Publications by authors named "Alexander C Fanaroff"

Article Synopsis
  • - We analyzed the revenues, costs, and contribution margins (CMs) for major cardiovascular procedures in Medicare patients from 2016 to 2019, focusing on how these factors differ across various procedures.
  • - Claim-level costs were determined using cost-to-charge ratios, and outliers were adjusted for accuracy, which helped us calculate the CMs as the difference between revenue and costs.
  • - Our findings showed significant variation in revenues, costs, and CMs for different cardiovascular procedures, with those procedures that are increasingly common generating substantial net CMs for hospitals in the US.
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Article Synopsis
  • Traditional analyses in clinical trials for antithrombotic agents evaluate bleeding and ischemic events separately, which have limitations; this study proposes using days alive and out of hospital (DAOH) as an alternative endpoint.
  • The AUGUSTUS trial involving 4614 patients compared two treatments (apixaban vs. warfarin and aspirin vs. placebo) and measured DAOH, finding no significant differences between treatment groups.
  • Despite apixaban showing lower rates of major bleeding and hospitalization, the study concludes that DAOH may not effectively capture the impact of antithrombotic therapies for patients with atrial fibrillation and acute coronary syndrome.
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Background: In the AUGUSTUS trial (An Open-Label, 2 x 2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban vs Vitamin K Antagonist and Aspirin vs Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), the combination of dual antiplatelet therapy plus oral anticoagulation increased the risk of bleeding without reducing ischemic events compared with a P2Y12 inhibitor plus oral anticoagulation among patients with atrial fibrillation and acute coronary syndrome or elective percutaneous coronary intervention. However, AUGUSTUS enrolled patients up to 14 days after acute coronary syndrome or percutaneous coronary intervention, and there may be a benefit to dual antiplatelet therapy plus oral anticoagulation early after an ischemic event.

Methods: In this secondary analysis of AUGUSTUS, we divided patients into groups based on whether they were enrolled <6 days (early) or ≥6 days (later) after their index acute coronary syndrome or percutaneous coronary intervention, and tested the interaction between time from the index event to enrollment and randomized treatment (apixaban versus vitamin K antagonist and aspirin versus placebo) on 30-day and 6-month clinical outcomes using Cox proportional hazards models.

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Background: The optimal antithrombotic regimen for patients with atrial fibrillation (AF) who had an acute coronary syndrome (ACS) or have undergone percutaneous coronary intervention (PCI) is not known.

Objectives: The authors sought to determine which antithrombotic regimen best balances safety and efficacy.

Methods: AUGUSTUS, a multicenter 2 × 2 factorial design randomized trial compared apixaban with vitamin K antagonist (VKA) and aspirin with placebo in patients with AF with recent ACS and/or PCI treated with a P2Y inhibitor.

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Background: In patients with or at risk for atherosclerotic vascular disease, statins reduce the incidence of major adverse cardiovascular events, but the majority of US adults with an indication for statin therapy are not prescribed statins at guideline-recommended intensity. Clinicians' limited time to address preventative care issues is cited as one factor contributing to gaps in statin prescribing. Centralized pharmacy services can fulfill a strategic role for population health management through outreach, education, and statin prescribing for patients at elevated ASCVD risk, but best practices for optimizing referrals of appropriate patients are unknown.

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Background: The extent and consequences of ischemia in patients with chronic limb-threatening ischemia (CLTI) may change rapidly, and delays from diagnosis to revascularization may worsen outcomes. We sought to describe the association between time from diagnosis to endovascular lower extremity revascularization (diagnosis-to-limb revascularization [D2L] time) and clinical outcomes in outpatients with CLTI.

Methods And Results: In the CLIPPER cohort, comprising patients between 66 and 86 years old diagnosed with CLTI betweeen 2010 and 2019, we used Medicare claims data to identify patients who underwent outpatient endovascular revascularization within 180 days of diagnosis.

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Background: Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline-recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally designed gamification, loss-framed financial incentives, or their combination on physical activity compared with attention control over 12-month intervention and 6-month postintervention follow-up periods.

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Antiplatelet therapy is the cornerstone of the secondary prevention of cardiovascular disease. Aspirin is indicated for all patients with chronic coronary disease to prevent recurrent ischemic events. A more potent antithrombotic therapy-including P2Y12 inhibitor monotherapy, dual antiplatelet therapy, or vascular dose anticoagulation-reduces the risk of ischemic events but also increases bleeding risk.

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Background: Supervised exercise therapy improves walking performance, functional capacity, and quality of life in patients with peripheral artery disease (PAD). However, few patients with PAD are enrolled in supervised exercise programs, and there are a number of logistical and financial barriers to their participation. A home-based walking intervention is likely to be more accessible to patients with PAD, but no fully home-based walking program has demonstrated efficacy.

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Article Synopsis
  • Inadequate representation of older patients, women, and racial and ethnic minorities in cardiovascular clinical trials hampers the applicability of findings and access to new treatments.
  • A study analyzed 139 clinical trials on valvular heart disease from 2005 to 2020 to assess the trends in the inclusion of these underrepresented groups.
  • Results showed that while the average age of participants slightly increased, the proportion of women remained steady at 41.1%, and racial/ethnic data was reported in only 9.4% of trials, with no significant changes in minority representation over time.
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Background: Racial residential segregation is associated with racial health inequities, but it is unclear if segregation may exacerbate Black-White disparities in cardiovascular disease (CVD) mortality. This study aimed to assess associations between Black-White residential segregation, CVD mortality rates among non-Hispanic (NH) Black and NH White populations, and Black-White disparities in CVD mortality.

Methods: This cross-sectional study analyzed Black-White residential segregation, as measured by county-level interaction index, of US counties, county-level CVD mortality among NH White and NH black adults aged 25 years and older, and county-level Black-White disparities in CVD mortality in years 2014 to 2017.

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  • The study analyzed the use of medical devices and outcomes related to lower extremity peripheral arterial interventions for different racial groups using data from the American College of Cardiology National Cardiovascular Data Registry from 2014 to 2019.
  • It found that while Black patients had higher rates of specific health conditions and socio-economic challenges, they received drug-eluting technologies more often than White patients, but there were no significant differences in the use of atherectomy or intravascular imaging.
  • Interestingly, Black patients were less likely to undergo surgical or repeat procedures after 1 year, although there were no differences in mortality or major amputations between the groups.
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Background: Chronic limb-threatening ischemia (CLTI) is a common condition with high rates of morbidity and mortality. Despite extensive literature documenting poor outcomes in patients with CLTI, as well as racial, ethnic, socioeconomic, and geographic disparities in these outcomes, process measures for high-quality CLTI care have not been developed. We developed the Chronic Limb threatening Ischemia Process PERformace (CLIPPER) cohort to develop and test the validity of CLTI care quality measures.

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Background: Higher levels of physical activity are associated with improvements in cardiovascular health, and consensus guidelines recommend that individuals with or at risk for atherosclerotic cardiovascular disease (ASCVD) participate in regular physical activity. However, most adults do not achieve recommended levels of physical activity. Concepts from behavioral economics have been used to design scalable interventions that increase physical activity over short time periods, but the longer-term efficacy of these strategies is uncertain.

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Background Inequitable access to high-technology therapeutics may perpetuate inequities in care. We examined the characteristics of US hospitals that did and did not establish left atrial appendage occlusion (LAAO) programs, the patient populations those hospitals served, and the associations between zip code-level racial, ethnic, and socioeconomic composition and rates of LAAO among Medicare beneficiaries living within large metropolitan areas with LAAO programs. Methods and Results We conducted cross-sectional analyses of Medicare fee-for-service claims for beneficiaries aged 66 years or older between 2016 and 2019.

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Background: Obesity is strongly associated with cardiovascular disease, particularly through its effects on blood pressure. Though maintaining a negative caloric balance leads to weight loss, many patients struggle to adhere to low calorie diets over the long term. Time-restricted eating, a subtype of intermittent fasting (IF), may be an easier dietary pattern for patients to initiate and maintain.

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Article Synopsis
  • Racial and ethnic minorities, along with socioeconomically disadvantaged patients, are often underrepresented in clinical trials, prompting a need for better inclusivity efforts.
  • The study aimed to examine differences in the racial, ethnic, and socioeconomic demographics of patients at US hospitals participating in clinical trials for new transcatheter therapies versus those that did not.
  • Findings revealed that hospitals involved in trials had patients with higher average household incomes and lower levels of community distress, indicating disparities in access to clinical trial participation.
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