Publications

BACKGROUND: Cardiovascular-kidney-metabolic (CKM) syndrome highlights the inter-related nature of cardiometabolic risk factors, kidney disease, and cardiovascular disease (CVD) and represents an important target for intervention amid rising cardiovascular mortality in the United States. However, contemporary treatment patterns of major cardiometabolic risk factors in this high-risk population are not well defined.

OBJECTIVES: The purpose of this study was to characterize national treatment rates of hypertension, diabetes, and hyperlipidemia among U.S. adults with CKM syndrome and to assess risk factor control among treated individuals from 2015 through 2023.

METHODS: We analyzed data from adults aged ≥20 years with CKM stage 2 and above who participated in the National Health and Nutrition Examination Survey from 2015 through August 2023. Treatment rates for hypertension, diabetes, and hyperlipidemia and rates of blood pressure, glycemic, and cholesterol control among treated individuals were estimated using age- and sex-adjusted analyses that accounted for the complex survey design.

RESULTS: The study included 6,384 adults with CKM stage 2 and above (weighted mean age 44.2 years; 51.2% women). Only approximately one-half of adults with hypertension (51.3% [95% CI: 49.7%-52.8%]) or hyperlipidemia (48.8% [95% CI: 46.7%-51.0%]) were receiving treatment, while diabetes treatment rates were higher (83.4% [95% CI: 80.1%-86.6%]). Among treated individuals, blood pressure control was achieved in 44.7% (95% CI: 41.6%-47.7%), glycemic control in 47.3% (95% CI: 42.7%-51.8%), and cholesterol control in 68.2% (95% CI: 65.2%-71.1%). Treatment rates for hypertension and hyperlipidemia increased across higher risk strata, while blood pressure and glycemic control were lower among treated adults with higher 10-year CVD risk. Adults aged 20-44 years consistently had the lowest treatment rates across all 3 conditions (hypertension 27.6% [95% CI: 24.8%-30.3%], diabetes 73.7% [95% CI: 63.8%-83.7%], hyperlipidemia 19.7% [95% CI: 15.2%-24.3%]), while women were less likely than men to receive treatment for diabetes and hyperlipidemia. Among racial and ethnic subgroups, Hispanic adults had the lowest treatment rates for hypertension and hyperlipidemia.

CONCLUSIONS: Among U.S. adults with CKM syndrome, treatment of hypertension and hyperlipidemia was low, and fewer than one-half of treated individuals achieved blood pressure or glycemic control. Gaps in treatment initiation were most pronounced among young adults, women, and Hispanic adults, and inadequate risk factor control was particularly evident among those with higher cardiovascular risk. These findings highlight substantial opportunities to improve cardiometabolic care in this high-risk population.

BACKGROUND: Cardiometabolic risk factors are major contributors to premature mortality in the United States. Little is known about recent changes in the cardiometabolic health of US adults by income level, particularly after the COVID-19 pandemic.

OBJECTIVE: To assess changes in the cardiometabolic health of US adults from 2009 to August 2023 by income level, and to evaluate pandemic-related shifts.

METHODS: We conducted a serial cross-sectional analysis of National Health and Nutrition Examination Survey participants aged ≥ 18 years (2009-2010 to August 2021-August 2023). Low-income was defined as ≤ 200% of the federal poverty level. We evaluated changes in the age- and sex-adjusted prevalence, treatment, and control of hypertension, diabetes, and high cholesterol, and the prevalence of obesity and smoking, among low- and higher-income adults. Linear regression models estimated pandemic-associated shifts.

RESULTS: Among 62,108 adults (mean age 46.3 years; 51.7% female), the prevalence of hypertension or high cholesterol did not change in either income group. Obesity prevalence rose among low-income adults (37.3% to 42.1%; absolute change +4.8 pp [95% CI, 1.1, 8.5]). Diabetes prevalence increased in both groups (low-income: +5.1 pp [1.4, 8.8]; higher-income: +2.5 pp [0.7, 4.3]), but remained higher among low-income adults (17.6% vs 12.4%; absolute difference +5.2 pp [1.6, 8.8]). While diabetes treatment did not change, an income-related gap in diabetes control emerged: by August 2021-August 2023, 43.0% of low-income adults achieved glycemic control compared to 52.8% of higher-income adults (absolute difference -9.8 pp [-17.5, -2.1]), coinciding with a greater-than-expected decline in diabetes control among low-income adults in the wake of the pandemic (level shift -8.7 pp [-16.7, -0.6]). The income-related gap in hypertension treatment in 2009-2010 had closed by August 2021-August 2023, following a greater-than-expected increase in treatment among low-income adults after the pandemic (level shift +7.8 pp [1.8, 13.8]). High cholesterol treatment and control improved in both groups, with no income-related differences. Smoking declined for both low-income (30.2% to 22.8%, absolute change -7.4 pp [-12.0, -2.8]) and higher-income (15.0% to 10.3%, absolute change -4.7 pp [-7.1, -2.3]) adults, but remained more than two-fold higher in the low-income group.

CONCLUSIONS: Between 2009 and August 2023, there was no improvement in the prevalence of hypertension or high cholesterol. Obesity and diabetes prevalence rose among low-income adults and a new income-related gap in diabetes control emerged, coinciding with a greater-than-expected decline in glycemic control among low-income adults after the pandemic. Targeted efforts are needed to improve risk factor prevention, strengthen glycemic control in low-income populations, and address persistent income-related disparities in cardiometabolic health.

The US health care system relies on international medical graduates, most of whom complete residency or fellowship postgraduate training in the US on J-1 visas. The nation's reliance on J-1 physicians-in-training increased between 2016 and 2024, particularly in regions and specialties facing workforce shortages. Disruptions to J-1 visa processing may therefore affect regions and specialties already facing workforce strain.

Emergency department (ED) crowding, constrained inpatient capacity, and long waits for outpatient cardiology delay care for patients with urgent cardiac symptoms. In 2016, the Beth Israel Deaconess Medical Center opened a non-ED-based, cardiologist-staffed Cardiac Direct Access Clinic with examination rooms, an infusion room, and six overnight observation beds to provide rapid specialty evaluation and short-stay care. Using administrative data and contribution-margin analyses, the authors assessed operational, clinical, and financial outcomes and summarized implementation strategies. Of 11,121 total patients seen in the clinic, 4239 patients - those most likely to have otherwise been sent to the ED - were admitted on the same day of referral. Of those patients, 59% were discharged home, 39% were managed in the Cardiac Direct Access Clinic's overnight unit, and 7% ultimately were admitted to inpatient floors. Among 1467 patients discharged from the overnight unit, the 30-day return rate to the ED was 6.4%. Overall patient experience scores were higher for the clinic than for the ED - 84.7 versus 56.9. Annual labor and supply costs for the clinic totaled approximately US$1.8 million. The contribution margin derived from the clinic's operations (US$245,000), admissions originating from the clinic (US$303,000), and inpatient capacity created (US$1.34 million) produced an estimated US$2.4 million annual contribution margin, underscoring financial sustainability. Key enablers included centralized prior-authorization teams, state approval to operate as an alternative care space for inpatient-level services, and codified diversion pathways for the ED and urgent care.

BACKGROUND: Cardiovascular mortality has worsened among rural adults compared with urban counterparts over recent decades. Medicare Advantage (MA) enrollment is increasing in rural areas, yet its impact on access and affordability for high-risk cardiovascular populations remains unclear. This study evaluated differences in health care access, preventive care, and affordability barriers between rural adults with cardiometabolic conditions enrolled in MA versus traditional Medicare.

METHODS: A cross-sectional analysis was performed using 2021 to 2022 Medicare Current Beneficiary Survey data. Multivariable logistic regression was used to estimate adjusted risk differences (aRD) in access, preventive care, and affordability barriers between rural MA and traditional Medicare enrollees, adjusting for sociodemographic characteristics.

RESULTS: The study included 4274 rural beneficiaries with cardiometabolic conditions (weighted population 16 352 800, 53% women). Compared with traditional Medicare, MA enrollees were significantly less likely to miss an annual wellness visit (40.1% versus 50.1%; aRD, -13.4% [95% CI, -17.0% to -9.8%]) or face barriers to preventive care, such as not having annual cholesterol checks (aRD, -3.2% [95% CI, -5.2% to -1.2%]) and influenza vaccinations (aRD, -4.3% [95% CI, -7.8% to -0.7%]). However, MA beneficiaries were more likely to have problems paying medical bills (12.2% versus 6.9%; aRD, 2.5% [95% CI, 0.4%-4.6%]).

CONCLUSIONS: Rural MA beneficiaries with cardiometabolic conditions experienced fewer barriers to preventive care but reported greater difficulty paying medical bills than those in traditional Medicare. As MA expands in rural America, policies are needed to address affordability challenges while preserving access to preventive services.