Practice Update: Cardiology

EDITOR’S PICKS 7

Elderly patients cared for by younger physicians have lower mortality rates BMJ: British Medical Journal Take-home message • The purpose of this observational study was to investigate whether physician age influences outcomes in hospitalized patients. The investigators examined data from 736,537 admissions between 2011 and 2014 for Medicare beneficiaries ≥65 years; patient care was managed by 18,854 hospitalist physicians. Adjusted 30-day mortality rates were lower in patients cared for by physicians under 40 years of age (10.8%), and increased step-wise as physician age increased: 11.1%mortality ratewhen the physician was 40 to 49 years, 11.3%when the physician was 50 to 59 years, and 12.1% when the physician was ≥60 years. Importantly, there was no association between age of a physician and 30-day mortality when a physician cared for a high volume of patients. Cost of medical care was slightly higher with older physicians, but readmission rates were not associated with physician age. • The authors conclude that elderly patients cared for by younger physicians have a lower mortality rate than patients cared for by older physicians, but this mortality difference is not present if the physician cares for a high volume of patients. Abstract OBJECTIVES To investigate whether outcomes of patients who were admitted to hospital differ between those treated by younger and older physicians. DESIGN Observational study. SETTING US acute care hospitals. PARTICIPANTS 20% random sample of Medicare fee-for-service beneficiaries aged ≥65 admitted to hospital with a medical condition in 2011-14 and treated by hospitalist physicians to whom they were assigned based on scheduled work shifts. To assess the generalizability of findings, analyses also included patients treated by general internists including both hospitalists and non-hospitalists. MAIN OUTCOME MEASURES 30 day mortality and readmissions and costs of care. RESULTS 736537 admissions managed by 18854 hospitalist physicians (median age 41) were included. Patients’ characteristics were similar across physician ages. After adjustment for characteristics of patients and physicians and hospital fixed effects (effectively comparing physicians within the same hospital), patients’ adjusted 30 day mortality rates were 10.8% for physicians aged <40 (95% con- fidence interval 10.7% to 10.9%), 11.1% for physicians aged 40–49 (11.0% to 11.3%), 11.3% for physicians aged 50–59 (11.1% to 11.5%), and 12.1% for physicians aged ≥60 (11.6% to 12.5%). Among physicians with a high volume of patients, however, there was no association between physician age and patient mortality. Readmissions did not vary with physician age, while costs of care were slightly higher among older physicians. Similar patterns were observed among general internists and in several sensitivity analyses. CONCLUSIONS Within the same hospital, patients treated by older physicians had higher mortality than patients cared for by younger physicians, except those phy- sicians treating high volumes of patients. Physician age and outcomes in elderly patients in hospital in the US: obser- vational study. BMJ 2017 May 16;357(xx)j1797, Y Tsugawa, JP Newhouse, AM Zaslavsky, et al. This mortality difference is not present if the physician cares for a high volume of patients.

Lower risk of heart failure and death in patients initiated on

SGLT-2 inhibitors vs other glucose-lowering drugs

Circulation

Take-home message • This study compared SGLT-2 inhibitors with other glucose-lowering drugs with respect to cardio- vascular risk reduction. The results revealed that patients receiving SGLT-2 inhibitors, regardless of the specific agent, had lower rates of cardiovas- cular death and heart failure compared with those receiving other glucose-lowering drugs. • The authors concluded that SGLT-2 inhibitors may offer the class effect of cardiovascular risk reduc- tion in patients with type 2 diabetes. Abstract BACKGROUND Reduction in cardiovascular death and hospital- ization for heart failure (HHF) was recently reported with the sodium-glucose co-transporter-2 inhibitor (SGLT-2i) empagliflozin in type 2 diabetes patients with atherosclerotic cardiovascular disease. We compared HHF and death in patients newly initiated on any SGLT-2i versus other glucose lowering drugs (oGLDs) in six countries to determine if these benefits are seen in real- world practice, and across SGLT-2i class. METHODS Data were collected via medical claims, primary care/ hospital records and national registries from the US, Norway, Denmark, Sweden, Germany and the UK. Propensity score for SGLT-2i initiation was used to match treatment groups. Hazard ratios (HRs) for HHF, death and their combination were estimated by country and pooled to determine weighted effect size. Death data were not available for Germany. RESULTS After propensity matching, there were 309,056 patients newly initiated on either SGLT-2i or oGLD (154,528 patients in each treatment group). Canagliflozin, dapagliflozin, and empag- liflozin accounted for 53%, 42% and 5% of the total exposure time in the SGLT-2i class, respectively. Baseline characteris- tics were balanced between the two groups. There were 961 HHF cases during 190,164 person-years follow up (incidence rate [IR] 0.51/100 person-years). Of 215,622 patients in the US, Norway, Denmark, Sweden, and UK, death occurred in 1334 (IR 0.87/100 person-years), and HHF or death in 1983 (IR 1.38/100 person-years). Use of SGLT-2i, versus oGLDs, was associated with lower rates of HHF (HR 0.61; 95% CI 0.51-0.73; p<0.001); death (HR 0.49; 95% CI 0.41-0.57; p<0.001); and HHF or death (HR 0.54; 95% CI 0.48-0.60, p<0.001) with no significant heter- ogeneity by country. CONCLUSIONS In this large multinational study, treatment with SGLT-2i versus oGLDs was associated with a lower risk of HHF and death, suggesting that the benefits seen with empagliflozin in a randomized trial may be a class effect applicable to a broad population of T2D patients in real-world practice (NCT02993614). Lower risk of heart failure and death in patients initiated on SGLT-2 inhibitors versus other glucose-lowering drugs: the CVD-REAL study. Circulation 2017 May 18;[EPub Ahead of Print], M Kosiborod, MA Cavender, AZ Fu, et al.

VOL. 2 • NO. 1 • 2017