Association Between Cardiac Rehabilitation and 1-Year Mortality by Frailty Level in Medicare Beneficiaries.

Introduction: Increased frailty before cardiovascular procedures is associated with poorer outcomes. While underutilized, cardiac rehabilitation (CR) is guideline-recommended for patients undergoing cardiovascular procedures and may help mitigate frailty through individualized, monitored exercise and risk factor reduction. Research Question/Hypothesis: Evaluate the relationship between preprocedural frailty, CR use, and one-year mortality. Methods: Medicare fee-for-service claims data were queried for patients who underwent inpatient percutaneous or surgical revascularization or aortic valve replacement between July 2016 and December 2018. Patients were stratified into quartiles (Q1 through Q4) using the validated claims-based frailty index. CR use was defined as attending any CR session within one year of discharge. Unadjusted and adjusted logistic regression was used to compare CR use across increasing frailty quartiles, and inverse probability treatment weighting was used to evaluate the effect of CR on one-year mortality across frailty quartiles. Results: Overall CR enrollment among the 570,851 beneficiaries was 35.3%; increasing frailty was associated with decreased CR use (unadjusted: frailty Q1: 48.3% vs Q4: 20.6%, p<0.001; adjusted OR: 0.61, p<0.001). Unadjusted one-year mortality was lower among CR users as opposed to non-users (2.7% vs 14.6%). After weighted adjustment, the absolute reduction in mortality associated with CR use was greater among frailer patients (Q4: -12.2%) relative to less frail patients (Q1: -2.9%) (Figure). Significant interaction effects between CR use and frailty quartiles indicated stronger associations of CR on mortality among more frail patients. Conclusions: Preprocedural frailty was associated with lower CR use despite greater absolute benefits on one-year mortality. Increasing CR enrollment in frail patients may enhance outcomes after cardiac interventions.

Participation in cardiac rehabilitation (CR) programs at Veterans Affairs (VA) facilities is low. Most veterans receive CR through purchased care at non-VA programs. However, limited literature exists on the comparison of outcomes between VA and non-VA CR programs. To compare 1-year mortality and 1-year readmission rates for myocardial infarction or coronary revascularization between VA vs non-VA CR participants. This cohort study included 7320 patients hospitalized for myocardial infarction or coronary revascularization at the VA between 2010 and 2014 who did not die within 30 days of discharge and who participated in 2 or more CR sessions after discharge. The study excluded individuals hospitalized for ischemic heart disease after December 2014 when the VA Choice Act changed referral criteria for non-VA care. Data analysis was performed from November 2019 to January 2020. Participation in 2 or more CR sessions within 12 months of discharge at a VA or non-VA facility. The 1-year all-cause mortality and 1-year readmission rates for myocardial infarction or coronary revascularization from date of discharge were compared between VA vs non-VA CR participants using Cox proportional hazards models with inverse probability treatment weighting. The 7320 veterans with ischemic heart disease who participated in CR programs had a mean (SD) age of 65.13 (8.17) years and were predominantly white (6005 patients [82.0%]), non-Hispanic (6642 patients [91.0%]), and male (7191 patients [98.2%]). Among these 7320 veterans, 2921 (39.9%) attended a VA facility, and 4399 (60.1%) attended a non-VA CR facility. Black and Hispanic veterans were more likely to attend CR programs at VA facilities (509 patients [17.4%] and 378 patients [12.9%], respectively), whereas white veterans were more likely to attend CR programs at non-VA facilities (3759 patients [85.5%]). After inverse probability treatment weighting, rates of 1-year mortality were 1.7% among VA CR participants vs 1.3% among non-VA CR participants (hazard ratio, 1.32; 95% CI, 0.90-1.94; P = .15). Rates of readmission for myocardial infarction or revascularization during the 12 months after discharge were 4.9% among VA CR participants vs 4.4% among non-VA CR participants (hazard ratio, 1.06; 95% CI, 0.83-1.35; P = .62). These findings suggest that rates of 1-year mortality and 1-year readmission for myocardial infarction or revascularization did not differ for participants in VA vs non-VA cardiac rehabilitation programs. Eligible patients with ischemic heart disease should participate in CR programs regardless of where they are provided.

Intro: Despite providing benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR enrollment. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods/Results: A cohort of 10,124 AVR episodes of care (TAVR n=5,121 from 24 hospitals; SAVR n=5,003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015 to 2019). CR enrollment was defined as the presence of a professional or facility claim (93797, 93798, G0422, G0423) within 90 days of discharge. Annual trends in CR were evaluated for TAVR, SAVR, and all AVR. CR use in SAVR was significantly higher than TAVR and increased over time for all modalities (p<0.001, Figure 1). Multilevel logistic regression analysis identified significant differences in CR enrollment across age groups, comorbidities, and payer status. At the hospital-level, CR enrollment rates for all AVR varied 10-fold (4.8% to 68.7%) and moderately correlated between SAVR and TAVR (Pearson r=0.56, p<0.01, Figure 2). Conclusions: Substantial variation exists in CR enrollment during AVR episodes of care across hospitals. However, within-hospital CR enrollment rates were significantly correlated across treatment strategies. These findings suggest that CR enrollment is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR enrollment can help assist future quality improvement efforts to increase CR use after AVR.

Relationship between Claims-Based Frailty Index and Eye Care Utilization among Medicare Beneficiaries with Glaucoma

Frailty Is Associated with an Increased Risk of Complications and Need for Repeat Procedures after Sling Surgery in Older Adults.

Introduction: Frailty is associated with increased morbidity and mortality in patients undergoing left atrial appendage closure (LAAC). We compared the performance of two claims-based frailty measures in predicting adverse outcomes following LAAC. Methods: We identified patients 65 years and older who underwent LAAC between October 1, 2016 and December 31, 2019 in Medicare fee-for-service claims. Frailty was assessed using the previously validated Hospital Frailty Risk Score (HFRS) and Kim Claims-based Frailty Index (CFI). Patients were identified as frail based on HFRS ≥5 and CFI ≥0.25. Results: Of the 21,787 patients who underwent LAAC, frailty was identified in 45.6% by HFRS and 15.4% by CFI. There was modest agreement between the two frailty measures (kappa 0.25, Pearson’s correlation 0.62). After adjusting for age, sex, and comorbidities, frailty was associated with higher risk of 30-day mortality, 1-year mortality, 30-day readmission, long hospital stay, and short time at home (p<0.01 for all) regardless of the frailty instrument used. Model discrimination was similar between the HFRS and the CFI with fair discrimination of all outcomes (C-statistic 0.686 - 0.759). The addition of frailty to standard comorbidities significantly improved model performance to predict 1-year mortality, long hospital stay, and short time at home (Delong p-value <0.001). Conclusions: Despite significant variation in frailty detection and only modest agreement between the two frailty measures, frailty status was highly predictive of mortality, readmission, long hospital stay, and days at home. Future studies should focus on prospective evaluation of frailty in patients eligible for LAAC, which may further refine the relationship between frailty and adverse outcomes, and help inform shared decision-making in this population.

Background: Cardiac rehabilitation (CR) after surgical aortic valve replacement (SAVR) is recommended by guidelines, but participation is low. This is partly because the supporting evidence is weak: prior trials were small with short follow-up and few clinical events. Because CR is guideline-recommended, randomized trials of CR vs. no CR would not be ethical, and high-quality observational comparative effectiveness studies are urgently needed. Research Question: Does CR reduce the risk of death and major adverse cardiovascular events (MACE, defined as acute myocardial infarction, stroke, or heart failure) in Medicare beneficiaries undergoing SAVR? Methods: We first specified a target trial – a hypothetical pragmatic randomized trial that would answer the causal question of interest – and then emulated the target trial using 100% Medicare claims ( Fig. 1 ). We included Medicare beneficiaries aged ≥65 years who underwent SAVR between 10/2016 and 12/2022. The intervention (“CR participation”) was defined as receipt of ≥2 CR sessions within 90 days of discharge, compared with receipt of 0 or 1 CR session (“control”). The cloning-censoring-weighting approach was used to align the time for determining eligibility, treatment assignment, and start of follow-up, and accounted for baseline and time-varying covariates. The primary outcome was death from any cause or hospitalization for MACE. Two falsification endpoints (new cancer; acute infection) were used to test for residual confounding. Results: Among 44,136 Medicare beneficiaries, 48.5% participated in ≥2 CR sessions after SAVR ( Fig. 2 ). CR participants were more likely to be male and identify as Non-Hispanic White, and less likely to be dually enrolled in Medicare and Medicaid or reside in neighborhoods with the highest social vulnerability. CR participants had a lower risk of the primary outcome at 3 years compared with the control (17.5% vs 20.1%; adjusted risk difference, -2.6 pp; 95% CI, -3.5 pp to -1.7 pp). Analyses of falsification endpoints were compatible with the absence of strong residual confounding ( Fig. 3 ). Discussion: In the largest and most diverse study of CR after SAVR, patients with CR participation had a lower risk of death or MACE at 3 years. Fewer than half of Medicare beneficiaries participated in CR after SAVR, with marked socioeconomic inequities. Our findings highlight the urgent need for strategies to equitably improve participation in CR after SAVR.

MP74-06 IMPACT OF SOCIOECONOMIC FACTORS AND FRAILTY ON ORAL OVERACTIVE BLADDER THERAPY UTILIZATION IN MEDICARE PART D BENEFICIARIES

A claims-based frailty index (CFI) allows measurement of frailty on a population scale. Our objective was to examine the association of changes in CFI over 12months with mortality and Medicare costs. We used a 5% sample of fee-for-service Medicare beneficiaries. We estimated CFI (range: 0–1: nonfrail (<0.25), mildly frail (0.25–0.34), moderately-to-severely frail (≥0.35) on January 1, 2015 and January 1, 2016. Beneficiaries were categorized as having a large decrease (-<0.045), small decrease (-≤0.045-0.015), stable (±0.015), small increase (>0.015-0.045), or large increase (>0.045). We used Cox proportional hazards model to estimate hazard ratio (HR) for mortality adjusting for age, sex, and 2015 CFI value and compared total Medicare costs from January 1, 2016 to December 31, 2016. The study population included 995664 beneficiaries (mean age 77years, 56.8% female). In nonfrail (n=906046), HR (95% confidence interval [CI]) ranged from 0.71 (0.67-0.75) for a large decrease to 2.75 (2.68-2.33) for a large increase. In moderate-to-severely frail beneficiaries (n=16527), the corresponding HR (95% CI) ranged from 0.63 (0.57-0.70) to 1.21 (1.06-1.38). The mean total Medicare cost per member per year (standard deviation) was from $12149 ($83508) in nonfrail beneficiaries to $61155 ($345904) in moderate-to-severely frail beneficiaries. One-year changes in CFI are associated with elevated mortality risk and health care costs across all levels of frailty.

Travel Distance, Urbanicity, and Cardiac Rehabilitation Participation in Medicare Beneficiaries.

Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). A cohort of 10 124 AVR episodes of care (TAVR n=5121 from 24 hospitals; SAVR n=5003 from 32 hospitals) were identified from the Michigan Value Collaborative statewide multipayer registry (2015-2019). CR enrollment was defined as the presence of a single professional or facility claim within 90 days of discharge: 93 797, 93 798, G0422, G0423. Annual trends and hospital variation in CR were described for TAVR, SAVR, and all AVR. Multilevel logistic regression was used to estimate effects of predictors and hospital risk-adjusted rates of CR enrollment. Overall, 4027 (39.8%) patients enrolled in CR, with significant differences by treatment strategy: SAVR=50.9%, TAVR=28.9% (P<0.001). CR use after SAVR was significantly higher than after TAVR and increased over time for both modalities (P<0.001). There were significant differences in CR enrollment across age, gender, payer, and some comorbidities (P<0.05). At the hospital level, CR participation rates for all AVR varied 10-fold (4.8% to 68.7%) and were moderately correlated between SAVR and TAVR (Pearson r=0.56, P<0.01). Substantial variation exists in CR participation during AVR episodes of care across hospitals. However, within-hospital CR participation rates were significantly correlated across treatment strategies. These findings suggest that CR participation is the product of hospital-specific practice patterns. Identifying hospital practices associated with higher CR participation can help assist future quality improvement efforts to increase CR use after AVR.

Introduction: Cardiac rehabilitation (CR) reduces hospitalization risk in patients with reduced ejection fraction heart failure (HF). The CR HF mortality impact remains unclear. Methods: We identified Medicare beneficiaries diagnosed with HF between 2014-2017 who were hospitalized with HF diagnosis in 2017. Primary exposure was CR initiation within 180 days of HF hospitalization discharge in 2017; primary outcome was all-cause mortality within 1 year. In full cohort,Cox regression modeled time from discharge to death with time-varying exposure to CR, adjusting for unbalanced characteristics and propensity to initiate CR. We applied propensity score weighting and stratification methods. Using propensity score for CR receipt and survival to the day of CR initiation, we matched 1730 patients who started CR within 180 days to 1730 who did not and modeled survival from CR initiation. We examined association between CR initiation and mortality following CR in a landmark cohort and assessed dose-response relationship between session number and mortality. We conducted sub-group analyses limited to patients with systolic HF ICD code. Results: Of 116,302 HF patients (mean age 82 years, 54% women) admitted at 4,119 hospitals, only 1.5% initiated CR in 6 months. Overall 35% of patients died within 1 year; 10.7% among those who initiated CR within 180 days and 35.2% among those who did not. CR initiation within 180 days was associated with survival benefit in full and landmark cohorts as well as in the propensity-matched analysis hazard ratio [HR]: 0.39, 95% CI: 0.33-0.47; P &lt; 0.001 Among patients who initiated CR within 180 days and survived more than 180 days, completing 3 CR sessions was associated with lower death risk HR: 0.91 95% CI, 0.87- 0.95. In patients with systolic HF, HR: was 0.47, 95% CI 0.41-0.54; P &lt; 0.001. Conclusions: Few patients (1.5%) with HF enrolled in CR within 180 days after hospitalization. CR initiation was associated with reduced 1-year mortality risk.

Introduction: Effectiveness of cardiac rehabilitation (CR) after transcatheter aortic valve replacement (TAVR) has not been examined in randomized trials. We used a novel causal inference approach called target trial emulation to evaluate whether participation in CR after TAVR reduces all-cause mortality. Methods: We emulated a target trial among Medicare beneficiaries age≥ 65 years who had undergone a TAVR from October 2016 through September 2019. The intervention was starting CR within 90 days of discharge (time 0) and the outcome was death from any cause. We created two exact copies of each patient’s data (“clones”) and assigned one clone to the control arm and the other to the intervention arm. This eliminated baseline confounding and immortal time bias. Each clone was censored when not consistent with the assigned treatment strategy (e.g., when a control clone initiated CR). Inverse probability weights accounted for potentially informative censoring. Falsification endpoints examined residual confounding. Results: Among 62,628 Medicare beneficiaries eligible for CR after TAVR, mean age was 80 years, and 43% were women. Of these, 28% initiated CR within the 90-day grace period. After adjusting for demographic, clinical, social, and economic differences, all-cause mortality at 2 years was lower in the CR arm than in the no CR arm (HR 0.74, 95% CI 0.63-0.87, p&lt;0.01) (Figure). Falsification endpoints suggested some residual confounding but absolute differences between the two groups were small. Conclusion Fewer than 1 in 3 eligible patients receive CR after TAVR. In the first-ever target trial emulation of CR in patients undergoing TAVR, patients who initiate CR had lower rates of all-cause death. Ongoing work will examine additional approaches to account for residual confounding and use alternative quasi-experimental study designs. If replicated, our findings suggest that innovation in CR access and delivery is needed to enhance uptake after TAVR.

Few studies examine the impact of frailty on long-term patient-oriented outcomes after emergency general surgery (EGS). We measured the prevalence of frailty among older EGS patients and examined the impact of frailty on 1-year outcomes. Retrospective cohort study using 2008 to 2014 Medicare claims. Acute care hospitals. Patients 65 years or older who received one of the five EGS procedures with the highest mortality burden (partial colectomy, small bowel resection, peptic ulcer disease repair, adhesiolysis, or laparotomy). A validated claims-based frailty index (CFI) identified patients who were not frail (CFI < .15), pre-frail (.15 ≤ CFI < .25), mildly frail (.25 ≤ CFI < .35), and moderately to severely frail (CFI ≥ .35). Multivariable Cox regression compared 1-year mortality. Multivariable Poisson regression compared rates of post-discharge hospital encounters (hospitalizations, intensive care unit stay, emergency department visit) and home time over 1 year after discharge. All regression models adjusted for age, sex, race, admission from facility, procedure, sepsis, inpatient palliative care delivery, trauma center designation, hospital bed size, and teaching status, and they were clustered by patient and hospital referral region. Among 468 459 older EGS adults, 37.4% were pre-frail, 12.4% were mildly frail, and 3.6% were moderately to severely frail. Patients with mild frailty experienced a higher risk of 1-year mortality compared with non-frail patients (hazard ratio = 1.97; confidence interval [CI] = 1.94-2.01). In the year after discharge, patients with mild and moderate to severe frailty had more hospital encounters compared with non-frail patients (7.8 and 11.5 vs 2.0 per person-year; incidence rate ratio [IRR] = 4.01; CI = 3.93-4.08 vs IRR = 5.89; CI = 5.70-6.09, respectively). Patients with mild and moderate to severe frailty also had fewer days at home in the year after discharge compared with non-frail patients (256 and 203 vs 302 mean days; IRR = .97; CI = .96-.97 vs IRR = .95; CI = .94-.95, respectively). Older EGS patients with frailty are at increased risk for poor 1-year outcomes and decreased home time. Targeted interventions for older EGS patients with frailty during the index EGS hospitalization are urgently needed to improve long-term outcomes. J Am Geriatr Soc 68:1037-1043, 2020.

Geographic Variation in Access to Cardiac Rehabilitation