<div><h4>Healthcare Access and Cardiovascular Risk Factor Management Among Working-Age US Adults During the Pandemic.</h4><i>Marinacci LX, Bartlett V, Zheng Z, Mein S, Wadhera RK</i><br /><AbstractText><b>Background:</b> Low-income working-age US adults disproportionately experienced healthcare disruptions at the onset of the COVID-19 pandemic. Little is known about how healthcare access and cardiovascular risk factor management changed as the pandemic went on, or if patterns differed by state Medicaid expansion status. <br /><b>Methods:</b><br/>Cross-sectional data from the Behavioral Risk Factor Surveillance System were used to compare self-reported measures of healthcare access and cardiovascular risk factor management among US adults aged 18-64 years in 2021 (pandemic) to 2019 (pre-pandemic) using multivariable Poisson regression models. We assessed for differential changes between low-income (<138% FPL) and high-income (>400% FPL) working-age adults by including an interaction term for income group and year. We then evaluated changes among low-income adults in Medicaid expansion versus non-expansion states using a similar approach. <br /><b>Results:</b><br/>The unweighted study population included 80,767 low-income and 184,136 high income adults. Low-income adults experienced improvements in insurance coverage (RR 1.10 [95% CI: 1.08-1.12]), access to a provider (RR 1.12 [1.09-1.14]), and ability to afford care (RR 1.07 [1.05-1.09]) in 2021 compared with 2019. While these measures also improved for high income adults, gains in coverage and ability to afford care were more pronounced among low income adults. However, routine visits (RR 0.96 [0.94-0.98]) and cholesterol testing (RR 0.93 [0.91-0.96]) decreased for low-income adults, while diabetes screening (RR 1.01 [0.95-1.08]) remained stable. Treatment for hypertension (RR 1.05 [1.02-1.08]) increased and diabetes focused visits and insulin use remained stable. These patterns were similar for high-income adults. Across most outcomes, there were no differential changes between low-income adults residing in Medicaid expansion versus non-expansion states. <b>Conclusions:</b> In this national study of working-aged adults in the US, measures of health care access improved for low- and high-income adults in 2021. However, routine outpatient visits and cardiovascular risk factor screening did not return back to pre-pandemic levels, while risk factor treatment remained stable. As many COVID-era safety net policies come to an end, targeted strategies are needed to protect healthcare access and improve cardiovascular risk factor screening for working-age adults.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Percutaneous Revascularisation for Ischemic Left Ventricular Dysfunction: Cost-Effectiveness Analysis of the REVIVED-BCIS2 Trial.</h4><i>Chivardi C, Morgan H, Sculpher MJ, Clayton T, ... Perera D, Saramago P</i><br /><AbstractText><b>Background:</b> Percutaneous coronary intervention (PCI) is frequently undertaken in patients with ischemic left ventricular systolic dysfunction (ILVD). The REVIVED-BCIS2 trial concluded that PCI did not reduce the incidence of all-cause death or heart failure (HF) hospitalization, however patients assigned to PCI reported better initial health-related quality of life than those assigned to optimal medical therapy (OMT) alone. The aim of this study was to assess the cost-effectiveness of PCI+OMT compared with OMT alone. <br /><b>Methods:</b><br/>REVIVED-BCIS2 was a prospective, multi-centre UK trial, which randomized patients with severe ILVD to either PCI+OMT or OMT alone. Healthcare resource use (including planned and unplanned revascularizations, medication, device implantation and HF hospitalizations) and health outcomes data (EQ-5D-5L questionnaire) on each patient were collected at baseline and up to 8 years post-randomization. Resource use was costed using publicly available national unit costs. Within trial mean total costs and quality-adjusted life years (QALYs) were estimated from the perspective of the UK health system. Cost-effectiveness was evaluated using estimated mean costs and QALYs in both groups. Regression analysis was used to adjust for clinically relevant predictors. <br /><b>Results:</b><br/>Between 2013 and 2020, 700 patients were recruited (mean age: PCI+OMT=70, OMT=68; male (%): PCI+OMT=87, OMT=88); median follow up was 3.4 years. Over all follow-up, patients undergoing PCI yielded similar health benefits at higher costs compared to OMT alone (PCI+OMT: 4.14 QALYs, £22,352; OMT alone: 4.16 QALYs; £15,569; Difference: -0.015; £6,782). For both groups most health resource consumption occurred in the first 2 years post-randomization. Probabilistic results showed that the probability of PCI being cost-effective was 0. <b>Conclusions:</b> Minimal difference in total QALYs was identified between arms and PCI+OMT was not cost-effective compared to OMT, given its additional cost. A strategy of routine PCI to treat ILVD does not appear to be a justifiable use of healthcare resource in the UK. <b>Clinical Trial Registration:</b> URL: https://clinicaltrials.gov/ Unique Identifier: NCT01920048.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients with Atrial Fibrillation in the United States.</h4><i>Sandhu A, Kaltenbach LA, Chiswell K, Shimoga V, ... Varosy PD, Hess PL</i><br /><AbstractText><b>Background:</b> Among patients hospitalized for atrial fibrillation (AF), the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary practice are unknown. <br /><b>Methods:</b><br/>Using the Get With The Guidelines® Atrial Fibrillation (GWTG-AF) registry, patients admitted from January 1st, 2014 to March 31st, 2020, and discharged on DOAC were stratified according to receipt of under, over, or recommended dosing. Factors associated with off-label dosing (defined as under or overdosing) were identified using logistic regression. Median odds ratio and time-series analyses were used to assess hospital-level variation and temporal trends, respectively. <br /><b>Results:</b><br/>Of 22,470 patients (70.1 +/- 12.1 years, 48.1% female, 82.5% White) prescribed a DOAC at discharge from hospitalization for AF (66% apixaban, 29% rivaroxaban, 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19953 (88.8%). The overall rate of off-label dosing was 11.2%. Patient-related factors associated with off-label dose included age (underdosing: OR 1.06 per 1-year increase [95% CI 1.06-1.07] and overdosing: OR 1.07 per 1-year increase [1.06-1.09]), dialysis dependence (underdosing: OR 5.50 [3.76-8.05] and overdosing: OR 5.47 [2.74-10.88]), female sex (overdosing: OR 0.79 [0.63-0.99]) and weight (overdosing: OR 0.96 per 1-Kg increase [0.95-1.00]). Across hospitals, the adjusted median odds ratio for off-label DOAC dose was 1.45 [95% CI 1.34-1.65] (underdosing: 1.52 [1.39-1.76] and overdosing: 1.32 [1.20-1.84]), indicating significant hospital-level variation. Over the study period, recommended dosing significantly increased over time (81.9% to 90.9%, p<0.0001 for trend) with a corresponding decline in under (14.4% to 6.6%, p<0.0001 for trend) and overdosing (3.8% to 2.5%, p=0.001 for trend). <b>Conclusions:</b> Over 1 in 10 patients hospitalized for AF is discharged on an off-label DOAC dose with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Nov 2023; epub ahead of print</small></div>

<div><h4>Evolution of Value in American College of Cardiology/American Heart Association Clinical Practice Guidelines.</h4><i>Luviano A, Pandya A</i><br /><b>Background</b><br />In January 2014, the American College of Cardiology/American Heart Association released a policy statement arguing for the inclusion of cost-effectiveness analysis (CEA) and value assessments in clinical practice guidelines. It is unclear whether subsequent guidelines changed how they incorporated such concepts.<br /><b>Methods</b><br />We analyzed guidelines of cardiovascular disease subconditions with a guideline released before and after 2014. We counted the words (total and per page) for 8 selected value- or CEA-related terms and compared counts and rates of terms per page in the guidelines before and after 2014. We counted the number of recommendations with at least 1 reference to a CEA or a CEA-related article to compare the ratios of such recommendations to all recommendations before and after 2014. We looked for the inclusion of the value assessment system recommended by the writing committee of the American College of Cardiology/American Heart Association policy statement of 2014.<br /><b>Results</b><br />We analyzed 20 guidelines of 10 different cardiovascular disease subconditions. Seven of the 10 cardiovascular disease subconditions had guidelines with a greater term per page rate after 2014 than before 2014. Across all 20 guidelines, the proportion of recommendations with at least 1 reference to a CEA changed from 0.44% to 1.99% (<i>P</i><0.01). The proportion of recommendations with at least 1 reference to a CEA-related article changed from 1.02% to 3.34% (<i>P</i><0.01). Only 3 guidelines used a value assessment system.<br /><b>Conclusions</b><br />The proportion of recommendations with at least 1 reference to a CEA or CEA-related article was low before and after 2014 for most of the subconditions, however, with substantial variation in this finding across the guidelines included in our analysis. There is a need to organize existing CEA information better and produce more policy-relevant CEAs so guideline writers can more easily make recommendations that incentivize high-value care and caution against using low-value care.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 03 Nov 2023:e010086; epub ahead of print</small></div>

<div><h4>Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association.</h4><i>Masterson Creber R, Dodson JA, Bidwell J, Breathett K, ... Kitsiou S, American Heart Association Cardiovascular Disease in Older Populations Committee of the Council on Clinical Cardiology and the Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Council on Peripheral Vascular Disease</i><br /><AbstractText>Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 Nov 2023:e000123; epub ahead of print</small></div>

<div><h4>Cost-Effectiveness of AF Screening With 2-Week Patch Monitors: The mSToPS Study.</h4><i>Reynolds MR, Stein AB, Sun X, Hytopoulos E, Steinhubl SR, Cohen DJ</i><br /><b>Background</b><br />The mSToPS study (mHealth Screening to Prevent Strokes) reported screening older Americans at risk for atrial fibrillation (AF) and stroke using 2-week patch monitors was associated with increased rates of AF diagnosis and anticoagulant prescription within 1 year and improved clinical outcomes at 3 years relative to matched controls. Cost-effectiveness of this AF screening approach has not been explored.<br /><b>Methods</b><br />We conducted a US-based health economic analysis of AF screening using patient-level data from mSToPS. Clinical outcomes, resource use, and costs were obtained through 3 years using claims data. Individual costs, survival, and quality-adjusted life years (QALYs) were projected over a lifetime horizon using regression modeling, US life tables, and external data where needed. Adjustment between groups was performed using propensity score bin bootstrapping.<br /><b>Results</b><br />Screening participants (mean age, 74 years, 41% female, median CHA<sub>2</sub>DS<sub>2</sub>-VASC score 3) wore on average 1.7 two-week monitors at a mean cost of $614/person. Over 3 years, outpatient visits were more frequent for monitored than unmonitored individuals (difference 190 per 100 patient-years [95% CI, 82-298]), but emergency department visits (-8.3 [95% CI, -12.6 to -4.1]) and hospitalizations (-15.2 [CI, -22 to -8.6]) were less frequent. Total adjusted 3-year costs were slightly higher (mean difference, $1551 [95% CI, -$1047 to $4038]) in the monitoring group. In patient-level projections, the monitoring group had slightly greater quality-adjusted survival (8.81 versus 8.71 QALYs, difference, 0.09 [95% CI, -0.05 to 0.24]) and slightly higher lifetime costs, resulting in an incremental cost-effectiveness ratio of $36 100/QALY gained. With bootstrap resampling, the incremental cost-effectiveness ratio for monitoring was <$50 000/QALY in 64% of study replicates, and <$150 000/QALY in 91%.<br /><b>Conclusions</b><br />Using lifetime projections derived from the mSToPS study, we found that AF screening using 2-week patch monitors in older Americans was associated with high economic value. Confirmation of these uncertain findings in a randomized trial is warranted.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT02506244.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 31 Oct 2023:e009751; epub ahead of print</small></div>

<div><h4>Comparison of Atherosclerotic Cardiovascular Risk Factors and Cardiometabolic Profiles Between Current and Never Users of Marijuana.</h4><i>Alhassan HA, Akunor H, Howard A, Donohue J, ... Onyeaka HK, Aiyer A</i><br /><b>Background</b><br />The relationship between marijuana use and cardiovascular health remains uncertain, with several observational studies suggesting a potential association with increased adverse atherosclerotic cardiovascular disease (ASCVD) outcomes. This study examined the relationship between marijuana use, ASCVD risk factors, and cardiometabolic risk profiles.<br /><b>Methods</b><br />US adults (18-59 years) without cardiovascular disease were identified from the National Health And Nutrition Examination Survey (2005-2018) based on self-reported marijuana use. Current users (used within the past month) and never users were compared with assess the burden and control of traditional ASCVD risk factors and biomarkers, using inverse probability of treatment weighting to adjust for sociodemographic and lifestyle factors, including tobacco use.<br /><b>Results</b><br />Of the 13 965 participants identified (mean age, 37.5; 51.2% female; 13% non-Hispanic Black), 26.6% were current users. Current users were predominantly male, low-income, and more likely to be concurrent tobacco users. Inverse probability of treatment weighting analysis showed no significant differences in the burden and control of hypertension (19.3% versus 18.8%, <i>P</i>=0.76; 79.8% versus 77.8%, <i>P</i>=0.75), dyslipidemia (24.0% versus 19.9%, <i>P</i>=0.13; 82% versus 75%, <i>P</i>=0.95), diabetes (4.8% versus 6.4%, <i>P</i>=0.19; 52.9% versus 50.6%, <i>P</i>=0.84), obesity (35.8% versus 41.3%, <i>P</i>=0.13), and physical activity levels (71.9% versus 69.3%, <i>P</i>=0.37) between current and never users. Likewise, mean 10-year ASCVD risk scores (2.8% versus 3.0%, <i>P</i>=0.49), 30-year Framingham risk scores (22.7% versus 24.2%, <i>P</i>=0.25), and cardiometabolic profiles including high-sensitivity C-reactive protein (3.5 mg/L versus 3.7 mg/L, <i>P</i>=0.65), neutrophil-lymphocyte ratio (2.1 versus 2.1, <i>P</i>=0.89), low-density lipoprotein (114.3 mg/dL versus 112.2 mg/dL, <i>P</i>=0.53), total cholesterol (191.2 mg/dL versus 181.7 mg/dL, <i>P</i>=0.58), and hemoglobin A1C (5.4% versus 5.5%, <i>P</i>=0.25) were similar between current and never users.<br /><b>Conclusions</b><br />This cross-sectional study found no association between self-reported marijuana use and increased burden of traditional ASCVD risk factors, estimated long-term ASCVD risk, or cardiometabolic profiles. Further studies are needed to explore potential pathways between adverse cardiovascular disease outcomes and marijuana use.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 20 Oct 2023:e009609; epub ahead of print</small></div>

<div><h4>Relationship Between Community-Level Distress and Cardiac Rehabilitation Participation, Facility Access, and Clinical Outcomes After Inpatient Coronary Revascularization.</h4><i>Thompson MP, Hou H, Stewart JW, Pagani FD, ... Sukul D, Likosky DS</i><br /><b>Background</b><br />Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes.<br /><b>Methods</b><br />A retrospective cohort study was conducted on a 100% sample of Medicare beneficiaries undergoing inpatient coronary revascularization between July 2016 and December 2018. Community-level distress was defined using the Distressed Community Index quintile at the beneficiary zip code level, with the first and fifth quintiles representing prosperous and distressed communities, respectively. Outpatient claims were used to identify any CR use within 1 year of discharge. Beneficiary and CR facility zip codes were used to describe access to CR facilities. Adjusted logistic regression models evaluated the association between Distressed Community Index quintiles, CR use, and clinical outcomes, including one-year mortality, all-cause hospitalization, and acute myocardial infarction hospitalization.<br /><b>Results</b><br />A total of 414 730 beneficiaries were identified, with 96 929 (23.4%) located in the first and 67 900 (16.4%) in the fifth quintiles, respectively. Any CR use was lower for beneficiaries in distressed compared with prosperous communities (26.0% versus 46.1%, <i>P</i><0.001), which was significant after multivariable adjustment (odds ratio, 0.41 [95% CI, 0.40-0.42]). A total of 98 458 (23.7%) beneficiaries had a CR facility within their zip code, which increased from 16.3% in prosperous communities to 26.6% in distressed communities. Any CR use was associated with absolute reductions in mortality (-6.8% [95% CI, -7.0% to -6.7%]), all-cause hospitalization (-5.9% [95% CI, -6.3% to -5.6%]), and acute myocardial infarction hospitalization (-1.3% [95% CI, -1.5% to -1.1%]), which were similar across each Distressed Community Index quintiles.<br /><b>Conclusions</b><br />Although community-level distress was associated with lower CR participation, the clinical benefits were universally received. Addressing barriers to CR in distressed communities should be considered a significant priority to improve survival after coronary revascularization and reduce disparities.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 19 Oct 2023:e010148; epub ahead of print</small></div>

<div><h4>Facilitating Harmonization of Variables in Framingham, MESA, ARIC, and REGARDS Studies Through a Metadata Repository.</h4><i>Mallya P, Stevens LM, Zhao J, Hong C, ... Pencina MJ, Hall JL</i><br /><b>Background</b><br />High-quality research in cardiovascular prevention, as in other fields, requires inclusion of a broad range of data sets from different sources. Integrating and harmonizing different data sources are essential to increase generalizability, sample size, and representation of understudied populations-strengthening the evidence for the scientific questions being addressed.<br /><b>Methods</b><br />Here, we describe an effort to build an open-access repository and interactive online portal for researchers to access the metadata and code harmonizing data from 4 well-known cohort studies-the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, FHS (Framingham Heart Study), MESA (Multi-Ethnic Study of Atherosclerosis), and ARIC (Atherosclerosis Risk in Communities) study. We introduce a methodology and a framework used for preprocessing and harmonizing variables from multiple studies.<br /><b>Results</b><br />We provide a real-case study and step-by-step guidance to demonstrate the practical utility of our repository and interactive web page. In addition to our successful development of such an open-access repository and interactive web page, this exercise in harmonizing data from multiple cohort studies has revealed several key themes. These themes include the importance of careful preprocessing and harmonization of variables, the value of creating an open-access repository to facilitate collaboration and reproducibility, and the potential for using harmonized data to address important scientific questions and disparities in cardiovascular disease research.<br /><b>Conclusions</b><br />By integrating and harmonizing these large-scale cohort studies, such a repository may improve the statistical power and representation of understudied cohorts, enabling development and validation of risk prediction models, identification and investigation of risk factors, and creating a platform for racial disparities research.<br /><b>Registration</b><br />URL: https://precision.heart.org/duke-ninds.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 18 Oct 2023:e009938; epub ahead of print</small></div>

<div><h4>Association Between Prescription Drug Discount Cards and Out-of-Pocket Costs for HFrEF Regimens.</h4><i>Wheeler JS, Heidel RE, Dong A, Pleines KM, Hauptman PJ</i><br /><b>Background</b><br />The burden from medication costs for treating heart failure can be financially toxic for uninsured/underinsured patients and their families. Prescription discount cards, which offer cash price reductions, may decrease out-of-pocket costs for patients without prescription benefits, but the degree to which they offer financial relief remains unclear. Our objective was to assess the financial burden for uninsured/underinsured patients prescribed a drug from each of the 4 standard classes of medications for heart failure with reduced ejection fraction. A second objective assessed whether discounts varied across economically and geographically diverse regions in Tennessee.<br /><b>Methods</b><br />This was a cross-sectional pricing analysis of guideline-directed medical therapy heart failure with reduced ejection fraction regimens utilizing prescription discount cards. Between February 9 and March 31, 2022, we conducted searches on 3 discount card websites (GoodRx, NeedyMeds, and Blink Health) for the prices of 30- and 90-day supplies of select guideline-directed medical therapy heart failure regimens for 6 Tennessee ZIP codes. Prices were compared with Amazon and Redbook prices.<br /><b>Results</b><br />Monthly costs among discount card services varied from $10.58 to $30.86 for a generic 3-drug regimen consisting of beta blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and mineralocorticoid receptor antagonists. With the addition of a sodium-glucose cotransporter-2 inhibitor, prices increased to $540.32 to $593.74. The ideal 4-drug regimen (beta blocker, angiotensin receptor neprilysin inhibitor, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter-2 inhibitor) ranged from $1188.31 to $1464.54. When compared with Amazon cash prices, the cards offered an average discount of 65% on a generic 3-drug regimen; when brand-name medications were added, discounts were modest (<12%). There were no significant variations in pricing based on ZIP codes in differing economic and geographic regions.<br /><b>Conclusions</b><br />Although prescription discount cards offered significant savings on generic medications, brand-name drug discounts were small and overall costs remained high. These findings highlight the potential for unequal access to life-saving therapies for heart failure with reduced ejection fraction.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 Oct 2023; 16:e009987</small></div>

<div><h4>Insurance-Based Disparities in Stroke Center Access in California: A Network Science Approach.</h4><i>Zachrison KS, Hsia RY, Schwamm LH, Yan Z, ... Camargo CA, Onnela JP</i><br /><b>Background</b><br />Our objectives were to determine whether there is an association between ischemic stroke patient insurance and likelihood of transfer overall and to a stroke center and whether hospital cluster modified the association between insurance and likelihood of stroke center transfer.<br /><b>Methods</b><br />This retrospective network analysis of California data included every nonfederal hospital ischemic stroke admission from 2010 to 2017. Transfers from an emergency department to another hospital were categorized based on whether the patient was discharged from a stroke center (primary or comprehensive). We used logistic regression models to examine the relationship between insurance (private, Medicare, Medicaid, uninsured) and odds of (1) any transfer among patients initially presenting to nonstroke center hospital emergency departments and (2) transfer to a stroke center among transferred patients. We used a network clustering method to identify clusters of hospitals closely connected through transfers. Within each cluster, we quantified the difference between insurance groups with the highest and lowest proportion of transfers discharged from a stroke center.<br /><b>Results</b><br />Of 332 995 total ischemic stroke encounters, 51% were female, 70% were ≥65 years, and 3.5% were transferred from the initial emergency department. Of 52 316 presenting to a nonstroke center, 3466 (7.1%) were transferred. Relative to privately insured patients, there were lower odds of transfer and of transfer to a stroke center among all groups (Medicare odds ratio, 0.24 [95% CI, 0.22-0.26] and 0.59 [95% CI, 0.50-0.71], Medicaid odds ratio, 0.26 [95% CI, 0.23-0.29] and odds ratio, 0.49 [95% CI, 0.38-0.62], uninsured odds ratio, 0.75 [95% CI, 0.63-0.89], and 0.72 [95% CI, 0.6-0.8], respectively). Among the 14 identified hospital clusters, insurance-based disparities in transfer varied and the lowest performing cluster (also the largest; n=2364 transfers) fully explained the insurance-based disparity in odds of stroke center transfer.<br /><b>Conclusions</b><br />Uninsured patients had less stroke center access through transfer than patients with insurance. This difference was largely explained by patterns in 1 particular hospital cluster.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 25 Sep 2023:e009868; epub ahead of print</small></div>

<div><h4>Psychosocial Stressors at Work and Coronary Heart Disease Risk in Men and Women: 18-Year Prospective Cohort Study of Combined Exposures.</h4><i>Lavigne-Robichaud M, Trudel X, Talbot D, Milot A, ... Dagenais GR, Brisson C</i><br /><b>Background</b><br />Psychosocial stressors at work, like job strain and effort-reward imbalance (ERI), can increase coronary heart disease (CHD) risk. ERI indicates an imbalance between the effort and received rewards. Evidence about the adverse effect of combined exposure to these work stressors on CHD risk is scarce. This study examines the separate and combined effect of job strain and ERI exposure on CHD incidence in a prospective cohort of white-collar workers in Quebec, Canada.<br /><b>Methods</b><br />Six thousand four hundred sixty-five white-collar workers without cardiovascular disease (mean age, 45.3±6.7) were followed for 18 years (from 2000 to 2018). Job strain and ERI were measured with validated questionnaires. CHD events were retrieved from medico-administrative databases using validated algorithms. Marginal Cox models were used to calculate hazard ratios (HR) stratified by sex. Multiple imputation and inverse probability weights were applied to minimize potential threats to internal validity.<br /><b>Results</b><br />Among 3118 men, 571 had a first CHD event. Exposure to either job strain or ERI was associated with an adjusted 49% CHD risk increase (HR, 1.49 [95% CI, 1.07-2.09]). Combined exposure to job strain and ERI was associated with an adjusted 103% CHD risk increase (HR, 2.03 [95% CI, 1.38-2.97]). Exclusion of early CHD cases and censoring at retirement did not alter these associations. Among 3347 women, 265 had a first CHD event. Findings were inconclusive (passive job HR, 1.24 [95% CI, 0.80-1.91]; active job HR, 1.16 [95% CI, 0.70-1.94]; job strain HR, 1.08 [95% CI, 0.66-1.77]; ERI HR, 1.02 [95% CI, 0.72-1.45]).<br /><b>Conclusions</b><br />In this prospective cohort study, men exposed to job strain or ERI, separately and in combination, were at increased risk of CHD. Early interventions on these psychosocial stressors at work in men may be effective prevention strategies to reduce CHD burden. Among women, further investigation is required.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 19 Sep 2023:e009700; epub ahead of print</small></div>

<div><h4>Global Cardio Oncology Registry (G-COR): Registry Design, Primary Objectives, and Future Perspectives of a Multicenter Global Initiative.</h4><i>Teske AJ, Moudgil R, López-Fernández T, Barac A, ... Lenneman CE, Sadler D</i><br /><b>Background</b><br />Global collaboration in cardio-oncology is needed to understand the prevalence of cancer therapy-related cardiovascular toxicity in different risk groups, practice settings, and geographic locations. There are limited data on the socioeconomic and racial/ethnic disparities that may impact access to care and outcomes. To address these gaps, we established the Global Cardio-Oncology Registry, a multinational, multicenter prospective registry.<br /><b>Methods</b><br />We assembled cardiologists and oncologists from academic and community settings to collaborate in the first Global Cardio-Oncology Registry. Subsequently, a survey for site resources, demographics, and intention to participate was conducted. We designed an online data platform to facilitate this global initiative.<br /><b>Results</b><br />A total of 119 sites responded to an online questionnaire on their practices and main goals of the registry: 49 US sites from 23 states and 70 international sites from 5 continents indicated a willingness to participate in the Global Cardio-Oncology Registry. Sites were more commonly led by cardiologists (85/119; 72%) and were more often university/teaching (81/119; 68%) than community based (38/119; 32%). The average number of cardio-oncology patients treated per month was 80 per site. The top 3 Global Cardio-Oncology Registry priorities in cardio-oncology care were breast cancer, hematologic malignancies, and patients treated with immune checkpoint inhibitors. Executive and scientific committees and specific committees were established. A pilot phase for breast cancer using Research Electronic Data Capture Cloud platform recently started patient enrollment.<br /><b>Conclusions</b><br />We present the structure for a global collaboration. Information derived from the Global Cardio-Oncology Registry will help understand the risk factors impacting cancer therapy-related cardiovascular toxicity in different geographic locations and therefore contribute to reduce access gaps in cardio-oncology care. Risk calculators will be prospectively derived and validated.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 13 Sep 2023:e009905; epub ahead of print</small></div>

<div><h4>Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.</h4><i>Thompson MP, Stewart JW, Hou H, Nathan H, ... Hawkins RB, Likosky DS</i><br /><b>Background</b><br />Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting.<br /><b>Methods</b><br />A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes.<br /><b>Results</b><br />In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; <i>P</i><0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; <i>P</i><0.001).<br /><b>Conclusions</b><br />The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 13 Sep 2023:e009639; epub ahead of print</small></div>

<div><h4>Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States.</h4><i>Hager K, Du M, Li Z, Mozaffarian D, ... Folta SC, Zhang FF</i><br /><b>Background</b><br />Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations.<br /><b>Methods</b><br />This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2-17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4-10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI <i>z</i>-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program.<br /><b>Results</b><br />After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68-1.02) and 0.26 (95% CI, 0.06-0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52-0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30-2.02]) and children (odds ratio, 2.37 [1.70-3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by -0.29% age points (-0.42 to -0.16); among adults with hypertension, systolic and diastolic blood pressures declined by -8.38 mm Hg (-10.13 to -6.62) and -4.94 mm Hg (-5.96 to -3.92); and among adults with overweight or obesity, BMI decreased by -0.36 kg/m<sup>2</sup> (-0.64 to -0.09). Child BMI <i>z</i>-score did not change -0.01 (-0.06 to 0.04).<br /><b>Conclusions</b><br />In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 29 Aug 2023:e009520; epub ahead of print</small></div>