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To provide an up-to-date analysis on the relationship between excise taxes and the prevalence of cigarette smoking in the United States. Linear mixed-effects models were used to model the relationship between excise taxes and prevalence of cigarette smoking in each state from 2001 through 2015. From 2001 through 2015, increases in state-level excise taxes were associated with declines in prevalence of cigarette smoking. The effect was strongest in young adults (age 18-24) and weakest in low-income individuals (<$25,000). Despite the shrinking pool of current smokers, excise taxes remain a valuable tool in public-health efforts to reduce the prevalence of cigarette smoking. States with high smoking prevalence may find increased excise taxes an effective measure to reduce population smoking prevalence. Since the effect is greatest in young adults, benefits of increased tax would likely accumulate over time by preventing new smokers in the pivotal young-adult years.

Non-invasive cardiac imaging allows detection of cardiac amyloidosis (CA) in patients with aortic stenosis (AS). Our objective was to estimate the prevalence of clinically suspected CA in patients with moderate and severe AS referred for cardiovascular magnetic resonance (CMR) in age and gender categories, and assess associations between AS-CA and all-cause mortality. We retrospectively identified consecutive AS patients defined by echocardiography referred for further CMR assessment of valvular, myocardial, and aortic disease. CMR identified CA based on typical late-gadolinium enhancement (LGE) patterns, and ancillary clinical evaluation identified suspected CA. Survival analysis with the Log rank test and Cox regression compared associations between CA and mortality. There were 113 patients (median age 74 years, Q1-Q3: 62–82 years), 96 (85%) with severe AS. Suspected CA was present in 9 patients (8%) all > 80 years. Among those over the median age of 74 years, the prevalence of CA was 9/57 (16%), and excluding women, the prevalence was 8/25 (32%). Low-flow, low-gradient physiology was very common in CA (7/9 patients or 78%). Over a median follow-up of 18 months, 40 deaths (35%) occurred. Mortality in AS + CA patients was higher than AS alone (56% vs. 20% at 1-year, log rank 15.0, P < 0.0001). Adjusting for aortic valve replacement modeled as a time-dependent covariate, Society of Thoracic Surgery predicted risk of mortality, left ventricular ejection fraction, CA remained associated with all-cause mortality (HR = 2.92, 95% CI = 1.09–7.86, P = 0.03). Suspected CA appears prevalent among older male patients with AS, especially with low flow, low gradient AS, and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

ObjectivesTo evaluate the prognostic value of the ratio between tricuspid annular plane systolic excursion (TAPSE)-pulmonary artery systolic pressure (PASP) as a determinant of right ventricular to pulmonary artery (RV-PA) coupling in patients undergoing transcatheter aortic valve replacement (TAVI).BackgroundRV function and pulmonary hypertension (PH) are both prognostically important in patients receiving TAVI. RV-PA coupling has been shown to be prognostic important in patients with heart failure but not previously evaluated in TAVI patients.MethodsConsecutive patients with severe aortic stenosis who received TAVI from July 2011 through January 2016 and with comprehensive baseline echocardiogram were included. All individual echocardiographic images and Doppler data were independently reviewed and blinded to the clinical information and outcomes. Cox models quantified the effect of TAPSE/PASP quartiles on subsequent all-cause mortality while adjusting for confounders.ResultsA total of 457 patients were included with mean age of 82.8±7.2 years, left ventricular ejection fraction (LVEF) 54%±13%, PASP 44±17 mm Hg. TAPSE/PASP quartiles showed a dose-response relationship with survival. This remained significant (HR for lowest quartile vs highest quartile=2.21, 95% CI 1.07 to 4.57, p=0.03) after adjusting for age, atrial fibrillation, LVEF, stroke volume index, Society of Thoracic Surgeons Predicted Risk of Mortality.ConclusionBaseline TAPSE/PASP ratio is associated with all-cause mortality in TAVI patients as it evaluates RV systolic performance at a given degree of afterload. Incorporation of right-side unit into the risk stratification may improve optimal selection of patients for TAVI.

ObjectivesTo determine the prevalence and factors associated with persistent pulmonary hypertension (PH) following transcatheter aortic valve replacement (TAVR) and its relationship with long-term mortality.MethodsConsecutive patients who underwent TAVR from July 2011 through January 2016 were studied. The prevalence of baseline PH (mean pulmonary artery pressure ≥25 mm Hg on right heart catheterisation) and the prevalence and the predictors of persistent≥moderate PH (pulmonary artery systolic pressure (PASP)>45 mm Hg on 1 month post-TAVR transthoracic Doppler echocardiography) were collected. Cox models quantified the effect of persistent PH on subsequent mortality while adjusting for confounders.ResultsOf the 407 TAVR patients, 273 (67%) had PH at baseline. Of these, 102 (25%) had persistent≥moderate PH. Mortality at 2 years in patients with no baseline PH versus those with PH improvement (follow-up PASP≤45 mm Hg) versus those with persistent≥moderate PH was 15.4%, 16.6% and 31.3%, respectively (p=0.049). After adjusting for Society of Thoracic Surgeons Predicted Risk of Mortality and baseline right ventricular function (using tricuspid annular plane systolic excursion), persistent≥moderate PH remained associated with all-cause mortality (HR=1.82, 95% CI 1.06 to 3.12, p=0.03). Baseline characteristics associated with increased likelihood of persistent≥moderate PH were ≥moderate tricuspid regurgitation, ≥moderate mitral regurgitation, atrial fibrillation/flutter, early (E) to late (A) ventricular filling velocities (E/A ratio) and left atrial volume index.ConclusionsPersistency of even moderate or greater PH at 1 month post-TAVR is common and associated with higher all-cause mortality.

Atrial fibrillation (AF) is the most common cause of arrhythmia-related hospitalizations. We assessed 30-day readmissions in patients admitted with AF in a national sample of US population. Data were extracted from Nationwide Readmissions Database for the calendar year 2013. Patients with primary discharge diagnosis of AF were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification, code 427.31. Patients who died during hospitalization and those <18 years were excluded. Our primary outcome was 30-day readmission rate. Causes and independent predictors of 30-day readmissions were examined. We identified 388,340 patients admitted with AF, of whom 58,634 patients (15.1%) were readmitted within 30 days. Patients who were readmitted tended to be older and have a higher burden of co-morbidities. AF and heart failure were the main causes of 30-day readmissions in our cohort. Advanced age, female gender, and multiple co-morbidities were independently associated with 30-day readmissions. In conclusion, 15% of patients admitted for AF were readmitted within 30 days. More than 1/3 of these readmissions were for AF or heart failure.

Patients with atrial fibrillation (AF) commonly have impaired renal function. The safety and efficacy of direct oral anticoagulants (DOACs) in patients with chronic kidney disease (CKD) and end-stage renal disease has not been fully elucidated. This study evaluated and compared the safety outcomes of DOACs versus warfarin in patients with nonvalvular AF and concomitant CKD. Patients in our health system with AF prescribed oral anticoagulants during 2010 to 2017 were identified. All-cause mortality, bleeding and hemorrhagic, and ischemic stroke were evaluated based on degree of renal impairment and method of anticoagulation. There were 21,733 patients with a CHA2DS2-VASc score of ≥2 included in this analysis. Compared with warfarin, DOAC use in patients with impaired renal function was associated with lower risk of mortality with a hazard ratio (HR): 0.76 (95% confidence interval [CI] 0.70 to 0.84, p value <0.001) in patients with eGFR >60, HR 0.74 (95% CI 0.68 to 0.81, p value <0.001) in patients with eGFR >30 to 60, and HR 0.76 (95% CI 0.63 to 0.92, p value <0.001) in patients with eGFR ≤30 or on dialysis. Bleeding requiring hospitalization was also less in the DOAC group with a HR 0.93 (95% CI 0.82 to 1.04, p value 0.209) in patients with eGFR >60, HR 0.83 (95% CI 0.74 to 0.94, p value 0.003) in patients with eGFR >30 to 60, and HR 0.69 (95% CI 0.50 to 0.93, p value 0.017) in patients with eGFR ≤30 or on dialysis. In conclusion, in comparison to warfarin, DOACs appear to be safe and effective with a lower risk of all-cause mortality and lower bleeding across all levels of CKD.

Cardiac resynchronization therapy (CRT) is an established therapy for heart failure and can be delivered through a CRT pacemaker (CRT-P) or a CRT defibrillator (CRT-D). CRT-P devices are smaller and less expensive, have better battery longevity, and have been subject to fewer recalls and advisories but cannot deliver high-energy shocks to terminate potentially lethal ventricular arrhythmias. As published guidelines do not distinguish between CRT-P and CRT-D indications, we examined the practice of prescribing these devices in older women and men with heart failure. A total of 512 CRT recipients (age ≥75 years, 26% women, 21% CRT-P) were included in this analysis. Baseline characteristics were collected on all patients, and overall survival was compared by gender and type of CRT device implanted. Women were more likely to receive CRT-Ps than men (26% vs 19%). Men with CRT-Ps were significantly older than women with CRT-Ps and both men and women with CRT-Ds (p = 0.04). In addition, women had lower all-cause mortality compared with men (hazard ratio [HR] 0.75, confidence interval [CI] 0.58 to 0.99, p = 0.04), mainly among CRT-P recipients (HR 0.48, CI 0.26 to 0.8, p = 0.02), but this association was attenuated after adjusting for differences in patient characteristics (HR 0.56, CI 0.26 to 1.18, p = 0.13). In conclusion, women are more likely to receive CRT-Ps than men. Whether this difference is driven by patient preference or physician biases remains unclear. Women with CRT, particularly CRT-Ps, have a better overall survival than men. These differences, which may be driven by unbalanced baseline characteristics of patients or by differences in gender response to CRT, deserve further investigation.

Background While receipt of surgery at regional referral centers is associated with improved perioperative outcomes, many vulnerable patients may experience barriers in accessing these hospitals. When these patients do manage to undergo surgery at referral centers, it remains unclear where they are readmitted to receive care when complications arise. Patients may be readmitted to the hospital where surgery was performed (index readmission) or to a different hospital (non‐index readmission). This study examined whether factors associated with readmission to index versus non‐index hospitals differ for patients undergoing surgery at referral centers compared to non‐referral centers. Methods We used data from the Pennsylvania Cancer Registry and the Pennsylvania Health Care Cost Containment Council (PHC4) to identify patients who had major cancer surgery and were subsequently readmitted within 90 days. We fit a multivariable logistic regression model to identify factors associated with 90 day readmission to an index versus non‐index hospital. We included an interaction term between referral center status and cancer type in this model. Results A total of 8215 patients were readmitted within 90 days of cancer surgery, of whom 78% (N = 6388) were readmitted to the index hospital. On multivariable analysis, factors associated with lower odds of index versus non‐index readmission included older age, high Elixhauser comorbidity scores, and longer travel times. There was no significant difference in odds of index readmission when patients were treated at referral versus non‐referral centers (OR = 0.77; 95% CI, 0.50–1.20). When assessing interactions, patients with lung cancer had lower odds of index readmission when treated at referral versus non‐referral centers, relative to other cancers (OR = 0.59; 95% CI, 0.41–0.84). Conclusions Higher clinical complexity and greater travel burdens were associated with lower odds of index readmission. Relative to other cancers, patients with lung cancer may be more likely to experience care fragmentation after undergoing surgery at a referral center. Older age, multiple comorbid conditions, and longer travel times were associated with lower odds of index readmissions. Referral center status yielded differing impacts by cancer type, with lung cancer patients experiencing lower odds of index readmission when treated at referral versus non‐referral centers.

Few studies have evaluated outcomes after percutaneous coronary intervention (PCI) in patients with both anemia (hemoglobin < 12 g/dl in women; <13 in men) and chronic kidney disease (CKD, estimated glomerular filtration rate < 60 ml/min/1.73 m2). Patients with coronary artery disease who underwent PCI in our health system from 2010 to 2018 were included (n = 10,756), excluding those with ST-elevation myocardial infarction or shock. We evaluated the individual and combined effects of anemia and CKD on outcomes. Five-year mortality was highest in the cohort with both anemia and CKD and lowest in those with neither. After multivariate analysis, with the group with neither anemia nor CKD as a reference, the adjusted hazard ratio for mortality was 1.68 (95% confidence interval [CI] 1.45 to 1.95, p <0.001) for those with anemia alone, 1.33 (95% CI 1.15 to 1.53, p <0.001) for those with CKD alone, and 2.83 (95% CI 2.49 to 3.22, p <0.001) for those with both anemia and CKD. With respect to readmission and reintervention, similar tends were observed, with patients with both CKD and anemia having the highest risk for these outcomes. In conclusion, the combined effects of anemia and CKD on outcomes post-PCI appear to be worse than either of their effects individually.

Patients with urologic diseases often experience financial toxicity, defined as high levels of financial burden and concern, after receiving care. The Price Transparency Final Rule, which requires hospitals to disclose both the commercial and cash prices for at least 300 services, was implemented to facilitate price shopping, decrease price dispersion, and lower health care costs. To evaluate compliance with the Price Transparency Final Rule and to quantify variations in the price of urologic procedures among academic hospitals and by insurance class. This was a cross-sectional study that determined the prices of 5 common urologic procedures among academic medical centers and by insurance class. Prices were obtained from the Turquoise Health Database on March 24, 2022. Academic hospitals were identified from the Association of American Medical Colleges website. The 5 most common urologic procedures were cystourethroscopy, prostate biopsy, laparoscopic radical prostatectomy, transurethral resection of the prostate, and ureteroscopy with laser lithotripsy. Using the corresponding Current Procedural Terminology codes, the Turquoise Health Database was queried to identify the cash price, Medicare price, Medicaid price, and commercial insurance price for these procedures. The Price Transparency Final Rule, which went into effect January 1, 2021. Variability in procedure price among academic medical centers and by insurance class (Medicare, Medicaid, commercial, and cash price). Of 153 hospitals, only 20 (13%) listed a commercial price for all 5 procedures. The commercial price was reported most often for cystourethroscopy (86 hospitals [56%]) and least often for laparoscopic radical prostatectomy (45 hospitals [29%]). The cash price was lower than the Medicare, Medicaid, and commercial price at 24 hospitals (16%). Prices varied substantially across hospitals for all 5 procedures. There were significant variations in the prices of cystoscopy (χ23 = 85.9; P = .001), prostate biopsy (χ23 = 64.6; P = .001), prostatectomy (χ23 = 24.4; P = .001), transurethral resection of the prostate (χ23 = 51.3; P = .001), and ureteroscopy with laser lithotripsy (χ23 = 63.0; P = .001) by insurance type. These findings suggest that, more than 1 year after the implementation of the Price Transparency Final Rule, there are still large variations in the prices of urologic procedures among academic hospitals and by insurance class. Currently, in certain situations, health care costs could be reduced if patients paid out of pocket. The Centers for Medicare & Medicaid Services may improve price transparency by better enforcing penalties for noncompliance, increasing penalties, and ensuring that hospitals report prices in a way that is easy for patients to access and understand.