Publications

BACKGROUND: Use of pulmonary vein isolation (PVI) to treat atrial fibrillation continues to increase. Despite great interest in leveraging administrative data for real-world analyses, contemporary procedural codes for identifying PVI have not been evaluated.

METHODS AND RESULTS: In this observational retrospective cohort study, inpatient PVIs were identified among US Medicare fee-for-service beneficiaries using Current Procedural Terminology (CPT) code 93656 in Carrier Line Files. Each patient was matched with their claims from Medicare Provider Analysis and Review to compare CPT with International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) claims submitted by health care facilities to bill for PVIs. We performed the reverse for commonly matched ICD-10-PCS codes, to identify corresponding CPT-billed procedures. Finally, we reviewed institutional cases for additional comparison of CPT and ICD-10-PCS assignation for PVI. We identified 25 617 inpatient PVIs from January 2017 to December 2021, of which 18 165 (71%) were linked to Medicare Provider Analysis and Review. Of these, 16 672 (92%) were billed as ICD-10-PCS 02583ZZ: "Destruction of Conduction Mechanism, Percutaneous Approach." The reverse process yielded heterogeneous results: among 75 003 procedures billed as ICD-10-PCS 02583ZZ, only 15 691 (21%) matched with CPT 93656 (PVI), as several other unrelated procedures were billed under this ICD-10-PCS code. Institutional case review confirmed the greater specificity of CPT codes.

CONCLUSIONS: The ICD-10-PCS code associated with CPT-billed PVI procedures actually referred to ablation of the atrioventricular junction. Yet this ICD-10-PCS code also matched with a wide range of other procedures distinct from PVI. We conclude that ICD-10-PCS codes alone are not sensitive nor specific for identifying PVI in claims and cannot be reliably used in isolation for health services research on this important procedure.

IMPORTANCE: In the 2020 Bostock v Clayton County decision, the US Supreme Court extended employment nondiscrimination protection to sexual minority adults. The health impacts of this ruling and similar policies related to sexual orientation-based discrimination are not currently known.

OBJECTIVE: To estimate changes in mental health following the Bostock decision among sexual minority adults in states that gained employment nondiscrimination protection (intervention states) compared with those in states with protections already in place (control states).

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used 2018-2022 data from the Behavioral Risk Factor Surveillance System and a difference-in-differences approach to evaluate changes in mental health after the Bostock decision by comparing sexual minority adults (aged ≥18 years and identifying as lesbian, gay, or bisexual) in 12 intervention states with those residing in 9 control states. Models were estimated for all participants and separately for employed participants. Data were analyzed between February and September 2024.

EXPOSURE: Residing in a state that gained employment nondiscrimination protection after the Bostock decision.

MAIN OUTCOMES AND MEASURES: The primary outcome was number of poor mental health days during the past 30 days, and the secondary outcome was severe mental distress (defined as 14 or more past-month poor mental health days).

RESULTS: Of 597 462 participants (306 365 in intervention states [77.7% aged 18-64 years and 22.3% aged ≥65 years; 51.7% female] and 291 097 in control states [77.5% aged 18-64 years and 22.5% aged ≥65 years; 50.6% female]), 5.1% in intervention states and 6.0% in control states self-identified as sexual minority adults. The mean (SE) number of past-month poor mental health days was unchanged after the Bostock decision among sexual minority adults in both intervention (from 8.70 [0.27] to 9.59 [0.24] days; adjusted difference, 0.57 [95% CI, -1.02 to 2.16] days) and control (from 8.53 [0.21] to 10.15 [0.20] days; adjusted difference, 1.17 [95% CI, -0.46 to 2.79] days) states, resulting in no differential change between the 2 groups (difference-in-differences, -0.60 days; 95% CI, -1.25 to 0.06 days). Among the subset of employed sexual minority adults, the mean (SE) number of poor mental health days did not change in intervention states (from 7.99 [0.38] to 8.83 [0.30] days; adjusted difference, 0.87 [95% CI, -0.49 to 2.22] days) but increased in control states (from 7.75 [0.27] to 9.75 [0.26] days; adjusted difference, 1.84 [95% CI, 0.44-3.24] days). These findings corresponded to a significant relative reduction in poor mental health days among employed sexual minority adults in intervention vs control states (difference-in-differences, -0.97 days; 95% CI, -1.74 to -0.21 days). Mean (SE) rates of severe mental distress increased less among employed sexual minority adults in intervention (from 26.35% [1.59%] to 29.92% [1.46%]; adjusted difference, 6.81% [95% CI, 2.20%-11.42%]) vs control (from 26.53% [1.27%] to 34.26% [1.16%]; adjusted difference, 10.30% [95% CI, 5.99%-14.61%) states, also corresponding to a significant relative reduction among employed sexual minority adults (difference-in-differences, -3.49%; 95% CI, -6.71% to -0.27%).

CONCLUSIONS AND RELEVANCE: These findings show significant relative reductions in past-month poor mental health days and severe mental distress among employed sexual minority adults after the implementation of a federal ban on employment discrimination based on sexual orientation. Larger and more consistent mental health benefits observed among sexual minority adults in the workforce underscore the importance of broadening protections to other social domains.

Despite advancements in diagnostics and therapeutics for cardiovascular disease, significant health disparities persist among patients from historically marginalized racial and ethnic groups, women, individuals who are socioeconomically under-resourced or underinsured, and those living in rural communities. While transcatheter interventions have revolutionized the treatment landscape in cardiology, populations bearing the greatest burden of disease continue to face inequitable access and poorer outcomes. A notable gap in the literature concerns the role of modern approaches to cardiovascular device innovation in shaping and perpetuating health disparities. Health equity has been declared one of the top strategic initiatives for 2022 to 2025 by the Food and Drug Administration Center for Devices and Radiological Health, underscoring the need for greater attention, dialogue, and targeted interventions in this space. This narrative review uses the cardiovascular device life cycle as a conceptual framework to enhance understanding and guide future efforts to mitigate disparities in the field of interventional cardiology. Drawing on illustrative examples from interventional cardiology, we examine current practices in cardiovascular device regulation and approval, clinical trial evaluation, adoption patterns, and postprocedural outcomes with the aim of uncovering potential mechanisms of disparities and identifying opportunities for targeted interventions.

Policymakers have intensified calls to expand work requirements in Medicaid across the United States, which could have implications for low-income adults who experience a high burden of cardiometabolic risk factors and disease. In this difference-in-differences analysis, we found that the implementation of Medicaid work requirements was associated with decreased health insurance coverage, no change in employment status, and a trend towards worse access to care. Our findings suggest that the expansion of work requirements could have major implications for the cardiovascular health of working-age adults in the US.