in-hospital death than the lowest income quartile (OR, 0.89; 95% CI, 0.85-0.93; P<.001). Self-paying patients had 41% greater odds of in-hospital death than Medicare patients (OR, 1.41; 95% CI, 1.26-1.57; P<.001). Fewer cancer patients were admitted, and they experienced greater complications. Low-income, self-pay, as well as Black, Asian or Pacific Islander, and Other race patients, had higher odds of mortality. Overall in-hospital mortality for cancer patients decreased over the pandemic, possibly indicating change in place of death. Meanwhile, COVID-19-positive patients experienced more complications and increased in-hospital mortality. These findings emphasize the need for resilient and equitable health care systems to maintain essential services during crises.
To compare the efficacy, safety and tolerability of elagolix with dienogest in women with moderate-to-severe endometriosis-associated pain. A multicentre, double-blind, double-dummy, randomised, parallel-group, active-controlled, non-inferiority phase III study. Nineteen clinical centres across India. Women (18-49 years) diagnosed with endometriosis and experiencing moderate-to-severe pain. Participants were randomised (1:1) to receive oral elagolix (150 mg once daily) or dienogest (2 mg once daily) for 24 weeks. The primary outcome was change in endometriosis-related pain (Numeric Rating Scale [NRS]) from baseline to Day 85. Secondary outcomes included changes in NRS (Day 169), dysmenorrhoea, non-menstrual pelvic pain (NMPP) scores (Days 85 and 169), rescue medication use, patient global impression of change (PGIC), adverse events and bone mineral density. Of 340 patients screened, 230 were randomised (115 per group). At Day 85, both arms showed similar reductions in NRS pain scores with a treatment difference of 0.04 (95% CI: -0.3, 0.37) [p = 0.9747] demonstrating non-inferiority as upper 95% CI was below pre-specified margin of 1.5. At Day 169, both arms showed comparable improvements in overall pain, dysmenorrhoea and NMPP from baseline (p = 0.9372, p = 0.8884, and p = 0.9616, respectively). Rescue medication use and PGIC were comparable between treatment arms. Adverse event incidence was similar (elagolix: 14.8%; dienogest: 19.1%), with no serious TEAEs or discontinuations. No significant bone mineral density changes were observed. Elagolix demonstrated non-inferiority to dienogest with an acceptable safety and tolerability profile, supporting its use in managing endometriosis-associated pain. ClinicalTrials.gov identifier: CTRI/2023/01/049292.
Private equity (PE) is one form of corporate investment that has rapidly expanded into primary care, with more than 2400 primary care physicians becoming PE-affiliated since 2019. There are concerns that profit incentives associated with PE investment might be detrimental to care quality and patient outcomes. To examine changes in patient outcomes for the traditional Medicare (TM) population after primary care practices are acquired by PE firms and to identify any changes in patient composition. This economic evaluation used a stacked difference-in-differences analysis with a 20% Medicare Part B sample from 2016 to 2022. Medicare beneficiaries with PE-acquired primary care physicians were matched to control patients based on age, risk score, sex, race and ethnicity, state of residence, and dual-eligibility status. Statistical analysis was performed from November 2024 to February 2026. Primary care practice acquisition by a PE firm, identified using PitchBook data. Primary outcomes at the patient-quarter level include number of all-cause hospitalizations, number of potentially avoidable hospitalizations for ambulatory-sensitive conditions, and number of emergency department (ED) visits. Secondary outcomes include measures of patient composition, including patient age, sex, race and ethnicity, and hierarchical condition category score. The analysis included 24 397 beneficiaries with PE-acquired primary care physicians, matched to 121 939 control patients. The mean (SD) age was 74 (10) years, and 56% of patients were female. After PE acquisition, the number of all-cause ED visits decreased by 1.36% (95% CI, -2.72% to -0.14%) per patient-quarter relative to baseline. Considering various sensitivity tests, there were no significant changes to the probability of or number of potentially preventable hospitalizations or all-cause hospitalizations. Patient composition remained unchanged. In this national study of traditional Medicare beneficiaries, PE acquisitions of primary care practices were not associated with meaningful short-term changes in acute care outcomes. Overall, findings contribute to policy discourse on understanding the role of PE investments in shaping care quality, suggesting heterogeneity in outcomes across health care settings.
Mobility is a critical determinant of healthy aging. Agility, gait, balance, and fall risk, when left unassessed and unaddressed, may diminish older adults' ability to age in place, often leading to more restrictive, supervised care environments. This study examined racial and ethnic disparities in a composite mobility/functional measure in Hawai'i and the associations of selected social determinants of health (SDOH) with limitation status. We analyzed data from the Hawai'i Behavioral Risk Factor Surveillance System collected from 2019 through 2021. The study population included community-dwelling adults aged 55 years or older from the 4 largest racial and ethnic groups in Hawai'i: White, Filipino, Japanese, and Native Hawaiian (unweighted n = 10,039; weighted population estimate = 350,922). We used weighted logistic regression to assess associations between mobility limitations and SDOH. Mobility limitations were reported by 28% of Native Hawaiian people aged 55 years or older, compared with 17% to 19% among other groups. Native Hawaiian adults aged 55 to 64 years also had substantially higher prevalence of mobility limitations than adults of the same age in other racial and ethnic groups. Higher income was protective against mobility limitations for both Native Hawaiian and White adults. In contrast, the associations of education and health insurance with mobility limitations varied across groups, with weaker protective associations of education among Native Hawaiian adults. Findings suggest the importance of considering mobility-focused prevention and assessment for Native Hawaiian adults before the Medicare eligibility age of 65 years. To be effective, these interventions must be culturally grounded and tailored to the unique needs and lived experiences of Native Hawaiian communities.
Medicare home health is a critical postacute care source for individuals with Alzheimer disease and related dementias (ADRD). The Home Health Value-Based Purchasing (HHVBP) program has substantially reshaped financial incentives in home health, but its implications for patients with ADRD are unclear. To assess the association between residence in a state with an HHVBP program and home health service volume within 30 days of home health initiation among Medicare beneficiaries with ADRD, and how this varies by patient race and/or ethnicity, dual eligibility, and home health agency (HHA) racial composition. This cohort study linked 2021 to 2022 Medicare claims data with Home Health Focus and Provider of Services files for Medicare fee-for-service beneficiaries with ADRD older than 65 years who initiated home health care within 14 days of hospital discharge in the 9 states in which an HHVBP program was piloted compared with non-HHVBP states. The analysis was conducted from November 2024 to June 2025. Residence in an HHVBP pilot state vs a non-HHVBP state. Number of nursing and therapy visits received within 30 days (main analysis) and 14 days (sensitivity analysis) of home health initiation. Negative binomial regression models with HHA random effects were estimated, and average marginal effects were reported. The analytic cohort included 264 601 Medicare beneficiaries with ADRD (median [IQR] age, 83 [77-89] years; 160 947 males [60.8%]), of whom 68 765 (26.0%) resided in HHVBP states. The overall racial and ethnic composition included Asian (3.1%; n = 8099), non-Hispanic Black (8.9%; n = 23 634), Hispanic (6.3%; n = 16 562), and non-Hispanic White (81.7%; n = 216 306) individuals, as determined by Research Triangle Institute race codes from the Master Beneficiary Summary File. Adjusted 30-day outcomes showed HHVBP state residence vs non-HHVBP state residence was associated with 0.46 fewer nursing visits (3.94 vs 4.40 visits; average marginal effect [AME] = -0.46; 95% CI, -0.52 to -0.41; P < .001) and 0.32 more therapy visits (6.37 vs 6.05 visits; AME = 0.32; 95% CI, 0.24-0.39; P < .001). In non-HHVBP states, dual-eligible beneficiaries and those receiving care from HHAs primarily serving a racial and ethnic minority population received more nursing but fewer therapy visits compared with non-dual-eligible beneficiaries and those receiving care from HHAs serving a predominantly White population. These differences became smaller in HHVBP states. For example, therapy visit gaps between patients receiving care from HHAs primarily serving a racial and ethnic minority population and those receiving care from HHAs serving a predominantly White patient population narrowed from -0.81 (95% CI, -0.90 to -0.73) to -0.27 (95% CI, -0.44 to -0.09) visits in non-HHVBP vs HHVBP states (P < .001). The findings of increasing use of therapy visits and smaller group differences were consistent within a 14-day window. In this cohort study of Medicare beneficiaries with ADRD, residence in an HHVBP state was associated with increased therapy use and smaller differences in home health service patterns between racial and/or ethnic minority and White patients, dual-eligible and non-dual-eligible beneficiaries, and patients receiving care from minority-serving HHAs and those receiving care from HHAs serving a predominantly White patient population compared with residence in a non-HHVBP state. These findings suggest that VBP models could reduce differences in postacute care.
Cardiovascular multimorbidity (CVD MM), defined as two or more cardiovascular conditions, poses a significant public health challenge. Substance use disorders (SUDs) may elevate CVD MM risk, and health insurance disparities could exacerbate this relationship. We examined if insurance type moderates the association between SUDs and CVD MM. We analyzed cross-sectional data from 45,133 US adults in the 2023 National Survey on Drug Use and Health (NSDUH). CVD MM was defined as two or more specific cardiovascular conditions. SUDs included illicit drugs and cannabis, excluding nicotine dependence and alcohol use disorder. Logistic regression models examined the SUDs-CVD MM relationship and tested for an interaction between insurance type and SUDs, adjusting for covariates. Individuals in the representative sample of US adults were 60.8% privately insured, 17.4% with Medicaid, 9.1% with Medicare, 8.7% uninsured, and 4.0% with other types of insurance. CVD MM (12.7% Uninsured to 47.7% Medicare; p < 0.0001) and SUDs (2.8% Medicare to 8.3% Medicaid; p < 0.0001) prevalence varied significantly by insurance type. In adjusted models, SUDs were not associated with CVD MM; however, Medicaid enrollees had higher odds of CVD MM than those privately insured. In interaction models, insurance type was a statistically significant moderator of the SUDs-CVD MM association (p = 0.0146). Stratified models showed uninsured adults with SUDs had higher odds of CVD MM (aOR:2.25, 95% CI:1.28,3.93) compared to uninsured counterparts without SUDs. No significant association was found among privately insured, Medicaid, or other insured individuals. Uninsured individuals with SUDs face an elevated risk of CVD MM. Interventions improving access to care for this vulnerable population are crucial for reducing cardiovascular health disparities.
Amputation leads to disability and loss of mobility. This study focuses on the short-term recovery, especially early functionality gains and quality of life (QOL) improvements and how rehabilitation practices, particularly, timely fitting of prostheses and how educational status in specific, influence rehabilitation success. To assess the health-related quality of life (HRQOL) and functionality at 1, 3, and 6 months after unilateral trans-tibial amputation in a tertiary care hospital, South India. A longitudinal cohort study was conducted among 76 participants over 1.5 years using the tools, Research and Development (RAND-36) survey to measure HRQOL and Amputee Mobility Predictor (AMP), to assess functionality.Inclusion criteria: 1) Age-18-75 years; 2) unilateral trans-tibial amputees; and 3) operated at the given setting. Diabetic foot was the leading cause for amputation. At the end of 6th month, there was significant improvement (p < 0.05) in all parameters with confidence interval of 95%, QOL (95.8-103.9), and functionality (10.1-20.8). In comparison to nonusers, prosthetic users had significant improvements by the 6th month, w.r.t HRQOL (106.3) and AMP scores (26.1); nonusers (102.2 and 17.2, respectively). Amputees with higher education had significantly higher, HRQOL (106.1), AMP (26.9) scores, Medicare Functional Classification Levels (K2 and K3), and prosthesis usage rates (73.7%). Approximately 55.6% prosthetic users returned to work, vs. 32.1% nonusers. The HRQOL and functionality improved remarkably by the 6th month. Prosthesis has a positive impact on functionality, QOL, and return to work. Education is a significant determinant of prosthesis adoption and rehabilitation success.
Purpose: To compare the Medicaid and Medicare physician reimbursement rates for the top 10 most common vitreoretinal surgeries. Methods: The Medicaid-to-Medicare reimbursement ratios were compared for the most frequently used Common Procedural Terminology (CPT) codes, adjusted for each state's proportion of Medicaid enrollment in the United States. Results: The most used CPT codes were 67042 (26%), 67036 (20%), 67108 (17%), 67041 (11%), 67113 (11%), 67040 (6.5%), 67039 (4.1%), 67121 (2.8%), 67218 (0.44%), and 67107 (0.43%). The weighted average (±SD) of the Medicaid reimbursement rate was 88% ± 2.3% of the Medicare rates. New Jersey had the lowest Medicaid-to-Medicare ratio (52% ± 2.33% of all Medicaid enrollees). Thirty-six states, comprising 80% of all US Medicaid enrollees, had lower Medicaid than Medicare rates; 30 of those states had lesser-of policies, under which physicians would be reimbursed at the lower Medicaid rates despite patients being dually enrolled in both Medicaid and Medicare. Conclusions: There were significant variations between states, but Medicaid reimbursements were on average 12% lower than Medicare rates. In most states, there was a significant opportunity cost for the physician performing the same surgery on a patient with Medicaid compared with Medicare. State governments should work to improve patient access to care, match the Medicaid and Medicare rates, and eliminate lesser-of payment policies.
This analysis offers an in-depth view of the financial potential and hurdles of radioligand therapies (RLT) for healthcare institutions covered under the 340B Drug Pricing Program. Using Pluvicto (lutetium Lu 177 vipivotide tetraxetan) as a case study, we aim to highlight the economic misalignment between healthcare institutions and radiation oncologists. We provide an overview of the 340B program and performed a financial analysis of Pluvicto. This was achieved by identifying acquisition and reimbursement costs and comparing the Wholesale Acquisition Cost (WAC) to the calculated 340B ceiling price using HRSA formulas. Additionally, we compared physician work incentives by analyzing Medicare wRVU generation for a standard six-course of Pluvicto versus a 20-fraction External Beam Radiation Therapy (EBRT) plan. This analysis discovered that under the 340B program, covered entities can acquire Pluvicto at a discount of approximately 31.7% below the WAC ($34,970.71 vs. $51,168.13 per dose). This was shown to generate a potential gross margin of over $101,000 for a full six-dose course. Even with the large gross margin generated, we discovered that physician compensation remains disproportionately low. A full course of Pluvicto generates approximately 20.6 wRVUs compared to 47 wRVUs for a standard EBRT course. This creates a "wRVU trap" where radiation oncologists are financially penalized for the time-intensive training and management required for RLT. The 340B program offers significant revenue opportunities for hospitals administering RLTs like Pluvicto. However, current physician compensation models do not align with the clinical effort required. To ensure sustainable RLT adoption, health systems must leverage 340B margins to develop alternative incentive models that adequately compensate radiation oncologists for their role in this precision therapy.
Older adults have higher rates of traumatic brain injuries (TBI) than other age groups, accounting for most TBI-related hospitalizations and mortality. However, there is no up-to-date data on annual trends and regional differences in older Medicare beneficiaries. Here we estimate the incidence of TBI-related hospitalizations and identify annual trends and regional differences. This is a retrospective cohort analysis of fee-for-service Medicare claims data from 2010 to 2022. The study population consisted of beneficiaries with at least 1 year of continuous coverage including parts A and B. ICD codes were used to identify TBI-related hospitalizations. We estimated generalized linear mixed Poisson regression models of the aggregated TBI counts and included age group, sex, race/ethnicity, a sex by race/ethnicity interaction, period, and a random state effect as covariates. Geographic variability was summarized by the state random effects. 704,409 total observations met eligibility with 684,869 unique beneficiaries. Majority of beneficiaries were in the age ranges of 81-85 (22%) and 86-90 (22%), and 56% (n = 394,024) were female. Majority of beneficiaries were White (n = 610,688, 87%) and 5% (n = 31,723) were Hispanic. Incidence of TBI hospitalizations increased with age and were higher in females, particularly in the oldest age groups of 86-90 (7.15 [CI 7.06-7.25] in females vs. 5.49 [CI 5.41-5.56] in males) and > 91 (8.39 [CI 8.27-8.51] in females vs. 6.97 [CI 6.8-7.07] in males). Higher incidence of TBI hospitalizations were seen in the South, Northeast and West, with lower rates in the Midwest. We demonstrate that over the years TBI-related hospitalizations are consistently higher in the oldest-old adults, and in females. There is regional variation with highest TBI-related hospitalizations in the Northeast and South. Future studies aimed at identifying interactions between clinical and demographic factors are indicated to develop targeted public health interventions at mitigating TBI in older adults.
Sepsis remains a leading cause of preventable morbidity and mortality worldwide, and adherence to the Centers for Medicare & Medicaid Services Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) remains modest and variable across institutions. Simultaneously, controversy persists regarding fixed-volume fluid resuscitation mandates, particularly given the increasing emphasis on individualized, physiology-guided management. Artificial intelligence (AI) has emerged as a potential strategy to address both operational and clinical gaps in sepsis care. This review examines the current state of SEP-1 implementation, key barriers to compliance, and ongoing debates surrounding early fluid administration. We then discuss contemporary evidence on AI-enabled tools designed to accelerate bundle processes and support personalized fluid management. Early warning systems, natural language processing-augmented models, and telemedicine-integrated platforms have demonstrated improvements in process measures such as time-to-antibiotics and bundle component completion when embedded within defined clinical workflows. Reinforcement learning, causal machine learning, and predictive models offer promise for individualized fluid strategies, although most data remain retrospective and hypothesis-generating. Successful integration will require prospective validation, clinician-in-the-loop oversight, governance frameworks, and continuous monitoring for safety, equity, and model drift. AI should augment-rather than replace-clinical judgment to improve reliability, timeliness, and personalization in sepsis management.
Sentinel lymph node biopsy (SLNB) is commonly used for axillary staging in breast cancer surgery. Traditional localization methods include technetium-99m, lymphazurin, methylene blue (MB), or a combination of these. Indocyanine green (ICG) is a safe and effective alternative with fewer complications. We compared the cost-effectiveness of ICG and MB for SLNB in breast cancer. A systematic PubMed review identified the success and complication rates for MB and ICG. Costs of successful breast cancer surgeries with SLNB and related complications were estimated using Centers for Medicare & Medicaid Services (CMS) rates via Current Procedural Terminology (CPT) and Diagnosis Related Group (DRG) codes. Published utility scores were used to calculate quality-adjusted life years (QALYs). A decision tree model was developed to determine the incremental cost-effectiveness ratio (ICER). One-way (deterministic) and Monte Carlo (probabilistic) sensitivity analyses were performed to assess uncertainty. The willingness-to-pay (WTP) threshold was set to $50,000/QALY. SLNB using ICG cost $287 more than MB but gained 0.07 QALY, resulting in an ICER of $4,044.44, well below the WTP threshold. Sensitivity analysis showed SLNB with ICG became cost-ineffective if the probability of complication exceeded 4.9% or if ICG costs exceeded $4,190 per vial. SLNB with MB became cost-effective if the likelihood of complications dropped below 2.6%. Monte Carlo analysis indicated an 80% probability that SLNB with ICG is the more cost-effective option. Given lower complication rates despite higher upfront cost, ICG proved more cost-effective than MB in SLNB for breast cancer due to its improved quality-adjusted outcomes.
Sex-related disparities affect diagnosis, referral, and prognosis of aortic valvular diseases. Contemporary US data on transcatheter aortic valve implantation (TAVI) by sex are limited. To characterize 10-year trends in TAVI use, periprocedural complications, and long-term outcomes among Medicare beneficiaries, stratified by sex. This nationwide, retrospective, population-based cohort study used US Medicare claims data from fee-for-service beneficiaries discharged after TAVI from January 1, 2013, to December 31, 2022. The median follow-up time was 2.19 (IQR, 0.94-3.79) years. Exclusions included patients who had concomitant valve surgery, infective endocarditis, valve-in-valve TAVI, transapical TAVI, TAVI for pure aortic insufficiency, or later conversion to Medicare Advantage. Analyses were conducted between October 1, 2024, and April 1, 2025. TAVI. The primary outcome was all-cause mortality. Secondary outcomes included periprocedural mortality, vascular complications, acute kidney injury, major or life-threatening bleeding, stroke, acute myocardial infarction (AMI), permanent pacemaker implantation (PPI), and hospitalization for heart failure (HF). Adjusted odds ratios (AORs) and hazard ratios (AHRs) with 95% CIs were estimated. The study included 314 123 patients (141 233 women [45.0%] and 172 890 men [55.0%]). Women were older than men (mean [SD] age, female: 80.3 [7.8] years; male: 79.4 [7.7] years; standardized mean difference, 12%). The proportion of female patients who underwent TAVI declined from 47.6% in 2013 to 43.6% in 2022 (P < .001). Compared with men, women had higher periprocedural mortality (2.5% vs 2.2%; AOR, 1.20 [95% CI, 1.14-1.26]), vascular complications (5.8% vs 3.6%; AOR, 1.65 [95% CI, 1.60-1.71]), and bleeding (10.4% vs 6.8%; AOR, 1.67 [95% CI, 1.62-1.71]) but less PPI (16.9% vs 20.0%; AOR, 0.81 [95% CI, 0.79-0.82]). Long-term mortality was lower in female patients (AHR, 0.92; 95% CI, 0.91-0.93), although their risks of HF hospitalization, AMI, stroke, and bleeding were higher. Among Medicare beneficiaries, women constituted a progressively declining proportion of patients treated with TAVI, experienced more periprocedural complications, and demonstrated modestly better long-term survival compared with men. Further work is needed to understand factors influencing these trends and to refine sex-specific strategies for optimal outcomes.
Disparities in interfacility transfer of patients with acute ischemic stroke have been identified at the regional level, but a national analysis has not been conducted. This study aims to evaluate patient-level trends and disparities in transfer rates based on sex, race, ethnicity, and insurance status using the Get With The Guidelines-Stroke registry. The Get With The Guidelines-Stroke registry was used to identify patients admitted with acute ischemic stroke between January 2016 and December 2021. We examined patient transfer rate by race/ethnicity groups and by patient insurance status. Odds of transferring out among each demographic group were calculated using a multivariable generalized linear mixed-effect model accounting for patient- and hospital-level confounders. Models were stratified by sex to test for any potential interaction between sex and race/ethnicity or insurance status. Among 776 556 patients transferred out of 1333 sites, Hispanic and Black patients had lower odds of being transferred compared with non-Hispanic Whites among both males and females after adjustment for stroke severity and hospital characteristics (odds ratio [OR], 0.79 [95% CI, 0.74-0.84] for Hispanic females; OR, 0.88 [95% CI, 0.83-0.93] for Hispanic males; OR, 0.80 [95% CI, 0.76-0.83] for Black females; and OR, 0.84 [95% CI, 0.81-0.88] for Black males). Differences in transfer frequency were also noted based on insurance status. In the unadjusted model and model adjusted for stroke severity, patients of all non-Medicare payment groups had higher odds of being transferred out compared with Medicare patients. However, after also adjusting for hospital characteristics, patients with Medicaid had a lower frequency of transfer compared with patients with Medicare among males and females (OR, 0.75 [95% CI, 0.71-0.78] for females with Medicaid; OR, 0.78 [95% CI, 0.75-0.82] for males with Medicaid). In this large, nationwide cohort of patients with acute ischemic stroke, Black and Hispanic patients were less likely to be transferred than non-Hispanic White patients, and patients with Medicaid were less likely to be transferred than patients with Medicare. Further work is needed to understand the contributors to this disparity and the impact on access to high-quality stroke care.
Recent evidence supports early intervention in patients with asymptomatic aortic stenosis (AS) and normal ejection fraction. The study objective was to compare longitudinal surgical aortic valve replacement (SAVR) outcomes in asymptomatic versus symptomatic patients with normal left ventricular ejection fraction (LVEF). The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was leveraged to identify patients who underwent isolated SAVR for asymptomatic or symptomatic severe AS with LVEF≥50% between July 2011 and June 2022. The cohort was linked to Centers for Medicare & Medicaid Services data. The primary outcome was risk-adjusted 10-year survival. Subgroup analysis evaluated long-term survival stratified by age, LVEF, and STS predicted risk of mortality (PROM). A total of 17,683 patients with LVEF≥50% underwent isolated SAVR, 16,284 (92.1%) were symptomatic and 1,399 (7.9%) were asymptomatic. Compared to symptomatic patients, asymptomatic patients were younger (mean age 74.2 years vs 75.0 years, p<0.001) and had lower STS PROM (1.9%±1.4 vs 2.5%±2.0, p<0.001). Following risk adjustment, asymptomatic patients demonstrated superior 10-year survival compared to symptomatic patients (aHR 1.19 [95% CI 1.09-1.29]). In subgroup analyses, long-term survival benefit was more pronounced in asymptomatic versus symptomatic patients aged ≥75 years (aHR 1.24 [95% CI 1.11-1.39]), LVEF ≥60% (aHR 1.20 [95% CI 1.08-1.34]) and STS PROM <2 (aHR 1.17 [95% CI 1.01-1.34]). In patients with severe AS and preserved LVEF, SAVR prior to symptom onset shows superior long-term survival. This study supports early SAVR in carefully selected patients with asymptomatic severe AS.
Previous methods for assessing organ procurement organization (OPO) performance have not been reliable, making it necessary to develop a direct measurement of donation service area donor potential. The purpose of this study was to use a previously validated direct measurement of donor potential using referral data from 6 US OPOs to assess its usability as an alternative to current methods. Records of all 45 458 potential organ donors referred to 6 US OPOs in 2023, based on Medicare requirements of hospital referral, were reviewed; reasons that cases did not proceed to donation were categorized and quantified. All hospital deaths were reviewed through tissue referrals and chart audits to assess whether potential organ donors had not been referred. Of the 45 458 referrals, 40 978 cases were ruled out for documented clinical reasons, leaving 4480 medically suitable potential donors. The percentage of medically suitable referrals by OPO varied from 7.5% to 12.4%. Hospitals referred to >99% of the medically suitable potential donors. A review of a large number of referral records was made possible by robust electronic systems in each OPO, which also makes auditing practical. Determining OPO donor potential directly from a comprehensive analysis of hospital referrals is feasible and can be validated across multiple OPOs. It is more accurate than measures that use administrative data sources and could be a suitable alternative. Efforts should be made by national organizations to further their development.