Temporal Trends In Use Research Articles

Temporal trends in use of antisecretory agents among patients administered clopidogrel-based dual antiplatelet therapy after percutaneous coronary intervention.

Antisecretory drugs are commonly prescribed with clopidogrel-based dual antiplatelet therapy (DAPT) to prevent gastrointestinal bleeding in high-risk patients after percutaneous coronary intervention (PCI). However, omeprazole and esomeprazole (inhibiting proton pump inhibitors [PPIs]) may increase cardiovascular event rates on co-administration with clopidogrel. This study aimed to examine trends in the use of antisecretory agents in patients administered clopidogrel-based DAPT and the concomitant use of clopidogrel and inhibiting PPIs. We used National Inpatient Sample data compiled by the Health Insurance Review & Assessment Service from 2009 to 2020. Further, we identified patients who were prescribed clopidogrel-based DAPT after PCI and investigated the concomitant use of antisecretory agents with clopidogrel. To verify the annual trend of drug utilization, we used the Cochran-Armitage trend test. From 2009 to 2020, the percentage of H2 receptor antagonist users decreased steadily (from 82.5% in 2009 to 25.3% in 2020); instead, the percentage of PPI users increased (from 23.7% in 2009 to 82.0% in 2020). The use of inhibiting PPI also increased (from 4.2% in 2009 to 30.7% in 2020). Potassium competitive acid blockers (P-CABs) were rarely used before 2019; however, in 2020, it accounted for 7.8% of the antisecretory users. Our study demonstrates that the use of inhibiting PPIs increased steadily in patients administered clopidogrel-based DAPT therapy. This is a major concern since the concomitant use of inhibiting PPIs with clopidogrel could increase the risk of cardiovascular events.

Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery

Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery. To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures. A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included. Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair. The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups. During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days). While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.

Drug Allergy Alert System in a Spanish University Hospital: Description and Dynamics of Use

Introduction: The drug allergy alert system reduces the frequency of adverse drug events, although it is subjected to collateral effects, since 80–90% of alerts are not real, and a large percentage of alerts are overridden (46.2–96.2%). We reviewed how the alert system is used at University Hospital Fundación Alcorcon (HUFA). Methods: Data were obtained from the drug allergy alert and the alert overriding notification forms (both in the period 2011–20). We also recorded drug allergy diagnoses at HUFA, drug consumption in primary care in 2016. We calculated the incidence of drug allergy alert activation, temporal trends in use, and correlations between the number of drugs in several datasets. Results: We collected 15,535 alerts. NSAIDs and penicillins were the drugs with the highest number of drug allergy alerts (36.55% and 26.91%, respectively). A correlation was found between the number of drug alerts and the type of drug allergy in HUFA in 2016. Only 6.83% of the alerts were removed, and, of these, 21.77% were reactivated. Approximately 100 overrides were recorded per year from 2016 (6.8% of 8,434 activated alerts during 2014–2020). Conclusions: The number of drug allergy alerts recorded via the drug allergy alert system of HUFA correlates with the distribution of drug allergy diagnoses in the hospital, although many of the alerts could be false positives (as per current published evidence). We detected a very low frequency of removed alerts (6.83%), a relevant frequency of reactivations (one quarter), and a very low frequency of overrides (6.8%).

Trends in use of proton pump inhibitors among adults in the United States from 1999 to 2018.

Proton pump inhibitors (PPIs) are among the most commonly used drugs in the United States (U.S.). We aimed to determine the trends in use of PPIs among adults in the U.S. from 1999 through 2018, hypothesizing the trend would follow an inverted U-shaped curve, with a decline in recent years due to safety concerns. Temporal trends in use of prescription PPIs were assessed using the 1999-2018 National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey of non-institutionalized U.S. civilians. Use of PPIs was defined as any use during the month preceding the survey. Descriptive statistics were produced and trends in PPI use were examined, stratified by sex, age, race, body mass index (BMI), and poverty level. Use of prescription PPIs increased from 4.1% of U.S. adults in 1999-2000 to 8.6% in 2017-2018 (p for trend <0.01). All of the increase was observed during the first half of the study period (4.6% increase from 1999 to 2008 vs. 0.5% decrease from 2009 to 2018) and almost all of it was among those aged 55 or more (8.6% increase among those aged ≥ 55 compared to 1.2% increase among those aged < 55, p for interaction based on age <0.01). Use of prescription PPIs increased from 1999 to 2008 and then plateaued through 2018. This rise was driven by increased usage among older NHANES respondents.

Abstract 15797: Cardiovascular Outcomes of Bariatric Surgery and Anti-Obesity Medications in Patients With New Onset Heart Failure and Obesity

Background: Intentional weight loss with bariatric surgery is associated with better outcomes in younger patients with prevalent HF. However, temporal trends in use of bariatric surgery and anti-obesity medications (AOM) among older patients with new onset HF and obesity, and their effect on CV outcomes are not well studied. Methods: Medicare patients with obesity and new onset HF from 2013 to 2019 were identified using the 100% inpatient files. Patients who underwent bariatric surgery were matched to controls in a 1:2 ratio (matched on age, sex, race, BMI, and HF diagnosis year, and comorbidities). In a random 5% sample with available Part D data, HF patients with obesity who were prescribed AOM (Semaglutide, liraglutide, naltrexone or orlistat) were identified and matched to HF controls as above. Cox models were used to evaluate the association of weight loss therapies (modeled as a time-varying dependent variable) and risk of mortality, atrial fibrillation (AF), and HF readmission rate. Results: Overall, 1.5% (2684 of 174,196) patients with new onset HF and BMI ≥35 underwent bariatric surgery (46% men, age 55 y and BMI 52 Kg/m2). Bariatric surgery use increased from 0.3% in 2013 to 1.4% in 2019 (P &lt;0.01). In propensity-matched analyses (surgery N=2144 vs. control N=3920, f/u of 4.2 y), bariatric surgery following incident HF was associated with a significantly lower risk of mortality and new-onset AF (Figure), and a lower rate of HF readmissions (pre- vs. post-surgery rate: 0.9 vs. 0.3/100 person-days). In the subset with Part D data (N=36603), use of AOM was low (3.7%). In propensity-matched analysis, (AOM N=611 vs. controls N=891, f/u of 1.8 y), use of AOM were associated with 30% lower risk of mortality and 35% lower risk of AF compared with controls. Conclusions: Bariatric surgery and AOM are associated with favorable CV outcomes among HF patients with obesity. However, their utilization remains extremely low highlighting an important gap in care of HF patients with obesity.

Twitter Corpus of the #BlackLivesMatter Movement and Counter Protests: 2013 to 2021

Black Lives Matter (BLM) is a decentralized social movement protesting violence against Black individuals and communities, with a focus on police brutality. The movement gained significant attention following the killings of Ahmaud Arbery, Breonna Taylor, and George Floyd in 2020. The #BlackLivesMatter social media hashtag has come to represent the grassroots movement, with similar hashtags counter protesting the BLM movement, such as #AllLivesMatter, and #BlueLivesMatter. We introduce a data set of 63.9 million tweets from 13.0 million users from over 100 countries which contain one of the following keywords: BlackLivesMatter, AllLivesMatter, and BlueLivesMatter. This data set contains all currently available tweets from the beginning of the BLM movement in 2013 to 2021. We summarize the data set and show temporal trends in use of both the BlackLivesMatter keyword and keywords associated with counter movements. Additionally, for each keyword, we create and release a set of Latent Dirichlet Allocation (LDA) topics (i.e., automatically clustered groups of semantically co-occuring words) to aid researchers in identifying linguistic patterns across the three keywords.

Socioeconomic Disparity Trends in End-of-Life Care for Cancer and Non-Cancer Patients: Are We Closing the Gap?

PurposeSocioeconomic disparities in end-of-life care have been reported across underlying diseases, but there is a paucity of information on potential time trends. Thus, we aimed to examine time trends in use of health-care services at the end of life according to socioeconomic position in patients dying from cancer and non-cancer diseases.Materials and MethodsWe conducted a nationwide registry-based study among adults dying from cancer or non-cancer diseases (diabetes, dementia, heart failure, ischemic heart disease, stroke, chronic liver disease, and chronic obstructive pulmonary disease) in Denmark in 2006–2016. We obtained data on patients’ educational level and income level and use of health-care services within three months before death. Use of health-care services according to educational level and income level was plotted by calendar year of death and compared by regression analyses adjusting for age, sex, comorbidity, cohabitation, and municipality.ResultsIn both cancer (n = 169,694) and non-cancer patients (n = 180,350), we found limited socioeconomic disparities and no clear temporal trends in use of hospital, intensive care, emergency room, general practice, home care nurse, and hospice. In 2006/2007, one percentage point more cancer patients with high income level compared with low income level were affiliated with hospital-based specialist palliative care (adjusted mean difference: 0.01 (95% confidence interval (CI): 0.01; 0.02)), whereas this was 12 percentage points in 2016 (adjusted mean difference: 0.12 (95% CI: 0.09; 0.14)).ConclusionSocioeconomic disparities in specialist palliative care tended to increase over time among cancer patients but were limited and without clear time trends in use of other health-care services in both cancer and non-cancer patients.

Trends in Treatments for Multisystem Inflammatory Syndrome in Children (MIS-C), United States, February 2020 - July 2021.

BackgroundMultisystem inflammatory syndrome in children (MIS-C) is a novel severe postinfectious condition associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The purpose of this report is to describe nationwide trends in the evolving clinical management of MIS-C.MethodsPatients with MIS-C were reported from state and local jurisdictions to the Centers for Disease Control and Prevention’s (CDC’s) MIS-C national surveillance system. Patients’ case reports were reviewed to ensure that they met the CDC MIS-C case definition and had sufficient data for analysis. The prevalence of use of treatments for MIS-C, temporal trends in use of these treatments, and frequency of administration of different treatment combinations were analyzed.ResultsThere were 4470 patients meeting the MIS-C case definition with onset dates from 19 February 2020 to 31 July 2021. The proportion of patients admitted to an intensive care unit (ICU) has declined over time, from 78.7% in April 2020 to 57.5% in June 2021 (P = .001). The most common treatments were intravenous immunoglobulin (IVIG), given to 85.6% of patients; steroids (77.7%), and antiplatelet medications (73.7%); use of each of these treatments has increased over time, particularly in patients not requiring admission to an ICU (all P < .001). Older patients and non-Hispanic Black patients were more likely to receive additional modes of therapy including vasoactive medication, noninvasive respiratory support, anticoagulation medication, and intubation/mechanical ventilation.ConclusionsIVIG, steroids, and antiplatelet medication have become increasingly utilized as standard treatment for MIS-C patients, while the use of other treatments may be contingent on the type and severity of clinical findings.

Temporal Trends in Use of Complementary Therapies Among Patients With Cardiovascular Disorders

This study aimed to evaluate the use and frequency of complementary and integrative medicine (CIM) therapies in an outpatient cohort with cardiovascular disease (CVD) and compare trends over time. This cross-sectional point-of-care prospective study assessed patients attending a cardiology outpatient clinic. As in our 2009 cohort, data were collected with a 17-question survey on demographic characteristics, CVD history, current use and future interest in CIM. In total, 964 patients completed the survey. CIM use continues to be high (2009 vs 2018, 83.4% vs 81.8%) (p=0.34), with dietary supplements the most common therapy (75% in both studies). We observed increased use of mind-body therapies (28.5% vs 23.9%, p=0.02), especially meditation, yoga, and tai chi. Of the patients receiving CIM therapies, 41.9% reported using CIM for heart-related symptoms. Relaxation, stress management, and meditation were the top three mind-body therapies for CVD-related symptoms in both cohorts. Reporting of CIM use to clinicians is low (15%) and interest on future use is high (47%). In conclusion, CIM is highly used in cardiology patients-4 of 10 patients use CIM for CVD-related symptoms. Most take dietary supplements, with an increased use of mind-body therapies. Our data highlight the importance of documenting CIM use in practice and the need for research to document efficacy.

Abstract 11566: Use of Temporary Mechanical Circulatory Support Devices in Heart Failure Patients with Cardiogenic Shock

Objective: Contemporary use of temporary mechanical circulatory support devices (tMCS) for heart failure (HF) without acute myocardial infarction (AMI) is not well described. Accordingly, we evaluated use patterns for tMCS in HF patients. Methods: This was a retrospective study of a large administrative claims dataset between 01/01/06 and 12/31/19. We included patients with HF or cardiogenic shock who received tMCS i.e. Impella, intra-aortic balloon pump (IABP) or extra-corporeal membrane oxygenator (ECMO) in the absence of AMI or coronary revascularization. Multinomial logistic regression model was used to identify predictors for type of tMCS device. Temporal trends in use of tMCS was also evaluated. Results: We included 2722 HF patients receiving tMCS: 1836 (68%) with ischemic cardiomyopathy (ICM) and 886 (32%) with non-ischemic cardiomyopathy (NICM). There were no gender or racial differences in device use. Table shows adjusted odds ratio for predictors associated with receipt of ECMO or Impella compared to IABP. After multivariable adjustment, patients with ICM or NICM placed on ECMO compared to IABP, had a higher comorbidity burden. For both groups, patients with valvular disease were more likely to receive IABP and patients with peripheral vascular disease an Impella. Over time, there was an increase in Impella and ECMO use with a decrease in IABP use (p &lt;0.05; Figure). Conclusions: In a real world cohort of HF patients with cardiogenic shock without AMI, use of Impella and ECMO has increased over the last decade and IABP has decreased. Patients receiving ECMO have a higher co-morbidity burden, whereas patients receiving IABP are more likely to have valvular heart disease.

Abstract PS1-05: Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system

Abstract Introduction Although temporal trends in breast conserving surgery (BCS) have been described for developed countries like the United States (US), there is a lack of information regarding the uptake of breast conservation in developing regions of the world. In developing countries, the implementation of breast conservation might be hindered by the availability of radiation therapy, lack of training among surgeons, or concerns regarding compliance with follow-up care and surveillance. In 2006, the Mexican government created Seguro Popular, which provided coverage for breast cancer care for all Mexican women, thus potentially mitigating the difficulties with obtaining care after BCS and improving access to multidisciplinary care. We undertook an overview of ten years of breast cancer surgery at our Mexican cancer center following the implementation of Seguro Popular, and explored changes in surgical technique over time. Methods A retrospective cohort analysis was conducted using the National Cancer Institute of Mexico (INCAN) database from 2006 to 2016. All patients with a diagnosis of breast cancer seen during that period were included. Patients who received surgery for breast cancer where then grouped together based on the type of surgery (mastectomy versus BCS). The effect of the year of diagnosis and of clinical stage at the time of presentation was evaluated. Logistic regression was used to model temporal trends in use of BCS over mastectomy for three 3-year periods (2006-2009, 2010-2012, and 2013-2016). Results The patient cohort consisted of 5289 women from the INCAN database, of which 4519 received some form of local surgical treatment. Sixty-one percent (n = 2764) had locally advanced disease (stages IIB-IIIC) at the time of presentation, and a quarter (n = 1156) had ≥60 days between diagnosis and receipt of surgical treatment. Eighty percent of the patients in the entire cohort (n = 3611) were treated with mastectomy, while 20% (n = 908) received BCS. For the 2006-2009 period, out of 1596 total surgeries, 9.9% were BCS (n = 158). The proportion of BCS increased for each of the other two studied periods, being 18.5% for the 2010-2012 period (n = 276/1490), and 33.1% for the 2013-2016 period (n = 474/1433) (p&amp;lt;0.01 for trend). While the increase in BCS was significant for all stages, it was most pronounced for women with early-stage disease (Stages I-IIA), going from 17% in 2006-2009 to 52% in 2013-2016 (p&amp;lt;0.01), than in those with locally-advanced disease (6.5 to 18%, p&amp;lt;0.01). Conclusions In the ten years after the start of the Seguro Popular public insurance program, the proportion of BCS at a Mexican cancer center increased significantly, particularly for women with early-stage disease. The rates seen at INCAN for the period between 2013-2106 resemble those reported by the US National Cancer Database, in which approximately 61% of women with stage I-II breast cancer and 20% of women with stage III disease receive BCS. Potential reasons for the increase in the uptake of BCS include improved access to adjuvant radiation therapy, improved access to systemic treatment, and higher adherence to follow-up care after the start of Seguro Popular, as well as improvements in surgical training. In addition, changes in BCS may also be related to improvements in the implementation of multidisciplinary teams over time, which may lead to a more homogeneous and comprehensive care. Our results show that improving access to care for patients living in developing countries positively impacts the uptake of BCS for women with breast cancer. Citation Format: Enrique Bargalló-Rocha, Nancy Reynoso-Noveron, Jaime Corona, Nereida Esparza-Arias, María Teresa Ramírez-Ugalde, Caros Daniel Robles-Vidal, Robin Shaw-Dulin, Armen Stankov, Rafael Vazquez-Romo, Patricia Villarreal-Colin, Sergio Aguilar-Villanueva, Jaime Hidalgo-Bahena, Milagros Perez-Quintanilla, Fernando U Lara-Medina, Juan Alejandro Torres, Enrique Soto-Perez-de-Celis, Paula Cabrera-Galeana, Alejandro Mohar, Abelardo Meneses-García. Trends in breast-conserving surgery in Mexico after the implementation of a public health insurance system [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-05.

Association of Medicaid Expansion With Rates of Utilization of Cardiovascular Therapies Among Medicaid Beneficiaries Between 2011 and 2018.

The Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to health care. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs. We used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants. We defined expander states as those who expanded Medicaid on or before January 1, 2014, and nonexpander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus nonexpander states. Between 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins (DID estimate [95% CI]: 22.5 [16.5-28.6], P<0.001), antihypertensives (DID estimate [95% CI]: 63.2 [47.3-79.1], P<0.001), and P2Y12 inhibitors (DID estimate [95% CI]: 1.7 [1.2-2.2], P<0.001). Between 2013 and 2018, >75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of nonexpander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher direct oral anticoagulants prescription rates (DID estimate [95% CI] 0.9 [-0.3 to 2.1], P=0.142). The 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.

Evaluation of the Prognostic Utility of Bone Marrow Biopsy in Diffuse Large B-Cell Lymphoma: A SEER-Medicare Linked Database Analysis

Background: Positron emission tomography-computed tomography (PET-CT) has become the primary modality for initial staging in diffuse large B-cell lymphoma (DLBCL) [Barrington et al, J Clin Oncol 2014; Cheson et al, J Clin Oncol 2014]. Recently, the role of a staging bone marrow biopsy (BMB) has become less clear. A meta-analysis suggested that PET-CT can miss bone marrow involvement [Adams et al, Eur J Nucl Med Mol Imaging 2014], but recent guidelines on staging suggested that BMB should be optional. We analyzed temporal trends in use of different screening modalities and evaluated the association between patient outcomes and staging modality (PET-CT with BMB compared to either PET-CT without BMB or CT with BMB) in patients with DLBCL in SEER-Medicare. We hypothesized that use of PET-CT as screening would increase over time and that use of BMB would decrease over time. We also hypothesized that use of BMB would not be associated with an improvement in overall survival in patients staged with PET-CT. Methods: 70,858 patients diagnosed with DLBCL in SEER-Medicare were identified with ICD-O-3 SEER histology codes 9680 and 9684. In this analysis, we included 7,159 patients who were diagnosed between 2002 and 2015, were treated with first-line rituximab, cyclophosphamide, vincristine, and doxorubicin chemotherapy regimens, and had claims for PET-CT and/or BMB within 30 days on either side of diagnosis. The patients were divided into screening categories of patients receiving PET-CT without BMB (PET-CT w/o BMB), patients receiving BMB with CT (i.e., no PET-CT) (CT w/ BMB), and patients receiving both screening modalities (PET-CT w/ BMB). Overall survival (OS) was calculated from date of diagnosis to death. Kaplan-Meier (KM) curves were used to estimate survival probabilities across screening categories and log-rank tests (LRT) were used to statistically evaluate differences between OS curves. Cox proportional hazards (CoxPH) models were used to estimate hazard ratios prior to and following adjustment for confounders. Results: 2,059 patients received PET-CT w/o BMB, 1,539 received CT w/ BMB, and 3,561 received PET-CT w/ BMB. Proportions of patients receiving PET-CT w/ BMB and PET-CT w/o BMB increased across years of diagnosis (36.7 to 51.9% and 17.4 to 36.1%, respectively, between 2002-2005 and 2013-2015), while the proportion of patients receiving CT w/ BMB decreased across years of diagnosis (45.8 to 12.0%) (Table 1). Similarly, the proportion of patients receiving BMB independent of imaging modality also decreased (28.8% to 16.8%). In bivariate analyses, categories of screening were significantly associated with age category, sex, year of diagnosis, race, stage, nodal status, poor performance status, Charlson Comorbidity Index (CCI), number of first-line cycles, and geographic classification, with receipt of PET-CT w/ BMB being more common in patients who are younger, male, diagnosed in later years in urban settings, and received &amp;gt;4 first-line cycles, with earlier stage at diagnosis, nodal disease, good performance status, and lower CCI (Table 1). In unadjusted KM analysis, median survival among patients receiving PET-CT w/ BMB was 8.7 years, compared to 8.1 and 7.6 years among patients receiving PET-CT w/o BMB and CT w/ BMB, respectively (LRT P&amp;lt;0.0001; Figure 1). In fully adjusted CoxPH models, patients receiving PET-CT w/ BMB did not have a significantly better OS compared to those receiving PET-CT w/o BMB (HR: 0.93; 95% CI, 0.84-1.02; P=0.1075). Separately, patients receiving CT w/ BMB had a significantly worse OS compared to those receiving PET-CT w/o BMB (HR: 1.13; 95% CI, 1.02-1.26; P=0.0212), even though OS was not significantly associated with year of diagnosis (P=0.6613). Conclusions: In this SEER-Medicare cohort of 7,159 patients with newly diagnosed DLBCL, we found temporal trends supporting increased use of pretreatment staging PET-CT and decreased use of BMB. We also found that use of PET-CT w/ BMB did not provide a survival benefit as compared to use of PET-CT w/o BMB. These data would suggest that use of BMB could be spared in patients newly diagnosed with DLBCL over the age of 65, unless otherwise clinically indicated. Interestingly, the finding of no OS benefit across years of diagnosis suggests that improvements in outcomes in recent trials may be due to patient selection. Given the limitations associated with registry data, the study warrants replication in more complete DLBCL data sets. Disclosures Rutherford: Genentech/Roche: Research Funding; Karyopharm: Consultancy, Research Funding; Regeneron: Research Funding; Celgene: Consultancy; Kite: Consultancy; Dova: Consultancy; Seattle Genetics: Consultancy; AstraZeneca: Consultancy; LAM Therapeutics: Research Funding; Heron: Consultancy; Juno: Consultancy. Leonard:Miltenyi: Consultancy; Karyopharm: Consultancy; Gilead/Kite: Consultancy; Sutro: Consultancy; Bayer: Consultancy; BMS/Celgene: Consultancy; MEI Pharma: Consultancy; Epizyme: Consultancy; Roche/Genentech: Consultancy; Regeneron: Consultancy; ADC Therapeutics: Consultancy; GenMab: Consultancy; AstraZeneca: Consultancy. Martin:Kite: Consultancy; Morphosys: Consultancy; Regeneron: Consultancy; Karyopharm: Consultancy, Research Funding; Janssen: Consultancy; Sandoz: Consultancy; I-MAB: Consultancy; Bayer: Consultancy; Incyte: Consultancy; Cellectar: Consultancy; Beigene: Consultancy; Celgene: Consultancy; Teneobio: Consultancy.

Surgical treatment for infective endocarditis over three decades: a nationwide study

Abstract Background An increasing number of patients with infective endocarditis (IE) are treated surgically over time. It is important to know how this affects patient outcome. Current studies are mainly from tertiary centres which may bias estimations of outcomes. We have therefore conducted a nationwide study of surgical outcomes during admission for IE over three decades. Purpose We set out to examine temporal trends in use of valve surgery for IE and these patients' characteristics and related outcomes in Denmark in the period 1998–2017. Methods Using Danish nationwide registries, we included patients with first-time IE (1998–2017). The study population was categorized into four groups of five-year intervals (1998–2002, 2003–2007, 2008–2012, 2012–2017). Annual number of patients with IE and the proportion who underwent valve surgery during admission were reported. Kaplan-Meier estimates and multivariable logistic regression analyses were used to compare the associated 30-day mortality risk between calendar periods. Kaplan-Meier estimates and multivariable adjusted Cox proportional hazard analyses were used compare the associated 1-year mortality risk between calendar periods. Results A total of 8,455 patients with first-time IE were identified in the period of 1998–2017 of which 1,906 (22.5%) underwent valve surgery (1998–2002; N=320, 2003–2007; N=468, 2008–2012; N=528, 2013–2017; N=595). The proportion of patients who underwent surgery was 21.5% in 1998 and 19.4% in 2017 (P=0.02 for trend). See figure. For patients undergoing surgery, the median age and proportion of males increased from 58.3 years (P25-P75: 48.2–67.4) and 69.1% to 66.7 years (P25-P75: 55.2–73.0) and 73.1% in 1998–2002 and 2013–2017, respectively. Patients had an increasing burden of comorbidities including diabetes (10.3% to 14.3%), hypertension (16.9% to 37.5%) and renal disease (9.1% to 9.6%) across calendar periods. The 30-day mortality risk for patients with IE who underwent valve surgery was 10.0% (1998–2002), 10.8% (2003–2007), 6.4% (2008–2012) and 8.5% (2013–2017), respectively (P=0.09). One-year mortality risk for patients with IE who underwent valve surgery was 16.7% (1998–2002), 21.2% (2003–2007), 15.2% (2008–2012) and 16.6% (2013–2017), respectively (P=0.08). The declining 30-day and 1-year mortality was statistically significant over time when adjusting for patient characteristics (P=0.01 and P≤0.0001, respectively). Conclusion From a nationwide, unselected cohort of patients with first-time IE, around 1/5 undergo surgery during admission. Surgical IE-cases are older and sicker now compared to 10–20 years ago. In spite of this, there was a trend towards a decreased associated 30-day and 1-year mortality over time. Our data show a lower rate of surgery in IE than in most prior studies and we believe that this is due to the nationwide, unselected nature of our study. Infective endocarditis and surgery Funding Acknowledgement Type of funding source: None

Trends in objectively measured and perceived mental health and use of mental health services: a population-based study in Ontario, 2002-2014.

Mental illness is widely perceived to be more of a public health concern now than in the past; however, it is unclear whether this perception is due to an increase in the prevalence of mental illness, an increase in help-seeking behaviours or both. We examined temporal trends in use of mental health services as well as objectively measured and perceived mental health. We conducted a repeat cross-sectional study of Ontario residents who participated in Statistics Canada's Canadian Community Health Survey (2002-2014). We assessed temporal trends in objectively measured past-year major depressive episode (based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, and International Classification of Diseases, 10th Revision) and past-month psychological distress (Kessler Psychological Distress Scale-6 score ≥ 8) and perceived, self-rated mental health. We also examined use of mental health services, including service use among those with a need for mental health care. A total of 260 090 survey participants were included. The age- and sex-standardized prevalence of a major depressive episode (4.8%, 95% confidence interval [CI] 4.2%-5.3% in 2002 v. 4.9%, 95% CI 4.2%-5.7% in 2012; p = 0.9) and psychological distress (7.0%, 95% CI 6.3%-7.6% in 2002 v. 6.5%, 95% CI 5.7%-7.5% in 2012; p = 0.4) did not change significantly over time. However, self-rated fair or poor mental health status increased from 4.9% in 2003-2005 to 6.5% in 2011-2014 (p trend < 0.001), as did the use of mental health services (7.2% to 12.8%, p trend < 0.001). The percentage of individuals who had subjective or objectively measured mental health problems and did not access mental health services decreased significantly over time. Given the stable prevalence of objectively measured psychiatric symptoms, the increase in use of mental health services appears to be, at least partly, explained by an increase in perceived poor mental health and help-seeking behaviours.

Temporal trends and outcomes of prolonged invasive mechanical ventilation and tracheostomy use in acute myocardial infarction with cardiogenic shock in the United States

BackgroundThere are limited data on prolonged invasive mechanical ventilation (IMV) and tracheostomy use in intubated acute myocardial infarction with cardiogenic shock (AMI-CS) patients. MethodsUsing the National Inpatient Sample, all admissions with AMI-CS requiring IMV between January 1, 2000, and December 31, 2014, were included. Prolonged IMV was defined as IMV use >96 h. Outcomes of interest included temporal trends in use of prolonged IMV and tracheostomy, in-hospital mortality, and resource utilization. ResultsIn this 15-year period, 185,589 intubated AMI-CS admissions met the inclusion criteria. Prolonged IMV (>96 h) and tracheostomy use were noted in 68,544 (36.9%) and 10,645 (5.7%), respectively. Prolonged IMV and tracheostomy were used more commonly in younger patients. The cohort with prolonged IMV had higher organ failure and greater use of cardiac and non-cardiac organ support. Temporal trends showed a decline in prolonged IMV (adjusted odds ratio {aOR} 0.61 [95% confidence interval {CI} 0.57–0.65]) and tracheostomy use (aOR 0.80 [95% CI 0.70–0.90]) in 2014 compared to 2000. Prolonged IMV (aOR 0.45 [95% CI 0.44–0.47]; p < 0.001) and tracheostomy (aOR 0.28 [95% CI 0.27–0.29]; p < 0.001) were associated with lower in-hospital mortality with a decreasing trend between 2000 and 2014 in intubated AMI-CS admissions. Patients with prolonged IMV and tracheostomy use had nearly three-fold higher health care costs, and four-fold longer hospital stays. ConclusionsIn this cohort of intubated AMI-CS admissions, prolonged IMV and tracheostomy showed a temporal decrease between 2000 and 2014. Prolonged IMV and tracheostomy use was associated with high resource utilization.

Abstract 172: Trends in Telestroke Care Delivery: A 15-Year Experience

Introduction: Telestroke provides vascular neurology expertise to hospitals without onsite neurologists, but little is known about the temporal trends in use and timeliness of consults by spokes. We describe a telestroke network of 2 comprehensive stroke center (CSC) hubs and associated spokes. Methods: Telestroke consults were analyzed from 2003 to 2018. Trends in volume of consult requests and IV-tPA use were determined by generalized estimating equations, trends in treatment times by Kendall’s τβ nonparametric test, and associations between treatment metrics and utilization of telestroke by linear regressions. Results: The 2 hubs served 43 spokes and performed 12,808 telestroke consults of which 16% received tPA and 10% were judged eligible for thrombectomy. Spokes were in the network an average of 7.87 years, 1.82 spokes joined per year, and 1.03 exited per year. There was an overall increase in consults annually (p for temporal trend &lt;0.0001) and patients treated with IV-tPA (p &lt; 0.0001). Over the study period, time from last seen well to ED arrival time (KT coefficient 0.88, p &lt;0.0001) and last seen well to consult request time (KT coefficient 0.28, p &lt;0.0001) increased, however in hospital performance improved with decreasing times from ED arrival to IV-tPA (KT -0.13, p &lt;0.0001), time of request to callback (KT -0.05, p &lt;0.0001), and consult to IV-tPA administration (KT -0.09, p &lt;0.0001) . The number of consults requested by a spoke and the number treated with IV-tPA at each spoke were positively associated (p=0.0002). Discussion: Telestroke was well-accepted by the spokes and utilization increased over time, with a net increase in spokes served per year. Higher consult utilization was associated with increased treatment with IV-tPA. ED time metrics have improved significantly. Being active in a telestroke network is associated with more stroke treatment which the spokes are delivering in a timely manner. Replication of these findings in other networks is warranted.

Temporal Trends in Utilization of Cardiac Therapies and Outcomes forMyocardial Infarction by Degree of Chronic Kidney Disease: AReport From the NCDR Chest Pain-MI Registry.

BackgroundWe sought to determine temporal trends in use of evidence‐based therapies and clinical outcomes among myocardial infarction (MI) patients with chronic kidney disease (CKD).Methods and Results MI patients from the NCDR (National Cardiovascular Data Registry) Chest Pain–MI Registry between January 2007 and December 2015 were categorized into 3 groups by degree of CKD (end‐stage renal disease on dialysis, CKD [glomerular filtration rate <60 mL/min per 1.73 m2] not requiring dialysis, and no CKD [glomerular filtration rate ≥60 mL/min per 1.73 m2]). Logistic regression modeling was used to determine the association between calendar years (2014–2015 versus 2007–2008) and each outcome by degree of CKD. Among 325 396 patients with ST‐segment–elevation MI, 1.0% had end‐stage renal disease requiring dialysis, and 26.1% had CKD not requiring dialysis. Use of primary percutaneous coronary intervention increased over time regardless of the presence or degree of CKD (P=0.40 for interaction). In‐hospital mortality was temporally higher among patients with preserved renal function (odds ratio: 1.25; 95% confidence interval, 1.13–1.39; P<0.001) but not among patients with CKD (P=0.035 for interaction). Among 506 876 non–ST‐segment–elevation MI patients, 3.4% had end‐stage renal disease requiring dialysis, and 34.4% had CKD not requiring dialysis. P2Y12 inhibitor use within 24 hours increased over time only among dialysis patients (P for interaction <0.001). Use of coronary angiography and percutaneous coronary intervention also increased, with the greatest increase among dialysis patients (P for interaction <0.001 and <0.001, respectively). In‐hospital mortality was lower, regardless of the presence or degree of CKD (P=0.64 for interaction).ConclusionsUptake of evidence‐based medical and invasive therapies has increased over the past decade among MI patients with CKD, particularly dialysis patients, with improvement of in‐hospital mortality observed among patients with non–ST‐segment–elevation MI, but not ST‐segment–elevation MI, and CKD.

Temporal trends in use of tests in UK primary care, 2000-15: retrospective analysis of 250 million tests

ObjectivesTo assess the temporal change in test use in UK primary care and to identify tests with the greatest increase in use.DesignRetrospective cohort study.SettingUK primary care.ParticipantsAll patients registered to UK...

Comparative Effectiveness of Computed Tomography- Versus Ultrasound-Guided Percutaneous Radiofrequency Ablation Among Medicare Patients 65 Years of Age or Older With Hepatocellular Carcinoma

BackgroundFor patients with hepatocellular carcinoma (HCC) not eligible for surgical resection, radiofrequency ablation (RFA) is a promising technique that reduces the risk of disease progression. ObjectivesTo evaluate whether the trend of image guidance for RFA is moving toward the more expensive computed tomography (CT) technology and to determine the clinical benefits of CT guidance over the ultrasound (US) guidance. MethodsA cohort of 463 patients was identified from the Surveillance, Epidemiology, and End Results and Medicare–linked database. The temporal trends in use of image guidance were assessed using the Cochrane–Armitage test. The associations between modality of image guidance and survival, complications, and costs were assessed using the Cox regression model, the logistic regression model, and the generalized linear model, respectively. ResultsThe use of CT-guided RFA increased sharply, from 20.7% in 2002 to 75.9% in 2011. Compared with CT-guided RFA, those who received US-guided RFA had comparable risk of periprocedural and delayed postprocedural complications. Stratified analyses by tumor size also showed no statistically significant difference. In adjusted survival analysis, no statistically significant difference was observed in overall and cancer-specific survival. Nevertheless, the cost of CT-guided RFA ($2847) was higher than that of US-guided RFA ($1862). ConclusionsDespite its rapid adoption over time, CT-guided RFA incurred higher procedural costs than US-guided RFA but did not significantly improve postprocedural complications and survival. Echoing the American Board of Internal Medicine’s Choosing Wisely campaign and the American Society of Clinical Oncology’s Value of Cancer Care initiative, findings from our study call for critical evaluation of whether CT-guided RFA provides high-value care for patients with HCC.