Deaths of participants and losses to follow-up pose challenges for defining outcomes in epidemiologic studies. The authors compared several definitions of incident chronic kidney disease (CKD) in terms of incidence, agreement, and risk factor associations. They used data from 14,873 participants in the community-based, multicenter, biracial Atherosclerosis Risk in Communities Study (1987-1999). The estimated glomerular filtration rate (eGFR) was based on serum creatinine at baseline and the 3- and 9-year follow-up visits. Hospitalizations were ascertained continuously. The authors compared 4 definitions of incident CKD: 1) low eGFR (<60 mL/minute/1.73 m(2)); 2) low and declining (> or =25%) eGFR; 3) an increase in serum creatinine (> or =0.4 mg/dL) at 3- or 9-year follow-ups; and 4) CKD-related hospitalization or death. From these definitions, they identified 1,086, 677, 457, and 163 cases, respectively. There was relatively good agreement among definitions 1-3, but definition 4 identified mostly different cases. Risk factor associations were consistent across definitions for hypertension and lipids. Diabetes showed weaker associations with definition 1 (incidence rate ratio = 1.5, 95% confidence interval: 1.2, 1.7) than with definition 4 (incidence rate ratio = 6.3, confidence interval: 4.4, 8.9). Associations with gender differed in direction and magnitude across definitions. Case definition can impact relative risk estimates for CKD risk factors.
The management of neuromuscular blockade (NMB) has evolved over time and remains a critical component of general anesthesia. However, NMB use varies by patient and procedural characteristics, clinical practices, protocols, and drug access. National utilization patterns are unknown. We describe changes in NMB and NMB reversal agent administration in surgical inpatients since the US introduction of sugammadex in December 2015. In a retrospective observational study of inpatients involving NMB with rocuronium or vecuronium in the Premier Healthcare Database, we estimate associations between factors related to choice of (1) active NMB reversal versus spontaneous recovery and (2) sugammadex versus neostigmine as the reversal agent. Among 4.3 million adult inpatient encounters involving rocuronium or vecuronium, the most widely administered NMB agent was rocuronium alone (86%). Over time, gradual declines in both neostigmine use and spontaneous reversal were observed (64% and 36% in 2014 to 38% and 28%, respectively in the first half of 2019). Several factors were independently associated with use of active versus spontaneous NMB recovery including years since 2016, patient (age, race, comorbidities), and procedure (admission and surgery type) characteristics. Among those actively reversed, these and other factors were independently associated with choice of reversal agent administered, including size and teaching affiliation of hospital. While both impacted choices in treatment, the direction and magnitude of effect of patient comorbidities and procedure type varied in their impact on choice of mode (pharmacologic vs. spontaneous) and agent (neostigmine vs. sugammadex) of NMB reversal independent of other factors and each other. Sites which adopted sugammadex earlier were more likely to choose sugammadex over neostigmine compared with later adopters independent of other factors. Among US adult inpatients administered NMBs, we observed complex relationships between patient, site, procedural characteristics, and NMB management choices as NMBA choice and active reversal options among inpatient cases changed over time. Neuromuscular blocking agents, medications that temporarily paralyze muscles, are used frequently during surgical procedures to facilitate intubation and patient immobility. Over time, muscle function can return spontaneously or through pharmacological reversal agents. This study looked at how the use of reversal agents in inpatients undergoing surgical procedures changed after a new reversal agent, sugammadex, became available for use in the USA in December 2015. Medical records of 4.3 million adult patients treated with neuromuscular blocking agents (rocuronium or vecuronium) in the USA were studied. In 2014 (before sugammadex was available), one-third of patients (36%) recovered spontaneously from a neuromuscular blocking agent and two-thirds (64%) were treated with the reversal agent neostigmine. The use of both neostigmine and spontaneous recovery reduced gradually after sugammadex became available, so that by the first half of 2019, 38% of patients were treated with neostigmine and 28% of patients recovered spontaneously. Whether or not a patient was treated with a reversal agent and what type of agent was chosen were affected by the length of time since 2016, patient characteristics, the type of surgical procedure that was performed as well as local hospital characteristics and practice differences.
Abstract Background Despite evidence that guideline-directed medical therapy (GDMT) improves outcomes in heart failure with reduced ejection fraction (HFrEF), many eligible patients remain untreated in the United States (US). Purpose To explore reasons why patients are not receiving GDMT and physician perceptions in management of their patients. Methods We conducted a cross-sectional survey of HF treatment practices (Adelphi Real World Heart Failure Disease Specific Programme) between August 2022 and February 2023, following publication of the 2022 US HF guidelines recommended that patients with HFrEF receive: angiotensin receptor/neprilysin inhibitors (ARNI), beta-blocker, mineralocorticoid receptor antagonists (MRA), and SGLT-2 inhibitors (SGLT2i). A total of 63 cardiologists and 39 primary care physicians in the US provided clinical and treatment patterns data on adult patients with HFrEF (ejection fraction ≤ 40%) and completed an attitudinal survey detailing reasons for treatment initiation. Results The study group included 323 patients with HFrEF (median age of 67 years [IQR 56-74]; 39% females) of which 59.4% were White, 19.8% African American and 9.6% Hispanic; half of the sample was insured by Medicare (50.2%), followed by commercial insurance (36.5%). GDMT prescription rates are presented in Table 1. Overall, 57.3% were not prescribed ARNI (185/323), 16.4% (53/323) were not prescribed a beta-blocker; 71.5% (231/323) were not prescribed MRA, and 65.3% (211/323) were not prescribed SGLT2i. Among patients not receiving GDMT, the most frequently reported physician reason for not prescribing ARNIs (54.1%), beta-blockers (43.4%), MRAs (54.5%) or SGLT-2is (53.6%) was physician deemed the patient to be clinically stable (Table 2). Most physicians (93.5%) reported being satisfied with treatment for patients with HFrEF and most (80.3%) believed that their patients with HFrEF were fully compliant with their treatments. Most physicians (91.2%) stated that they based their treatment decisions on both clinical experience and laboratory tests, as opposed to laboratory tests/imaging only (9.8%) or personal judgement only (16.7%). Conclusions In this cohort of patients with HFrEF from the US, the most common primary reason physicians reported for their patients not receiving GDMT was that the patient was clinically stable. Patient medication costs, contraindications, and proven intolerance were each reported as primary reasons for non-treatment in only a small minority of cases. These data suggest a strong culture of clinical inertia and lack of therapeutic urgency as the dominant driver of large gaps in use of GDMT in the US.GDMT prescriptions in HFrEF (n = 323)Physician-reasons for no GDMT
Five percent of adult patients undergoing noncardiac inpatient surgery experience a major pulmonary complication. The authors hypothesized that the choice of neuromuscular blockade reversal (neostigmine vs. sugammadex) may be associated with a lower incidence of major pulmonary complications.
Dyslipidemia, including low levels of high-density lipoprotein cholesterol (HDL-C), is a relatively well-established risk factor for cardiovascular disease. However, the independent association between changes in HDL-C and the subsequent risk of cardiovascular events has not been well studied. The retrospective cohort analysis was conducted to evaluate the association between changes in HDL-C and cardiovascular (CV) and/or cerebrovascular (CB) events among statin-treated patients. Patient demo-graphics, clinical characteristics, laboratory data, and CV/CB events, were collected from the UK General Practice Research Database. The association between the risk of an incident event and changes in patients’ HDL-C was estimated using multivariate Cox pro-portional hazards models. Among 17,923 statin-treated patients with an average follow-up of 1.9 years, there were 815 CV events and 220 CB events. The average change in HDL-C experienced was 0.4 mg/dL, ranging from 11 mg/dL average decrease in the lowest change quartile to 12 mg/dL average increase in the highest change quartile. CV events occurred at an average overall rate of 21 per 1000 person-years and 17 per 1000 person-years among individuals in the highest quartile of change in HDL-C levels. Fully adjusted Cox regression estimated a 6% decrease in hazards (HR, 0.94; 95% CI, 0.90, 0.98) of a subsequent CV event associated with each 5 mg/dL increase in HDL-C. Similar results (HR: 0.95, 95% CI, 0.92, 0.98) were observed when assessing the association with changes in HDL-C and the composite outcome of CV/CB event. Among statin-treated patients from UK clinical practices, increases in HDL-C were associated with a significantly decreased relative risk of experiencing CV/CB events with a more pronounced effect on CV events. Therefore, a more aggressive treatment to increase HDL-C could benefit patients by reducing the risk of CV/CB events.
BACKGROUND: Neuromuscular blockade (NMB) is a critical part of many surgical procedures. Data on practice patterns of NMB agents (NMBAs) and NMB reversal in recent years in the US ambulatory surgical care setting are limited. METHODS: This retrospective analysis of US adult outpatients was conducted using the Premier Healthcare Database. We describe anesthesia practice trends in NMB management and assess the association of patient, procedural, and site characteristics with NMB reversal approach using multivariable logistic regression. RESULTS: Approximately 5.2 million outpatient surgical encounters involving NMB and 4.6 million involving rocuronium or vecuronium between January 2014 and June 2019 were included. Following the introduction of sugammadex to US clinical practice (~2016), there was an increased use of rocuronium or vecuronium and a decrease in succinylcholine alone. Before 2016, NMB was pharmacologically reversed with neostigmine in approximately two-thirds of outpatient encounters. Over time, active reversal increased; by 2019, 42.3% and 36.0% of encounters were reversed by neostigmine and sugammadex, respectively, with 21.7% undergoing spontaneous recovery. Choice of NMBA (rocuronium or vecuronium alone), time since 2016, obesity, peripheral vascular disease, and procedures on the digestive, ocular, and female genital systems (vs musculoskeletal procedures) were independently and positively associated with pharmacologic reversal (versus spontaneous reversal). Conversely, advanced age; Western geography; and cardiovascular, endocrine, hemic/lymphatic, respiratory, and ear, nose, and throat procedures were independently and negatively associated with pharmacologic reversal of NMB. Among pharmacologic reversals, time since 2016 was positively and independently associated with sugammadex compared with neostigmine (odds ratios [ORs], ranged from 1.8 in 2017 to 3.2, P < .0001 in 2019). Those administered rocuronium or vecuronium without succinylcholine, with increased age and history of certain comorbidities, and those undergoing ocular or respiratory procedures (compared with musculoskeletal) were positively associated with reversal with sugammadex and endocrine procedure negatively and independently associated with reversal with sugammadex. There was variability in the association of several factors with NMB reversal choices by geographic region, particularly in patients’ race, ethnicity, and size of affiliated hospital. CONCLUSIONS: Overall, active pharmacological reversal of NMB increased in US adult outpatients following the introduction of sugammadex, although there remains significant practice variability. The multifactorial relationship between patient-, procedural-, and environmental-level characteristics and NMB management is rapidly evolving. Additional research on how these anesthesia practice patterns may be impacted by the shift to the ambulatory care setting and how they may impact patient outcomes and health disparities is warranted.
