Peter W. Groeneveld

Incidence of treated cardiac arrest in hospitalized patients in the United States.

Objective:The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response. Design:Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003–2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends. Setting:Get With The Guidelines-Resuscitation registry. Patients:Adult inhospital cardiac arrest with a resuscitation response. Measurements and Main Results:The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests. Conclusions:There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.

Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease

BACKGROUND & AIMS Endoscopic screening and periodic surveillance for patients with Barretts esophagus has been shown to be cost-effective in patients with esophageal dysplasia, with treatment for esophageal cancer limited to esophagectomy. Most gastroenterologists refer patients with high-grade dysplasia for esophagectomy, and effective endoscopic therapies are available for nonoperative patients with esophageal cancer. The cost-effectiveness of screening strategies that incorporate these nonsurgical treatment modalities has not been determined. METHODS We designed a Markov model to compare lifetime costs and life expectancy for a cohort of 50-year-old men with chronic reflux symptoms. We compared 10 clinical strategies incorporating combinations of screening and surveillance protocols (no screening, screening with periodic surveillance for both dysplastic and nondysplastic Barretts esophagus, or periodic surveillance for dysplasia only), treatment for high-grade dysplasia (esophagectomy or intensive surveillance), and treatment for cancer (esophagectomy or surgical and endoscopic treatment options). RESULTS Screening and surveillance of patients with both dysplastic and nondysplastic Barretts esophagus followed by esophagectomy for surgical candidates with high-grade dysplasia or esophageal cancer and endoscopic therapy for cancer patients who were not operative candidates cost

Drug-Eluting Compared With Bare-Metal Coronary Stents Among Elderly Patients

12,140 per life-year gained compared to no screening. Other screening strategies, including strategies that had no endoscopic treatment options, were either less effective at the same cost, or equally effective at a higher cost. CONCLUSIONS The cost-effectiveness of screening and subsequent surveillance of patients with dysplastic as well as nondysplastic Barretts esophagus followed by endoscopic or surgical therapy in patients who develop cancer compares favorably to many widely accepted screening strategies for cancer.

Racial Disparity in Cardiac Procedures and Mortality Among Long-Term Survivors of Cardiac Arrest

OBJECTIVES We sought to determine whether drug-eluting stents (DES) were associated with improved clinical outcomes compared with bare-metal stents (BMS) among a nationally representative, nonexperimental elderly patient cohort. BACKGROUND Randomized controlled clinical trials comparing DES and BMS for treatment of coronary artery disease indicate that although the use of DES reduces rates of coronary restenosis after percutaneous coronary intervention, it does not reduce the rates of mortality or acute myocardial infarction (AMI). Nevertheless, clinical outcomes of DES in nonexperimental, routine clinical practice are uncertain. METHODS We assembled a retrospective cohort of elderly Medicare beneficiaries (n = 76,525) who received DES within 9 months after Food and Drug Administration approval of the sirolimus-eluting stent (April 2003 to December 2003). Using propensity score methods, we assembled 2 matched control cohorts who received BMS from July 2002 to March 2003 (historical controls) or from April 2003 to December 2003 (contemporary controls). Patient enrollment and claims records were obtained through December 2005 to ascertain mortality, hospitalization for AMI, and subsequent coronary revascularization. RESULTS Receipt of a DES was associated with a significant survival benefit, with an adjusted mortality hazard ratio of 0.83 (95% confidence interval 0.81 to 0.86) compared with contemporary controls, and a hazard ratio of 0.79 (95% confidence interval 0.77 to 0.81) compared with historical controls (control group heterogeneity: p < 0.001). Patients with DES had significantly lower adjusted rates of revascularization procedures within the first 2 years after PCI and lower hospitalization rates for subsequent AMI. CONCLUSIONS In contrast to clinical trial results, DES receipt was associated with fewer subsequent revascularization procedures, lower rates of hospitalization for AMI, and improved survival among elderly Medicare beneficiaries.

Appropriateness of primary prevention implantable cardioverter- defibrillators at the time of generator replacement: Are indications still met?

Background It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long‐term survival after cardiac arrest. Methods and Results A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Associations annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverterdefibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD. Conclusions There is racial disparity in long‐term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life‐saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients. (Circulation. 2003; 108:286‐291.)

Ethnic and racial disparities in cardiac resynchronization therapy

OBJECTIVES This study sought to determine how often patients with primary prevention implantable cardioverter-defibrillators (ICDs) meet guideline-derived indications at the time of generator replacement. BACKGROUND Professional societies have developed guideline criteria for the appropriate implantation of an ICD for the primary prevention of sudden cardiac death. It is unknown whether patients continue to meet criteria when their devices need replacement for battery depletion. METHODS We performed a retrospective chart review of patients undergoing replacement of primary prevention ICDs at 2 tertiary Veterans Affairs Medical Centers. Indications for continued ICD therapy at the time of generator replacement included a left ventricular ejection fraction (LVEF) ≤35% or receipt of appropriate device therapy. RESULTS In our cohort of 231 patients, 59 (26%) no longer met guideline-driven indications for an ICD at the time of generator replacement. An additional 79 patients (34%) had not received any appropriate ICD therapies and had not undergone reassessment of their LVEF. Patients with an initial LVEF of 30% to 35% were less likely to meet indications for ICD therapy at the time of replacement (odds ratio: 0.52; 95% confidence interval: 0.30 to 0.88; p = 0.01). Patients without ICD indications subsequently received appropriate ICD therapies at a significantly lower rate than patients with indications (2.8% vs. 10.7% annually, p < 0.001). If ICD generator explantations were performed instead of replacements in the patients without ICD indications, the cost savings would be

Cost-Effectiveness of Therapeutic Hypothermia After Cardiac Arrest

1.6 million. CONCLUSIONS Approximately 25% of patients who receive primary prevention ICDs may no longer meet guideline indications for ICD use at the time of generator replacement, and these patients receive subsequent ICD therapies at a significantly lower rate.

Preventing tomorrow's sudden cardiac death today: Dissemination of effective therapies for sudden cardiac death prevention

BACKGROUND Racial/ethnic differences in the use of cardiac resynchronization therapy with defibrillator (CRT-D) may result from underprovision or overprovision relative to published guidelines. OBJECTIVE The purpose of this study was to examine the National Cardiovascular Data Registry (NCDR) ICD Registry for ethnic/racial differences in use of CRT-D. METHODS We studied white, black, and Hispanic patients who received either an implantable cardioverter-defibrillator (ICD) or CRT-D between January 2005 and April 2007. Two multivariate logistic regression models were fit with the following outcome variables: (1) receipt of either ICD or CRT-D and (2) receipt of CRT-D outside of published guidelines. RESULTS Of 108,341 registry participants, 22,205 met inclusion criteria for the first analysis and 27,165 met criteria for the second analysis. Multivariate analysis indicated CRT-eligible black (odds ratio [OR] 0.84; 95% confidence interval [CI], 0.75-0.95; P <.004) and Hispanic (OR 0.83; 95% CI, 0.71-0.99; P <.033) patients were less likely to receive CRT-D than were white patients. A substantial proportion of patients received CRT-D outside of published guidelines, although black (OR 1.18; 95% CI, 1.02-1.36; P = .001) and Hispanic (OR 1.17; 95% CI, 1.02-1.36; P = .03) patients were more likely to meet all three eligibility criteria. CONCLUSION Black and Hispanic patients who were eligible for CRT-D were less likely to receive therapy compared with white patients. Conversely, in the context of widespread out-of-guideline use of CRT-D, black and Hispanic patients were more likely to meet established criteria. Our findings suggest systematic racial/ethnic differences in the treatment of patients with advanced heart failure.

Geographic variation in cardiovascular procedure use among medicare fee-for-service vs medicare advantage beneficiaries

Background—Therapeutic hypothermia can improve survival and neurological outcomes in cardiac arrest survivors, but its cost-effectiveness is uncertain. We sought to evaluate the cost-effectiveness of treating comatose cardiac arrest survivors with therapeutic hypothermia. Methods and Results—A decision model was developed to capture costs and outcomes for patients with witnessed out-of-hospital ventricular fibrillation arrest who received conventional care or therapeutic hypothermia. The Hypothermia After Cardiac Arrest (HACA) trial inclusion criteria were assumed. Model inputs were determined from published data, cooling device companies, and consultation with resuscitation experts. Sensitivity analyses and Monte Carlo simulations were performed to identify influential variables and uncertainty in cost-effectiveness estimates. The main outcome measures were quality-adjusted survival after cardiac arrest, cost of hypothermia implementation, cost of posthospital discharge care, and incremental cost-effectiveness ratios. In our model, postarrest patients receiving therapeutic hypothermia gained an average of 0.66 quality-adjusted life years compared with conventional care, at an incremental cost of

Association of Distance From a Transplant Center With Access to Waitlist Placement, Receipt of Liver Transplantation, and Survival Among US Veterans

31 254. This yielded an incremental cost-effectiveness ratio of