BACKGROUND:Frailty before cardiovascular procedures is associated with poorer outcomes. While underutilized, cardiac rehabilitation (CR) is guideline-recommended for patients undergoing cardiovascular procedures and may help mitigate the effects of frailty. This study evaluated the association between preprocedural frailty and CR use, as well as the interaction of frailty and CR use on 1-year mortality. METHODS:Medicare fee-for-service claims were queried for patients undergoing percutaneous or surgical revascularization or aortic valve replacement between July 2016 and December 2018. Patients who experienced mortality during the index admission or within 30 days of discharge were excluded. Patients were stratified into quartiles (Q1-Q4) using the validated claims-based frailty index (CFI). CR use was defined as attending any CR session within 1 year of discharge. Unadjusted comparisons and multivariable analyses were used to evaluate the relationship between frailty and CR use (CFI-Q4 versus CFI-Q1). An inverse probability treatment weighting model was used to determine if there was an interaction between CR, frailty, and 1-year mortality. RESULTS:Overall CR use among the 501 049 beneficiaries was 37.7%; the average age was 75.9 years (SD, 7.3), and 37.0% were female. Increasing frailty was associated with decreased CR use (CFI-Q1: 49.7%, CFI-Q2: 42.2%, CFI-Q3: 35.3%, and CFI-Q4: 23.7%; P<0.001; adjusted odds ratioCFI-Q4 versus CFI-Q1, 0.63 [95% CI, 0.62-0.64]). Unadjusted 1-year mortality was higher with increasing frailty (CFI Q1: 2.5%, CFI-Q2: 5.1%, CFI-Q3: 9.0%, and CFI Q4: 16.9%; P<0.001). After adjustment, the reduction in mortality associated with CR use was greater among frailer patients relative to less frail patients (CFI-Q4: 9.2% and CFI-Q1: 1.7%; P<0.001). CR use was associated with a significantly reduced association between CFI and 1-year mortality (P<0.001). CONCLUSIONS:Preprocedural frailty is associated with lower CR use despite greater absolute benefits on 1-year mortality. Increasing CR use of frail Medicare beneficiaries may reduce 1-year mortality after cardiac interventions.
BACKGROUND:Given the large variation in out-of-hospital cardiac arrest (OHCA) survival, the Resuscitation Academy has developed a comprehensive training and mentorship program for emergency medical service (EMS) agencies to improve OHCA care. This study will evaluate whether Resuscitation Academy training is associated with higher OHCA survival at EMS agencies, particularly those with lower OHCA survival. METHODS:Within the Cardiac Arrest Registry to Enhance Survival, we will conduct a prospective mixed-methods study of EMS agencies participating in Resuscitation Academy training between October 2024 and December 2026 with ≥2 years of OHCA data collection and ≥20 OHCAs annually. Enrollment of EMS agencies with low baseline OHCA survival and diverse sociodemographic and socioeconomic characteristics will be prioritized, with a goal of 100 enrolled agencies. Changes in OHCA survival (primary outcome: survival to hospital admission) between EMS agencies enrolled in the Resuscitation Academy, compared with control agencies, will be compared using a difference-in-difference analysis. We will also quantify changes in processes of care within individual Resuscitation Academy domains to identify those most strongly associated with survival improvement. Finally, we will identify facilitators and barriers to implementation of Resuscitation Academy recommendations through in-depth semistructured interviews with key stakeholders (EMS director, medical director, dispatchers, quality improvement director, and paramedics). RESULTS:As of December 31, 2024, 15 EMS agencies have been prospectively enrolled. Twelve (80.0%) had below median OHCA survival rates to hospital admission (<24.9%), 5 (33.3%) had catchment areas that were majority (>50% of residents in the EMS catchment area) Black or Hispanic, and 7 (46.7%) served communities with below median annual household income (<$71 623) levels. CONCLUSIONS:This study will provide key insights for a potential intervention to improve OHCA survival, especially at EMS agencies with lower survival. Moreover, it may serve as a roadmap for the evaluation of future health policy investments to improve OHCA care and reduce disparities.
BACKGROUND:Living in neighborhoods with a greater burden of violence is associated with higher cardiovascular disease risk. However, the interpretation of place-based findings is impeded by methodological challenges. To address challenges related to the influence of correlated neighborhood exposures, we utilized a case-crossover design to examine whether patients were more likely to have experienced a violent crime in their neighborhood during the month before their hypertension-related emergency department (ED) visit, compared with control periods 1 year before and after. METHODS:Participants were patients who made ED visits to a single hospital in the Northwestern Medicine Health System between 2016 to 2019 and had a valid address in Chicago. Neighborhood violent crime was quantified at the block group level and modeled as both a dichotomous exposure (testing for an absolute effect, where any crime increases hypertension risk) and a continuous exposure (testing for a relative effect, where crime increases relative to the area norms increase hypertension risk). The primary outcome was a hypertension-related ED visit. Conditional logistic regression (without covariate adjustment) was the principal analytic method. RESULTS:The sample (N=22 173) had a mean age = 66.0 years and was 52.7% female; 39.9% White, 35.7% Black, 12.4% Hispanic. Among the patients, 51.5% lived in block groups where a violent crime occurred in the month before the ED visit (ie, case period); 50.7% lived in block groups where a violent crime occurred during the control periods. Neighborhood violent crime was associated with a greater likelihood of a hypertension-related ED visit, both when observing absolute changes in violent crime (odds ratio, 1.05 [95% CI, 1.01-1.09]) and relative changes in violent crime (odds ratio, 1.03 [95% CI, 1.01-1.05]). CONCLUSIONS:This research has clinical and policy implications related to the importance of public safety and the potential cardiovascular-related risks following exposure to neighborhood violent crime.
BACKGROUND:Heart failure with reduced ejection fraction guideline-directed medical therapy remains underused, particularly in socioeconomically disadvantaged populations. It has been proposed that the use of combination pills (polypills) may facilitate prescribing of guideline-directed medical therapy and increase adherence. Understanding patient perspectives on implementation barriers and facilitators to the use of polypills is needed for developing effective strategies. METHODS:A convergent, parallel, mixed-methods study was conducted with participants who participated in a phase II randomized controlled trial of a heart failure with reduced ejection fraction polypill (POLY HF) in Dallas, TX. Six focus groups were conducted with participants from both polypill and usual care arms, followed by brief surveys. Qualitative data were analyzed using directed content analysis organized by a socioecological framework to identify barriers and facilitators across individual, interpersonal, and systems levels. Descriptive statistics characterized medication burden and polypill preferences. RESULTS:Study participants (n=41) included trial participants (n=36, mean 53 years, 53% Black race, 39% Hispanic) and caregivers (n=5). Quantitative data revealed substantial medication burden, with 58% taking ≥6 medications and 50.0% reporting missed doses, primarily due to forgetting (44%). 88.6% expressed interest in a polypill approach, and 83% believed it would improve adherence. Qualitative analysis identified multilevel implementation barriers and facilitators. Individual-level barriers included pill size concerns and uncertainty about polypill contents, while facilitators encompassed reduced pill burden, psychological benefits of taking fewer medications, and perceived health improvements. Interpersonal facilitators included caregiver enthusiasm for simplified medication management and strong provider trust. Systems-level barriers centered on cost concerns, while institutional trust facilitated acceptance. Mixed-methods integration revealed convergent findings. Quantitative medication burden aligned with qualitative themes of regimen complexity, while high quantitative interest in polypills was contextualized by practical implementation considerations regarding formulation and delivery. CONCLUSIONS:In socioeconomically disadvantaged patients with heart failure with reduced ejection fraction, a polypill strategy demonstrated strong patient acceptability, supporting further implementation research. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT04633005.
BACKGROUND: Cardiac rehabilitation (CR) reduces morbidity and mortality among individuals with heart disease. Although the COVID-19 pandemic disrupted health services, its impact on CR participation remains poorly understood—especially among commercially insured populations, for whom CR utilization trends are poorly documented. METHODS: This cross-sectional time series study of enrollees aged 18 to 64 years with ≥1 CR-qualifying event (acute myocardial infarction, coronary artery bypass graft, heart valve repair/replacement, percutaneous coronary intervention, or heart/heart-lung transplant) during 2017 to 2022, with follow-up through 2023, used MarketScan commercial claims data. Adjusted analyses used Poisson log-linear models with robust standard errors to examine trends in enrollment and completion (≥36 sessions), and generalized linear models with negative binomial distribution and log-link function to examine trends in days to enrollment and number of sessions. RESULTS: The sample included 143 870 unique individuals aged 18 to 64 years with a CR-qualifying event. Of the sample, the mean age was 53.9 (SD, 8.1), and 70% were men. On average, from 2017 to 2023, enrollment was 24.2%, days to enrollment were 46.3 (SD, 51.4 days), the number of sessions was 13.9 (SD, 12.8), and completion was 9.6%. Compared with year 2017, 2020 was associated with a 12% lower prevalence of enrollment (adjusted prevalence ratio, 0.88 [95% CI, 0.85–0.90]), 6-day longer time to enrollment on average (adjusted difference, 6.04 [95% CI, 4.36–7.72]), 1.2 fewer sessions on average (adjusted difference, −1.24 [95% CI, −1.72 to −0.75]), and 13% lower prevalence of completion (prevalence ratio, 0.87 [95% CI, 0.78–0.97]). All metrics rebounded to prepandemic levels, except days to enrollment (4 days longer in 2022 versus 2017; adjusted difference, 3.78 [95% CI, 2.22–5.34]). CONCLUSIONS: Among commercially insured adults <65 years, only one-quarter of eligible individuals participated in CR. CR metrics worsened during the COVID-19 pandemic in 2020, but most rebounded to prepandemic levels. These findings highlight an opportunity for health systems and public health initiatives to support broader CR uptake.
BACKGROUND:Targeted, digital recruitment strategies such as tailored websites using motivational themes may improve recruitment in clinical trials, but their effectiveness remains unclear. We hypothesized that themes emphasizing community well-being, personal health benefits, or access to perks would increase engagement and prescreening sign-ups compared with a standard contribution to science message in a clinical trial focused on Black adults. METHODS:We implemented A/B testing of website themes for recruitment in two randomized trials testing the dietary approaches to stop hypertension diet intervention on blood pressure among Black adults. Website themes were derived from predeveloped motivational categories and included (1) contribution to science (control group), (2) community well-being, (3) personal blood pressure improvement, and (4) access to perks (groceries or cash). A/B randomization directed visitors to a theme randomly between June and December 2024. Using an open-source Web analytics platform, we captured data on 2 primary outcomes: (1) sign-up rate defined as the proportion of unique visitors who completed the trial's prescreening form and (2) engagement defined as (a) mean pageviews per session and (b) mean time spent on site per session. We compared themes using the Welch t tests with statistical significance assessed as 2-tailed P<0.05. RESULTS:Among 11 484 visitors over 6 months, the themes of community well-being (13.8%), personal blood pressure improvement (14.1%), and access to perks (13.1%) all attracted higher sign-up rates than contribution to science (11.1%; P<0.05 for all comparisons). All alternative themes also led to significantly higher mean pageviews compared with the contribution to science theme (P<0.05 for all comparisons), while mean time on site was similar across all themes (range, 52-55 seconds with P>0.05 for all comparisons). There were no statistical differences noted across the 3 alternative motivational themes for these outcomes. CONCLUSIONS:Tailored websites with digital messages emphasizing community well-being, personal health benefits, and access to perks significantly improved engagement and prescreening sign-up rates, demonstrating that they may enhance recruitment within cardiovascular research. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifiers: NCT05393232 and NCT05121337.
BACKGROUND:The dissemination of novel procedures should attempt to strike a balance between access and procedure quality. This study aimed to evaluate the temporal trends and geographic dispersion of mitral transcatheter edge-to-edge repair (M-TEER) sites and to examine the associations of site volume and site-to-population density with patient outcomes. METHODS:We used the Medicare administrative databases in the United States to identify sites performing M-TEER in patients aged 65 to 99 years from 2017 to 2020 and examined the annualized volume and site-to-population density (per million beneficiaries in each corresponding hospital referral region). A hierarchical Cox regression analysis accounting for site-level clustering was performed to assess the association of site volume and density with 30-day and 1-year all-cause mortality. RESULTS:We identified 456 sites performing M-TEER in 16 810 patients (median [interquartile range] age, 81 [75-86] years; female, 47%). The case number of M-TEER increased by 54% from 3125 in 2017 to 4820 in 2020, while sites performing M-TEER increased by 71% from 252 in 2017 to 432 in 2020, corresponding to a decline in the median patient-to-site distances from 37.1 kilometers (interquartile range, 14.4-105.0) to 28.6 kilometers (interquartile range, 12.8-74.9). Higher site volume (every 10 cases/y) was associated with lower 30-day (adjusted hazard ratio, 0.94 [95% CI, 0.91-0.99]) and 1 year (adjusted hazard ratio, 0.98 [95% CI, 0.96-1.00]) mortality, while there was insufficient evidence to determine the association between higher site density (every 1 site/million-beneficiaries) and 30-day (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.02]) and 1-year (adjusted hazard ratio, 1.00 [95% CI, 0.99-1.01]) mortality. CONCLUSIONS:Although sites performing M-TEER have been rapidly expanding, we did not find associations between higher regional site density and patient mortality. Continuous careful planning in disseminating M-TEER while ensuring adequate procedure volume per site may optimize patient outcomes.
BACKGROUND:Invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI) are common procedures for the diagnosis and treatment of coronary artery disease (CAD). These procedures are typically performed within the parameters of insurance coverage, but little is known about how insurance policies align with guidelines and landmark randomized clinical trials. METHODS:We developed 6 use cases (3 each for ICA and PCI) of clinical scenarios for stable CAD commonly encountered in clinical practice and compared policies of the largest US public and private payers (based on total revenue and number of beneficiaries) to the 2012 and 2023 professional society guidelines as well as the ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) and ISCHEMIA (Initial Invasive or Conservative Strategy for Stable Coronary Disease) trials. We classified policies as more restrictive, equal, or less restrictive than the guidelines and published randomized clinical trials by evaluating them on parameters of optimal medical therapy (OMT) and noninvasive imaging for ICA policies; and OMT, anatomic severity of CAD, and ability to proceed with PCI for PCI policies. We summarized findings with descriptive statistics. RESULTS:Among 33 payers, 18 (55%) ICA and 14 (42%) PCI policies were publicly available. When comparing requirements for OMT among symptomatic patients before ICA, 22% of policies were less restrictive, 75% were equivalent, and 3% were more restrictive than the 2012 and 2023 professional society guidelines. For the number of OMT medications among symptomatic patients before ICA, 44% were less restrictive and 56% were equivalent compared with the ORBITA trial. When comparing requirements for OMT for symptomatic patients before PCI, 21% of policies were less restrictive, 75% were equivalent, and 4% were more restrictive than the 2012 and 2023 guidelines. CONCLUSIONS:ICA and PCI coverage policies were only publicly available for approximately half of the largest US insurers, indicating need for greater transparency. When available, policies were variable in their alignment with clinical practice guidelines.
Equitable, timely, and evidence-based care remains a central goal across health care ecosystems, yet significant quality gaps, care variability, and health disparities persist. Professional societies, including the American Heart Association, have long developed clinical practice guidelines to provide standardized, evidence-based recommendations across the cardiovascular care continuum. These guidelines are operationalized into quality measures to monitor care, identify gaps, and guide improvement. Professional societies, agencies, and health systems have applied implementation science strategies, such as education, data sharing, and evaluation, to improve care quality and achieve quality measures defined in the clinical practice guidelines. American Heart Association's Get With The Guidelines programs target inpatient quality measures for stroke, heart failure, atrial fibrillation, resuscitation, and coronary artery disease, complemented by ambulatory quality improvement programs to support seamless care transitions. Decades of Get With The Guidelines implementation have enabled American Heart Association teams and volunteers to refine these programs, improving guideline adherence at local, regional, and national levels. Lessons learned informed the development of the Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand Framework, designed to guide successful quality improvement initiatives. While existing quality improvement frameworks provide structured approaches, many are costly, slow, or siloed, limiting rapid-cycle, data-driven innovation across diverse health systems. The Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand framework addresses these limitations as an adaptable model, applicable across care settings, disease areas, patient populations, system size, budgets, and target end points. Here, we illustrate the Observe, Uncover, Trial, Personalize, Accelerate, Check, Expand framework through 2 recent American Heart Association programs: Target: Aortic Stenosis and the IMPLEMENT-HF initiative, demonstrating its utility in guiding effective, scalable quality improvement.
BACKGROUND:The Target Stroke Phase III program is a national quality improvement initiative led by the American Heart Association, which sought to improve the quality of care for patients with acute stroke undergoing acute reperfusion therapy including endovascular thrombectomy (EVT). METHODS:A retrospective, observational cohort study was performed using data from the American Heart Association Get With The Guidelines-Stroke Program between January 1, 2017, and March 31, 2022. Three categories of patients were analyzed: (1) patients who arrived directly at the thrombectomy hospital and had EVT, (2) patients who were transferred in from a nonthrombectomy hospital and had EVT, and (3) patients at a nonthrombectomy hospital who were potentially eligible for EVT, received intravenous thrombolysis, and were transferred out. The primary end point of this study for thrombectomy hospitals was door-to-puncture time. RESULTS:In direct-arriving EVT patients, 2 Target Stroke Phase III strategies were independently associated with shorter door-to-puncture time: (1) alerting the neurointerventional team based on emergency medical services prenotification (-21.9 [95% CI, -42.5 to -1.3] minutes) and (2) performance of a brain computed tomography and computed tomography angiography in all patients presenting ≤24 hours from time last known well (-6.6 [95% CI, -11.8 to -1.5] minutes). In transfer-in EVT patients, 2 Target Stroke Phase III strategies were independently associated with a shorter door-to-puncture time: (1) increased use of stroke screening tools (-3.5 [95% CI, -6.4 to -0.6] minutes per 25% increase in use of the screening tool) and (2) increased use of a camera during telestroke consultations (-5.8 [95% CI, -10.7 to -0.9] minutes per 25% increase in camera use). CONCLUSIONS:Several Target Stroke Phase III strategies are associated with more timely care, which are distinctly different for thrombectomy and nonthrombectomy hospitals and for patients arriving by emergency medical services compared with interfacility transfer.
BACKGROUND:In a universal health care system, geographic disparities in atrial fibrillation (AF) outcomes remain poorly understood. This study aimed to evaluate rural-urban differences in clinical outcomes among patients presenting to the emergency department (ED) with AF. METHODS:We conducted a population-based retrospective cohort study of all adults (aged ≥18 years) presenting to an ED in Ontario, Canada, with a primary diagnosis of AF between April 1, 2012, and March 31, 2022. Rural residence was defined as living in a community with a population of ≤10 000. The primary outcome was a composite of all-cause mortality or hospital admission within 1 year; secondary outcomes included the individual components of the primary outcome and all-cause ED visits. Comparisons were adjusted for demographics and baseline comorbidities using inverse probability of treatment weighting. Cox regression was used for end points that included death. RESULTS:Among 104 195 eligible patients, 16 860 (16.2%) resided in rural communities. After inverse probability of treatment weighting, baseline characteristics were well balanced (standardized differences <0.1) as the mean age was 69.4 years in rural and urban groups; 47.2% were women in the rural group versus 47.1% in the urban group. Within 1 year, patients with AF presenting to the ED in rural Ontario had higher rate of all-cause mortality or admission compared with the urban group (34.6% versus 33.5%; hazard ratio, 1.04 [95% CI, 1.01-1.07]), driven primarily by increased hospital admission rates (31.3% versus 29.7%; hazard ratio, 1.06 [95% CI, 1.03-1.09]). ED visit rates were higher in rural patients (63.8% versus 55.3%; hazard ratio, 1.27 [95% CI, 1.25-1.30]), while mortality was similar (9.8% versus 9.9%; hazard ratio, 1.00 [95% CI, 0.95-1.04]). CONCLUSIONS:Despite universal health care coverage, rural-urban disparities in AF outcomes persist. Rural patients with AF had higher acute care utilization compared with urban patients. System interventions are needed to address inequities for rural populations.
BACKGROUND:The potential J-shaped relationship whereby lower diastolic blood pressure (DBP) is associated with a higher risk of adverse cognitive outcomes has raised concerns regarding intensive systolic blood pressure (SBP) lowering. However, the current guidelines advocate a stricter SBP target of <130 mm Hg, with no clear consensus on a DBP target, especially with respect to brain health. The present study aimed to determine the relationship between treated DBP and cognitive function, as well as cerebral perfusion and structure, in adults who achieved an SBP <130 mm Hg. METHODS:This secondary analysis of SPRINT-MIND (Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension) included hypertensive participants with achieved SBP <130 mm Hg, irrespective of their original assignment to the intensive or standard treatment arm. We evaluated cognitive outcomes (probable dementia and mild cognitive impairment) and changes in cerebral blood flow, white matter lesions, and total brain volume according to achieved DBP category (<60, 60-69, 70-79, and ≥80 mm Hg) and achieved DBP as a continuous variable. Cox regression models and linear mixed models were used in analyses. RESULTS:In total, 4424 participants (67.4±9.1 years; 2875 [65.0%] men) were included. In the crude model, low on-treatment DBP was significantly associated with increased risks of probable dementia and mild cognitive impairment. However, after correction for all potential covariates, the statistical significance of the association was lost (all P>0.05). Treated DBP was not associated with changes in white matter lesions or total brain volume; however, there was a significant inverse relationship between achieved DBP and cerebral blood flow changes (P for trend =0.029; difference in change, -1.94 mL/100 g per minute [95% CI, -3.50 to -0.39] per 5-mm Hg increase). CONCLUSIONS:In patients achieving an SBP <130 mm Hg, treated DBP was not associated with dementia, mild cognitive impairment, or changes in white matter lesions and total brain volume. However, there was an increased risk of impaired cerebral perfusion in patients with elevated on-treatment DBP.
