Dynamic "spiked helmet sign": Further evidence for prolonged QT.

A 69-year-old woman was admitted after a cardiac arrest. She developed status epilepticus and was later found to have variable morphologies of a "spiked helmet sign" (SHS) on ECGs in the setting of prolonged QT interval, raising the question of whether this sign is a manifestation of QT prolongation.

Widening Gender Gap in Life Expectancy in the US, 2010-2021.

This cross-sectional study systematically examines the contributions of COVID-19 and other underlying causes of death to the widened gender life expectancy gap from 2010 to 2021.

Prices for Common Services at Quaternary vs Nonquaternary Hospitals.

This study uses commercial claims data to assess whether quaternary hospitals charge higher prices for common, unspecialized services also offered by nonquaternary hospitals.

Cost-Effectiveness of Quadruple Therapy in Management of Heart Failure With Reduced Ejection Fraction in the United States.

BACKGROUND: The 2022 clinical guidelines for management of heart failure with reduced ejection fraction call for quadruple therapy. Quadruple therapy consists of an angiotensin receptor-neprilysin inhibitor (ARNi), sodium-glucose cotransporter-2 inhibitor (SGLT2i), mineralocorticoid receptor antagonist, and beta blocker. The ARNi and sodium-glucose cotransporter-2 inhibitor are newer additions to standard of care with the ARNi replacing ACE (angiotensin-converting enzyme) inhibitors and angiotensin II receptor blockers. METHODS: We investigate the cost-effectiveness of sequentially adding the SGLT2i and ARNi to form quadruple therapy as compared with the previous standard of care with ACE inhibitor/mineralocorticoid receptor antagonist/beta blocker. Using a 2-stage Markov model, we projected the expected lifetime discounted costs and quality-adjusted life years (QALYs) of a simulated cohort of US patients who underwent each treatment option and calculated incremental cost-effectiveness ratios. We assessed incremental cost-effectiveness ratios using criteria for health care value (<$50 000/quality-adjusted life year [QALY] indicating high-value, $50 000-150 000/QALY indicating intermediate value, and >$150 000/QALY indicating low-value) and a standard $100 000/QALY cost-effectiveness threshold. RESULTS: Compared with the previous standard of care, the SGLT2i addition had an incremental cost-effectiveness ratio of $73 000/QALY and weakly dominated the ARNi addition. The addition of both the ARNi and SGLT2i for quadruple therapy offered 0.68 additional discounted QALYs over the SGLT2i addition alone at a lifetime discounted cost of $66 700, resulting in an incremental cost-effectiveness ratio of $98 500/QALY. In sensitivity analysis varying drug prices, the incremental cost-effectiveness ratio for quadruple therapy ranged from $73 500/QALY using prices available to the US Department of Veterans Affairs to $110 000/QALY using drug list prices. CONCLUSIONS: While quadruple therapy offers intermediate value, it is borderline cost effective compared with adding the SGLT2i alone to previous standard of care. Thus, its cost-effectiveness is sensitive to a payer's ability to negotiate discounts off the increasing list prices for ARNI and SGLT2is. The demonstrated benefits of ARNi and SGLT2is should be weighed against their high prices in payer and policy considerations.

Changes in Medicare Accountable Care Organization Spending, Utilization, and Quality Performance 2 Years Into the COVID-19 Pandemic.

This cohort study uses data from the Medicare Shared Savings Program to assess changes in spending, utilization, and quality performance from before the COVID-19 pandemic (2019) to year 2 of the pandemic (2021).

Changes in spending, utilization, and quality of care among Medicare accountable care organizations during the COVID-19 pandemic.

The COVID pandemic disrupted health care spending and utilization, and the Medicare Shared Savings Program (MSSP), Medicare's largest value-based payment model with 11.2 million assigned beneficiaries, was no exception. Despite COVID, the 513 accountable care organizations (ACO) in MSSP returned a program record $1.9 billion in net savings to Medicare in 2020. To understand the extent of COVID's impact on MSSP cost and quality, we describe how ACO spending changed in 2020 and further analyze changes in measured quality and utilization. We found that non-COVID per capita spending in MSSP fell by 8.3 percent from $11,496 to $10,537 (95% confidence interval(CI),-1,223.8 to-695.4, p<0.001), driven by 14.6% and 7.5% reductions in per capita acute inpatient and outpatient spending, respectively. Utilization fell across inpatient, emergency, and outpatient settings. On quality metrics, preventive screening rates remained stable or improved, while control of diabetes and blood pressure worsened. Large reductions in non-COVID utilization helped ACOs succeed financially in 2020, but worsening chronic disease measures are concerning. The appropriateness of the benchmark methodology and exclusion of COVID-related spending, especially as the virus approaches endemicity, should be revisited to ensure bonus payments reflect advances in care delivery and health outcomes rather than COVID-related shifts in spending and utilization patterns.

Neurologic Dysfunction Associated With Mechanically Assisted Crevice Corrosion and Elevated Cobalt Ion Levels After Total Hip Arthroplasty.

Adverse local tissue reactions secondary to mechanically assisted crevice corrosion (MACC) at the trunnion is a complication of total hip arthroplasty known to cause local soft-tissue damage. However, what is not as well appreciated is that MACC in metal-on-polyethylene (MOP) articulations can lead to cobalt ion serum elevations with associated neurological dysfunction just as in metal-on-metal articulations. We report a compelling case for the association of neurologic dysfunction tied to metal ion elevations secondary to MACC at two distinct MOP tapers in a 58-year-old intensive care unit nurse with two hips implanted 3 years apart. This report further raises awareness about the potential of MACC-generated elevated ion levels to produce neurological symptoms that might otherwise be overlooked in patients with MOP articulations.

Death Toll of COVID-19 on Asian Americans: Disparities Revealed.

The coronavirus disease 2019 (COVID-19) pandemic has underscored the structural inequities facing communities of color and its consequences in lives lost. However, little is known about the COVID-related disparities facing Asian Americans amidst the heightened racism and violence against this community. We analyze the mortality toll of COVID-19 on Asian Americans using multiple measures. In 2020, one in seven Asian American deaths was attributable to COVID-19. We find that while Asian Americans make up a small proportion of COVID-19 deaths in the USA, they experience significantly higher excess all-cause mortality (3.1 times higher), case fatality rate (as high as 53% higher), and percentage of deaths attributed to COVID-19 (2.1 times higher) compared to non-Hispanic Whites. Mounting evidence suggest that disproportionately low testing rates, greater disease severity at care presentation, socioeconomic factors, and racial discrimination contribute to the observed disparities. Improving data reporting and uniformly confronting racism are key components to addressing health inequities facing communities of color.

The Opioid Epidemic Blunted the Mortality Benefit of Medicaid Expansion.

Although the Affordable Care Act's Medicaid expansion reduced uninsurance, less is known about its impact on mortality, especially in the context of the opioid epidemic. We conducted a difference-in-differences study comparing trends in mortality between expansion and nonexpansion states from 2011 to 2016 using the Centers for Disease Control and Prevention mortality data. We analyzed all-cause deaths, health care amenable deaths, drug overdose deaths, and deaths from causes other than drug overdose among adults aged 20 to 64 years. Medicaid expansion was associated with a 2.7% reduction (p = .020) in health care amenable mortality, and a 1.9% reduction (p = .042) in mortality not due to drug overdose. However, the expansion was not associated with any change in all-cause mortality (0.2% reduction, p = .84). In addition, drug overdose deaths rose more sharply in expansion versus nonexpansion states. The absence of all-cause mortality reduction until drug overdose deaths were excluded indicate that the opioid epidemic had a mitigating impact on any potential lives saved by Medicaid expansion.

Understanding Medicare ACO Adoption in the Context of Market Factors.

Medicare Accountable Care Organizations (ACOs) have achieved high-quality performance and recent cost savings, but little is known about how local market conditions influence provider adoption. The authors describe physician practice participation in Medicare ACOs at the county level and use adjusted logistic regression to assess the association between ACO presence and 3 characteristics hypothesized to influence ACO formation: physician market concentration, Medicare Advantage (MA) penetration, and commercial health insurance market concentration. Analyses are repeated on urban and rural county subgroups to examine geographic differences in ACO adoption. Practice participation in ACOs grew 19% nationally from 5.4% to 6.4% of practices between 2015 to 2017, but participation lagged in the West and rural counties, the latter of which had relatively concentrated physician markets and low MA penetration. After controlling for urban location, population density, and other covariates, ACO presence in a county was independently associated with less concentrated physician markets and moderate MA penetration but not commercial insurance concentration. The evidence suggests that Medicare ACO programs have continued appeal to physician practices, but additional engagement strategies may be needed to expand adoption in rural areas. In addition, greater practice competition and MA experience may facilitate ACO adoption. These insights into the relationship between market conditions and ACO participation have important implications for policy efforts to accelerate Medicare payment transformation.

Changes in Mental Health Following the 2016 Presidential Election.

BACKGROUND: The 2016 presidential election and the controversial policy agenda of its victor have raised concerns about how the election may have impacted mental health. OBJECTIVE: Assess how mental health changed from before to after the November 2016 election and how trends differed in states that voted for Donald Trump versus Hillary Clinton. DESIGN: Pre- versus post-election study using monthly cross-sectional survey data. PARTICIPANTS: A total of 499,201 adults surveyed in the Behavioral Risk Factor Surveillance System from May 2016 to May 2017. EXPOSURE: Residence in a state that voted for Trump versus state that voted for Clinton and the candidate's margin of victory in the state. MAIN MEASURES: Self-reported days of poor mental health in the last 30 days and depression rate. KEY RESULTS: Compared to October 2016, the mean days of poor mental health in the last 30 days per adult rose from 3.35 to 3.85 in December 2016 in Clinton states (0.50 days difference, p = 0.005) but remained statistically unchanged in Trump states, moving from 3.94 to 3.78 days (- 0.17 difference, p = 0.308). The rises in poor mental health days in Clinton states were driven by older adults, women, and white individuals. The depression rate in Clinton states began rising in January 2017. A 10-percentage point higher margin of victory for Clinton in a state predicted 0.41 more days of poor mental health per adult in December 2016 on average (p = 0.001). CONCLUSIONS: In states that voted for Clinton, there were 54.6 million more days of poor mental health among adults in December 2016, the month following the election, compared to October 2016. Clinicians should consider that elections could cause at least transitory increases in poor mental health and tailor patient care accordingly, especially with the 2020 election upon us.

Impact of Age on Long-Term Outcomes of Surgery for Malignant Pleural Mesothelioma.

BACKGROUND: Although malignant pleural mesothelioma (MPM) is generally a disease associated with more advanced age, the association of age, treatment, and outcomes has not been well-characterized. We evaluated the impact of age on outcomes in patients with MPM to provide data for use in the treatment selection process for elderly patients with potentially resectable disease. PATIENTS AND METHODS: Overall survival (OS) of patients younger than 70 and 70 years or older with Stage I to III MPM who underwent cancer-directed surgery or nonoperative management in the Surveillance, Epidemiology, and End Results database (2004-2010) was evaluated using multivariable Cox proportional hazard models and propensity score-matched analysis. RESULTS: Cancer-directed surgery was used in 284 of 879 (32%) patients who met inclusion criteria, and was associated with improved OS in multivariable analysis (hazard ratio, 0.71; P = .001). Cancer-directed surgery was used much less commonly in patients 70 years and older compared with patients younger than 70 years (22% [109/497] vs. 46% [175/382]; P < .001), but patients 70 years and older had improved 1-year (59.4% vs. 37.9%) and 3-year (15.4% vs. 8.0%) OS compared with nonoperative management. The benefit of surgery in patients 70 years and older was observed even after propensity score-matched analysis was used to control for selection bias. CONCLUSION: Surgical treatment is associated with improved survival compared with nonoperative management for both patients younger than 70 years and patients aged 70 years or older.