National Trends In Use Research Articles

National Trends in Use of Surgeon-modified Grafts for Complex Aortic Aneurysms

National Trends in Use of Surgeon-modified Grafts for Complex Aortic Aneurysms

Sixteen-Year National Trends in Use and Outcomes of VA-ECMO in Cardiogenic Shock

There is a lack of data on contemporary trends in the use and outcomes of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) for cardiogenic shock (CS) at a national level. Patients with CS admitted during January 1st, 2002-December 31, 2018, were identified from the United States National Inpatient Sample. Among all patients admitted with CS, those who received VA-ECMO were identified. We report the trends in use and outcomes in terms of mortality, exit strategies and complications among all patients who received VA ECMO for CS. Among a total of approximately 1.6 million patients admitted with CS during the period from January 1st, 2002 to December 31, 2018; 25, 621(1.5 %) received VA-ECMO. There has been a 23-fold increase in the use of VA-ECMO over the study period, from 0.1 % in 2002 to 3 % in 2018, with a simultaneous decreasing trend of in hospital mortality from 77 % in 2002 to 50 % in 2018. Only approximately 15 % of VA-ECMO patients are discharged home with most survivors discharged to a skilled nursing facility or short-term rehabilitation. Moreover, only a minor proportion of patients on VA ECMO are bridged to heart replacement therapy with durable LVAD (6 %) or cardiac transplantation (2.5 %). In conclusion, the use of VA-ECMO in CS has increased 23-fold from January 2002 to December 2018 with a concomitant decrease in mortality from 77 % in 2002 to 50 % in 2018, only a minority of patients on VA-ECMO for CS are bridged to durable LVAD or cardiac transplantation.

National Trends in Use of Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists by Cardiologists and Other Specialties, 2015 to 2020.

BackgroundSodium‐glucose cotransporter‐2 inhibitors (SGLT2is) and glucagon‐like peptide‐1 receptor agonists (GLP‐1RAs) mitigate cardiovascular risk in individuals with type 2 diabetes, but most eligible patients do not receive them. We characterized temporal trends in SGLT2i and GLP‐1RA use by cardiologists compared with other groups of clinicians.Methods and ResultsWe conducted a descriptive analysis of serial, cross‐sectional data derived from IQVIA’s National Prescription Audit, a comprehensive audit capturing ≈90% of US retail prescription dispensing and projected to population‐level data, to estimate monthly SGLT2is and GLP‐1RAs dispensed from January 2015 to December 2020, stratified by prescriber specialty and molecule. We also used the American Medical Association’s Physician Masterfile to calculate average annual SGLT2is and GLP‐1RAs dispensed per physician. Between January 2015 and December 2020, a total of 63.2 million SGLT2i and 63.4 million GLP‐1RA prescriptions were dispensed in the United States. Monthly prescriptions from cardiologists increased 12‐fold for SGLT2is (from 2228 to 25 815) and 4‐fold for GLP‐1RAs (from 1927 to 6981). Nonetheless, cardiologists represented only 1.5% of SGLT2i prescriptions and 0.4% of GLP‐1RA prescriptions in 2020, while total use was predominated by primary care physicians/internists (57% of 2020 SGLT2is and 52% of GLP‐1RAs). Endocrinologists led in terms of prescriptions dispensed per physician in 2020 (272 SGLT2is and 405 GLP‐1RAs). Cardiologists, but not noncardiologists, increasingly used SGLT2is over GLP‐1RAs, with accelerated uptake of empagliflozin and dapagliflozin coinciding with their landmark cardiovascular outcomes trials and subsequent US Food and Drug Administration label expansions.ConclusionsWhile use of SGLT2is and GLP‐1RAs by cardiologists in the United States increased substantially over a 6‐year period, cardiologists still account for a very small proportion of all use, contributing to marked undertreatment of individuals with type 2 diabetes at high cardiovascular risk.

National Trends in Use of and Spending on Oral Anticoagulants Among US Medicare Beneficiaries From 2011 to 2019

This cross-sectional study examines patterns of use of direct oral anticoagulants and their association with Medicare spending.

National trends of use of oral anticoagulants and severities of stroke among patients with atrial fibrillation

Abstract Background Underuse of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is a common issue in the daily practice. The introduction of non-vitamin K antagonist OACs (NOACs) has changed the landscape of stroke prevention in AF. The goal of the present study was to investigate the trends of use of OACs and severities of stroke among AF patients using a nationwide AF database. Methods The present study used the Taiwan Nationwide Health Insurance Research Database (NHIRD). From year 2002 to 2015, a total of 66,331 AF patients aged >20 years who experienced ischemic stroke were identified from 447,259 AF patients. The temporal trends of use of OACs (either warfarin or NOACs) and the severities of stroke were analyzed. The estimated National Institutes of Health Stroke Scale (eNIHSS) calculated by 7-item NHIRD based stroke severity index, which has been validated before, was used to represent the stroke severities. Results The percentages of AF patients who were already anticoagulated when stroke occurred significantly increased from 20.3% in year 2002 to 40.5% in year 2015 (Figure A). The increment was more obvious in the era of NOACs (after year 2012 in Taiwan). In year 2015, NOACs accounts for around 69.6% of prescriptions of OACs. The mean eNIHSS gradually decreased from 17.3 (year 2002) to 14.3 (year 2015) (Figure B). Conclusions In the era of NOACs, the prescription rates of OACs significantly increased among AF patients who experienced ischemic stroke, temporally associated with a decrease in the stroke severity. Funding Acknowledgement Type of funding source: None

National Trends of Tobacco, Alcohol, and Drug Use in Patients Admitted With Acute Myocardial Infarction

BackgroundAcute myocardial infarction (AMI) is a significant health and economic burden in the US. Tobacco, alcohol, and drug use are established risk factors. We sought to evaluate the national trend of use of each substance in patients admitted with AMI. MethodsWe used the National Inpatient Sample between 2005 and 2017. We included adult patients hospitalized with AMI. International Classification of Diseases, Ninth and Tenth Revisions codes were used to define tobacco, alcohol, cocaine, opioid, cannabis and other drug use. Trends of each substance use were assessed using multivariable Poisson regression, and were expressed as annual percent change (APC) with their 95% confidence intervals (CIs). ResultsA total of 10,796,844 hospitalizations with AMI were included. Among all substances used, tobacco was the most common (32.7%), followed by alcohol (3.2%). Between 2005 and 2017, the prevalence ratio of tobacco use increased from 21.5% to 44.5% with an APC +6.2% (95%CI 6.2%–6.2%). Tobacco users had more percutaneous coronary intervention (41%vs25%) and coronary artery bypass surgery (6.9%vs4.9%), p < 0.001. Further, there were positive trends in alcohol (APC +3.1%; 95%CI 3.0%–3.2%), opioid (APC +9.0%; 95%CI 8.7%–9.2%), cannabis (APC + 7.2; 95% CI 7%–7.4%), and combined all drug use (+7.1%; 95%CI 7%–7.2%). Meanwhile, there was a slight negative trend in cocaine use. ConclusionsThis analysis outlines the national trends of substance use in patients admitted with AMI and reveals an increasing prevalence of tobacco use, alcohol and drug use. More effective cessation measures are necessary to reduce the risk for AMI and its burden on the healthcare system and economy.

Annual Wellness Visits in the Era of Value-Based Care: National Trends in Use, 2011-2018.

Annual Wellness Visits in the Era of Value-Based Care: National Trends in Use, 2011-2018.

National Trends in Use of Regional Anesthesia and Postoperative Patterns of Opioid Prescription Filling in Shoulder Arthroscopy: A Procedure-Specific Analysis in Patients With or Without Recent Opioid Exposure.

Background:There are few large database studies on national trends in regional anesthesia for various arthroscopic shoulder procedures and the effect of nerve blocks on the postoperative rate of opioid prescription filling.Hypothesis:The use of regional nerve block will decrease the rate of opioid prescription filling after various shoulder arthroscopic procedures. Also, the postoperative pattern of opioid prescription filling will be affected by the preoperative opioid prescription-filling history.Study Design:Cohort study; Level of evidence, 3.Methods:Patient data from Humana, a large national private insurer, were queried via PearlDiver software, and a retrospective review was conducted from 2007 through 2015. Patients undergoing arthroscopic shoulder procedures were identified through Current Procedural Terminology codes. Nerve blocks were identified by relevant codes for single-shot and indwelling catheter blocks. The blocked and unblocked cases were age and sex matched to compare the pain medication prescription-filling pattern. Postoperative opioid trends (up to 6 months) were compared by regression analysis.Results:We identified 82,561 cases, of which 54,578 (66.1%) included a peripheral nerve block. Of the patients who received a block, 508 underwent diagnostic shoulder arthroscopy; 2449 had labral repair; 4746 had subacromial decompression procedure; and 12,616 underwent rotator cuff repair. The percentage of patients undergoing a nerve block increased linearly over the 9-year study period (R 2 = 0.77; P = .002). After matching across the 2 cohorts, there was an identical trend in opioid prescription filling between blocked and unblocked cases (P = .95). When subdivided by procedure, there was no difference in the trends between blocked and unblocked cases (P = .52 for diagnostic arthroscopies; P = .24 for labral procedures; P = .71 for subacromial decompressions; P = .34 for rotator cuff repairs). However, when preoperative opioid users were isolated, postoperative opioid prescription filling was found to be less common in the first 2 weeks after surgery when a nerve block was given versus not given (P < .001).Conclusion:An increasing percentage of shoulder arthroscopies are being performed with regional nerve blocks. However, there was no difference in patterns of filled postoperative opioid prescriptions between blocked and unblocked cases, except for the subgroup of patients who had filled an opioid prescription within 1 to 3 months prior to shoulder arthroscopy. Future research should focus on recording the amount of prescribed opioids consumed in national databases to reinforce our strategy against the opioid epidemic.

4:12 PM Abstract No. 316 Variations in endovascular management of infrapopliteal arterial disease: national trends from the Medicare procedure database

Growing evidence for the efficacy of endovascular interventions for infrapopliteal atherosclerotic arterial disease has led to increased utilization of these procedures. We aim to characterize developing national trends in use of balloon angioplasty (PTA), stenting, and atherectomy across clinical settings and provider specialties. The Medicare Physician/Supplier Procedure Summary data were used to quantify endovascular interventions performed for infrapopliteal arterial disease between 2011 and 2017 based upon submitted current procedural terminology (CPT) codes. Enrollment-adjusted results were stratified by year and analyzed by provider specialty (cardiology, radiology, and surgery) and clinical setting (office-based lab (OBL), hospital outpatient, and hospital inpatient). Between 2011 and 2017 there was a shift in treatment strategy of infrapopliteal disease, from PTA alone (59.8% to 48.4% of interventions) to substantially increased use of atherectomy (32.4% to 47.8%). Cardiologists were the first to adopt atherectomy as primary therapy (52.8% of interventions). By 2017, radiologists used PTA-only and atherectomy equally (49.3% atherectomy) and surgeons still performed more PTA-only than atherectomy (43.2% atherectomy). Stenting was consistent across specialties, accounting for 8% of cases in 2011 and 4% of cases in 2017. Clinical location impacted the intervention performed, with increasing use of atherectomy in the OBL setting compared to the hospital outpatient setting (58.9% OBL and 31.2% outpatient in 2011, 74.2% OBL and 32.8% outpatient in 2017). Hospital inpatient atherectomy was infrequently used (27.2% in 2011 and 25.3% in 2017). Endovascular treatment of infrapopliteal disease has shifted in recent years to predominant use of atherectomy. Cardiologists were early adopters of atherectomy, followed by radiologists, with surgeons still performing comparatively more PTA-only procedures. Atherectomy is much more prevalent in OBL than the hospital outpatient setting, suggesting possible inappropriate use. Stenting rates remained low and continued to decline, suggesting decreasing bailout for complications of other interventions.

Abstract 16915: Extracorporeal Membrane Oxygenation for Pulmonary Embolism With Acute Right Ventricular Failure and Shock: National Trends of Use, Demographics and In-Patient Mortality in the United States 2011-2014

Background: Extracorporeal membrane oxygenation (ECMO) is an emerging option for cardio-pulmonary support for patients with massive pulmonary emboli (PE) as a bridge to definitive treatments. Goal of this study is to assess the national trends of use, demographics and in-patient mortality of patients managed with ECMO for PE associated with acute right ventricular failure and shock. Methods: The National Inpatient Sample database was queried for patients above 18 years of age hospitalized between 2011-2014 with pulmonary emboli (ICD diagnoses codes 415.1, 415.11, 415.19). Patients with acute right ventricular failure and shock with hemodynamic instability were identified (ICD diagnoses codes 415.0, 785.59, 785.51, 785.50). Patients treated with ECMO were identified using the procedure code 39.65. SPSS version 24 was used for statistical analysis. Results: During the study period, there were 1,262,542 admissions with pulmonary emboli, out of which 32,978 had acute right ventricular failure and shock. ECMO was used in 450 patients and that showed an increasing trend over the years (figure 1), with an in-patient mortality rate of 59.2%. Mean length of stay was 23 days. More than 90% of these patients were managed in large urban teaching hospitals with bed-size more than 500. Around half (43%) of these were in the Southern US hospitals. Factors associated with higher mortality were male sex (68.8%), age &gt;80 years (100%), Hispanic race (65%), lack of insurance (71.4%) and low socio-economic strata (income quartile 1st, 74.4%), p&lt;0.05. Conclusion: Use of ECMO for cardio-pulmonary support in patients hospitalized for PE with acute right ventricular failure and shock is increasing over the years. Among these patients, male sex, age &gt;80 years, Hispanic race, lack of insurance and lower socio-economic strata are associated with higher mortality.

Estimated Impact of US Preventive Services Task Force Recommendations on Use and Cost of Statins for Cardiovascular Disease Prevention.

US Preventive Services Task Force (USPSTF) released new recommendations on statin use for atherosclerotic cardiovascular disease (ASCVD) prevention. The Affordable Care Act (ACA) mandates USPSTF recommendations with an "A" or "B" grade receive insurance coverage without copayment. We assessed the potential impact of these recommendations. To assess the US population meeting criteria for statin use and factors associated with use, and calculate associated costs. We estimated 10-year ASCVD event risk scores from National Health and Nutrition Examination Survey data using Pooled Cohort Equations from the American College of Cardiology/American Heart Association and applied them to Medical Expenditure Panel Survey data. We estimated the population meeting USPSTF criteria and calculated the number of statin prescription fills and out-of-pocket and total costs. We assessed associations between statin use and sociodemographic and health characteristics and national trends in use from 1996 to 2014. A nationally representative sample of people aged ≥ 40years, representing 150 million people living in the USA. Of 26.8 million adults recommended for statins, only 41.8% were taking them. Female sex, Hispanic ethnicity, uninsured status, or living in the South was associated with lower odds of using statins. Under ACA, people with private insurance would avoid out-of-pocket cost of $9 for each generic prescription, resulting in savings of approximately $44 in annual costs. ACA's mandate for insurance coverage would result in a $193 million shift in out-of-pocket cost for statins from patients to private insurers. New USPSTF recommendations may result in decreased out-of-pocket costs and expanded access to statins. Previous research has shown that eliminating copayments increased adherence and decreased rates of ASCVD events without increasing overall healthcare costs. Future research will determine whether the USPSTF's recommendations will result in similar findings.

National trends in use and costs of oral anticancer drugs in France: An 8-year population-based study.

During the last decade, many oral anticancer drugs (OAcDs) have been marketed, providing interesting but potentially costly pharmaceutical alternatives to intravenous treatments. This study aims to provide updated information on their use and costs. A cross-sectional yearly repeated study was conducted from 2006 to 2014 using the representative sample of the French national health care insurance system claims database (EGB). OAcD use was described for each year, among prevalent (ie, patients with at least 1 OAcD reimbursement) and incident users (ie, patients with no OAcD reimbursement within the prior year) and according to their pharmacological classes (Hormone Therapy [HT], Cytotoxic Therapy [CT], Targeted Therapy [TT], and others). Demographic characteristics were described for both users; comorbidities and direct medical costs were described for incident users only. The yearly prevalence and incidence of OAcD use, mainly represented by HT, remained stable from 2006 to 2014 (1.2%; 0.4%). Compared with users of other OAcD classes, the proportion of TT users substantially increased over the 8-year study period (+9.3%), and TT incident users had more severe comorbidities at treatment initiation. The health expenditures were the most important in TT users with median monthly medical direct costs varying from 2995€ to 4968€ per patient between 2006 and 2014. With the development of new OAcDs, the TTs use reaches a wider population of patients but is responsible for increasing health expenditures.

National Trends in Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in the Veterans Health Administration

National Trends in Use of Monitored Anesthesia Care for Outpatient Gastrointestinal Endoscopy in the Veterans Health Administration

National Trends in Use of Opioid Drugs Among Cirrhosis-Related Hospitalizations in the United States, 2004-2012

National Trends in Use of Opioid Drugs Among Cirrhosis-Related Hospitalizations in the United States, 2004-2012

National Trends of Use of Various Routes and Indications of Liver Biopsy: Based on NIS Database

National Trends of Use of Various Routes and Indications of Liver Biopsy: Based on NIS Database

Use, complications, and costs of stereotactic body radiotherapy for localized prostate cancer

Stereotactic body radiotherapy (SBRT) for localized prostate cancer has potential advantages over traditional radiotherapies. Herein, the authors compared national trends in use, complications, and costs of SBRT with those of traditional radiotherapies. The authors identified men who underwent SBRT, intensity-modulated radiotherapy (IMRT), brachytherapy, and proton beam therapy as primary treatment of prostate cancer between 2004 and 2011 from Surveillance, Epidemiology, and End Results Program (SEER)-Medicare linked data. Temporal trend of therapy use was assessed using the Cochran-Armitage test. Two-year outcomes were compared using the chi-square test. Median treatment costs were compared using the Kruskal-Wallis test. A total of 542 men received SBRT, 9647 received brachytherapy, 23,408 received IMRT, and 800 men were treated with proton beam therapy. There was a significant increase in the use of SBRT and proton beam therapy (P<.001), whereas brachytherapy use decreased (P<.001). A higher percentage of patients treated with SBRT and brachytherapy had low-grade cancer (Gleason score ≤ 6 vs ≥ 7) compared with individuals treated with IMRT and proton beam therapy (54.0% and 64.2% vs 35.2% and 49.6%, respectively; P<.001). SBRT compared with brachytherapy and IMRT was associated with equivalent gastrointestinal toxicity but more erectile dysfunction at 2-year follow-up (P<.001). SBRT was associated with more urinary incontinence compared with IMRT and proton beam therapy but less compared with brachytherapy (P<.001, respectively). The median cost of SBRT was $27,145 compared with $17,183 for brachytherapy, $37,090 for IMRT, and $54,706 for proton beam therapy (P<.001). The use of SBRT and proton beam therapy for localized prostate cancer has increased over time. Despite men of lower disease stage undergoing SBRT, SBRT was found to be associated with greater toxicity but lower health care costs compared with IMRT and proton beam therapy. Cancer 2016;122:2496-504. © 2016 American Cancer Society.

National Trends in Use of Endovascular Stroke Treatment Among Academic Medical Centers (2009-2015) (P2.287)

National Trends in Use of Endovascular Stroke Treatment Among Academic Medical Centers (2009-2015) (P2.287)

Minimally invasive surgery and sphincter preservation in rectal cancer

BackgroundNational adoption of sphincter-preserving surgery (SPS) and minimally invasive surgery (MIS) has not been well documented. We examined national trends in use of SPS and MIS. Materials and methodsThe National Inpatient Sample was used to evaluate open, laparoscopic, and robotic low anterior resection (LAR) or abdominoperineal resection (APR) for patients undergoing rectal cancer surgery from 2009 to 2011. Trends in SPS and MIS were stratified by hospital volume. Propensity score matching was used. ResultsA total of 24,999 (62.0%) patients underwent LAR, and 15,288 (38.0%) underwent APR from 2009 to 2011. A total of 22,310 (89.2%) LARs were open and 2689 (10.8%) MIS. A total of 11,600 (75.9%) APRs were open and 3688 (24.1%) MIS. Most procedures were at high-volume centers. In propensity-matched analysis, length of stay for LAR was longer in open surgery (6 versus 5 d; P = 0.01); in APR, MIS patients were less likely to have wound, infectious, urinary, and gastrointestinal complications, and length of stay was shorter (6 versus 8 d; P < 0.01). ConclusionsSPS and MIS rates have increased nationally, especially in high-volume centers. In addition, the perioperative benefits seen in randomized clinical trials are maintained in a national database. Further studies should focus on understanding differences in survival and oncologic outcomes with MIS techniques.

Abstract 161: National Trends in Use of Radial Access for Percutaneous Coronary Intervention in China: 2001-2011

Background: The use of radial access for percutaneous coronary intervention (r-PCI) is associated with reduced risk of bleeding complications and higher patient satisfaction. However, the use of r-PCI differs greatly by country and is unknown in China. We examined trends in the adoption of r-PCI in China over the past decade and identified factors associated with its use. Methods: We used a two-stage random sampling strategy to create a nationally representative sample of 5,462 patients undergoing percutaneous coronary intervention (PCI) in China in 2001 (n=402; 24 sites), 2006 (n=1,390; 44 sites), and 2011 (n=3,670; 54 sites). We calculated the weighted proportion of patients receiving r-PCI in each time period and conducted multivariable analysis to identify the patient and hospital characteristics associated with not receiving r-PCI in 2011. Results: Among 5,462 patients who underwent PCI, the use of r-PCI increased markedly over time (2001: 3.4% [95% CI 0.0%-8.5%]; 2006: 36.5% [95% CI 34.2%-38.9%], 2011: 74.7% [95% CI 73.9-75.6]; P for trend &lt;0.001). Increases in r-PCI use were widespread, including high-risk subgroups such as the elderly, women, and patients with acute coronary syndromes (Figure). In multivariable analysis of 3,670 patients undergoing PCI in 2011, cardiogenic shock and emergency PCI were strongly associated with failure to use r-PCI in 2011. Conclusion: Over a recent ten-year period, radial access became the predominant strategy for PCI in China, even among high-risk patients. This study demonstrates the responsiveness of the interventional cardiology community to emerging evidence. A deeper understanding of the factors facilitating r-PCI adoption in China may help increase its usage in countries in which r-PCI use remains low.

Abstract 18977: Trends in Use of Thrombolytic Therapy Among Fee-For-Service Medicare Beneficiaries With Acute Pulmonary Embolism

Background: Thrombolytic therapy may improve the outcomes of select patients with acute pulmonary embolism (PE); however, it has historically rarely been used in older adults. Contemporary national trends in use of thrombolytic therapy among elderly patients with PE are not known. Methods: Using the inpatient Medicare Standard Analytic Files, we identified all Fee-For-Service patients aged ≥65 years old with a principal discharge diagnosis of PE between 1999 and 2010 and also identified those who received thrombolytic therapy. We used the Vital Status Files to determine rates of 30-day and 1-year mortality and fitted mixed-effects models to calculate adjusted mortality. Results: During the study period, there were 545,131 patients with a principal discharge diagnosis of PE, of whom 7158 (1.3%) received thrombolysis. The number of PE patients undergoing thrombolysis increased from 380 in 1999 to 840 in 2010 (P&lt;0.001 for linear trend), in large part owing to increased utilization among patients 65-74 years. The proportion of patients with PE receiving thrombolysis changed from 12 per 1000 in 1999 to 16 per 1000 in 2010 (p=0.09 for linear trend). In-hospital mortality rates among patients receiving thrombolysis ranged between 15% and 21.2% in the study period. Adjusted 30-day and 1-year mortality rates ranged between 17.9% to 23% and 26.1% to 31.4% across the years. Conclusions: Recent trials (e.g., PEITHO) suggest thrombolysis may confer benefits in PE, even among older adults. We observed more widespread use in older age groups in recent years, but thrombolysis is still rarely applied for elderly patients compared with other age groups.