Regional differences in Medicare spending are largely explained by the more inpatient-based and specialist-oriented pattern of practice observed in high-spending regions. Neither quality of care nor access to care appear to be better for Medicare enrollees in higher-spending regions.

Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care. Efforts to reduce spending should proceed with caution, but policies to better manage further spending growth are warranted.

There is evidence of increased oxidative stress and acute-phase inflammation in patients with stage 3-5 chronic kidney disease compared to healthy subjects that does not closely correlate with estimates of GFR. Among CKD patients, inflammatory biomarkers correlate with known CVD and inversely correlate with the use of angiotensin II inhibitors and statins. A further increase in oxidative stress was noted in diabetic and hypercholesterolemic patients. Inflammation and oxidative stress may contribute to cardiovascular risk in CKD patients.

BACKGROUND To describe short and long-term survival of patients with descending thoracic aortic aneurysms (TAA) following open and endovascular repair (TEVAR). METHODS AND RESULTS Using Medicare claims from 1998–2007, we analyzed patients who underwent repair of intact and ruptured TAA, identified using a combination of procedural and diagnostic ICD-9 codes. Our main outcome measure was mortality, defined as peri-operative mortality (death occurring before hospital discharge or within 30 days), and five year survival, using life-table analysis. We examined outcomes across repair type (open repair. or TEVAR) in crude, adjusted (age, sex, race, procedure year, and Charlson comorbidity score), and propensity-matched cohorts. Overall, we studied 12,573 Medicare patients who underwent open repair, and 2,732 patients who underwent TEVAR. Peri-operative mortality was lower in patients undergoing TEVAR as compared to open repair for both intact (6.1% versus 7.1%, p=0.07) and ruptured TAA (28% versus 46%, p<0.0001). However, patients with intact TAA selected for TEVAR had significantly worse survival than open patients at one year (87% open, 82% TEVAR, p=0.001) and five years (72% open, 62% TEVAR, p= 0.001). Further, in adjusted and propensity-matched cohorts, patients selected for TEVAR had worse 5-year survival than patients selected for open repair. CONCLUSIONS While peri-operative mortality is lower with TEVAR, Medicare patients selected for TEVAR have worse long-term survival than patients selected for open repair. The results of this observational study suggest that higher risk patients are being offered TEVAR, and that some do not benefit based on long-term survival. Future work is needed to identify TEVAR candidates unlikely to benefit from repair.

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Background Many believe that variation in vascular practice may affect limb salvage rates in patients with severe PAD. However, the extent of variation in procedural vascular care obtained by patients with critical limb ischemia (CLI) remains unknown. Methods and Results Using Medicare 2003–2006, we identified all patients with CLI who underwent major lower extremity amputation in the 306 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare. For each patient, we studied the use of lower extremity vascular procedures (open surgery or endovascular intervention) in the year prior to amputation. Our main outcome measure was the intensity of vascular care, defined as the proportion of patients in the HRR undergoing vascular procedure in the year before amputation. Overall, 20,464 patients with CLI underwent major lower extremity amputations during the study period, and collectively underwent 25,800 vascular procedures in the year prior to undergoing amputation. However, these procedures were not distributed evenly − 54% of patients had no vascular procedures performed in the year prior to amputation, 14% underwent 1 vascular procedure, and 21% underwent more than one vascular procedure. In the regions in the lowest quintile of vascular intensity, vascular procedures were performed in 32% of patients. Conversely, in the regions in the highest quintile of vascular intensity, revascularization was performed in 58% of patients in the year prior to amputation (p<0.0001). In analyses accounting for differences in age, sex, race, and comorbidities, patients in high intensity regions were 2.4 times as likely to undergo revascularization in the year prior to amputation than patients in low intensity regions (adjusted OR=2.4, 95% CI 2.1–2.6, p<0.001). Conclusions Significant variation exists in the intensity of vascular care provided to patients in the year prior to major amputation. In some regions, patients receive intensive care, while in other regions, far less vascular care is provided. Future work is needed to determine the association between intensity of vascular care and limb salvage.

Acute kidney injury, a common complication of cardiac surgery with cardiopulmonary bypass, is associated with increased morbidity and mortality. Ischemic preconditioning at a remote site mitigates ischemia-reperfusion injury and may prevent acute kidney injury after cardiac surgery, thus providing clinical benefit. To further study this, we enrolled 120 adult patients undergoing elective cardiac surgery for whom cardiopulmonary bypass was anticipated in a randomized, single-blind, and controlled pilot trial. Patients were stratified for the type of surgery and equally assigned to a control group or to receive remote ischemic preconditioning by an automated thigh tourniquet consisting of three 5-min intervals of lower extremity ischemia separated by 5-min intervals of reperfusion. The primary end point was acute kidney injury defined as an elevation of serum creatinine of ≥0.3 mg/dl or ≥50% within 48 h after surgery. Fifty-nine patients in each group were analyzed on an intention-to-treat basis. Acute kidney injury occurred in 12 remote ischemic preconditioned and 28 control patients, reflecting an absolute risk reduction of 0.27 and a significantly reduced relative risk due to preconditioning of 0.43. Hence, remote ischemic preconditioning prevents acute kidney injury in patients undergoing cardiopulmonary bypass-assisted cardiac surgery.

Context.-The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the Asymptomatic Carotid Atherosclerosis Study (ACAS) demonstrated the efficacy of carotid endarterectomy (CEA) in reducing the risk of stroke and death in selected patients when surgery was performed in institutions whose participation depended on demonstrated excellence. Thirty-day mortality rates in the trials were very low: 0.6% in NASCET and 0.1% in ACAS. Objective.-To assess perioperative mortality among Medicare patients undergoing CEA in all nonfederal institutional settings. Design.-Retrospective national cohort study. Setting and Patients.-All 113 300 Medicare patients undergoing CEA during 1992 and 1993 in "trial hospitals" (those participating in NASCET and ACAS, n=86) and "nontrial hospitals" (all other nonfederal institutions performing CEAs, n=2613). Nontrial hospitals were stratified into terciles based on volume of CEAs performed. Main Outcome Measures.-Crude and adjusted perioperative (30 day) mortality rates. Results.-The perioperative mortality rate was 1.4% (95% confidence interval [CI], 1.2%-1.7%) at trial hospitals; mortality in nontrial hospitals was higher: 1.7% (95% CI, 1.6%-1.8%) (high volume); 1.9% (95% CI, 1.7%-2.1%) (average volume); 2.5% (95% CI, 2.0%-2.9%) (low volume); (P for trend, Ͻ.001). In multivariate modeling, patients undergoing their procedures at trial hospitals had a mortality risk reduction of 15% (95% CI, 0%-31%) compared with high-volume nontrial hospitals, 25% (95% CI, 7%-40%) compared with average-volume hospitals, and 43% (95% CI, 25%-56%) compared with low-volume hospitals (P for trend, Ͻ.001). Conclusion.-Medicare patients' perioperative mortality following CEA is substantially higher than that reported in the trials, even in those institutions that participated in the randomized studies. Caution is advised in translating the efficacy of carefully controlled studies of CEA to effectiveness in everyday practice.