Interhospital variability in cardiac rehabilitation use after cardiac surgery among Medicare beneficiaries.

OBJECTIVE: Despite guideline recommendation, cardiac rehabilitation (CR) after cardiac surgery remains underused, and the extent of interhospital variability is not well understood. This study evaluated determinants of interhospital variability in CR use and outcomes. METHODS: This retrospective cohort study included 166,809 Medicare beneficiaries undergoing cardiac surgery who were discharged alive between July 1, 2016, and December 31, 2018. CR participation was identified in outpatient facility claims within a year of discharge. Hospital-level CR rates were tabulated, and multilevel models evaluated the extent to which patient, organizational, and regional factors accounted for interhospital variability. Adjusted 1-year mortality and readmission rates were also calculated for each hospital quartile of CR use. RESULTS: Overall, 90,171 (54.1%) participated in at least 1 CR session within a year of discharge. Interhospital CR rates ranged from 0.0% to 96.8%. Hospital factors that predicted CR use included nonteaching status and lower-hospital volume. Before adjustment for patient, organizational, and regional factors, 19.3% of interhospital variability was attributable to the admitting hospital. After accounting for covariates, 12.3% of variation was attributable to the admitting hospital. Patient (0.5%), structural (2.8%), and regional (3.7%) factors accounted for the remaining explained variation. Hospitals in the lowest quartile of CR use had greater adjusted 1-year mortality rates (Q1 = 6.7%, Q4 = 5.2%, P < .001) and readmission rates (Q1 = 37.6%, Q4 = 33.9%, P < .001). CONCLUSIONS: Identifying best practices among high CR use facilities and barriers to access in low CR use hospitals may reduce interhospital variability in CR use and advance national improvement efforts.

The relationship between discharge location and cardiac rehabilitation use after cardiac surgery.

BACKGROUND: Cardiac rehabilitation (CR) is a guideline-recommended risk-reduction program offered to cardiac surgical patients. Despite CR's association with better outcomes, attendance remains poor. The relationship between discharge location and CR use is poorly understood. METHODS: This study was a nationwide, retrospective cohort analysis of Medicare fee-for-service claims for beneficiaries undergoing coronary artery bypass grafting and/or surgical aortic valve repair between July 1, 2016, and December 31, 2018. The primary outcome was attendance of any CR session. Discharge location was categorized as home discharge or discharge to extended care facility (ECF) (including skilled nursing facility, inpatient rehabilitation, and long-term acute care). Multivariable logistic regression models evaluated the association between discharge location, CR attendance, and 1-year mortality. RESULTS: Of the 167,966 patients who met inclusion criteria, 34.1% discharged to an ECF. Overall CR usage rate was 53.9%. Unadjusted and adjusted CR use was lower among patients discharged ECFs versus those discharged home (42.1% vs 60.0%; adjusted odds ratio, 0.66; P < .001). Patients discharged to long-term acute care were less likely to use CR than those discharged to skilled nursing facility or inpatient rehabilitation (reference category: home; adjusted odds ratio for long-term acute care, 0.36, adjusted odds ratio for skilled nursing facility, 0.69, and adjusted odds ratio for inpatient rehabilitation, 0.71; P < .001). CR attendance was associated with a greater reduction in adjusted 1-year mortality in patients discharged to ECFs (9.7% reduction) versus those discharged home (4.3% reduction). CONCLUSIONS: In this national analysis of Medicare beneficiaries, discharge to ECF was associated with lower CR use, despite a greater association with improved 1-year mortality. Interventions aimed at increasing CR enrollment at ECFs may improve CR use and advance surgical quality.

Incomplete Anterior Spinal Artery Syndrome Responsive to Intrathecal Baclofen.

Anterior cord syndrome (ACS) occurs as a result of ischemia in the territory of the anterior spinal artery (ASA). Although spinal cord strokes are rare, the ASA is the most commonly affected vessel in the spinal cord. The typical presentation of an ASA stroke is paraparesis or paraplegia, bilateral loss of pain and temperature sensation, and fecal or urinary incontinence; the underlying neural structures responsible for these symptoms include the corticospinal tracts and anterior horns, anterolateral spinothalamic tracts, and lateral horns, respectively. ACS is a feared complication of aortic procedures and has been well-documented to occur during or after endovascular abdominal aortic aneurysm revascularization (EVAR). We report a case of incomplete or partial ACS presenting with delayed-onset spasticity and instability several months following EVAR, who was subsequently treated with intrathecal baclofen. We hypothesize that this patient's ischemia selectively damaged descending white matter tracts responsible for modulating the stretch receptor reflex, including damage to the corticospinal tract, which likely also impaired positional stability.

Area Deprivation and Medicare Spending for Coronary Artery Bypass Grafting: Insights From Michigan.

BACKGROUND: Prior work has established that high socioeconomic deprivation is associated with worse short- and long-term outcomes for patients undergoing coronary artery bypass grafting (CABG). The relationship between socioeconomic status and 90-day episode spending is poorly understood. In this observational cohort analysis, we evaluated whether socioeconomically disadvantaged patients were associated with higher expenditures during 90-day episodes of care after isolated CABG. METHODS: We linked clinical registry data from 8728 isolated CABG procedures from January 1, 2012, to December 31, 2018, to Medicare fee-for-service claims data. Our primary exposure variable was patients in the top decile of the Area Deprivation Index. Linear regression was used to compare risk-adjusted, price-standardized 90-day episode spending for deprived against nondeprived patients as well as component spending categories: index hospitalization, professional services, post acute care, and readmissions. RESULTS: A total of 872 patients were categorized as being in the top decile. Mean 90-day episode spending for the 8728 patients in the sample was $55 258 (SD, $26 252). Socioeconomically deprived patients had higher overall 90-day spending compared with nondeprived patients ($61 579 vs $54 557; difference, $3003; P = .001). Spending was higher in socioeconomically deprived patients for index hospitalizations (difference, $1284; P = .005), professional services (difference, $379; P = .002), and readmissions (difference, $1188; P = .008). Inpatient rehabilitation was the only significant difference in post-acute care spending (difference, $469; P = .011). CONCLUSIONS: Medicare spending was higher for socioeconomically deprived CABG in Michigan, indicating systemic disparities over and above patient demographic factors.

High Socioeconomic Deprivation and Coronary Artery Bypass Grafting Outcomes: Insights From Michigan.

BACKGROUND: Cardiovascular outcomes are worse among individuals from areas with limited socioeconomic resources. This study evaluated the relationship between high socioeconomic deprivation and isolated coronary artery bypass grafting (CABG) outcomes. METHODS: We linked statewide Society of Thoracic Surgeons Adult Cardiac Surgery Database data to Medicare Fee-for-Service records for 10 423 Michigan residents undergoing isolated CABG between January 2012 and December 2018. High socioeconomic deprivation was defined as residing in the highest decile of the ZIP Code-level area deprivation index (ADI). Multivariable logistic regression estimated the relationship between top ADI decile and major morbidity, in-hospital mortality, and operative mortality. Survival analyses evaluated long-term survival comparing patients in the top vs not in the top ADI decile. RESULTS: A total of 1036 patients were in the top decile of ADI (ADI >82.4), and they were more likely to be female, Black, and have a higher predicted risk of mortality. Patients in the top ADI decile had significantly higher rates of major morbidity (17.4% vs 11.4%; adjusted odds ratio, 1.26; 95% CI, 1.04-1.54; P = .021) and in-hospital mortality (3.2% vs 1.3%, adjusted odds ratio, 1.84; 95% CI, 1.18-2.86, P = .007) but not operative mortality. The adjusted hazard of mortality was 16% higher for patients residing in the top ADI decile (95% CI, 1.01-1.33; P = .032). CONCLUSIONS: Isolated CABG patients residing in the highest areas of socioeconomic deprivation differed with respect to demographic and clinical characteristics and experienced worse short- and long-term outcomes compared with those not in the top ADI decile.

Evaluating treatment-specific post-discharge quality-of-life and cost-effectiveness of TAVR and SAVR: Current practice & future directions.

BACKGROUND: Aortic stenosis is a prevalent valvular heart disease that is treated primarily by surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR), which are common treatments for addressing symptoms secondary to valvular heart disease. This narrative review article focuses on the existing literature comparing recovery and cost-effectiveness for SAVR and TAVR. METHODS: Major databases were searched for relevant literature discussing HRQOL and cost-effectiveness of TAVR and SAVR. We also searched for studies analyzing the use of wearable devices to monitor post-discharge recovery patterns. RESULTS: The literature focusing on quality-of-life following TAVR and SAVR has been limited primarily to single-center observational studies and randomized controlled trials. Studies focused on TAVR report consistent and rapid improvement relative to baseline status. Common HRQOL instruments (SF-36, EQ-5D, KCCQ, MLHFQ) have been used to document that TF-TAVR is advantageous over SAVR at 1-month follow-up, with the benefits leveling off following 1 year. TF-TAVR is economically favorable relative to SAVR, with estimated incremental cost-effectiveness ratio values ranging from $50,000 to $63,000/QALY gained. TA-TAVR has not been reported to be advantageous from an HRQOL or cost-effectiveness perspective. CONCLUSIONS: While real-world experiences are less described, large-scale trials have advanced our understanding of recovery and cost-effectiveness of aortic valve replacement treatment strategies. Future work should focus on scalable wearable device technology, such as smartwatches and heart-rate monitors, to facilitate real-world evaluation of TAVR and SAVR to support clinical decision-making and outcomes ascertainment.

Use of Telehealth by Surgical Specialties During the COVID-19 Pandemic.

Importance: While telehealth use in surgery has shown to be feasible, telehealth became a major modality of health care delivery during the COVID-19 pandemic. Objective: To assess patterns of telehealth use across surgical specialties before and during the COVID-19 pandemic. Design, Setting, and Participants: Insurance claims from a Michigan statewide commercial payer for new patient visits with a surgeon from 1 of 9 surgical specialties during one of the following periods: prior to the COVID-19 pandemic (period 1: January 5 to March 7, 2020), early pandemic (period 2: March 8 to June 6, 2020), and late pandemic (period 3: June 7 to September 5, 2020). Exposures: Telehealth implementation owing to the COVID-19 pandemic in March 2020. Main Outcomes and Measures: (1) Conversion rate defined as the rate of weekly new patient telehealth visits divided by mean weekly number of total new patient visits in 2019. This outcome adjusts for a substantial decrease in outpatient care during the pandemic. (2) Weekly number of new patient telehealth visits divided by weekly number of total new patient visits. Results: Among 4405 surgeons in the cohort, 2588 (58.8%) performed telehealth in any patient care context. Specifically for new patient visits, 1182 surgeons (26.8%) used telehealth. A total of 109 610 surgical new outpatient visits were identified during the pandemic. The median (interquartile range) age of telehealth patients was 46.8 (34.1-58.4) years compared with 52.6 (38.3-62.3) years for patients who received care in-person. Prior to March 2020, less than 1% (8 of 173 939) of new patient visits were conducted through telehealth. Telehealth use peaked in April 2020 (week 14) and facilitated 34.6% (479 of 1383) of all new patient visits during that week. The telehealth conversion rate peaked in April 2020 (week 15) and was equal to 8.2% of the 2019 mean weekly new patient visit volume. During period 2, a mean (SD) of 16.6% (12.0%) of all new patient surgical visits were conducted via telehealth (conversion rate of 5.1% of 2019 mean weekly new patient visit volumes). During period 3, 3.0% (2168 of 71 819) of all new patient surgical visits were conducted via telehealth (conversion rate of 2.5% of 2019 new patient visit volumes). Mean (SD) telehealth conversion rates varied by specialty with urology being the highest (14.3% [7.7%]). Conclusions and Relevance: Results from this study showed that telehealth use grew across all surgical specialties in Michigan in response to the COVID-19 pandemic. While rates of telehealth use have declined as in-person care has resumed, telehealth use remains substantially higher across all surgical specialties than it was prior to the pandemic.