BackgroundThe incremental effects of risk factor combinations for atrial fibrillation (AF) and stroke are incompletely understood. We sought to quantify the risks of incident AF and stroke for combinations of established risk factors in a large US sample.Methods and ResultsPatients with no evidence of AF or stroke in 2007 were stratified by combinations of the following risk factors: heart failure, hypertension, diabetes, age 65 to 74, age ≥75, coronary artery disease, and chronic kidney disease. Patients with ≥2 of the first 5 or ≥3 of the first 7, classified as “high-risk,” and an age-matched sample of patients with fewer risk factors, classified as “low-risk,” were followed over 2008–2010 for incident AF and stroke. Annualized incidence rates and risks were quantified for each combination of factors by using Cox regression. Annualized incidence rates for AF, stroke, and both were 3.59%, 3.27%, and 0.62% in 1 851 653 high-risk patients and 1.32%, 1.48%, and 0.18% in 1 156 221 low-risk patients, respectively. Among patients with 1 risk factor, those with age ≥75 had the highest hazards of incident AF and stroke (HR 9.2, 6.9). Among patients with 2 risk factors, those with age ≥75 and heart failure had the highest annualized incidence rates of AF and stroke (10.2%, 5.9%). The combination of age ≥75 and hypertension was prevalent and had the highest incidences of AF and stroke.ConclusionsAdults with combinations of known risk factors are at increased risk of incident AF and stroke, but combinations of risk factors are not always additive.
PurposeTo examine imaging utilization in a matched cohort of patients with and without implantable cardioverter defibrillators (ICD) and to project magnetic resonance imaging (MRI) utilization over a 10‐year period.Materials and MethodsThe Truven Health MarketScan Commercial claims and Medicare Supplemental health insurance claims data were used to identify patients with continuous health plan enrollment in 2009–2012. Patients with ICDs were identified using ICD‐9 and CPT codes, and matched to patients with the same demographic and comorbidity profile, but no record of device implantation. Diagnostic imaging utilization was compared across the matched cohorts, in total, by imaging categories, and in subpopulations of stroke, back pain, and joint pain. MRI use in the nonimplant group over the 4‐year period was extrapolated out to 10 years for ICD‐indicated patients.ResultsA cohort of 18,770 matched patients were identified; average age 65.5 ± 13.38 and 21.9% female. ICD patients had significantly less MRI imaging (0.23 0.70 SD vs. 0.00 0.08 SD, P < 0.0001) than nonimplant patients. Among patients with records of stroke/transient ischemic attack (TIA) (ICD 5%, nonimplant 4%) and accompanying diagnostic imaging, 44% of nonimplant patients underwent MRI vs. 1% of ICD patients (P < 0.0001). Forecast models estimated that 53% to 64% of ICD‐eligible patients may require an MRI within 10 years.ConclusionMRI utilization is lower in ICD patients compared to nonimplant patients, yet the burden of incident stroke/TIA, back, and joint pain suggests an unmet need for MR‐conditional devices. J. MAGN. RESON. IMAGING 2016;43:115–127.
While potentially life-saving, ICD shocks, both appropriate and inappropriate, can also increase long-term morbidity and mortality. 4,5 Trials of device programming to reduce shocks have been shown to improve survival. 6,7 See Editorial by Borne and PetersonHowever, there is limited information on healthcare utilization (HCU) associated with ICD shocks and whether inappropriate and appropriate shocks have differences in type, intensity, or cost of care. Moreover, detailed knowledge of utilization following an appropriate versus inappropriate shock may elucidate downstream patterns of care and potential mediators of the differences in patient survival following shocks. We therefore evaluated HCU and expenditures after inappropriate and appropriate shock events by linking ICD remote monitoring data to healthcare administrative data. Methods Study Design and Data SourcesWe performed a retrospective cohort study of patients with ICDs from national (United States) implant registration and remote monitoring data linked to healthcare claims. Cohort structure and patient selection are detailed in Figure 1. Data, stripped of personal identifiers of name, date of birth, medical record number, and social security, were first obtained from the Medtronic Data Warehousing and Analytics Service (DWAS; Medtronic plc, Mounds View, MN). DWAS is a device implant record data set containing patient demographics (age, sex, 3-digit zip codes for patient location, and implant site location), implant date, device information (device type, model, and leads), Background-In patients with implantable cardioverter-defibrillators, healthcare utilization (HCU) and expenditures related to shocks have not been quantified. Methods and Results-We performed a retrospective cohort study of patients with implantable cardioverter-defibrillators identified from commercial and Medicare supplemental claims databases linked to adjudicated shock events from remote monitoring data. A shock event was defined as ≥1 spontaneous shocks delivered by an implanted device. Shock-related HCU was ascertained from inpatient and outpatient claims within 7 days following a shock event. Shock events were adjudicated and classified as inappropriate or appropriate, and HCU and expenditures, stratified by shock type, were quantified. Of 10 266 linked patients, 963 (9.4%) patients (61.3±13.6 years; 81% male) had 1885 shock events (56% appropriate, 38% inappropriate, and 6% indeterminate). Of these events, 867 (46%) had shock-related HCU (14% inpatient and 32% outpatient). After shocks, inpatient cardiovascular procedures were common, including echocardiography (59%), electrophysiology study or ablation (34%), stress testing (16%), and lead revision (11%). Cardiac catheterization was common (71% and 51%), but percutaneous coronary intervention was low (6.5% and 5.0%) after appropriate and inappropriate shocks. Expenditures related to appropriate and inappropriate shocks were not significantly different. Conclusions-After implantable cardioverter-defibrillator shock, related ...
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