Association Between Industry Payments to Physicians and Device Selection in ICD Implantation.

Importance: Little is known about the association between industry payments and medical device selection. Objective: To examine the association between payments from device manufacturers to physicians and device selection for patients undergoing first-time implantation of a cardioverter-defibrillator (ICD) or cardiac resynchronization therapy-defibrillator (CRT-D). Design, Setting, and Participants: In this cross-sectional study, patients who received a first-time ICD or CRT-D device from any of the 4 major manufacturers (January 1, 2016-December 31, 2018) were identified. The data from the National Cardiovascular Data Registry ICD Registry was linked with the Open Payments Program's payment data. Patients were categorized into 4 groups (A, B, C, and D) corresponding to the manufacturer from which the physician who performed the implantation received the largest payment. For each patient group, the proportion of patients who received a device from the manufacturer that provided the largest payment to the physician who performed implantation was determined. Within each group, the absolute difference in proportional use of devices between the manufacturer that made the highest payment and the proportion of devices from the same manufacturer in the entire study cohort (expected prevalence) was calculated. Exposures: Manufacturers' payments to physicians who performed an ICD or CRT-D implantation. Main Outcomes and Measures: The primary outcome of the study was the manufacturer of the device used for the implantation. Results: Over a 3-year period, 145 900 patients (median age, 65 years; 29.6% women) received ICD or CRT-D devices from the 4 manufacturers implanted by 4435 physicians at 1763 facilities. Among these physicians, 4152 (94%) received payments from device manufacturers ranging from $2 to $323 559 with a median payment of $1211 (interquartile range, $390-$3702). Between 38.5% and 54.7% of patients received devices from the manufacturers that had provided physicians with the largest payments. Patients were substantially more likely to receive devices made by the manufacturer that provided the largest payment to the physician who performed implantation than they were from each other individual manufacturer. The absolute differences in proportional use from the expected prevalence were 22.4% (95% CI, 21.9%-22.9%) for manufacturer A; 14.5% (95% CI, 14.0%-15.0%) for manufacturer B; 18.8% (95% CI, 18.2%-19.4%) for manufacturer C; and 30.6% (95% CI, 30.0%-31.2%) for manufacturer D. Conclusions and Relevance: In this cross-sectional study, a large proportion of ICD or CRT-D implantations were performed by physicians who received payments from device manufacturers. Patients were more likely to receive ICD or CRT-D devices from the manufacturer that provided the highest total payment to the physician who performed an ICD or CRT-D implantation than each other manufacturer individually.

Thirty-day readmissions after atrial fibrillation catheter ablation in patients with heart failure.

BACKGROUND: Randomized clinical trial data have demonstrated catheter ablation (CA) as a viable treatment modality for atrial fibrillation (AF). Patients with heart failure (HF) undergoing AF CA appear to derive improvements in quality of life and mortality compared to those treated with medical therapy (MT). Contemporary national data on 30-day readmissions after CA compared to MT among patients with HF are lacking. METHODS: From the 2016 Nationwide Readmissions Databases, 749 776 (weighted national estimate: 1 421 673) AF HF patients were identified of which 2204 (0.3%) underwent CA and 747 572 (99.7%) received MT. Propensity matching balanced baseline clinical characteristics. Thirty-day readmission rates, causes, predictors, and costs of 30-day readmission were compared. RESULTS: Among both the unmatched and matched cohorts, 30-day readmissions were lower for patients treated with CA compared to MT (16.8% vs 20.1%, P < .001 and 16.8% vs 18.8%, P = .020). CA was associated with reduced risk of readmission compared to MT (odds ratio 0.86, 95% confidence interval [CI]: 0.77-0.97). HF exacerbation and arrhythmias were the most common cause for 30-day readmission after CA. CA costs were higher during index hospitalization but similar to MT during readmission among the matched cohort ($15 858 ± $21 636 vs $16 505 ± $29 171, P = .67). Predictors of readmission were largely nonmodifiable risk factors among both the CA and MT groups. CONCLUSIONS: Nearly one in six patients with HF is readmitted within 30-days after undergoing CA. In propensity matched analyses, CA was associated with decreased rate and risk for readmission compared to MT. CA has higher index hospitalization costs, but lower readmission costs.

Quality management in the cardiac catheterization laboratory.

The development of quality assurance (QA) and quality improvement (QI) initiatives have paralleled the expansion and proliferation of cardiac catherization laboratories. Quality cardiovascular care aims to deliver high standards for patient safety by developing processes and systems to optimize patient-team interactions. Quality can be assessed at the individual operator, team, program, facility or system level. Cardiovascular societies and organizations have developed national registries to help institutions benchmark their process and outcomes against national standards. Various quality measurement techniques are available to assess current performance and identify opportunities for improvement. Appropriate use criteria (AUC) for revascularization were implemented to serve as a QA measure to examine the use of medical procedures. In today's value-based payment systems-focused healthcare climate, quality metrics are followed closely by many payors. In this review, the framework for quality in the cardiac catheterization laboratory and tools to achieve continuous quality improvement (CQI) are discussed.

Epinephrine use results in 'stress' cardiomyopathy.

Epinephrine is a frequently used catecholamine, particularly in emergencies and during resuscitation attempts. It is not without side effects. We report a rare case of epinephrine-induced cardiomyopathy. Epinephrine was administered for bradycardia in our patient. He was treated conservatively and responded well to the treatment. Through our work we wish to highlight this adverse cardiac effect of epinephrine. We hope to increase awareness among residents and practicing physicians while using epinephrine. .

Resident and fellow assessment of health policy attitudes and advocacy priorities.

BACKGROUND: House staff physicians (medical residents and fellows) represent a significant proportion of the physician workforce in the U.S. and are a potentially important force in health care transformation, but little is known about house staff health policy attitudes or priorities. METHODS: We conducted a cross-sectional survey of all house staff at Yale-New Haven Hospital (YNHH) and the University of Connecticut Health Center (UCHC). We calculated means of Likert-scale attitude response scores and rankings of health policy priorities. We then performed linear regression of postgraduate year (PGY) and surgical specialty on health policy priorities. RESULTS: We received back 308 surveys (response rate of 19%). One hundred thirty-five responses (44%) were from UCHC and 173 responses were from YNHH (56%). Eighty-nine percent agreed that health policy was important to them, but only 21% felt confident in their knowledge of health policy. Thirty-two percent felt they had a good understanding of the Affordable Care Act. In terms of health policy priorities, malpractice reform and future salary were ranked the highest. There was a statistically significant positive association between PGY and malpractice reform as well as a negative association with Medicaid expansion and PGY after adjusting for surgical specialty. CONCLUSION: House staff physicians feel that health policy is important to them, but they are not confident in their knowledge of health policy. Malpractice reform and future salary are policy priorities for house staff, and malpractice reform is increasingly important to house staff as they advance through their postgraduate training.

Exploring the link between dystonia genes and idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is characterized by a complex curvature of the spine of unknown etiology. Unknown genetic factors likely play a role in disease pathogenesis. Recent studies suggest that AIS could result from central nervous system dysfunction and be related to dystonia. On the basis of this information, we hypothesized that genes linked to dystonia contribute to the pathogenesis of AIS. METHODS: To test this hypothesis, we evaluated the potential association between sequence variants in candidate dystonia genes and AIS. We sequenced the coding region of 5 selected dystonia-causing genes in 24 subjects with AIS, followed by targeted confirmation in additional 89 patients and 73 controls. RESULTS: No mutations were identified in any of the dystonia genes studied. CONCLUSIONS: We found no genetic link between dystonia and AIS. CLINICAL RELEVANCE: This investigation is a genetic evaluation of the association between dystonia and AIS. Despite the support in the literature for a pathogenic link between both the disorders, we have not identified any mutations in dystonia genes in patients with AIS.