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.
