Importance:Housing cost burden is at an all-time high in the US and may disproportionately affect health outcomes among low-income populations. Medicaid-insured individuals and those diagnosed with cardiovascular (CV) disease, such as heart failure (HF), may be especially at increased risk of adverse health outcomes associated with housing cost burden. Objective:To assess the association between area-level housing cost burden and the probability of CV-related hospitalization or emergency department (ED) visits among Medicaid beneficiaries aged 19 to 64 years with HF. Design, Setting, and Participants:This cross-sectional study used individual-level health care utilization data obtained from the Transformed Medicaid Statistical Information System Analytic Files (2018-2019). All zip codes in the US with resident Medicaid beneficiaries aged 19 to 64 years who had a preexisting diagnosis of HF and were continuously enrolled in 2019 were included except for those in Alabama, Rhode Island, and Utah due to data quality issues. Data were analyzed from October 2024 to October 2025. Exposure:Area-level housing cost burden was defined as the zip code-level proportion of housing units occupied by individuals with an annual household income less than $35 000 who spent 30% or more of their income on housing costs. Main Outcomes and Measures:The probability of a CV-related hospitalization and of a CV-related ED visit in 2019. Generalized estimating equation models were used to evaluate the association between housing cost burden and outcomes after adjusting for individual and area-level factors. Results:This study included 233 195 individuals (mean [SD] age, 51.5 [9.6] years, 107 447 female [46.1%]) who were living in 19 577 zip codes. The mean (SD) zip code housing cost burden was 67.4% (16.5%). In 2019, 42 886 beneficiaries (18.4%) had at least 1 CV-related hospitalization and 75 392 (32.3%) had an ED visit. After covariate adjustment, a 10-percentage point increase in housing cost burden was associated with higher odds of CV-related hospitalizations (odds ratio [OR], 1.03; 95% CI, 1.01-1.06) and ED visits (OR, 1.03; 95% CI, 1.01-1.04). There were also higher odds of HF-related hospitalizations (OR, 1.04; 95% CI, 1.01-1.07). Conclusions and Relevance:The findings of this study suggest that area-level housing cost burden may be associated with outcomes among Medicaid beneficiaries with HF and highlights the need to investigate whether strategies that address housing affordability can play a role in improving health outcomes in this population.

Background:Degenerated bioprosthetic aortic valves are associated with substantial morbidity, mortality, and health care resource use. Treatment options include redo-surgical aortic valve replacement (redo-SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV-TAVR). ViV-TAVR has been associated with shorter length of stay, but its higher device costs have raised uncertainty about its overall economic value. We constructed a decision-analytic model to compare the cost-effectiveness of ViV-TAVR vs redo-SAVR for the management of degenerated bioprosthetic aortic valves. Methods:Cost-effectiveness was evaluated by calculating deaths averted and incremental cost-effectiveness ratios (ICERs). The main outcome was ICER defined as US dollars/deaths averted. Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. Results:In the probabilistic analysis, the mean total cost of ViV-TAVR was $88,829 (95% CI, $88,554-$89,104) with a 2-month survival probability of 0.97 (95% CI, 0.969-0.970). For redo-SAVR, the mean cost was $91,411 (95% CI, $91,163-$91,659) with a 2-month survival probability of 0.96 (95% CI, 0.959-0.961). ViV-TAVR was the dominant strategy, resulting in a mean ICER of -$259,323 per death averted (95% CI, -$304,599 to -$220,679). ViV-TAVR was cost effective in 57% to 58% of simulations for willingness-to-pay thresholds ranging from $0 to $150,000. Conclusions:ViV-TAVR is an economically dominant strategy for the management of degenerated bioprosthetic aortic valves, yielding lower costs and marginally improved short-term survival relative to redo-SAVR. However, given a moderate degree of decisional uncertainty, trial-level comparative data and longer-term modeling are required to refine these estimates.

Background Degenerated bioprosthetic mitral valves (MVs) are associated with significant morbidity and health care expenditures. For certain patients, valve-in-valve transcatheter MV replacement (ViV TMVR) has emerged as a promising treatment option due to fewer complications and shorter hospital length of stay when compared with redo surgical MV replacement (redo-SMVR). We constructed a decision-analytic model comparing the cost-effectiveness of ViV TMVR to redo-SMVR for the management of degenerated bioprosthetic valves. Methods Cost-effectiveness was determined by calculating deaths averted and incremental cost-effectiveness ratios (ICERs). Uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. The main outcome was ICERs defined as United States (US) dollars/deaths averted. Results In the base case analysis, the cost associated with ViV TMVR was estimated at $87,724 with a 0.93 probability of survival at 1 month. For the redo-SMVR strategy, the cost was $104,444, and the probability of survival at 1 month was 0.89. Overall, ViV TMVR resulted in savings of $418,001 per death averted (ICER, −$418,001/death averted). In cost-effectiveness acceptability curves, ViV TMVR was cost-effective in 83% to 88% of simulations for a willingness-to-pay threshold ranging from $0 to $100,000. Conclusions ViV TMVR is an effective strategy that may result in significant health care savings for the management of degenerated bioprosthetic valves.

BACKGROUND Catheter ablation is effective in the treatment of atrial fibrillation (AF), however, it requires a significant amount of resources that may not be available in all areas. OBJECTIVE We sought to understand geographic, racial, ethnic, and socioeconomic differences in the utilization of catheter ablation for AF. METHODS Medicare fee-for-service beneficiaries with a diagnosis of AF were identified from the Medicare Inpatient and Outpatient data files between 2016 and 2019. To study inequities in utilization, we generated Generalized Estimating Equations to model the association between ZIP code-level racial, ethnic, and socioeconomic composition and ZIP code-level catheter ablation rates among patients with AF. RESULTS For each 10% increase in the percentage of patients who were dual-eligible for Medicaid (a marker of poverty) in a ZIP code, 275 fewer patients per 10,000 underwentAF ablation (P = .0003). After adjusting fordual-eligible status, for each 10% increase in the percentage of Black patients in a ZIP code, 618 fewer underwent AF ablation (P < .0001), whereas for each 10% increase in the percentage of Hispanic patients, 430 fewer underwent AF ablation (P = .002). CONCLUSION There are significant inequities in utilization of AF ablation, associated with racial, ethnic, and socioeconomic differences. Inequitable utilization in marginalized groups of patients may generate and propagate inequities in health.

Background: Educational attainment is an important socioeconomic marker. Recent trends in cardiovascular (CV) mortality by educational attainment are unknown. This study examines CV mortality trends by educational attainment from 2010 to 2023 among US adults aged 25 years and older. Methods: Mortality data from the National Center for Health Statistics were used to identify all CV deaths (ICD-10: I00-I99 ). Educational attainment from death certificates was categorized as high school or less, some college, and graduate/professional degree. Age-specific population estimates by education level were obtained from US Census data. Mortality rates were standardized to the 2010 Census population. Negative binomial models with year and education indicators were fit and the mean annual percent change (APC) was calculated. Piecewise linear models were fit to identify changes in trends over the study period. Estimates are presented with 95% confidence intervals. Results: Between 2010 and 2023, there were 10,552,366 CV deaths: 61.3% among adults with a high school education or less, 31.8% with some college, and 6.9% with a graduate/professional degree. Age-adjusted mortality was higher for the least educated compared to the other groups (Figure). The absolute difference in mortality rates between the highest and lowest educated groups was wider in 2023 than in 2010. Among men, the mean APC was 0.1% (0.08, 0.2) in the high school or less group, -0.6% (95% CI -0.7, -0.5) for some college, and -0.8% (-0.9, -0.7) for graduate/professional degrees. Among women, the mean APC was -0.1% (-0.2, -0.06), -1.4% (-1.4, -1.3), and -2.2% (-2.3, -2.0), respectively. For men in the high school or lower group, the APC in the 2019 to 2021 period was 4.2% (2.6%, 5.4%) and was -3.5% (-5.1, -1.5%) between 2021 and 2023, while for those with some college the APC was 1.9% (0.6%, 3.0%) in the 2019 to 2021 period and -3.0% (-4.7%, -1.2%) in the 2021 to 2023 period. Mortality rates were stable among the more than college group. Similar trends were noted among women. Conclusions: Educational disparities in CV mortality widened from 2010 to 2023, with mortality rates among adults in the lowest education group stagnant or increasing, while declining in the higher educated groups. A sharp pandemic era increase in mortality in the least educated group had not fully returned to prior levels by 2023. These findings highlight the growing disparity in CV disease by educational attainment in the US.

Background Social determinants of health (SDOH) are increasingly recognized as contributors to disparities in cardiovascular outcomes. However, their incremental value in risk prediction models for ST‐segment–elevation myocardial infarction (STEMI) death remains uncertain. Methods We analyzed hospital admissions for STEMI between 2018 and 2020 using the American Heart Association's GWTG‐CAD (Get With The Guidelines–Coronary Artery Disease) registry. Logistic regression models were constructed: a clinical model including demographic, clinical, and medical history variables, and a full SDOH model that additionally incorporated zip code–level SDOH (college graduation, high school graduation, per‐capita income, poverty, foreign‐born status, and median household income). Discrimination was assessed using the concordance statistic/area under the receiver operating characteristic curve, and incremental value was evaluated with DeLong's test. Missing data were addressed with multiple imputation by chained equations. Results The imputed cohort included 749 410 STEMI admissions (median age, 62 years, 72% men). Both the clinical and SDOH models demonstrated excellent discrimination (concordance statistic, 0.95; area under the receiver operating characteristic curve, 0.85), with no meaningful difference in overall predictive performance. In exploratory analyses, the addition of high school graduation, college graduation, per‐capita income, poverty, and foreign‐born status each had a modest statistical improvement in model discrimination, whereas median household income did not. Conclusions Incorporating SDOH variables into an already high‐performing clinical risk model for in‐hospital STEMI death did not meaningfully enhance prediction. These findings indicate that short‐term, in‐hospital survival is primarily driven by immediate clinical factors rather than upstream socioenvironmental risks.

Importance:The Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for veterans to obtain care outside the VA. However, the impact on health care outcomes is uncertain. Objective:To measure the MISSION Act's impact on travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR). Design, Setting, and Participants:This retrospective difference-in-differences cohort study included veterans receiving nonemergent/nonurgent PCI, CABG, or AVR between October 2016 and September 2022 in non-VA hospitals under MISSION Act coverage or in VA hospitals in the 48 contiguous US states or the District of Columbia. Analyses were conducted in 2023-2024. Exposures:Veterans eligible for non-VA care under the MISSION Act by living far from ( >60 minutes) the nearest VA medical center vs veterans living near (≤60 minutes) a VA medical center. Main Outcomes and Measures:Major adverse cardiovascular events (MACE), defined as rehospitalization for cardiovascular cause or mortality within 30 days of the procedure, and travel times for care were the primary outcomes. Results:The cohort comprised veterans receiving PCI (n = 43 000; 42 066 [98%] male; mean [SD] age, 69 [8.8] years), CABG (n = 23 301; 22 197 [98%] male; mean [SD] age, 69 [7.7] years), or AVR (n = 14 682; 14 336 [98%] male; mean [SD] age, 74 [9.6] years). After MISSION implementation, mean PCI travel times increased by 1.3 minutes for near patients and decreased by 29.2 minutes for far patients (difference in differences, -30.5 minutes; P < .001). Mean CABG travel times increased by 9.4 minutes for near patients and decreased by 18.1 minutes for far patients (difference in differences, -27.4 minutes; P < .001). Mean travel times for AVR increased by 10.0 minutes for near patients and decreased by 23.0 minutes for far patients (difference in differences, -33.1 minutes; P < .001). After MISSION implementation, mean PCI MACE rates decreased by 0.5 percentage points for near patients and increased by 2.3 percentage points for far patients (difference in differences, 2.8 percentage points; P <.001). Mean CABG MACE rates decreased by 6.5 percentage points for near patients and increased by 1.6 percentage points for far patients (difference in differences, 8.1 percentage points; P < .001). AVR MACE rates were not statistically different between the groups (P = .45). Conclusions and Relevance:MISSION Act implementation was associated with substantial decreases in travel times among veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act implementation was also associated with worsened 30-day MACE rates.

Background To understand the relative safety and efficacy of endovascular treatment modalities used for superficial femoral artery (SFA) disease, we performed a network meta-analysis to compare outcomes between percutaneous transluminal angioplasty (PTA), atherectomy (A), bare metal stent (BMS), brachytherapy/radiotherapy, covered stent graft (CSG), cutting balloon angioplasty (CBA), drug-coated balloon (DCB), drug-eluting stent (DES), and intravascular lithotripsy (L). Methods We performed a systematic literature search of PubMed from January 2000 to January 2023 to identify randomized trials comparing endovascular interventions for the treatment of SFA disease. The primary end points were technical success and 12-month primary patency. Results In total, 57 studies (9089 patients) were included. The mean age of the included patients was 68.4 years, 41.4% had diabetes, 18.3% had critical limb ischemia, and 81.3% had de novo lesions. A mean of 1.2 lesions were treated per patient. Technical success was superior for CSG, BMS, and A+DCB compared with PTA, while A+DCB and CSG were superior to DCB. All interventions except brachytherapy alone had superior primary patency compared with PTA. There were no significant differences in 12-month mortality or major amputation. All interventions except L+DCB, PTA+A, and CBA were superior to PTA regarding target lesion revascularization, while only DCB, DES, and BMS were better than PTA at improving Rutherford classification. Conclusions In SFA disease, PTA alone is mostly inferior to other endovascular techniques. This comparison of other endovascular techniques will be valuable for endovascular device selection in the treatment of SFA disease.

BACKGROUND:Hospitals and health systems must balance the demand for transcatheter aortic valve replacement (TAVR) against financial sustainability. Patients may be eligible for both TAVR and surgical aortic valve replacement (SAVR), but financial realities for hospitals may affect differential access to those therapies. We sought to understand the landscape of costs and reimbursement for TAVR and SAVR in the US and to understand the association of procedural reimbursement with receipt of either. METHODS:We included fee-for-service Medicare beneficiaries undergoing isolated TAVR or SAVR in 2016-2019. For each TAVR and SAVR, inpatient revenues and direct costs were calculated at the claim level. The contribution margin (CM) for each TAVR or SAVR was then calculated as total revenues minus total direct costs, which defines the net profit for the procedure for the hospital. Multivariate logistic regressions were used to identify hospital characteristics associated with positive TAVR CMs. Multivariate linear regression was used to assess the relationship between relative volume of TAVR cases and relative differences in TAVR versus SAVR CMs at the hospital level. RESULTS:Of 542 sites, 377 (69.6%) had positive CMs, and 165 (30.4%) had negative CMs for TAVR; 505 (93.2%) had positive CMs for SAVR. Median revenues, costs, and CMs for TAVR decreased between 2016 and 2019. The median (IQR) total CM per hospital for TAVR decreased from $10,574 ($1,331-$22,259) in 2016 to $6,744 ($6,099-$17,511) in 2019 (P < 0.001). Teaching hospital status (aOR 1.77, 95% CI 1.07-2.93) and for-profit status (aOR 3.7, 95% CI 1.8-7.6) were associated with increased odds of positive TAVR CMs relative to nonteaching hospital status and nonprofit status, respectively, in multivariate logistic regression models. The median (IQR) proportion of TAVR of total AVR was 76.67% (69.6%-82.5%) compared with 74.6% (66.9%-80.4%) at hospitals with negative TAVR CMs (P = .04). There was no significant linear relationship between hospital-level difference in median TAVR and SAVR CMs and hospital-level proportion of TAVR of total AVR in multivariate models. CONCLUSIONS:Most hospitals had positive CMs for TAVR and nearly all had positive CMs for SAVR. Positive CMs for TAVR for individual hospitals were associated with a significant increase in the utilization of TAVR. However, the magnitude of difference in TAVR versus SAVR CM was not associated with differential procedural use.

This study investigates the impact of geographic and socioeconomic barriers on access to transcatheter aortic valve replacement (TAVR). Utilizing Medicare data from the US Centers for Medicare and Medicaid Services, this study analyzed TAVR and surgical aortic valve replacement (SAVR) procedures among beneficiaries from 2017 to 2022. Geographic units were defined by 5-digit zip codes, categorized on the basis of TAVR/SAVR volume into four categories: (1) no TAVR or SAVR, (2) no-TAVR zone (SAVR present, no TAVR), (3) low-TAVR zone (TAVR/SAVR ratio ≤ 0.5), and (4) TAVR accessible (TAVR/SAVR ratio > 0.5). The differential distance index (DDI) was developed to measure travel hurdles, calculated as the difference in miles from a patient’s zip code center to the treatment hospital (TAVR versus SAVR, CABG (coronary artery bypass grafting), and PCI (percutaneous coronary intervention) comparators). This study maintained a continuous access variable to model outcomes such as the ratio or volume of TAVR/SAVR and the percentage share of TAVR/AVR within each zip code over biennial periods (2017–2018, 2019–2020, 2021–2022). Covariates in the model included population density, area deprivation index (ADI), and calendar time, with an exploration of the interaction between DDI and ADI. The analysis revealed significant geographic disparities in TAVR access across the USA, with no-TAVR zone and low-TAVR zone areas often featuring lower population densities, higher ADIs, and more rural settings. Increased travel distance (DDI) significantly correlated with lower TAVR utilization, emphasizing distance as a critical barrier. Furthermore, both ADI and DDI emerged as significant predictors of TAVR volume and share, underlining the compound effect of socioeconomic status and geographic distance on healthcare access. This study highlights the critical role of geographic and socioeconomic barriers in accessing advanced medical treatments like TAVR. Addressing these barriers may ensure equitable healthcare distribution, guiding policymakers and providers towards more accessible healthcare solutions for all populations.

Background The 2021 Price Transparency Rule was implemented to increase market competition, facilitate price shopping, and reduce prices and health care costs. We sought to measure inter‐ and intrahospital variation in prices, measure price variation across payer types, and identify hospital characteristics associated with increased commercial prices for 16 common cardiovascular admission diagnoses, diagnostic tests, and therapeutic procedures. Methods and Results Prices were obtained from Turquoise Health, a platform that aggregates hospital prices from publicly available machine‐readable files, for each diagnosis, test, and procedure based on Current Procedural Terminology (CPT) and Medicare Severity Diagnosis Related Group (DRG) codes. Hospital characteristics were identified using Dartmouth Atlas data. Inter‐ and intrahospital price variations were measured using ratios. Multivariate linear mixed‐effects models were fit to determine the association between hospital characteristics and hospital‐level median commercial negotiated rates. We evaluated 1 020 349 unique rates across all diagnoses, tests, and procedures. The median (interquartile range) ratio of maximum to minimum commercial prices within hospitals ranged from 1.71 (1.14–2.53) for syncope and collapse to 3.1 (2.06–4.58) for cardiac valve surgery. Many hospital referral regions had 90th percentile commercial prices 2 to 3 times larger than 10th percentile commercial prices. Nonprofit status and high hospital market concentration were associated with increased commercial prices across all diagnoses, tests, and procedures. Conclusions There is significant price variation for common cardiovascular admission diagnoses, tests, and procedures across and within hospitals as well as across payer types. Increased hospital market concentration is associated with increased commercial prices, so efforts to improve market competition alongside improving transparency compliance are warranted.

BACKGROUND: Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care. METHODS: Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates. RESULTS: Among 73 237 patients who underwent major lower extremity amputation, 40 320 (55.1%) had an outpatient vascular subspecialist visit, 60 109 (82.1%) had lower extremity arterial testing, and 28 345 (38.7%) underwent lower extremity revascularization in the year before amputation. Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio [adjOR], 0.87 [95% CI, 0.84–0.90]) or revascularization (adjOR, 0.90 [95% CI, 0.86–0.93]) than White patients. Compared with patients without low SES or residing in urban areas, patients with low SES or residing in rural areas were less likely to have an outpatient vascular specialist visit (adjOR, 0.62 [95% CI, 0.60–0.64]; low SES versus nonlow SES; adjOR, 0.82 [95% CI, 0.79–0.85]; rural versus urban), lower extremity arterial testing (adjOR, 0.78 [95% CI, 0.75–0.81]; low SES versus nonlow SES; adjOR, 0.90 [95% CI, 0.0.86–0.94]; rural versus urban), or revascularization (adjOR, 0.65 [95% CI, 0.63–0.67]; low SES versus nonlow SES; adjOR, 0.89 [95% CI, 0.86–0.93]; rural versus urban). CONCLUSIONS: Black race, rural residence, and low SES are associated with failure to receive subspecialty chronic limb-threatening ischemia care before amputation. To reduce disparities in amputation, multilevel interventions to facilitate equitable chronic limb-threatening ischemia care are needed.

BACKGROUND:Aortic stenosis (AS) is the leading cause of valvular heart disease-related morbidity and mortality, but there are no medical treatments to slow its progression. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have pleiotropic effects which could be disease modifying in AS. OBJECTIVES:The purpose of this study was to determine if SGLT2i usage is associated with slower progression of AS. METHODS:A target trial emulation comparing the effect of the initiation of SGLT2i compared with no SGLT2i in patients with nonsevere AS was performed using retrospective electronic medical record data from the Yale New Haven Health System from January 2016 to September 2022. Patients with native aortic valve sclerosis or nonsevere AS with at least 12 months of echocardiographic follow-up were included. Patients were excluded if they had an estimated glomerular filtration rate <30 mL/min/1.73 m2 or had initiated SGLT2i >1 year before the index echocardiogram. The prespecified primary outcome was progression to severe AS. RESULTS:A total of 458 patients prescribed SGLT2i and 11,240 patients never prescribed SGLT2i were included. Patients were on SGLT2i for a median of 0.9 years. Patients on SGLT2i were younger and had higher rates of diabetes and chronic kidney disease. Patients on SGLT2i were more likely to have ejection fraction ≤40%. There were no differences between groups in baseline AS severity (66% sclerosis, 23% mild stenosis, and 11% moderate in overall cohort). Patients ever prescribed SGLT2i were less likely to progress to severe AS (HR: 0.61; 95% CI: 0.39-0.94; P = 0.03) with a progressively lower risk among patients on SGLT2i for >3, 6, and 12 months (HR: 0.54, 0.48, and 0.27, respectively). CONCLUSIONS:This retrospective, multicenter, observational study suggests that SGLT2i may slow the progression of nonsevere AS.

Introduction We sought to measure the revenues, costs, and contribution margins (CMs) for major inpatient cardiovascular procedures in the Medicare population in years 2016-2019, evaluate the differences in CMs across procedures, and identify temporal trends in CMs. Methods Claim-level costs were calculated using cost-to-charge ratios and subsequently Winsorized to adjust for outliers, and CMs were assessed as the difference between revenue and costs. Results and Discussion We found that revenues, costs, and CMs vary widely across major inpatient cardiovascular procedures and that rapidly proliferating cardiovascular procedures contribute sizeable net CMs to US hospitals. (Am Heart J 2025;281:43-48.)

Background There may be variability in willingness to perform percutaneous coronary intervention (PCI) in higher‐risk patients who present with ST‐segment–elevation myocardial infarction (STEMI). We sought to describe current treatment selection patterns and hospital‐level variability. Methods and Results We identified patients presenting with STEMI with a culprit lesion on coronary angiography between January 1, 2019, and March 31, 2023, using the NCDR (National Cardiovascular Data Registry) CPMI (Chest Pain–Myocardial Infarction) registry. We compared patient‐level characteristics of patients who did and did not undergo PCI at each hospital. There were 178 984 patients from 582 US hospitals presenting with STEMI who were included. Among patients with STEMI and a culprit lesion, 6180 did not undergo PCI (3.5%). Patients with a presentation of STEMI and a culprit lesion who did not undergo PCI were older (67 [interquartile range, 58–76]) years versus 62 ([interquartile range, 54–71] years, P<0.001), more likely to present with heart failure (15.0% versus 7.4%, P<0.001), and more likely to have cardiac arrest before arrival (9.7% versus 5.1%, P<0.001) than patients who underwent PCI. Patients who did not undergo PCI had higher predicted mortality rates (12.5%±17.9% versus 6.5%±11.5%, P<0.001) and observed mortality rates (21.7% versus 6.4%, P<0.001) compared with patients who underwent PCI. Conclusions There is variability in the percentage of patients with culprit lesions on invasive coronary angiography undergoing PCI for STEMI, with 3.5% of patients with STEMI not receiving PCI overall, and >5% of patients not undergoing PCI in a quarter of US hospitals. Differences in observed versus predicted mortality rates for patients who did or did not undergo PCI may highlight the effects of risk‐avoidant behavior.

OBJECTIVE:Peripheral artery disease (PAD) affects >12 million Americans and poses significant financial burdens on patients, but the relationship between delayed/forgone (D/F) care and resource use in this population is unknown. We sought to assess the relationship between D/F care, resource use, and health care expenditures among patients with PAD. METHODS:Adults with PAD in the United States were identified in the Medical Expenditure Panel Survey for years 2007 to 2017. Unweighted counts of reasons for D/F care were tabulated. Proportions of patients with ≥1 emergency department (ED), ≥1 inpatient, ≥1 outpatient, and >5 office-based encounters were compared using Rao-Scott adjusted χ2 tests. Annual per capita total, out-of-pocket, ED, inpatient, outpatient, office-based visits, and prescription medication expenditures were compared using two-part econometric models. RESULTS:The study cohort included 2,926,654 patients with PAD. Among the 264,172 patients with PAD (9%) reporting D/F care, 41.2% of patients cited financial barriers as the primary reason for D/F care. There were greater proportions of patients with ≥1 ED visits (52% vs 31%; P < .001), ≥1 outpatient hospital visits (56% vs 43%; P = .004), and >5 office-based visits (81% vs 71%; P = .04) among those reporting D/F care vs those who did not. Patients with D/F care had $7742 (95% confidence interval, $3170-$12,314; P = .001) greater per capita total and $5156 (95% confidence interval, $692-$9,619; P = .02) greater per capita inpatient expenditures per year than patients without D/F care. CONCLUSIONS:D/F care is associated with increased resource use and health care expenditures among patients with PAD. Further work is needed to elucidate the underlying causes of D/F care and mitigate financial burdens on patients with PAD.

Importance Extreme heat in the US is increasing due to climate change, while extreme cold is projected to decline. Understanding how extreme temperature along with demographic changes will affect population health is important for devising policies to mitigate the health outcome of climate change. Objective To assess the burden of extreme temperature-related deaths in the contiguous US currently (2008-2019) and estimate the burden in the mid-21st century (2036-2065). Design, Setting, and Participants This cross-sectional study used historical (1979-2000) daily mean temperatures to calculate monthly extreme heat (>97.5th percentile value) and extreme cold days (<2.5th percentile value) for all contiguous US counties for 2008 to 2019 (current period). Temperature projections from 20 climate models and county population projections were used to estimate extreme temperature-related deaths for 2036 to 2065 (mid-21st century period). Data were analyzed from November 2023 to July 2024. Exposure Current monthly frequency of extreme heat days and projected mid-21st century frequency using 2 greenhouse gas emissions scenarios: Shared Socioeconomic Pathway (SSP)2-4.5, representing socioeconomic development with a lower emissions increase, and SSP5-8.5, representing higher emissions increase. Main Outcomes and Measures Mean annual estimated number of extreme temperature-related excess deaths. Poisson regression model with county, month, and year fixed effects was used to estimate the association between extreme temperature and monthly all-cause mortality for older adults (aged >= 65 years) and younger adults (aged 18-64 years). Results Across the contiguous US, extreme temperature days were associated with 8248.6 (95% CI, 4242.6-12 254.6) deaths annually in the current period and with 19 348.7 (95% CI, 11 388.7-27 308.6) projected deaths in the SSP2-4.5 scenario and 26 574.0 (95% CI, 15 408.0-37 740.1) in the SSP5-8.5 scenario. The mortality data included 30 924 133 decedents, of whom 15 573 699 were males (50.4%), with 6.3% of Hispanic ethnicity, 11.5% of non-Hispanic Black race, and 79.3% of non-Hispanic White race. Non-Hispanic Black adults (278.2%; 95% CI, 158.9%-397.5%) and Hispanic adults (537.5%; 95% CI, 261.6%-813.4%) were projected to have greater increases in extreme temperature-related deaths from the current period to the mid-21st century period compared with non-Hispanic White adults (70.8%; 95% CI, -5.8% to 147.3%). Conclusions and Relevance This cross-sectional study found that extreme temperature-related deaths in the contiguous US were projected to increase substantially by mid-21st century, with certain populations, such as non-Hispanic Black and Hispanic adults, projected to disproportionately experience this increase. The results point to the need to mitigate the adverse outcome of extreme temperatures for population health.

BACKGROUND:The American College of Cardiology, American Heart Association, and Centers for Medicare and Medicaid Services recommend shared decision-making (SDM) for patients with severe aortic stenosis choosing between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Although tools such as patient decision aids (DAs) and training in SDM have been shown to improve SDM, implementation of SDM and DAs is limited. The IMproving treatment decisions for Patients with AortiC stenosis Through Shared Decision Making (IMPACT SDM) study aims to (1) determine the effectiveness of the interventions (a DA and clinician SDM training) in achieving SDM (primary outcome) and improving the quality of decisions about aortic valve replacement, (2) determine the reach of the DAs and adoption of training, and (3) explore potential mechanisms of effectiveness and implementation at the patient-, clinician-, and clinic-level. METHODS:The study is a hybrid type II effectiveness-implementation study using a cluster randomized batched stepped wedge trial with 8 sites across the USA. Eligible patients will be surveyed before and after visits with the heart valve team; clinicians will be surveyed after visits. Reach of DAs and adoption of training will be tracked. Clinicians will be interviewed regarding barriers and facilitators to implementation. DISCUSSION:The IMPACT SDM Study seeks to provide evidence of the ability of the interventions to improve SDM and decision quality, and also to shed light on barriers and facilitators to SDM implementation to promote future implementation efforts. TRIAL REGISTRATION:ClinicalTrials.gov NCT06171737. Registered on December 15, 2023.