David J Magid

University of Colorado, Denver, Colorado, United States

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Publications (218)1395.97 Total impact

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    ABSTRACT: We aimed to characterize the use of cardiovascular testing for patients with incident heart failure (HF) hospitalization who participated in the National Heart, Lung, and Blood Institute sponsored Cardiovascular Research Network (CVRN) Heart Failure study.
    JACC. Cardiovascular imaging. 06/2014;
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    ABSTRACT: The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42–0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.
    Journal of Clinical Hypertension 04/2014; · 2.36 Impact Factor
  • David J Magid, Steven A Farmer
    Circulation Cardiovascular Quality and Outcomes 03/2014; · 5.66 Impact Factor
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    ABSTRACT: Newer approaches for classifying gradations of pediatric obesity by level of body mass index (BMI) percentage above the 95th percentile have recently been recommended in the management and tracking of obese children. Examining the prevalence and persistence of severe obesity using such methods along with the associations with other cardiovascular risk factors such as hypertension is important for characterizing the clinical significance of severe obesity classification methods. This retrospective study was conducted in an integrated healthcare delivery system to characterize obesity and obesity severity in children and adolescents by level of body mass index (BMI) percentage above the 95th BMI percentile, to examine tracking of obesity status over 2-3 years, and to examine associations with blood pressure. Moderate obesity was defined by BMI 100-119 % of the 95th percentile and severe obesity by BMI >=120 % x 95th percentile. Hypertension was defined by 3 consecutive blood pressures >=95th percentile (for age, sex and height) on separate days and was examined in association with obesity severity. Among 117,618 children aged 6-17 years with measured blood pressure and BMI at a well-child visit during 2007-2010, the prevalence of obesity was 17.9 % overall and was highest among Hispanics (28.9 %) and blacks (20.5 %) for boys, and blacks (23.2 %) and Hispanics (21.5 %) for girls. Severe obesity prevalence was 5.6 % overall and was highest in 12-17 year old Hispanic boys (10.6 %) and black girls (9.5 %). Subsequent BMI obtained 2-3 years later also demonstrated strong tracking of severe obesity. Stratification of BMI by percentage above the 95th BMI percentile was associated with a graded increase in the risk of hypertension, with severe obesity contributing to a 2.8-fold greater odds of hypertension compared to moderate obesity. Severe obesity was found in 5.6 % of this community-based pediatric population, varied by gender and race/ethnicity (highest among Hispanics and blacks) and showed strong evidence for persistence over several years. Increasing gradation of obesity was associated with higher risk for hypertension, with a nearly three-fold increased risk when comparing severe to moderate obesity, underscoring the heightened health risk associated with severe obesity in children and adolescents.
    International Journal of Pediatric Endocrinology 03/2014; 2014(1):3.
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    ABSTRACT: PurposeAssessing the safety and effectiveness of medical products with observational electronic medical record data is challenging when the treatment is time-varying. The objective of this paper is to develop a Cox model stratified by event times with stabilized weights (SWs) adjustment to examine the effect of time-varying treatment in observational studies. Methods Time-varying SWs are calculated at unique event times and are used in a Cox model stratified by event times to estimate the effect of time-varying treatment. We applied this method in examining the effect of an antiplatelet agent, clopidogrel, on events, including bleeding, myocardial infarction, and death after a drug-eluting stent was implanted in coronary artery. Clopidogrel use may change over time on the basis of patients' behavior (e.g., non-adherence) and physicians' recommendations (e.g., end of duration of therapy). We also compared the results with those from a Cox model for counting processes adjusting for all covariates used in creating SWs. ResultsWe demonstrate that the (i) results from the stratified Cox model without SWs adjustment and the Cox model for counting processes without covariate adjustment are identical in analyzing the clopidogrel data; and (ii) the effects of clopidogrel on bleeding, myocardial infarction, and death are larger in the stratified Cox model with SWs adjustment compared with those from the Cox model for counting processes with covariate adjustment. Conclusions The Cox model stratified by event times with time-varying SWs adjustment is useful in estimating the effect of time-varying treatments in observational studies while balancing for known confounders. Copyright © 2014 John Wiley & Sons, Ltd.
    Pharmacoepidemiology and Drug Safety 03/2014; · 2.90 Impact Factor
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    ABSTRACT: Few studies have directly investigated the association of clinicians' implicit (unconscious) bias with health care disparities in clinical settings. To determine if clinicians' implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians' black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians' implicit biases and ethnic or racial differences in hypertension care and outcomes. Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients (P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. Implicit bias did not affect clinicians' provision of care to their minority patients, nor did it affect the patients' outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.
    Journal of General Internal Medicine 02/2014; · 3.28 Impact Factor
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    ABSTRACT: Background Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients, but have not been well described in patients transferred for primary percutaneous coronary intervention (PCI). Methods We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry®-Get With The Guidelines™ hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess. Results Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies prior to catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes) and glycoprotein IIb/IIIa inhibitor (GPI; 107 vs. 60 minutes, p<0.0001 for both). Administration of low molecular weight heparin (LMWH) and GPI at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, while early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (unfractionated heparin: adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.04–1.58, LMWH: OR 1.54, 95% CI 1.09–2.18) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03–1.17). Conclusions STEMI patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.
    American Heart Journal. 01/2014;
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    ABSTRACT: -Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction (HFREF), but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown. -Using electronic data from 3 health systems 2005-2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for HFREF who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years and 37.1% were female. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Pre-initiation K was >5.0 mmol/L in 1.4% and Cr >2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of post-initiation K testing (c-statistic 0.67). -While laboratory monitoring prior to MRA initiation for HFREF is common, laboratory monitoring following MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.
    Circulation Heart Failure 11/2013; · 6.68 Impact Factor
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    ABSTRACT: Background-Patients with heart failure (HF) are typically designated as having reduced or preserved ejection fraction (HFREF, HFPEF) because of the importance of left ventricular ejection fraction (LVEF) on therapeutic decisions and prognosis. Such designations are not necessarily static, yet few data exist to describe the natural history of LVEF over 0;time.Methods and Results-We identified 2413 patients from Kaiser Permanente Colorado with a primary discharge diagnosis of HF between January 1, 2001, and December 31, 2008, who had ≥2 LVEF measurements separated by ≥30 days. We used multi-state Markov modeling to examine transitions among HFREF, HFPEF, and death. We observed a total of 8183 transitions. Women were more likely than men to transition from HFREF to HFPEF (hazard ratio, 1.85; 95% confidence interval, 1.38-2.47). Patients who were adherent to β-blockers were more likely to transition from HFREF to HFPEF (hazard ratio, 1.53; 95% confidence interval, 1.10-2.13) compared with patients who were nonadherent to β-blockers, whereas angiotensin-converting enzyme or angiotensin II receptor blocker adherence was not associated with LVEF transitions. Patients who had a previous myocardial infarction were more likely to transition from HFPEF to HFREF (hazard ratio, 1.75; 95% confidence interval, 1.26-2.42).Conclusions-In this cohort of patients with HF, LVEF is a dynamic factor related to sex, coexisting conditions, and drug therapy. These findings have implications for left ventricular systolic function ascertainment in patients with HF and support evidence-based therapy use, especially β-blockers.
    Circulation Cardiovascular Quality and Outcomes 10/2013; · 5.66 Impact Factor
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    ABSTRACT: Background/Aims We posit that as rates of hypertension (HT) control improve nationally, recidivism from controlled to uncontrolled HT will emerge as a major obstacle to ongoing improvement in overall population rates of HT control. To probe this hypothesis, we examined rates and predictors of HT recidivism in adults with baseline adequate HT control who are receiving care at medical groups that have overall high rates of HT control. Methods Study subjects were adults with controlled hypertension at baseline based on two consecutive visits with normal BP readings (<140/90 mmHg or <130/80 mmHg for those with diabetes) at Medical Group A (MG-A; N = 12,766) and Medical Group B (MG-B; N = 9,768). We classified HT recidivism after follow-up for 4-16 months after the initial BP measures using the mean of the last two BP readings for each patient. Results At baseline, the proportion of adults with HT who were at BP goals was 55% at MG-A, and 66% at MG-B. HT recidivism occurred in 19% of subjects with baseline controlled HT (based on two consecutive baseline visits) at MG-A and 13% of subjects at MG-B. At MG-A, men (P = .008) and those with higher BMI (P <.001) were more likely to have HT recidivism. At MG-B, those who were younger (P <.001) and with higher BMI (P <.001) were more likely to have BP recidivism. At both MGs, DBP was more likely to rise to uncontrolled levels in those age 50 or under compared to older age groups, while SBP was more likely to rise to uncontrolled levels in those age 65 or older compared to younger age groups. Conclusions HT recidivism occurred in 13% to 19% of patients with previously controlled HT over a mean of 14 months of follow-up time. In medical groups with relatively high levels of baseline HT control, HT recidivism represents a brake on efforts to improve overall BP control. Effective strategies to minimize HT recidivism have great potential to improve overall levels of HT control on a population basis, and could improve HT-related quality measures at the medical group and individual provider level.
    Clinical Medicine &amp Research 09/2013; 11(3):139-140.
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    ABSTRACT: Background/Aims Overweight and obesity among US children and adolescents is an important public health problem. Conditions associated with obesity, such as type 2 diabetes, hypertension, and hypercholesterolemia, are becoming more common in children. This study examined the relationship between changes in BMI percentile and incident prehypertension and hypertension in a cohort of children and adolescents. Methods Study subjects were 23,578 patients, ages 3-17, with three or more outpatient primary care visits between 2007 and 2010 at HealthPartners Medical Group, Kaiser Permanente Colorado, or Kaiser Permanente Northern California. Data were extracted from electronic health records (EHR). Change in BMI was defined as: increase, decrease, stayed obese, stayed overweight, and stayed healthy weight using established BMI percentile cut-points. Incident prehypertension and hypertension were defined using blood pressures and diagnosis codes from the EHR. We used time-dependent Cox proportional hazards models to estimate the hazard of change in BMI percentile with incident prehypertension and hypertension. Results Over a median 2.6 years follow-up, there were 7,232 cases of incident prehypertension, 148 diagnoses of incident hypertension, and 107 additional cases of incident hypertension based on blood pressure data from the EHR. Seventy-one prehypertensives went on to develop hypertension. Those who stayed obese, stayed overweight, and increased BMI had increased hazard of incident prehypertension (1.96, 1.39, and 1.49, respectively) and increased hazard of incident hypertension (3.61, 1.21, and 1.83, respectively) compared with those who stayed healthy weight. Conclusions Persistently high BMI or increasing BMI over time was associated with pronounced increase in risk of both incident prehypertension and hypertension. Future research should examine factors associated with the development and recognition of hypertension.
    Clinical Medicine &amp Research 09/2013; 11(3):139.
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    ABSTRACT: Background/Aims The aim of the study was to ascertain frequency of glucose screening in children and adolescents, in predefined age, gender, BMI, and race strata. Methods Study subjects included 68,322 individuals age 3-17 years at cohort entry and followed for a median of 37 months. Subjects had at least one office visit at HealthPartners Medical Group (HPMG). Subjects had their laboratory data examined for date and results of any fasting or random glucose, glycated hemoglobin (A1c), or oral glucose tolerance tests done in an outpatient setting. We report descriptive statistics on rate of glucose testing and rate of tests indicating pre-diabetes by age, gender, BMI, race/ethnicity group, and calendar year. Results Overall rate of glucose screening was 10.7% (7278/68322). Rates increased in recent years compared to earlier years, were similar in males and females, and were greater in older subjects, those with obesity, and those of minority race or Hispanic ethnicity. The test rate was 4.4% (1145/26245) per year in 2007 compared to 19.7% (1687/8563) in 2010. Glucose screening was most often done with fasting or random glucose, but 7.7% (560/7278) of tests were glycated hemoglobin (A1c). About 13.9% (1013/7278) of tests showed results indicating pre-diabetes. Of the 1013 with a test result indicating pre-diabetes, 79.1% (801/1013) were age 12 and older, 60% (608/1013) were of minority race or Hispanic ethnicity, and 30.9% (313/1013) were obese. Diabetes diagnosis (250.xx) was present in 2.2% (161/7278) of the subjects with one or more glucose/A1c tests. Conclusions Rates of glucose testing are highest in demographic subgroups with the highest risk, and have increased markedly in recent years. As the rate of screening increases further, it is likely that the proportion that screen positive for pre-diabetes or diabetes will decline. A substantial number of adolescents have recently been identified as having pre-diabetes, and further work is needed to characterize care subsequently provided to these subjects, and to characterize other CV risk factors.
    Clinical Medicine &amp Research 09/2013; 11(3):145.
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    ABSTRACT: Background/Aims The National High Blood Pressure Education Program (NHBPEP) guidelines define hypertension (HT) in children and adolescents as blood pressure (BP) measures above the 95th percentile on three consecutive clinic visits. In contrast, the Expert Panel of Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents (Expert Panel) clinical practice guidelines define HT as the average of three consecutive BP measures above the 95th percentile. Here we quantify the impact of these two different case definitions of HT on occurrence of HT in a defined population of children and adolescents. Methods Study subjects were a cohort of 117,329 pediatric primary care patients, drawn from three large, geographically dispersed health systems. Subjects were 3-17 years old at entry between January 1, 2007 and December 31, 2010. Subjects having an elevated initial BP were not excluded, nor were subjects having BP diagnosis codes at baseline or follow-up. We estimated the period prevalence rate of HT using NHBPEP and Expert Panel definitions, applying a rolling window to the longitudinal BP measurements to consider each successive block of three BP measures. Analyses were performed separately for children (3-11 years) and adolescents (12-17 years). Data were analyzed by Poisson regression to estimate annual rates of HT. Results Subjects were followed for an average of 2.1 years. HT defined by elevated BP ≥95th percentile on 3 consecutive clinic visits occurred at a rate of 0.25%/year in children, and 0.42%/year in adolescents. HT defined as the average BP ≥95th percentile from 3 successive clinic visits occurred at higher rates; 0.49%/year in children (P ≤0.00005) and 0.75%/year in adolescents (P ≤0.00005). For subjects with HT defined by elevated BP ≥95th percentile on 3 consecutive clinic visits, the average time between elevated measurements was 19 weeks (s.d. 25 weeks). Conclusions HT rates in children and adolescents were twice as high when using an average of 3 consecutive measures (Expert Panel method) as when using 3 consecutive hypertensive levels (NHBPEP definition). The impact of these differences in HT rates on downstream risk of persistent HT and CV events later in life requires further investigation.
    Clinical Medicine &amp Research 09/2013; 11(3):137.
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    ABSTRACT: IMPORTANCE Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures. OBJECTIVE To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states. MAIN OUTCOMES AND MEASURES Rates of coronary angiography, PCI, and CABG surgery. RESULTS We evaluated a total of 878 339 Medicare Advantage patients and 5 013 650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates. CONCLUSIONS AND RELEVANCE Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.
    JAMA The Journal of the American Medical Association 07/2013; 310(2):155-62. · 29.98 Impact Factor
  • David J Magid, Beverly B Green
    JAMA The Journal of the American Medical Association 07/2013; 310(1):40-41. · 29.98 Impact Factor
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    ABSTRACT: BACKGROUND AND OBJECTIVE:Screening for hypertension in children occurs during routine care. When blood pressure (BP) is elevated in the hypertensive range, a repeat measurement within 1 to 2 weeks is recommended. The objective was to assess patterns of care after an incident elevated BP, including timing of repeat BP measurement and likelihood of persistently elevated BP.METHODS:This retrospective study was conducted in 3 health care organizations. All children aged 3 through 17 years with an incident elevated BP at an outpatient visit during 2007 through 2010 were identified. Within this group, we assessed the proportion who had a repeat BP measured within 1 month of their incident elevated BP and the proportion who subsequently met the definition of hypertension. Multivariate analyses were used to identify factors associated with follow-up BP within 1 month of initial elevated BP.RESULTS:Among 72 625 children and adolescents in the population, 6108 (8.4%) had an incident elevated BP during the study period. Among 6108 with an incident elevated BP, 20.9% had a repeat BP measured within 1 month. In multivariate analyses, having a follow-up BP within 1 month was not significantly more likely among individuals with obesity or stage 2 systolic elevation. Among 6108 individuals with an incident elevated BP, 84 (1.4%) had a second and third consecutive elevated BP within 12 months.CONCLUSIONS:Whereas >8% of children and adolescents had an incident elevated BP, the great majority of BPs were not repeated within 1 month. However, relatively few individuals subsequently met the definition of hypertension.
    PEDIATRICS 07/2013; · 4.47 Impact Factor
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    ABSTRACT: BACKGROUND: -Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown. METHODS AND RESULTS: -We identified all members with HF between 2005 and 2008 from 4 integrated health care systems in the Cardiovascular Research Network. LVEF was categorized as preserved (LVEF ≥50% or normal), borderline (41-49% or mildly reduced), and reduced (≤40% or moderately to severely reduced). We used Cox regression models to identify independent predictors of death and hospitalization by LVEF category. Among 30,094 ambulatory adults with HF, mean age was 74 years and 46% were women. LVEF was preserved in 49.5%, borderline in 16.2%, and reduced in 34.3% of patients. Over a median follow up of 1.8 years (IQR 0.8-3.1), 8,060 (26.8%) patients died, 8,108 (26.9%) were hospitalized for HF, and 20,272 (67.4%) were hospitalized for any reason. In multivariable models, nearly all tested covariates performed similarly across LVEF strata for the outcome of death from any cause, as well as for HF-related and all-cause hospitalizations. CONCLUSIONS: -We found that in a large, diverse contemporary HF population, risk assessment was strikingly similar across all LVEF categories. These data suggest that, although many HF therapies are uniquely applied to patients with reduced LVEF, individual prognostic factor performance does not appear to be significantly related to level of left ventricular systolic function.
    Circulation Heart Failure 05/2013; · 6.68 Impact Factor
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    ABSTRACT: Background-There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction (HF-PEF).Methods and Results-We identified a community-based cohort of patients with HF. Electronic medical record data were used to divide into HF-PEF and reduced left ventricular EF on the basis of quantitative and qualitative estimates. Level of CKD was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all-cause). Multivariable Cox regression estimated the adjusted relative-risk of outcomes by level of CKD, separately for HF-PEF and HF with reduced left ventricular EF. We identified 14 579 patients with HF-PEF and 9762 with HF with reduced left ventricular EF. When compared with patients with eGFR between 60 and 89 mL/min per 1.73 m(2), lower eGFR was associated with an independent graded increased risk of death and hospitalization. For example, among patients with HF-PEF, the risk of death was nearly double for eGFR 15 to 29 mL/min per 1.73 m(2) and 7× higher for eGFR<15 mL/min per 1.73 m(2), with similar findings in those with HF with reduced left ventricular EF.Conclusions-CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective interventions for the growing number of patients with HF complicated by CKD.
    Circulation Cardiovascular Quality and Outcomes 05/2013; · 5.66 Impact Factor
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    ABSTRACT: Randomized trials of implantable cardioverter-defibrillators (ICDs) for primary prevention predominantly used single-chamber devices. In clinical practice, patients often receive dual-chamber ICDs, even without clear indications for pacing. The outcomes of dual- vs single-chamber devices are uncertain. To compare outcomes of single- and dual-chamber ICDs for primary prevention of sudden cardiac death. Retrospective cohort study of admissions in the National Cardiovascular Data Registry's (NCDR) ICD registry from 2006-2009 that could be linked to Centers for Medicare & Medicaid Services fee-for-service Medicare claims data. Patients were included if they received an ICD for primary prevention and did not have a documented indication for pacing. MAIN OUTCOMES AND MEASURES: Adjusted risks of 1-year mortality, all-cause readmission, heart failure readmission, and device-related complications within 90 days were estimated with propensity-score matching based on patient, clinician, and hospital factors. Among 32,034 patients, 12,246 (38%) received a single-chamber device and 19,788 (62%) received a dual-chamber device. In a propensity-matched cohort, rates of complications were lower for single-chamber devices (3.51% vs 4.72%; P < .001; risk difference, -1.20 [95% CI, -1.72 to -0.69]), but device type was not significantly associated with 1-year mortality (unadjusted rate, 9.85% vs 9.77%; hazard ratio [HR], 0.99 [95% CI, 0.91 to 1.07]; P = .79), 1-year all-cause hospitalization (unadjusted rate, 43.86% vs 44.83%; HR, 1.00 [95% CI, 0.97-1.04]; P = .82), or hospitalization for heart failure (unadjusted rate, 14.73% vs 15.38%; HR, 1.05 [95% CI, 0.99-1.12]; P = .19). Among patients receiving an ICD for primary prevention without indications for pacing, the use of a dual-chamber device compared with a single-chamber device was associated with a higher risk of device-related complications and similar 1-year mortality and hospitalization outcomes. Reasons for preferentially using dual-chamber ICDs in this setting remains unclear.
    JAMA The Journal of the American Medical Association 05/2013; 309(19):2025-34. · 29.98 Impact Factor
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    ABSTRACT: WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: The prevalence of obesity in the United States has increased dramatically over the past three decades. There is a growing spectrum of severe obesity among children and adolescents. Obesity trends and race/ethnic differences may be evident at a young age. WHAT THIS STUDY ADDS: Among children aged 3-5 years, the prevalence of obesity and severe obesity was higher in boys than in girls, and highest among children of Hispanic ethnicity. Within this young age group, higher body mass index (BMI) was associated with greater height percentile. Among obese children aged 5 years, provider recognition of obesity or elevated BMI was high, approaching 80% of children. BACKGROUND: Early childhood adiposity may have significant later health effects. This study examines the prevalence and recognition of obesity and severe obesity among preschool-aged children. METHODS: The electronic medical record was used to examine body mass index (BMI), height, sex and race/ethnicity in 42 559 children aged 3-5 years between 2007 and 2010. Normal or underweight (BMI < 85th percentile); overweight (BMI 85th-94th percentile); obesity (BMI ≥ 95th percentile); and severe obesity (BMI ≥ 1.2 × 95th percentile) were classified using the 2000 Centers for Disease Control and Prevention growth charts. Provider recognition of elevated BMI was examined for obese children aged 5 years. RESULTS: Among 42 559 children, 12.4% of boys and 10.0% of girls had BMI ≥ 95th percentile. The prevalence was highest among Hispanics (18.2% boys, 15.2% girls), followed by blacks (12.4% boys, 12.7% girls). A positive trend existed between increasing BMI category and median height percentile, with obesity rates highest in the highest height quintile. The prevalence of severe obesity was 1.6% overall and somewhat higher for boys compared with girls (1.9 vs. 1.4%, P < 0.01). By race/ethnicity, the highest prevalence of severe obesity was seen in Hispanic boys (3.3%). Among those aged 5 years, 77.9% of obese children had provider diagnosis of obesity or elevated BMI, increasing to 89.0% for the subset with severe obesity. CONCLUSIONS: Obesity and severe obesity are evident as early as age 3-5 years, with race/ethnic trends similar to older children. This study underscores the need for continued recognition and contextualization of early childhood obesity in order to develop effective strategies for early weight management.
    Pediatric Obesity 05/2013; · 2.28 Impact Factor

Publication Stats

5k Citations
1,395.97 Total Impact Points


  • 2002–2014
    • University of Colorado
      • • Division of Cardiology
      • • Department of Medicine
      Denver, Colorado, United States
  • 2001–2014
    • Kaiser Permanente
      • • Center for Health Research (Oregon, Hawaii, and Georgia)
      • • Pharmacy Department
      Oakland, California, United States
  • 2013
    • University of Massachusetts Medical School
      • Department of Quantitative Health Sciences
      Worcester, MA, United States
    • University of Colorado at Boulder
      • Department of Psychology and Neuroscience
      Boulder, CO, United States
  • 2012
    • MedStar Health Research Institute
      Maryland, United States
  • 2007–2012
    • Massachusetts General Hospital
      • Department of Emergency Medicine
      Boston, MA, United States
  • 2004–2012
    • Minneapolis Medical Research Foundation
      Minneapolis, Minnesota, United States
    • Mental Health Center of Denver
      Denver, Colorado, United States
  • 2011
    • Longmont United Hospital
      Longmont, Colorado, United States
  • 2009–2011
    • VHA National Center for Organization Development (NCOD)
      Cincinnati, Ohio, United States
    • The University of Arizona
      • College of Pharmacy
      Tucson, AZ, United States
  • 2010
    • Duke University Medical Center
      • Duke Clinical Research Institute
      Durham, NC, United States
    • Brigham and Women's Hospital
      • Center for Brain Mind Medicine
      Boston, MA, United States
  • 2007–2010
    • U.S. Department of Veterans Affairs
      Washington, Washington, D.C., United States
  • 2008
    • VA Eastern Colorado Health Care System
      Denver, Colorado, United States
  • 1997–2008
    • Permanente Medical Group
      Pasadena, California, United States
  • 2006–2007
    • Yale University
      • Section of Cardiovascular Medicine
      New Haven, CT, United States
  • 2004–2007
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
  • 2004–2005
    • VA Puget Sound Health Care System
      Washington, Washington, D.C., United States
  • 2003
    • University of Washington Seattle
      • Department of Epidemiology
      Seattle, WA, United States