Researchers examined 63,563 adults with acute ischemic stroke from the Austrian Stoke Unit Registry. AFib was documented in 18,962 patients (29.8 percent) and more severe strokes were found in women than men. National Institutes of Health Stroke Scale points were nine in women and six in men. Stroke severity increased with age regardless of whether the stroke was related to AFib; however AFib-related strokes were generally more severe than those of other causes. This is the first study to show that the difference in stroke severity between women and men is only found for strokes caused by AFib. The study also showed that total anterior circulation syndrome was significantly more frequent in women compared with men (27.1 vs. 18.3 percent), a difference that was detectable over all age groups.

Previous research with this population found no differences in the quality of care given to women and men experiencing acute stroke, apart from sex-specific differences in stroke management, which the authors say may be a potential cause of the observed effect. Wake-up stroke prevalence and hospital arrival times also did not explain the difference in stroke severity.

The authors hypothesize that this difference may be the result of biological differences or an effect of sex hormones such as estrogen, which has been shown to reduce fibrinolytic activity and to activate the coagulation system, which may lead to large or denser thrombi.

The researchers conclude the data support the need to strictly adhere to current guidelines and to avoid the underuse of oral anticoagulation, especially in women. They add that the findings need to be confirmed in an independent population.

Lang C, Seyfang L, Ferrari J, et al. Stroke 2017;Feb 1:[Epub ahead of print].

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This Mendelian randomization study used publicly available, summary-level data from four genome-wide association studies conducted from 2007 to 2015, including up to 322,154 participants, as well as individual-level, cross-sectional data from the UK Biobank collected from 2007-2011, including 111,986 individuals.

Results showed that a 1 SD increase in WHR adjusted for BMI mediated by the polygenic risk score was associated with 27 mg/dl higher triglyceride levels, 4.1 mg/dl higher 2-hour glucose levels, and 2.1 mm Hg higher systolic blood pressure (each p < 0.001). In addition, a 1 SD genetic increase in WHR adjusted for BMI was associated with a higher risk of type 2 diabetes (odds ratio [OR], 1.77) and CHD (OR, 1.46).

The authors conclude that genetic predisposition to higher WHR adjusted for BMI was associated with increased levels of quantitative risk factors (lipids, insulin, glucose and systolic blood pressure), and a higher risk for type 2 diabetes and CHD.

“These findings lend human genetic support to previous observations associating abdominal adiposity with cardiometabolic disease,” said lead author Connor A. Emdin, DPhil, et al. The results suggest that body fat distribution, beyond simple measurement of BMI, could explain part of the variation in risk of type 2 diabetes and CHD they found across individuals and subpopulations. Further, the authors explain, “WHR adjusted for BMI might prove useful as a biomarker for the development of therapies to prevent type 2 diabetes and CHD.”

In an accompanying editorial, George Davey Smith, MD, DSc, et al., comments on the study’s use of Mendelian randomization for its “methodology that incorporates the natural randomization inherent in the generation of genetic individuality,” and suggests that the adoption of Mendelian randomization may improve prediction of what randomized clinical trials will show.

Emdin CA, Khera AV, Natarajan P, et al. JAMA 2017;317:626-34.

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Karin A. Kasza, MA, et al., used data from the national longitudinal Population Assessment of Tobacco and Health study from the U.S. Food and Drug Administration (FDA) and National Institutes of Health, and presented prevalence estimates for 12 types of tobacco products. They looked at 45,971 adult and youth participants who were asked about their use of cigarettes, e-cigarettes, traditional cigars, cigarillos, smokeless tobacco and other various tobacco products.

Results showed that nearly 28 percent of adults were current users of at least one type of tobacco product in 2013 and 2014, and a total of 8.9 percent of youths had used a tobacco product in the previous 30 days, with 1.6 percent of youths reporting to use tobacco daily. Approximately 40 percent of tobacco users across all ages used multiple tobacco products. Adults ages 18 to 24 years, male adults and youths, members of racial minorities and members of sexual minorities generally reported higher use of tobacco than their counterparts.

These findings will serve as baseline data to examine changes in the use of tobacco products over time.

The authors conclude that these findings will serve as baseline data to examine changes in the use of tobacco products over time. As the study progresses, researchers hope to identify additional factors associated with quitting tobacco and associated health repercussions. They add that findings from the study may be used to inform future FDA actions on tobacco-related regulations.

Kasza, KA, Ambrose, BK, Conway, KP, et al. N Engl J Med 2017;376:342-53.

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The first study, led by J. Michael McWilliams, MD, PhD of Harvard Medical School, used fee-for-service Medicare claims from a random 20 percent sample of beneficiaries, including more than 8.3 million hospital admissions and more than 1.5 million stays in skilled nursing facilities (SNFs), to examine changes in post-acute care spending and the use of post-acute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP).

Results showed that for ACOs, entrance into MSSP in 2012 was associated with a 9 percent differential reduction in post-acute spending by 2014, driven by reductions in discharges to facilities, length of facility stays and acute inpatient care. Reported reductions were smaller for later program entrants and similar for ACOs with and without financial ties to hospitals.

Overall, participation in the MSSP has been associated with significant reductions in post-acute care spending without ostensible changes in quality, suggesting gains in the value of health care. McWilliams, et al. conclude that, “Post-acute care spending reductions were more consistent with efforts by clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs. Understanding such early successes can support regulatory policy that enhances rather than inhibits the effectiveness of payment and delivery system reform.”

In a second study, K. John McConnell, PhD, of the Oregon Health and Science University in Portland, led an examination of early performance in Medicaid ACOs in Oregon and Colorado.

Supported by a $1.9 billion investment from the federal government, Oregon initiated its Medicaid transformation by moving enrollees into 16 Coordinated Care Organizations which managed care within a global budget. Colorado initiated its Medicaid Accountable Care Collaborative in 2011, creating seven Regional Care Collaborative Organizations funded to coordinate care with providers and connect Medicaid enrollees with community services.

Results showed that standardized expenditures for selected services declined in both states from 2010 to 2014, with reports showing no difference between the states. Oregon’s model was associated with reductions in emergency department and primary care visits, as well as other improvements in some utilization, access and quality measures.

The study’s analysis did not include prescription drug expenditures, a growing portion of Medicaid spending. The authors conclude that further evaluation of Medicaid reforms and payment models is needed to inform the most effective and sustainable approaches to improving this public program.

In an editorial comment reviewing both studies, Carrie H. Colla, PhD, and Elliott S. Fisher, MD, MPH, write, “We still have much to learn … we know little about the effects of ACOs on patients’ health and quality of life.” They add that, “Perhaps most important for ACO leaders and the long-term success of these programs, we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts … A long-term commitment to alternative payment model evaluation is necessary to ensure effective, sustainable payment and delivery system reform.”

McWilliams JM, Gilstrap LG, Stevenson DG, et al. JAMA Intern Med 2017;Feb 13:[Epub ahead of print].

McConnell KJ, Renfro S, Chan BK, et al. JAMA Intern Med 2017;Feb 13:[Epub ahead of print].

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