Geographic Variation in Trends and Disparities in Heart Failure Mortality in the United States, 1999 to 2017.

Background Cardiovascular disease mortality related to heart failure (HF) is rising in the United States. It is unknown whether trends in HF mortality are consistent across geographic areas and are associated with state-level variation in cardiovascular health (CVH). The goal of the present study was to assess regional and state-level trends in cardiovascular disease mortality related to HF and their association with variation in state-level CVH. Methods and Results Age-adjusted mortality rates (AAMR) per 100 000 attributable to HF were ascertained using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research from 1999 to 2017. CVH at the state-level was quantified using the Behavioral Risk Factor Surveillance System. Linear regression was used to assess temporal trends in HF AAMR were examined by census region and state and to examine the association between state-level CVH and HF AAMR. AAMR attributable to HF declined from 1999 to 2011 and increased between 2011 and 2017 across all census regions. Annual increases after 2011 were greatest in the Midwest (ß=1.14 [95% CI, 0.75, 1.53]) and South (ß=0.96 [0.66, 1.26]). States in the South and Midwest consistently had the highest HF AAMR in all time periods, with Mississippi having the highest AAMR (109.6 [104.5, 114.6] in 2017). Within race‒sex groups, consistent geographic patterns were observed. The variability in HF AAMR was associated with state-level CVH (P<0.001). Conclusions Wide geographic variation exists in HF mortality, with the highest rates and greatest recent increases observed in the South and Midwest. Higher levels of poor CVH in these states suggest the potential for interventions to promote CVH and reduce the burden of HF.

Heart Failure Risk Distribution and Trends in the United States Population, NHANES 1999-2016.

BACKGROUND: Implementation of effective preventive interventions requires identification of high-risk individuals. We sought to define the distribution and trends of heart failure risk in the US population. METHODS: We calculated 10-year predicted heart failure risk among a representative sample of US adults aged 30-79 years, without baseline cardiovascular disease, from the National Health and Nutrition Examination Surveys (NHANES) 1999-2016. We used the published Pooled Cohort Equations to Prevent Heart Failure (PCP-HF) model, which integrates demographic and risk factor data, to estimate 10-year heart failure risk. Participants were stratified by NHANES cycle, sex, age, and race/ethnicity and by 10-year heart failure risk, defined as low (<1%), intermediate (1% to <5%), and high (≥5%). RESULTS: From 1999-2000 to 2015-2016, mean predicted 10-year heart failure risk increased significantly from 2.0% to 3.0% (P < .05) in the population, most notably among non-Hispanic black (2.1% to 3.7%) and non-Hispanic white (2.4% to 3.6%) men. In 2013-2016, 17.6% of the studied population was at high predicted 10-year heart failure risk. The prevalence of high predicted heart failure risk was highest among non-Hispanic black men (23.1%), followed by non-Hispanic white men (19.2%) and non-Hispanic white women (17.9%). DISCUSSION: Mean population risk of heart failure increased significantly from 1999-2016. A substantial proportion of US adults are at high 10-year heart failure risk (≥5%), particularly non-Hispanic black men. These data underscore the importance of identifiying individuals at increased heart failure risk for targeted prevention measures to reduce the future burden of heart failure.

Changes in task-based effective connectivity in language networks following rehabilitation in post-stroke patients with aphasia.

In this study, we examined regions in the left and right hemisphere language network that were altered in terms of the underlying neural activation and effective connectivity subsequent to language rehabilitation. Eight persons with chronic post-stroke aphasia and eight normal controls participated in the current study. Patients received a 10 week semantic feature-based rehabilitation program to improve their skills. Therapy was provided on atypical examples of one trained category while two control categories were monitored; the categories were counterbalanced across patients. In each fMRI session, two experimental tasks were conducted: (a) picture naming and (b) semantic feature verification of trained and untrained categories. Analysis of treatment effect sizes revealed that all patients showed greater improvements on the trained category relative to untrained categories. Results from this study show remarkable patterns of consistency despite the inherent variability in lesion size and activation patterns across patients. Across patients, activation that emerged as a function of rehabilitation on the trained category included bilateral IFG, bilateral SFG, LMFG, and LPCG for picture naming; and bilateral IFG, bilateral MFG, LSFG, and bilateral MTG for semantic feature verification. Analysis of effective connectivity using Dynamic Causal Modeling (DCM) indicated that LIFG was the consistently significantly modulated region after rehabilitation across participants. These results indicate that language networks in patients with aphasia resemble normal language control networks and that this similarity is accentuated by rehabilitation.

Timely and appropriate access to healthcare. The way forward--the roles of the players.

Through the leadership of a number of Canadian healthcare organizations and the Canadian Policy Research Networks, invitational conferences focused on the "wait-time problem" have been held in Ottawa over the past three years. This paper, utilizing both the views and information presented at the most recent conference and the author's own experience and views, seeks to outline directions that could help us achieve timely and appropriate access to care in Canada.

Sustaining change: the imperative for patient access strategies.

The paper by Trypuc, MacLeod and Hudson provides a timely and important overview of methods to sustain provincial wait time strategies. The emphasis on accountability for patient access to timely care throughout the healthcare system comes through strongly--as it should. These accountabilities are made "real" through purchase service agreements. Physician-hospital relationships are a fundamental aspect of this accountability. This commentary suggests the inclusion of two additional supporting tools in addition to those cited by the authors of the lead paper--quality monitoring and the use of industrial engineering techniques for queue management and patient flow analysis. Strong and persistent leadership of patient access strategies will ensure sustainable change.

The Saskatchewan Surgical Care Network--toward timely and appropriate access.

Earlier this year, a paper in Hospital Quarterly, "Creating a Surgical Wait List Management Strategy for Saskatchewan," described the development of a surgical wait list strategy for Saskatchewan. The initial strategy development process uncovered several issues that needed to be addressed including lack of data, inconsistent priorities and frustration on the parts of both providers and patients. This second paper outlines the key points of the recommended surgical wait list strategy and the work to date in its implementation.

Creating a surgical wait list management strategy for Saskatchewan.

In the summer of 2001, Saskatchewan Health asked Dr. Peter Glynn, Health Care Consultant, Dr. Mark Taylor, the Deputy Head of General Surgery at St. Boniface General Hospital in Winnipeg and Dr. Alan Hudson, a Toronto-based neurosurgeon and former CEO of the University Health Network, to advise on the creation of a provincial surgical wait list management strategy to address growing concerns about waiting times for many non-emergent surgical procedures. Although the work was focused on Saskatchewan, this is a common issue across the country.