Providing specialty consultant expertise to primary care: an expanding spectrum of modalities

In most models of health care delivery, the bulk of services are provided in primary care and there is frequent request for the input of specialty consultants. A critical issue for current and future health care systems is the effective and efficient delivery of specialist expertise for clinicians and patients. Input on a patient's care from specialty consultants usually requires a face-to-face visit between the patient and the consultant. New and complementary models of knowledge sharing have emerged. We describe a framework assessment of a spectrum of knowledge-sharing methods in the context of a patient-centered medical home. This framework is based on our experience in the Veterans Health Administration and a purposive review of the literature. These newer modes of specialty consultation include electronic consultation, secure text messaging, telemedicine of various types, and population preemptive consults. In addition to describing these modes of consultation, our framework points to several important areas in which further research is needed to optimize effectiveness.

Invasive coronary procedure use and outcomes among veterans with posttraumatic stress disorder: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Posttraumatic stress disorder (PTSD) is prevalent in the general population and US veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and postprocedural outcomes of veterans with and without PTSD undergoing coronary angiography.

METHODS

This is a multicenter observational study of patients who underwent coronary angiography in Veterans Affairs hospitals nationally from October 2007 to September 2011. We described patient characteristics at angiography, angiographic results, and after coronary angiography, we compared risk-adjusted 1-year rates of all-cause mortality, myocardial infarction (MI), and revascularization by the presence or absence of PTSD.

RESULTS

Overall, of 116,488 patients undergoing angiography, 14,918 (12.8%) had PTSD. Compared with those without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7; P < .001), had higher rates of cardiovascular risk factors, and were more likely to have had a prior MI (26.4% vs 24.7%; P < .001). Patients with PTSD were more likely to present for stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%) and less likely to have obstructive CAD identified at angiography (55.9% vs 62.2%; P < .001). After coronary angiography, PTSD was associated with lower unadjusted 1-year rates of MI (hazard ratio (HR), 0.86; 95% CI [0.75-1.00]; P = 0.04), revascularization (HR, 0.88; 95% CI [0.83-0.93]; P < .001), and all-cause mortality (HR, 0.66; 95% CI [0.60-0.71]; P < .001). After adjustment for cardiovascular risk, PTSD was no longer associated with 1-year rates of MI or revascularization but remained associated with lower 1-year all-cause mortality (HR, 0.91; 95% CI [0.84-0.99]; P = .03). Findings were similar after further adjustment for depression, anxiety, alcohol or substance use disorders, and frequency of outpatient follow-up.

CONCLUSIONS

Among veterans undergoing coronary angiography in the Veterans Affairs, those with PTSD were more likely to present with elective indications and less likely to have obstructive CAD. After coronary angiography, PTSD was not associated with adverse 1-year outcomes of MI, revascularization, or all-cause mortality.

Clopidogrel prescription filling delays and cardiovascular outcomes in a pharmacy system integrating inpatient and outpatient care: insights from the Veterans Affairs CART Program

BACKGROUND

Delays in filling clopidogrel prescriptions after percutaneous coronary intervention (PCI) have been demonstrated previously and associated with adverse outcomes.

METHODS

This was a retrospective cohort study of 11,418 patients undergoing PCI with stent placement in Veterans Affairs (VA) hospitals between January 1, 2005, and September 30, 2010. Data were obtained from the national VA Clinical Assessment, Reporting, and Tracking Program, including post-PCI clopidogrel prescription fill date and outcomes of myocardial infarction and death within 90 days of discharge. Patients who did not fill a clopidogrel prescription on the day of discharge were considered to have a delay. Multivariable models assessed the association between clopidogrel delay and myocardial infarction/death using clopidogrel delay as a time-varying covariate.

RESULTS

Of the patients, 7.2% had a delay in filling their clopidogrel prescription. Delay in filling clopidogrel was associated with increased risk of major adverse events (hazard ratio 2.34, 95% CI 1.66-3.29, P < .001). The percentage of patients who delayed filling varied by hospital, ranging from 0 to 43.5% with a median of 6.2% (P < .001, χ(2) for difference across hospitals) and a median odds ratio of 2.13 (95% CI 1.85-2.68) suggesting large site variation in clopidogrel delay across hospitals.

CONCLUSIONS

In a health care system with integrated inpatient and outpatient pharmacy services, 1 in 14 patients delays filling a clopidogrel prescription. The large site variation suggests a need to identify best practices that allow hospitals to optimize prescription filling at discharge to potentially improve patient outcomes.

Dynamic medication adherence modeling in primary prevention of cardiovascular disease: a Markov microsimulation methods application

BACKGROUND

Real-world patients' medication adherence is lower than that of clinical trial patients. Hence, the effectiveness of medications in routine practice may differ.

OBJECTIVES

The study objective was to compare the outcomes of an adherence-naive versus a dynamic adherence modeling framework using the case of statins for the primary prevention of cardiovascular (CV) disease.

METHODS

Statin adherence was categorized into three state-transition groups on the basis of an epidemiological cohort study. Yearly adherence transitions were incorporated into a Markov microsimulation using TreeAge software. Tracker variables were used to store adherence transitions, which were used to adjust probabilities of CV events over the patient's lifetime. Microsimulation loops "random walks" estimated the average accrued quality-adjusted life-years (QALYs) and CV events. For each 1,000-patient microsimulations, 10,000 outer loops were performed to reflect second-order uncertainty.

RESULTS

The adherence-naive model estimated 0.14 CV events avoided per person, whereas the dynamic adherence model estimated 0.08 CV events avoided per person. Using the adherence-naive model, we found that statin therapy resulted in 0.40 QALYs gained over the lifetime horizon on average per person while the dynamic adherence model estimated 0.22 incremental QALYs gained. Subgroup analysis revealed that maintaining high adherence in year 2 resulted in 0.23 incremental QALYs gained as compared with 0.16 incremental QALYs gained when adherence dropped to the lowest level.

CONCLUSIONS

A dynamic adherence Markov microsimulation model reveals risk reduction and effectiveness that are lower than with an adherence-naive model, and reflective of real-world practice. Such a model may highlight the value of improving or maintaining good adherence.

Abstract 181: Patterns of Waveform and Energy Use in Defibrillation for Cardiac Arrest: Insights from the Get With The Guidelines-Resuscitation Registry

Background: Early defibrillation for termination of life-threatening arrhythmias is key to survival of cardiac arrest. Biphasic waveform defibrillation has been suggested as superior to monophasic waveform defibrillation, but little is known about trends in defibrillation waveform and energy used for in-hospital cardiac arrest.

Methods: Within Get With The Guidelines-Resuscitation, a national registry of in-hospital cardiac arrest, we identified subjects over age 18 with an in-hospital cardiac arrest due to ventricular fibrillation or pulseless ventricular tachycardia between 2005 and 2012. We restricted the study cohort to this time period, as defibrillation waveform and energy were not captured prior to 2005. We examined calendar year trends in defibrillation waveform and energy of first defibrillation attempt using the chi-square test.

Results: A total of 22,108 patients from 504 facilities were identified. In 2005, in which there were 2898 in-hospital cardiac arrest cases, 1911 (66%) events were treated with biphasic defibrillation and 987 (34%) with monophasic defibrillation. By 2012, nearly all (97% [1460/1502]) events were treated with biphasic defibrillation; p for trend < 0.0001 (see Figure). For biphasic defibrillation, the predominant energy used for first defibrillation attempt was 200 J (55.91% of events) with 150 J being the next most common (18.21% of events) with a trend toward more frequent use of 200 J (p < 0.0001).

Conclusion: Biphasic defibrillation at 200 J is now the predominant waveform and energy used for initial defibrillation during in-hospital cardiac arrest. Additional work is needed to determine if a rise in use of biphasic defibrillation is improving outcomes.

Abstract 2: Facility-level Variation in 30-day PCI Mortality, Readmission, and Costs in the VA Health Care System: Insights About Short-term Healthcare Value From The VA CART Program

Background: Value in health care, defined as the health outcomes achieved per dollar spent, is emerging as a framework for improvement in health care delivery. We sought to describe facility-level variation in 30-day PCI mortality, readmission and costs.

Methods: Using national data from the VA CART Program, we evaluated all patients who had PCI from 2008 to 2010. 30-day total patient costs, readmission, and mortality were attributed to the hospital where the PCI was performed. Risk standardized costs and outcomes were calculated using standardized covariates, adjusting for cardiac and non-cardiac comorbidities.

Results: There were 60 hospitals (21,173 patients) that performed more than 20 PCIs during the study period with a mean of 353 PCIs. The unadjusted mean mortality rate was 2.5%, with no significant variation in facility-level risk standardized mortality. The unadjusted mean readmission rate was 10.6%. The risk standardized readmission rate ranged from 0.8 to 1.58 times the average, with 2 hospitals significantly below and 8 hospitals significantly above the risk standardized average. The facility-level median per patient total costs was $26,491 (IQR $20,943 to $31,866). The index hospitalization accounted for 42.4% of 30-day total costs, and readmission accounted for 5.6% of the 30-day total costs at the facility-level. Comparison of risk standardized costs identified 17 hospitals with lower than expected costs and 15 hospitals with higher than expected costs. Facilities with low readmission rates were not overrepresented among low cost facilities, suggesting readmissions are not a major contributor to facility-level 30-day cost (Figure).

Conclusion: We observed no variation in facility-level 30-day PCI mortality despite large variation in cost. Although readmission rates varied, readmission accounted for less than 6% of 30-day cost and was not related to facility-level costs. Further studies are needed to determine factors associated with high-value PCI care, defined by low morbidity and mortality despite similar or lower costs.

Abstract 322: Chronic Kidney Disease Does Not Impact Health Status Following Acute Myocardial Infarction

Introduction: Chronic kidney disease is strongly associated with mortality after acute myocardial infarction (AMI), however, its association with health status outcomes (symptoms, function and quality of life (QoL)) is unknown.

Methods: Patients with AMI were enrolled between 2003 and 2008 in the TRIUMPH registry, a national, prospective, multi-center study of health status outcomes after AMI. Detailed interviews with the disease-specific Seattle Angina Questionnaire (SAQ) and generic Short Form-12 (SF-12) were attempted on all survivors at 1, 6 and 12 months following AMI admission. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation and based on the highest calculated eGFR recorded during the AMI hospitalization. Patients with CKD, based on an eGFR < 60 ml/min, were compared to those without CKD. Linear repeated measures models of SAQ angina frequency and QoL and SF-12 PCS and MCS scores were used to control for treatment site, baseline health status and known covariates to assess the independent association between CKD and health status after AMI.

Results: Of 3592 3,617 patients, 3,041 (84%) had no CKD and 551 576 (16%) had CKD;, 7980% stage 3 (eGFR 30-59); 1312% stage 4 (eGFR 15-29); and 8% stage 5 (eGFR <15). Patients with CKD were older (67.5 vs. 587.8) and had more co-morbidities, including heart failure, CVA, and PVD. CKD patients were more likely to have 3-vessel CAD, left ventricular dysfunction and less likely to undergo revascularization during their hospitalization. CKD patients also also had a higher 1-year mortality (8.59% vs. 2.3%; p<0.0001). Among AMI survivors at 1 -year, patients with and without CKD had similar QoL 81.9 8 vs. 81.7 (adj. difference of 0.4624, [95% CI, -1.2646, ,2.181.95]), angina frequency 91.4 vs. 93.1 (adj. difference of 1.2327, [95% CI, -0.0605, ,2.589]), and mental health scores 52.7 vs. 51.9 (adj. difference of -0.0907, [95% CI, -0.90, 2,0.7475]). Physical functioning scores were low overall at 1-year and CKD patients had slightly lower scores, 38.0 4 vs. 44.4 ((adj. difference -1.6861, [95% CI, -2.562.49, -0.749]).

Conclusion: Among AMI survivorspatients who survived to 1 year, CKD patients have similar quality of life and angina burden compared to those without CKD despite a higher burden of co-morbidities. While CKD patients had lower physical functioning scores, this difference was not clinically significant compared to patients without CKD. These findings suggest that among AMI patients surviving to 1 yearsurvivors, CKD patients can achieve similar health status outcomes compared to non-CKD patients.

Abstract 137: Anticoagulation clinic provider’s perspective on management of patients on target specific oral anticoagulants: insights from the Veterans Affairs Health Care System

Background: Patients on target specific anticoagulants (TSOACs) such as dabigatran do not require routine laboratory testing and dose adjustment. In the Veterans Health Administration (VHA), anticoagulation clinics (ACCs) may elect to follow and manage patients on TSOACs, but whether it is needed or the optimal duration of follow-up is unknown. Our objective was to assess the perspective of anticoagulation clinic providers on follow-up care for dabigatran patients and to identify site-level practices associated with improved adherence to dabigatran.

Methods: We ascertained ACC providers’ perspectives through semi-structured interviews by a single, trained internist. Purposive sampling was utilized to recruit senior ACC providers or supervisors at VHA sites with over 20 patients on dabigatran. We stratified sites into high and low performing sites based on whether sites had ≥ 75% of their patients adherent, based on a proportion-of-days-covered calculation. Data from the interviews was analyzed by 2 reviewers in an iterative process to identify recurrent and unifying themes. Constant comparative method of qualitative data analysis was used to identify best practices across various sites.

Results: We interviewed ACC providers from 39 sites - including 18 providers at 16 high-performing sites and 25 providers at 23 low-performing sites. Follow-up practices for dabigatran varied across sites, with 6 sites not providing any follow-up, 14 sites following-up patients for less than 3 months, 9 sites following-up patients for 6 months, and 10 sites following-up patients indefinitely. During these follow-up visits, patients were contacted at regular intervals, mostly via telephone, by ACC providers to provide education, assess side-effects and adherence. Key strategies implemented at high-performing sites compared to low-performing sites included (1) examining adherence to other twice daily medications prior to approving dabigatran (2) education of patients by ACC providers prior to dabigatran initiation (3) continued telephone follow up by ACC staff despite no need for INR checks. Over a third of ACC providers expressed concerns regarding patient adherence to dabigatran. Most common reasons for this concern included its special storage requirements and high incidence of gastrointestinal side effects leading to high discontinuation rates.

Conclusion: Dedicated follow-up of patients on dabigatran is associated with improved adherence. A multi-disciplinary approach involving anti-coagulation clinic providers to provide education and follow-up may be beneficial in management of TSOACs. Future work should compare the apparent benefit of this strategy with its non-trivial cost.

Abstract 310: 30-day Readmission Following PCI Predicts Worse Long-term Patient Outcomes: Insights from the VA CART Program

Background: 30-day readmission after percutaneous coronary intervention (PCI) is a common, expensive and potentially preventable problem. The relationship between 30-day readmission and long-term patient outcomes has not been studied within integrated care delivery settings. We sought to determine the association between 30-day readmission after PCI and long-term patient outcomes in the VA.

Methods: We evaluated all VA patients who underwent PCI from October 2007 through September 2011 using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program. Patient outcomes were followed through September 2012. Our primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), revascularization, and the composite of all three outcomes. We compared patient demographics, clinical characteristics, and procedural factors by 30-day readmission status. The association between 30-day readmission status and outcomes was assessed using Cox proportional hazards models.

Results: Among 32,551 patients undergoing PCI, 4,829 (14.8%) were readmitted within 30 days. Median follow-up after discharge was 30.3 months (IQR: 19.5, 43.6). Over this period of follow-up, a total of 4,548 (14%) died, 2,021 (6.2%) suffered an MI, and 7,040 (21.6%) underwent revascularization. Patients with subsequent readmission were more likely to have chronic kidney disease (26% vs 18%, P<.01) or chronic obstructive pulmonary disease (32% vs 23%, P<.01) and more likely to be presenting with an acute coronary syndrome (60% vs 48%, P<0.01) during the index hospitalization. Thirty-day readmission was associated with worse risk-adjusted outcomes (Table 1).

Conclusions: In the VA, approximately 15% of patients were readmitted within 30 days of PCI - a rate that is comparable to prior studies from community settings. Patients readmitted within 30-days had significantly higher long-term mortality risks. Future research should aim to understand modifiable causes of readmission and the extent to which 30-day readmission is a quality metric rather than a risk marker.

Abstract 24: Non-Obstructive Coronary Artery Disease Is Not Benign: Insights from the VA CART Program on the Association between Non-Obstructive Disease and Cardiac Events

Introduction: The traditional focus of cardiac care on obstructive (>70% stenosis) CAD potentially distracts from the risks inherent in non-obstructive CAD. However, surprisingly little is known about non-obstructive CAD outcomes. Therefore, we determined the association between non-obstructive CAD and cardiovascular outcomes.

Methods: Using the national VA CART program, we studied all veterans undergoing elective coronary angiography for angina between October 2007 and September 2012. Patients were categorized by CAD extent (none (no stenosis >20%), non-obstructive (no stenosis >=70%), obstructive (any stenosis >=70%)) and distribution (1, 2, or 3 vessel), and assessed for major adverse cardiac events (MACE), defined as all-cause mortality and MI. We adjusted for demographic, clinical, and treatment factors using Cox proportional hazards modeling. Secondary analyses sub-divided non-obstructive CAD into mild (20-49% stenosis) and moderate (50-69% stenosis) disease.

Results: During the study period, 40,872 veterans underwent catheterization. Of these, 8411 (20.6%) had no CAD, 5219 (17.7%) had 1V non-obstructive CAD, 3034 (10.3%) had 2V non-obstructive CAD, 1388 (4.7%) had 3V non-obstructive CAD, 8588 (29.1%) had 1V obstructive, 5227 (17.7%) had 2V obstructive, and 6017 (20.4%) had 3V/LM obstructive CAD. MACE rates progressively increased with increasing CAD severity (Figure). This association persisted after risk adjustment (HR 1.28 (1.08, 1.51) for 1V non-obstructive, 1.29 (1.08, 1.52) 2V non-obstructive, 1.44 (1.12, 1.86) 3V non-obstructive, 1.93 (1.64, 2.28) 1V obstructive, 2.73 (2.28, 3.27) 2V obstructive, and 2.98 (2.52, 3.53) 3V/LM obstructive CAD)). A trend toward higher MACE in moderate 3V non-obstructive compared to 1V obstructive CAD (HR 1.34 (0.71, 2.52)) was noted.

Conclusions: Non-obstructive CAD, relative to no CAD, is associated with 28-44% higher odds of MACE. MACE risk progressively increases by CAD extent, rather than abruptly increasing between non-obstructive and obstructive CAD. The risks of adverse events were similar for 3V non-obstructive CAD and 1V obstructive CAD, highlighting the limitations of a dichotomous characterization of angiographic CAD and a need to recognize the risks inherent in non-obstructive CAD.

Abstract 113: Pharmacists' Perspectives of an Intervention to Improve Medication Adherence after ACS Hospitalization A Qualitative Analysis

Background: Despite the success of pharmacist-led interventions to improve medication adherence, pharmacists’ perspectives of these interventions are unknown. Our objective was to understand the pharmacists’ perspectives of a successful multifaceted intervention to improve medication adherence after acute coronary syndrome (ACS) hospitalization.

Methods: We ascertained pharmacist perspectives’ through qualitative inquiry that included an open-ended survey, semi-structured interviews, and a focus group with the four pharmacists who participated in the intervention. Transcripts of surveys and interviews were analyzed using a content analysis approach. The intervention components included: 1) patient education; 2) assessment tools for potential medication adherence barriers; 3) collaborative care; and 4) automated medication refill reminders and educational messages. Pharmacists’ perspectives on each of these components were evaluated.

Results: The pharmacists felt the intervention could be sustained in routine clinical care and identified key themes that facilitated intervention success. Pharmacists believed educating patients about their cardiovascular medications filled a gap in usual care. In addition, assessment tools that identified medication discrepancies and gaps in knowledge were helpful in tailoring patient education, while face-to-face conversations were more helpful in identifying mental and cognitive deficits that were barriers to adherence. Pharmacists also noted that the intervention led to the development of bi-directional relationships with patients through increased in-person and tele-health communication. As a result, poor adherence related to medication side effects was more readily addressed. Potential areas for improvement identified by the pharmacists included 1) emphasizing in-person visits to build relationships (begin the educational process while the patient is hospitalized and schedule both the follow-up clinic appointment and pharmacy visit at the same time); 2) utilizing the patient centered medical home concept to improve access to providers; 3) allowing sites to determine provider type to support the personal contact (i.e. pharmacist, nurse practitioner, registered nurse); and 4) employing interactive voice response (IVR) technology to facilitate communication.

Conclusions: Pharmacists’ perspectives of a medication adherence intervention gave insights into reasons for the intervention success and suggestions for improvements and dissemination. We found that in-person meetings between pharmacists and patients led to bi-directional conversations and relationships with providers, which positively influenced patient adherence behavior. Future interventions designed to improve medication adherence should incorporate these pharmacist-identified factors.

Abstract 283: Health Status Outcomes in Acute Myocardial Infarction Patients Following Rehospitalization for Unplanned Revascularization or Unstable Angina

Background: Rehospitalizations for unplanned coronary revascularization and unstable angina (UA) among patients after myocardial infarction (MI) are common. The association of these events with health status is unknown.

Methods: Patients with MI were enrolled between 2005 and 2008 in the TRIUMPH registry-a prospective, 24 center U.S. study. Follow-up was attempted on all survivors at 1, 6 and 12 months after index MI admission. Data on all reported re-hospitalizations were adjudicated. Staged revascularizations and elective coronary artery bypass grafts performed within the first month after the index MI were excluded. Health status was assessed using the Seattle Angina Questionnaire (SAQ) and Euroqol-5D Visual Analog Scale (EQ-5D VAS). One-year health status was compared between those who did and did not experience a rehospitalization due to a coronary revascularization or UA using hierarchical, repeated measures analyses in 2 propensity-matched cohorts created for each of these events.

Results: A total of 3,283 MI patients were analyzed; mean age was 59 years, 33% were female and 70% were Caucasian. In the year following the MI there were 144 (4.4%) re-hospitalizations for unplanned coronary revascularization and 140 (4.3%) for UA. Baseline health status was comparable between patients with and without re-hospitalizations. In contrast, SAQ summary scores at 1 year post-MI were lower in patients with re-hospitalizations for unplanned revascularization (-10.1; 95% CI -12.4, -7.9) and UA readmissions (mean difference -6.9; 95% CI -9.1, -4.7) vs. those without. Similarly, EQ-5D VAS scores were lower among patients with readmissions for unplanned revascularization and UA readmissions (Table). Individual domains of the SAQ score indicated higher angina frequency, worse quality of life, and more physical limitations over the year following the index MI among patients re-hospitalized for UA and revascularization.

Conclusions: Rehospitalizations within the first year following a MI for unplanned coronary revascularization and UA are associated with more angina and worse health status. Whether more aggressive treatment of patients’ health status can prevent these events, or if preventing these events can improve patients’ health status, requires further study.

Abstract 27: Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction

Background: Cardiac rehabilitation (CR) is a class Ia recommendation and endorsed performance measure for the quality of care in acute myocardial infarction (AMI) survivors. While participation in CR after AMI is associated with reduced mortality, conflicting data exists on its association with health status outcomes.

Methods: Using data from 2 prospective AMI registries (TRIUMPH and PREMIER), we identified patients for whom baseline and follow-up health status scores and documentation of CR participation (attendance of 1 or more sessions within 6 months post-AMI) were available. Health status was assessed by four Seattle Angina Questionnaire (SAQ) domain scores (quality of life [QoL], angina frequency [AF], treatment satisfaction [TS], and physical limitation [PL]), as well as SF-12 physical and mental health composite scores ( PCS & MCS ). We created propensity matched cohorts of CR participants and non-participants to examine the association between CR participation with health status (6 and 12 months) and all-cause mortality (up to 7 years), using conditional repeated measures and proportional hazards models, respectively.

Results: Among 3,957 AMI patients from 31 sites, 2,015 patients (51%) participated in CR after discharge. Compared to non-participants, CR participants were more often Caucasian (83.6% vs. 65.4%), had higher rates of health insurance (90.6% vs. 79.3%), but clinically similar baseline SAQ and SF-12 scores in all domains. After propensity matching, all covariates were well-balanced (Standardized Difference <10 for all patient characteristics) between CR participants and non-participants. In the repeated measures analysis, the mean SAQ and SF-12 domain scores were clinically similar for both groups at 6 and 12 months after hospital discharge (Table). Using a conditional proportional hazards model, a decrease in all-cause mortality was noted in the CR participant group (HR 0.59, 95% CI [0.46, 0.75]).

Conclusion: In a large, multi-center AMI cohort, we found that although CR participation seemed to improve survival, CR participants had similar health status improvements after AMI as non-participants. Further investigation is required to identify how CR programs can further maximize the health status benefits to post-AMI participants.

Abstract 370: Temporal Variation in Clopidogrel Filling Delays after Percutaneous Coronary Intervention Hospital Discharge: Insights from the VA CART

Background: A prior study demonstrated significant variation between hospitals in the proportion of patients who delay filling a clopidogrel prescription after percutaneous coronary intervention (PCI). We assessed whether this variation changes over time.

Methods: Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we determined the hospital proportion of patients with a clopidogrel filling delay at the 62 VA cath labs performing at least 20 PCI annually between October 1, 2009 and September 30, 2012. Delay was defined as filling a clopidogrel prescription any time after the day of PCI hospital discharge. We categorized hospitals into quintiles based on the proportion of patients with delay in 6-month time intervals for each hospital and assessed whether hospitals changed quintiles over time.

Results: There were 31,002 PCIs performed from 2009-2012 at 62 PCI sites with an average number of 170.3 (sd. 99.3, median149.5) PCIs performed annually. Patient characteristics included: average age 65.2 ±9.0, 1.7% were women, 48.0% were diabetic, and 33.6% had prior history of MI. 26.7% (n=8,272) of PCIs were performed for acute coronary syndrome (ACS). The mean and median proportion of patients who delayed was 9.2% (7.5%) and by quintiles was: Q5 - 16.6% (15.3%), Q4 - 11.3% (10.2%), Q3 - 8.3% (7.8%), Q2 - 6.4% (6.2%), Q1 - 3.5% (3.6%). Over the 3 years of follow-up, 14 sites remained in the same quintile (9 in the highest, 1 in the third, 1 in the second, and 3 in the lowest quintile) and 48 sites moved between quintiles. In addition, 18 hospitals had increasing proportion of patients with delay, 14 hospitals had decreasing, while the rest of the hospitals (n=30) had fluctuating proportions of patients with delay over time.

Conclusion: There is significant temporal variation in clopidogrel delays across PCI hospitals. Future studies should assess what types of processes of care are being implemented at hospitals with low or decreasing rates of clopidogrel delay over time. In addition, these finding highlight an opportunity to implement quality improvement efforts at hospitals with persistently high or increasing rates of clopidogrel delay over time.

Figure 1. Hospital Level Proportion of Delay in 14 Sites That Stayed Within Quintile

Abstract 183: Optimal Medical Therapy for Cardiovascular Disease in the Obese Undergoing Elective Percutaneous Coronary Intervention: Insights from the VA CART Program

Background: Stigma against obese patients is well described in primary care settings and may contribute to bias in therapeutic decision-making. It is unknown if similar stigma exists in obese patients referred for elective PCI. Accordingly, we evaluated the association between body mass index (BMI) and pre-procedural guideline-recommended medication use in patients undergoing elective PCI. The presence of lower medication use in overweight and obese patients may suggest the presence of a treatment bias.

Methods: Using data from the VA Clinical Assessment, Reporting, and Tracking System (CART) Program, we identified patients undergoing elective PCI from 2007-2012. We classified patients by BMI into normal (19-25), overweight (25-30), obese (>30). Rates of guideline-indicated medication use by BMI were assessed among eligible patients: beta-blockers (BB) for HF or prior MI, statins for CAD or equivalent (DM, CVD, PAD), anticoagulation for AFib and CHADS2> 1, and ACEI/ARB for HF. We also assessed composite rates of BB and statin in eligible MI patients and BB and ACEI/ARB use in eligible HF patients, respectively. Multivariable logistic regression analyses assessed the association between BMI class and use of indicated medications.

Results: Among 9,630 patients undergoing elective PCI from 2007-2012, 13.9% of patients had normal BMI, 35.6% overweight, and 50.6% obese. Overweight and obese patients were more likely to have sleep apnea, HTN and DM, while normal BMI patients were more likely to smoke, have lung disease, and CVD. Rates of medication use ranged from 45% to 69% depending on the class of medication assessed. After adjustment for CV risk factors, overweight and obese patients were more likely to receive statins and ACE/ARBs and equally likely to receive the other classes of medications compared to normal BMI patients (Table).

Conclusions: Over 85% of patients undergoing elective PCI in the VA are overweight or obese. Rates of indicated medication use remained low across BMI categories (<70%). There was an association between overweight and obese patients with greater use of some guideline-indicated medications, suggesting that a treatment bias against obesity prior to elective PCI does not exist. Future studies should assess for any impact of BMI on treatment of patients during and following elective PCI.

Abstract 271: Anti-coagulation and Ischemic Stroke Risk in Patients with Chronic Kidney Disease and Atrial Fibrillation: Insights from the Kaiser Permanente Colorado Atrial Fibrillation Registry

Background: There is uncertainty about the benefits of anticoagulation therapy for stroke reduction in CKD patients with atrial fibrillation. Accordingly, we assessed the association between anticoagulation use and stroke risk in CKD patients with atrial fibrillation.

Methods: The Kaiser Permanente Colorado Atrial Fibrillation Registry is comprised of patients with incident atrial fibrillation between January 1, 2006 and June 30, 2012 from Kaiser Permanente Colorado. Incident atrial fibrillation was defined by ICD-9 codes 427.31 (Atrial Fibrillation) or 427.32 (Atrial Flutter) and without a diagnosis in the prior year. Patients with mitral valve replacement, renal transplant, or use of anticoagulants other than warfarin were excluded. CKD status was determined by ICD-9 codes or by two consecutive outpatient laboratory results with estimated glomerular filtration rate < 60 ml/min/1.73m2 by the CKD-EPI equation. The primary outcome was ischemic stroke identified by ICD-9 codes and validated by chart review. We assessed the association between warfarin use and ischemic stroke in patients with and without CKD using Cox proportional hazards models adjusted for CHA2DS2-VASc score and an interaction for warfarin use and CKD.

Results: Of 5,728 patients with incident atrial fibrillation, 2,070 (36.1%) had CKD. Patients with CKD were older, more likely to be female, had a higher CHA2DS2-VASc score, and were more likely to receive warfarin than those without CKD (see Table). During a mean follow up of 2.6 years (SD 1.8 years), stroke occurred in 49 (2.4%) patients with CKD and 83 (2.3%) patients without CKD. In multivariable analysis adjusting for CHA2DS2-VASc score, warfarin use was associated with lower hazard of stroke (HR 0.36; 95% CI 0.24 - 0.53). When stratified by CKD status, warfarin use remained associated with lower hazard of stroke in CKD (HR 0.35; 95% CI 0.18 - 0.66) and non CKD (HR 0.36; 95% CI 0.22 - 0.60) patients.

Conclusion: 1 in 3 patients with atrial fibrillation have CKD. There were similar reductions in the risk of stroke associated with warfarin use for CKD and non-CKD patients. These findings reinforce current clinical practice guidelines, which recommend warfarin use based on thromboembolic risk without consideration for CKD status.

Abstract 153: Stress Testing Following PCI in the VA Health Care System: Insights from the VA CART Program

Background: Use of stress testing following percutaneous coronary intervention (PCI) is common in community practice with 60% of patients undergoing stress testing within 24 months of PCI. Rates of stress testing following PCI within integrated and salaried healthcare systems like the VA are unknown.

Methods: Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had PCI from October 2007-September 2011. We assessed the proportion of patients undergoing stress testing, stress test type, and timing of stress testing in the 2 years following PCI. To be consistent with prior studies, we excluded stress tests performed within 60 days of PCI as these may reflect assessment of residual ischemia in anticipation of staged procedures. Timing of follow-up stress testing was determined from 30-day incremental windows of follow-up.

Results: Overall, 7,145 of 21,635 patients (33.0%) had a stress test performed within 2 years of PCI. The vast majority of stress tests following PCI were performed with nuclear imaging (80.8%). Treadmill stress ECG without imaging represented 15.2% of stress tests and stress echo 3.9%. Patients undergoing stress testing in follow-up were younger (63.4 vs 65.7 years, P<.001) and less likely to have comorbid congestive heart failure (21.8% vs 25.1%, P<.001) or chronic obstructive pulmonary disease (23.2% vs 25.5%, P<.001). In 30-day incremental windows of follow-up, first stress tests were most commonly performed in the 60-90 days following PCI (Figure).

Conclusions: About 1 in 3 patients had a stress test performed in the 2 years following PCI in the VA. This rate is nearly half that reported from prior studies of community practice. Further study is needed to understand if this represents underuse of stress testing in VA or overuse in fee-for-service care.

Adherence to dabigatran therapy and longitudinal patient outcomes: insights from the veterans health administration

BACKGROUND

Dabigatran is a novel oral anti-coagulant (NOAC) that reduces risk of stroke in patients with non-valvular atrial fibrillation (NVAF). It does not require routine monitoring with laboratory testing which may have an adverse impact on adherence. We aimed to describe adherence to dabigatran in the first year after initiation and assess the association between non-adherence to dabigatran and clinical outcomes in a large integrated healthcare system.

METHODS

We studied a national cohort of 5,376 patients with NVAF, initiated on dabigatran between October-2010 and September-2012 at all Veterans Affairs hospitals. Adherence to dabigatran was calculated as proportion of days covered (PDC) and association between PDC and outcomes was assessed using standard regression techniques.

RESULTS

Mean age of the study cohort was 71.3 ± 9.7 years; 98.3% were men and mean CHADS2 score was 2.4 ± 1.2 (mean CHA2DS2VASc score 3.2 ± 1.4). Median PDC was 94% (IQR 76%-100%; mean PDC 84% ± 22%) over a median follow-up of 244 days (IQR 140-351). A total of 1,494 (27.8%) patients had a PDC <80% and were classified as non-adherent. After multivariable adjustment, lower adherence was associated with increased risk for combined all-cause mortality and stroke (HR 1.13, 95% CI 1.07-1.19 per 10% decrease in PDC). Adherence to dabigatran was not associated with non-fatal bleeding or myocardial infarction.

CONCLUSIONS

In the year after initiation, adherence to dabigatran for a majority of patients is very good. However, 28% of patients in our cohort had poor adherence. Furthermore, lower adherence to dabigatran was associated with increased adverse outcomes. Concerted efforts are needed to optimize adherence to NOACs.

Estimating the effects of time-varying exposures in observational studies using Cox models with stabilized weights adjustment

PURPOSE

Assessing 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.

RESULTS

We 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.

Multifaceted intervention to improve medication adherence and secondary prevention measures after acute coronary syndrome hospital discharge: a randomized clinical trial

IMPORTANCE

Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor.

OBJECTIVE

To test a multifaceted intervention to improve adherence to cardiac medications.

DESIGN, SETTING, AND PARTICIPANTS

In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge.

INTERVENTIONS

The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls).

MAIN OUTCOMES AND MEASURES

The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P< .001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P = .03), statins (93.2% vs 71.3%; P < .001), and ACEI/ARB (93.1% vs 81.7%; P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals.

CONCLUSIONS AND RELEVANCE

A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00903032.

Association between hyperglycemia at admission during hospitalization for acute myocardial infarction and subsequent diabetes: insights from the veterans administration cardiac care follow-up clinical study

OBJECTIVE

Among patients with acute myocardial infarction (AMI) without known diabetes, hyperglycemia at admission is common and associated with worse outcomes. It may represent developing diabetes, but this association is unclear. Therefore, we examined the association between hyperglycemia (≥140 mg/dL) at admission and evidence of diabetes among patients with AMI without known diabetes within 6 months of their hospitalization.

RESEARCH DESIGN AND METHODS

We studied a national cohort of consecutive patients with AMI without known diabetes presenting at 127 Veterans Affairs hospitals between October 2005 and March 2011. Evidence of diabetes either at discharge or in the following 6 months was ascertained using diagnostic codes, medication prescriptions, and/or elevated hemoglobin A1c. Association between hyperglycemia at admission and evidence of diabetes was evaluated using regression modeling.

RESULTS

Among 10,499 patients with AMI without known diabetes, 98% were men and 1,761 (16.8%) had hyperglycemia at admission. Within 6 months following their index hospitalization, 208 patients (11.8%) with hyperglycemia at admission had evidence of diabetes compared with 443 patients (5.1%) without hyperglycemia at admission (P < 0.001). After multivariable adjustment, hyperglycemia at admission was significantly associated with subsequent diabetes odds ratio 2.56 (95% CI 2.15-3.06). Among those with new evidence of diabetes, 41% patients (267 of 651) had a hemoglobin A1c ≥6.5% without accompanying diagnostic codes or medication prescriptions, suggesting they had unrecognized diabetes.

CONCLUSIONS

Hyperglycemia at admission occurred in one of six patients with AMI without known diabetes and was significantly associated with new evidence of diabetes in the 6 months following hospitalization. In addition, two of five patients with evidence of diabetes were potentially unrecognized. Accordingly, diabetes-screening programs for hyperglycemic patients with AMI may be an important component of optimal care.

Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels

IMPORTANCE

Rates of testosterone therapy are increasing and the effects of testosterone therapy on cardiovascular outcomes and mortality are unknown. A recent randomized clinical trial of testosterone therapy in men with a high prevalence of cardiovascular diseases was stopped prematurely due to adverse cardiovascular events raising concerns about testosterone therapy safety.

OBJECTIVES

To assess the association between testosterone therapy and all-cause mortality, myocardial infarction (MI), or stroke among male veterans and to determine whether this association is modified by underlying coronary artery disease.

DESIGN, SETTING, AND PATIENTS

A retrospective national cohort study of men with low testosterone levels (<300 ng/dL) who underwent coronary angiography in the Veterans Affairs (VA) system between 2005 and 2011.

MAIN OUTCOMES AND MEASURES

Primary outcome was a composite of all-cause mortality, MI, and ischemic stroke.

RESULTS

Of the 8709 men with a total testosterone level lower than 300 ng/dL, 1223 patients started testosterone therapy after a median of 531 days following coronary angiography. Of the 1710 outcome events, 748 men died, 443 had MIs, and 519 had strokes. Of 7486 patients not receiving testosterone therapy, 681 died, 420 had MIs, and 486 had strokes. Among 1223 patients receiving testosterone therapy, 67 died, 23 had MIs, and 33 had strokes. At 3 years after coronary angiography, the Kaplan-Meier estimated cumulative percentages with events were 19.9%in the no testosterone therapy group vs 25.7%in the testosterone therapy group,with an absolute risk difference of 5.8%(95%CI, -1.4%to 13.1%) [corrected].The Kaplan-Meier estimated cumulative percentages with events among the no testosterone therapy group vs testosterone therapy group at 1 year after coronary angiography were 10.1% vs 11.3%; at 2 years, 15.4% vs 18.5%; and at 3 years, 19.9% vs 25.7 [corrected].There was no significant difference in the effect size of testosterone therapy among those with and without coronary artery disease (test for interaction, P = .41).

CONCLUSIONS AND RELEVANCE

Among a cohort of men in the VA health care system who underwent coronary angiography and had a low serum testosterone level, the use of testosterone therapy was associated with increased risk of adverse outcomes. These findings may inform the discussion about the potential risks of testosterone therapy.

Variations in coronary artery disease secondary prevention prescriptions among outpatient cardiology practices: insights from the NCDR (National Cardiovascular Data Registry)

OBJECTIVES

This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.

BACKGROUND

Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.

METHODS

Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.

RESULTS

Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.

CONCLUSIONS

Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

Failure to reassess ejection fraction after acute myocardial infarction in potential implantable cardioverter/defibrillator candidates: insights from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health Status (TRIUMPH) registry

BACKGROUND

Current practice guidelines advocate delaying assessment of primary prevention implantable cardioverter/defibrillator (ICD) candidacy at least 40 days after an acute myocardial infarction (AMI) because early ICD implantation after AMI has not demonstrated survival benefit. The rate at which interval reassessment of left ventricular ejection fraction (LVEF) occurs in potential primary prevention ICD candidates is unknown.

METHODS

We examined patients with AMI in the TRIUMPH registry with inhospital LVEF <40% discharged alive after their index presentation, excluding patients with a prior ICD and those who declined ICD during the index admission or were discharged to hospice. We conducted multivariable Poisson modeling to identify independent factors associated with LVEF reassessment by 6 months after AMI.

RESULTS

Of the 533 patients meeting the inclusion criteria, only 187 (35.1%) reported LVEF reassessment in the first 6 months after AMI and only 13 patients (2.4%) underwent ICD implantation by 1 year. In multivariable analysis, early cardiology follow-up after AMI was associated with a higher likelihood of LVEF reassessment (odds ratio 1.16, 95% confidence interval 1.06-1.28), whereas uninsured status and cardiologist-driving inpatient medical decision making were associated with a lower likelihood of LVEF reassessment (odds ratios 0.84 [95% CI 0.74-0.96] and 0.78 [95% CI 0.68-0.91], respectively).

CONCLUSIONS

In contemporary practice, almost 2 of 3 potential primary prevention ICD candidates did not report follow-up LVEF evaluation, with a very low rate of ICD implantation at 1 year. These results suggest an important gap in quality, highlighting the need for better transitions of care.

Chronic kidney disease is associated with adverse outcomes among elderly patients taking clopidogrel after hospitalization for acute coronary syndrome

BACKGROUND

Chronic kidney disease (CKD) is associated with worse outcomes among patients with acute coronary syndrome (ACS). Less is known about the impact of CKD on longitudinal outcomes among clopidogrel treated patients following ACS.

METHODS

Using a retrospective cohort design, we identified patients hospitalized with ACS between 10/1/2005 and 1/10/10 at Department of Veterans Affairs (VA) facilities and who were discharged on clopidogrel. Using outpatient serum creatinine values, estimated glomerular filtration rate [eGFR (1.73 ml/min/m2)] was calculated using the CKD-EPI equation. The association between eGFR and mortality, hospitalization for acute myocardial infarction (AMI), and major bleeding were examined using Cox proportional hazards models.

RESULTS

Among 7413 patients hospitalized with ACS and discharged taking clopidogrel, 34.5% had eGFR 30-60 and 11.6% had eGFR < 30. During 1-year follow-up after hospital discharge, 10% of the cohort died, 18% were hospitalized for AMI, and 4% had a major bleeding event. Compared to those with eGFR > =60, individuals with eGFR 30-60 (HR 1.45; 95% CI: 1.18-1.76) and < 30 (HR 2.48; 95% CI: 1.97-3.13) had a significantly higher risk of death. A progressive increased risk of AMI hospitalization was associated with declining eGFR: HR 1.20; 95% CI: 1.04-1.37 for eGFR 30-60 and HR 1.47; 95% CI: 1.22-1.78 for eGFR < 30. eGFR < 30 was independently associated with over a 2-fold increased risk in major bleeding (HR 2.09; 95% CI: 1.40-3.12) compared with eGFR > = 60.

CONCLUSION

Lower levels of kidney function were associated with higher rates of death, AMI hospitalization, and major bleeding among patients taking clopidogrel after hospitalization for ACS.

Abstract 162: Procedural and 1-Year Outcomes between PCI Centers with and without On-Site CT Surgery: Insights from the VA CART Program

Background: Clinical trials demonstrate that percutaneous coronary intervention (PCI) can be safely performed at medical centers without on-site cardiothoracic (CT) surgery, and current PCI guidelines support this practice with effective quality oversight. Translation of these trial findings and guideline recommendations into clinical practice has not been described. In 2005, the VA initiated a policy to expand PCI access by performing procedures at centers without on-site CT surgery under strict quality standards. The impact of this policy on procedural and longer-term patient outcomes has not been evaluated.

Methods: We studied all PCIs conducted in the VA health care system between 2007-2010. We used data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program, a national clinical quality program that collects real-time data on coronary procedures, procedural complications, and outcomes. Procedural complications (need for emergent CABG and in-lab death), 1-year all-cause mortality, myocardial infarction (MI), and rates of repeat revascularization procedures were compared by presence of on-site CT surgery. We used multivariate survival analysis to assess the association between the presence of on-site CT surgery and 1-year outcomes. The analyses were further stratified by procedural indication (ACS vs. elective) and cath lab PCI volume (≥ vs. <165 PCIs/year).

Results: 24,387 patients received a PCI at 59 centers in the VA health care system between 2007-2010. 6,900 (28.3%) patients underwent PCI at 19 centers without on-site CT surgery. Rates of procedural complications were similar for PCI centers with and without on-site CT surgery (emergent CABG: 13 (0.1%) at PCI centers with on-site CT surgery vs. 2 (<0.05%) at PCI centers without on-site CT surgery, p-value 0.26; deaths: 15 (0.1%) at PCI centers with on-site CT surgery vs. 5 (0.1%) at PCI centers without on-site CT surgery, p-value 0.74). Adjusted 1-year combined all-cause mortality and MI rates were similar between centers (HR 0.995, 95% CI 0.84, 1.17), but revascularization rates were higher at sites without on-site CT surgery centers (HR 1.20, 95% CI 1.05, 1.33). Neither PCI indication nor cath lab volume significantly modified these results.

Conclusions: Our findings demonstrate that procedural and 1-year patient outcomes are similar between PCI centers with and without on-site CT surgery. These results indicate that the clinical trial evidence of PCI safety without on-site CT surgery can be effectively translated to clinical practice. The VA’s policy allowing for PCI centers without on-site CT surgery in the setting of a quality oversight program may serve as a potential model for improving PCI access in large, integrated health care systems.

Abstract 352: A Multimodal Radiation Reduction Intervention for Intra-procedural Radiation Exposure in Patients Undergoing Cardiac Catheterization in Veterans Affairs Hospitals

Background: Radiation exposure to patients from invasive cardiac procedures is substantial and contributes to a significant portion of overall radiation exposure from medical testing. Efforts to minimize intra-procedural radiation exposure are important for patient safety. This pilot study evaluated the effectiveness of a multimodal radiation intervention to reduce intra-procedural radiation exposure.

Methods: Two VA cardiac catheterization laboratories (Site 1, Site 2) were evaluated for baseline radiation dosing use over a three month period. Following this initial run-in period, the operators and cath lab staff underwent a three-tiered intervention: 1) radiation safety and minimization education, 2) an in-lab radiation monitoring protocol with verbal feedback at pre-specified radiation doses and 3) monthly site and provider-specific report cards comparing radiation dose at the site and provider level within the VA system. Radiation dosing (RD, measured as Dose-Area-Product [Gy*cm2]) was then measured following this intervention at monthly intervals over a three-month period.

Results: We examined 624 cases at Site 1 and 258 cases at Site 2 in the pre-intervention period, and 502 (site 1) and 208 (site 2) in the post-intervention period. Site 1 did not differ significantly in median RD following intervention (71.9 Gy*cm2 [IQR 48.0-114.0] pre-intervention versus 79.5 Gy*cm2 [IQR 50.0-124.8] post-intervention, p=0.34; see Fig 1). Site 2 showed a significant decrease in median radiation dose following intervention (118.72 Gy*cm2 [IQR 73.6-190.0] vs. 92.8 Gy*cm2 [IQR 56.6-158.3], p = 0.004, Fig 1). The national median radiation dose over the same time interval did not change significantly (91.53 Gy*cm2 [IQR 58.0-145.4] pre-intervention versus 90.0 Gy*cm2 [IQR 56.3-142.0] post-intervention, p=0.47, Fig 1).

Conclusion: A three-tiered, multi-modal radiation reduction intervention was associated with reduced radiation exposure in a laboratory with high baseline radiation utilization. Similar reductions were not observed in a laboratory with low baseline radiation utilization. These findings suggest that radiation reduction interventions targeted at higher radiation use centers may result in meaningful decreases in patient radiation exposure.

Abstract 105: Normal Coronary Rates for Elective Angiography in the VA Health Care System: Insights from the VA CART Program

Background. Prior studies have shown that rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. It has been suggested that this variation may in part reflect incentives in fee-for-service care. The rates of normal coronaries within an integrated healthcare system are unknown.

Methods. Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had elective coronary angiography from October 2007-September 2010 at the 76 VA cardiac catheterization labs. Normal coronary angiography was defined as <20% stenosis in all vessels. We assessed patients’ demographics, risk factors, noninvasive preprocedural testing, and angiographic findings. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries.

Results. Overall, 5,108 of 22,001 patients (22.8%) had normal coronary angiography. Hospital proportions of normal coronaries varied modestly (median hospital proportion 21.2%, interquartile range, 17.3% to 26.1% range, 7.9% to 56.6; Figure 1). Patients with normal coronaries were more likely to have low Framingham risk scores (36.6% versus 16.5%, p<0.001), less likely to undergo a preprocedural stress test (70.3% versus 77.8%, p<0.001), and among those with stress testing, less likely to have results positive for ischemia (42.6% versus 47.2%, p<0.001). By hospital quartile of normal coronary rates, patients at hospitals with lower normal coronary rates were more likely to undergo stress testing prior to angiography (79.8% vs. 78.6% vs. 77.4% vs. 64.4%, p<0.001).

Conclusions. About 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests barriers to consistent patient selection for diagnostic coronary angiography despite an integrated care delivery system.

Abstract 5: The Association between Patient Rural Status, Distance to Cath Lab, and Likelihood to Undergo Coronary Angiography: Insights from the VA CART Program

Background. Prior studies suggest rural patients are less likely to receive coronary procedures. This finding may represent the fact that rural patients live further than urban patients from the closest cath lab, but these studies failed to incorporate a direct measure of distance to cath lab. Accordingly, we incorporated patient distance to cath lab with rural location on the likelihood to undergo elective coronary angiography as a better explanation of this relationship.

Methods. Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all patients who underwent elective coronary angiography from October 2007 through September 2010. We calculated geodesic distance from patient home to cath. Patient rural status was determined using the VA Urban/Rural/Highly Rural (URH) system. Normal coronary angiography (an indirect measure of patient selection for elective coronary angiography) was defined as <20% stenosis in all vessels. Using generalized linear mixed modeling, we estimated the probability of angiographically normal coronaries as a function of distance to cath, modified by patient rural status.

Results. Among 22,523 patients undergoing elective coronary angiography, 22.8% of patients had normal coronaries. Rural patients were more likely to have high Framingham risk (highly rural 44.2% vs. rural 39.8% vs. urban 36.9%, p<0.001). Rural patients who lived further from cath labs were associated with a lower probability of normal coronaries compared to rural patients closer to cath labs and urban patients across all distances(p=0.0014). For patients living within 50 miles of a cath lab, urban/rural status did not influence the probability of normal coronary angiography. From 50 to 150 miles, rural patients were less likely to have normal coronaries at angiography. (Figure 1).

Conclusions. Among patients undergoing elective angiography in the VA, those who lived further from cath labs in rural locations were less likely to have normal coronaries. These findings suggest that patient location, rather than clinical factors, may affect the use of coronary procedures. Further study to understand the causes of this relationship, including potential for under- or over-use based on distance and rural status, may help optimize patient access for coronary procedures.

Abstract 184: Patterns of Outpatient Follow-up after Acute Myocardial Infarction: Follow-up Frequency is Associated with Utilization of Evidence-based Therapies

Background: ACC/AHA guidelines recommend that patients with acute myocardial infarction (AMI) follow-up within several weeks of hospital discharge. Recommendations regarding intensity of following-up in the year following AMI are not provided. The relationship between frequency of follow-up and use of evidence-based therapies following AMI is unknown.

Methods: 6,838 patients from 2 multicenter prospective AMI registries, PREMIER and TRIUMPH registries were studied. We divided the number of patient self-reported outpatient follow-up visits with cardiologists, primary care providers, or both into tertiles: low, medium, and high. The primary outcome was use of statins, beta blockers, aspirin, ACE/ARBs, and a composite of all four medications at 12 months among eligible patients. The association between tertiles of visits following AMI among patients who had at least one visit and primary outcome was evaluated using hierarchical multivariable modified Poisson models.

Results: Mean number of follow-up visits in the year following AMI was 6 (IQR 3 - 8) and 189 (4%) of patients had no visits. In lowest tertile, patients had 1 to < 4 visits, in the medium tertile, 4 to < 7 visits, and in highest tertile, 7 to 59 visits. Patients in medium and high intensity tertiles were older, more likely to have insurance, and had higher GRACE 6-month mortality risk scores compared to the lowest tertile. In multivariable analyses, patients in the medium tertile were more likely to use statins and ASA than those in the lowest tertile (Figure). There were no differences in use of individual medications when comparing the highest and medium tertiles although individuals in the highest tertile were less likely to use all four medications.

Conclusions: Significant variability exists in follow-up frequency following AMI and 4% of the cohort had no follow-up. Patients who had medium intensity visits were more likely to use some evidence-based medications than those with low intensity. Higher intensity visits was not associated with greater medication use. It is possible that the observed differences may be attributed to unmeasured differences among patients rather than the actual follow-up visits. Prospective studies are needed to assess key elements of outpatient visits that may lead to better utilization of evidence-based therapies.

Abstract 330: Hospital-Level Variation in One-Year Mortality and Angina Following Myocardial Infarction is Not Explained by In-Hospital Quality of Care in the TRIUMPH Registry

Background: Studies demonstrating variation in hospital quality of care using longitudinal outcomes have been limited in the amount of clinical data used to stratify patients’ risks and have not examined health status outcomes. We sought to describe hospital-level variation in risk-adjusted health status and mortality in the year following myocardial infarction (MI) and describe the extent to which hospital quality of care explains this variation.

Methods: 4,316 patients from the TRIUMPH registry, a prospective cohort study of MI patients at 24 hospitals, were included for analysis. Using hierarchical models, we described the hospital-level variation in angina (yes/no) and 1-year mortality rates. We then added hospital quality of care measures for MI applicable to the time period studied (ASA and beta blockers within 24 hours of arrival and at discharge, ACE/ARB at discharge, thrombolytics within 30 minutes, PCI within 90 minutes, and smoking cessation instructions at discharge) to these models to determine if hospital variation in one-year mortality and angina were explained by index MI quality of care.

Results: The mortality rate at one year was 6.2% and the incidence of angina at one year was 23.0%. Unadjusted hospital-level 1-year mortality ranged from 0% to 10.8% and unadjusted presence of angina ranged from 9.3% to 66.7%. Statistically significant hospital-level variation in one-year mortality and angina was observed, with risk-adjusted mortality rates ranging from 5% to 8.3% (p<0.0001) and risk-adjusted angina rates ranging from 17.6% to 31.9% (p<0.0001). In-hospital quality of care measures did not attenuate hospital-level variation in mortality or angina (Figure 1).

Conclusions: Hospital-level variation in 1-year mortality and angina was observed among the 24 hospitals participating in this MI registry. However, this variation was not explained by in-hospital MI performance measures. Future studies should assess care delivery factors that impact longitudinal outcomes following MI.

Comparative effectiveness of 2 β-blockers in hypertensive patients

BACKGROUND

Randomized controlled trials have demonstrated the efficacy of selected β-blockers for preventing cardiovascular (CV) events in patients following myocardial infarction (MI) or with heart failure (HF). However, the effectiveness of β-blockers for preventing CV events in patients with hypertension has been questioned recently, but it is unclear whether this is a class effect.

METHODS

Using electronic medical record and health plan data from the Cardiovascular Research Network Hypertension Registry, we compared incident MI, HF, and stroke in patients who were new β-blocker users between 2000 and 2009. Patients had no history of CV disease and had not previously filled a prescription for a β-blocker. Cox proportional hazards regression was used to examine the associations of atenolol and metoprolol tartrate with incident CV events using both standard covariate adjustment (n = 120,978) and propensity score-matching methods (n = 22,352).

RESULTS

During follow-up (median, 5.2 years), there were 3517 incident MI, 3272 incident HF, and 3664 incident stroke events. Hazard ratios for MI, HF, and stroke in metoprolol tartrate users were 0.99 (95% CI, 0.97-1.02), 0.99 (95% CI, 0.96-1.01), and 0.99 (95% CI, 0.97-1.02), respectively. An alternative approach using propensity score matching yielded similar results in 11,176 new metoprolol tartrate users, who were similar to 11,176 new atenolol users with regard to demographic and clinical characteristics.

CONCLUSIONS

There were no statistically significant differences in incident CV events between atenolol and metoprolol tartrate users with hypertension. Large registries similar to the one used in this analysis may be useful for addressing comparative effectiveness questions that are unlikely to be resolved by randomized trials.

Health system factors and antihypertensive adherence in a racially and ethnically diverse cohort of new users

BACKGROUND

The purpose of this study was to identify potential health system solutions to suboptimal use of antihypertensive therapy in a diverse cohort of patients initiating treatment.

METHODS

Using a hypertension registry at Kaiser Permanente Northern California, we conducted a retrospective cohort study of 44 167 adults (age, ≥18 years) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between race/ethnicity, specific health system factors, and early nonpersistence (failing to refill the first prescription within 90 days) and nonadherence (<80% of days covered during the 12 months following the start of treatment), respectively, controlling for sociodemographic and clinical risk factors.

RESULTS

More than 30% of patients were early nonpersistent and 1 in 5 were nonadherent to therapy. Nonwhites were more likely to exhibit both types of suboptimal medication-taking behavior compared with whites. In logistic regression models adjusted for sociodemographic, clinical, and health system factors, nonwhite race was associated with early nonpersistence (black: odds ratio, 1.56 [95% CI, 1.43-1.70]; Asian: 1.40 [1.29-1.51]; Hispanic: 1.46 [1.35-1.57]) and nonadherence (black: 1.55 [1.37-1.77]; Asian: 1.13 [1.00-1.28]; Hispanic: 1.46 [1.31-1.63]). The likelihood of early nonpersistence varied between Asians and Hispanics by choice of first-line therapy. In addition, racial and ethnic differences in nonadherence were appreciably attenuated when medication co-payment and mail-order pharmacy use were accounted for in the models.

CONCLUSIONS

Racial/ethnic differences in medication-taking behavior occur early in the course of treatment. However, health system strategies designed to reduce patient co-payments, ease access to medications, and optimize the choice of initial therapy may be effective tools in narrowing persistent gaps in the use of these and other clinically effective therapies.

Modifiable factors associated with failure to attain low-density lipoprotein cholesterol goal at 6 months after acute myocardial infarction

BACKGROUND

Although controversial, reducing low-density lipoprotein cholesterol (LDL-C) to target levels remains a common therapeutic goal after acute myocardial infarction (AMI). We sought to illuminate patient and provider characteristics associated with LDL-C goal nonattainment after AMI.

METHODS

In an observational registry of 24 US hospitals, we included 366 patients with AMI who had baseline LDL-C levels ≥100 mg/dL and underwent 6-month fasting LDL-C reassessment. Our primary outcome was failure to reach the guideline-recommended LDL-C goal of <100 mg/dL at 6 months post-AMI.

RESULTS

One in 3 patients with AMI with initially elevated LDL-C failed to attain LDL-C goal at 6 months. Compared with those who attained LDL-C goal, those who did not were more often discharged without a statin (21% vs 9%, P < .001), despite only 4% having documented contraindications. Patients not achieving LDL-C goal also more frequently discontinued statin use by 6 months (24% vs 6%, P < .001). Multivariable modeling (c index, 0.78) revealed the absence of a statin prescription at discharge and lack of persistence on statin therapy as the strongest independent factors associated with failure to reach LDL-C goal. Additional independent risk factors were patient report of not consistently adhering to prescribed medications, not participating in cardiac rehabilitation, nonwhite race, and lack of insurance.

CONCLUSIONS

One-third of patients with AMI with baseline hyperlipidemia do not attain the LDL-C goal of <100 mg/dL at 6 months. Our findings support targeted interventions in the transition of AMI care to promote affordable statin prescription at discharge, medication persistence and adherence, and cardiac rehabilitation participation.

Hospital length of stay in patients with non-ST-segment elevation myocardial infarction

PURPOSE

Substantial heterogeneity in hospital length of stay exists among patients admitted with non-ST-segment elevation myocardial infarction. Furthermore, little is known about the factors that impact length of stay.

METHODS

We examined 39,107 non-ST-segment elevation myocardial infarction patients admitted to 351 Acute Coronary Treatment Intervention Outcomes Network Registry-Get With The Guidelines hospitals from January 1, 2007-March 31, 2009 who underwent cardiac catheterization and survived to discharge. Length of stay was categorized into 4 groups (≤2, 3-4, 5-7, and ≥8 days), where prolonged length of stay was defined as >4 days.

RESULTS

The overall median (25(th), 75(th)) length of stay was 3 (2, 5) days. Patients with a length of stay of >2 days were older with more comorbidities, but were less likely to receive evidence-based therapies or percutaneous coronary intervention. Among the factors associated with prolonged length of stay >4 days were delay to cardiac catheterization >48 hours, heart failure or shock on admission, female sex, insurance type, and admission to the hospital on a Friday afternoon or evening. Hospital characteristics such as academic versus nonacademic or urban versus rural setting, were not associated with prolonged length of stay.

CONCLUSION

Patients with longer length of stay have more comorbidities and in-hospital complications, yet paradoxically, are less often treated with evidence-based medications and are less likely to receive percutaneous coronary intervention. Hospital admission on a Friday afternoon or evening and delays to catheterization appear to significantly impact length of stay. A better understanding of factors associated with length of stay in patients with non-ST-segment elevation myocardial infarction is needed to promote safe and early discharge in an era of increasingly restrictive health care resources.

Clopidogrel Use and Hospital Quality in Medically Managed Patients With Non–ST-Segment–Elevation Myocardial Infarction

Background—

Clopidogrel prescription is a class I guideline recommendation for medically managed patients with non–ST-segment–elevation myocardial infarction (NSTEMI). However, clopidogrel has historically been underused in this population. We evaluated contemporary rates of its use and evaluated associated factors, with a particular focus on hospital quality of myocardial infarction (MI) care.

Methods and Results—

We examined clopidogrel prescription rates among 23 186 patients with NSTEMI discharged from 382 US hospitals between October 2009 and March 2011. Associations between clopidogrel prescription and various patient and hospital factors, including hospital quality of MI care, were determined with regression modeling. Of the sample, 54.9% of eligible patients with NSTEMI received clopidogrel prescription at hospital discharge. Variation in rate by hospital was large, ranging from 22% to 97%. A variety of patient and hospital factors were associated with clopidogrel prescription. Hospital quality of MI care demonstrated modest association with clopidogrel prescription (odds ratio, 0.68; 95% CI, 0.54–0.85) between the lowest and highest hospital quality quartile) and accounted for 5.7% of the variation in prescription rates.

Conclusions—

Clopidogrel prescription is significantly underused in the medically managed NSTEMI population and demonstrates wide variability by hospital. Although hospital quality of MI care is associated with its use, the findings suggest that it only has a modest effect. Therefore, efforts to improve clopidogrel use likely will require measures beyond improving the overall hospital quality of MI care.

Patient-Centered Adherence Intervention After Acute Coronary Syndrome Hospitalization

Background—

Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications.

Methods and Results—

To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care.

Conclusions—

If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.

The association between medication adherence and treatment intensification with blood pressure control in resistant hypertension

Patients with resistant hypertension are at risk for poor outcomes. Medication adherence and intensification improve blood pressure (BP) control; however, little is known about these processes or their association with outcomes in resistant hypertension. This retrospective study included patients from 2002 to 2006 with incident hypertension from 2 health systems who developed resistant hypertension or uncontrolled BP despite adherence to ≥3 antihypertensive medications. Patterns of hypertension treatment, medication adherence (percentage of days covered), and treatment intensification (increase in medication class or dose) were described in the year after resistant hypertension identification. Then, the association between medication adherence and intensification with 1-year BP control was assessed controlling for patient characteristics. Of the 3550 patients with resistant hypertension, 49% were male, and mean age was 60 years. One year after resistance hypertension determination, fewer patients were taking diuretics (77.7% versus 92.2%; P<0.01), β-blockers (71.2% versus 79.4%; P<0.01), and angiotensinogen-converting enzyme inhibitor/angiotensin receptor blocker (64.8% versus 70.1%; P<0.01) compared with baseline. Rates of BP control improved over 1 year (22% versus 55%; P<0.01). During this year, adherence was not associated with 1-year BP control (adjusted odds ratio, 1.18 [95% CI: 0.94-1.47]). Treatment was intensified in 21.6% of visits with elevated BP. Increasing treatment intensity was associated with 1-year BP control (adjusted odds ratio, 1.64 [95% CI, 1.58-1.71]). In this cohort of patients with resistant hypertension, treatment intensification but not medication adherence was significantly associated with 1-year BP control. These findings highlight the need to investigate why patients with uncontrolled BP do not receive treatment intensification.

A comparison between antihypertensive medication adherence and treatment intensification as potential clinical performance measures

BACKGROUND

Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care provided. Whereas previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure (BP) control at the patient level, less is known about whether adherence and TI is associated with BP control at the clinic level.

METHODS AND RESULTS

We included 162 879 patients among 89 clinics in the Cardiovascular Research Network Hypertension Registry with incident hypertension who were started on antihypertensive medications. Adherence was measured by the proportion of days covered (PDC). TI was defined by the standard based method with scores ranging between -1 to 1 and categorized as: -1 indicated no TI occurred when BP was elevated; 0 indicated TI occurred when BP was elevated; and 1 indicated that TI was made at all visits, even when BP was not elevated. Logistic regression models assessed the association between adherence and TI with blood pressure control (BP ≤ 140/90 at the clinic visit closest to 12 months after study entry) at the patient and clinic levels. Mean adherence was 0.77 ± 0.28 (PDC ± SD) at the patient level and 0.78 ± 0.05 at the clinic level. Mean TI was 0.026 ± 0.23 at the patient level and 0.01 ± 0.04 at the clinic level. At the patient level, for each 0.25 increase in adherence and TI, the odds (OR) of achieving blood pressure control increased by 28% and 55%, respectively [OR for adherence, 1.28 (1.26-1.29), and for TI, 1.55 (1.53-1.57)]. At the clinic level, each 0.04 increment increase in treatment intensification was associated with a 25% increased odds of achieving blood pressure control (OR, 1.24; 95% CI, 1.21-1.27). In contrast, there was an inverse association between increasing adherence and BP control (OR, 0.93; 95% confidence interval, 0.90-0.95).

CONCLUSIONS

Patient adherence to antihypertensive medications is not associated with BP control at the clinic level and may not be suitable as a performance measure. TI is associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.

Abstract 40: Hospital Variation in Premature Clopidogrel Discontinuation following Drug Eluting Stent Placement and Adverse Cardiovascular Outcomes from the VA Clinical Assessment, Reporting, and Tracking System for Cath Labs (CART-CL)

Background: Clopidogrel is recommended for 1 year following drug eluting stent (DES) placement and premature discontinuation has been associated with adverse outcomes. The extent of variation in premature discontinuation across hospitals within an integrated healthcare system is unknown. Accordingly, we assessed variation in premature clopidogrel discontinuation across all VA PCI sites and whether there was an association between hospitals with higher rates of premature discontinuation and adverse outcomes.

Methods: We used the VA CART-CL registry which includes all PCIs with drug eluting stents performed between 10/01/08 and 09/30/09 at 55 VA cath labs that used CART. We evaluated the frequency of patients who prematurely discontinue clopidogrel at 6 and 9 months using pharmacy refill data. Multivariable regression assessed the association between premature discontinuation and all-cause mortality and/or myocardial infarction (MI). We then grouped sites into quartiles of premature discontinuation and evaluated the association between hospital level premature discontinuation and adverse outcomes.

Results: Of the 7,022 patients who received a DES, 6.3% discontinued by 6 months, and 10.2% by 9 months. After risk adjustment, patients who discontinued clopidogrel prematurely had increased risk of adverse events with HR of 5.42 at 6 months (95% CI 4.22 – 6.99), and 6.24 at 9 months (95% CI 4.98 – 7.83). There was a significant trend in the unadjusted rates within quartiles toward increased risk of adverse outcomes among hospitals with greater rates of patients who discontinue prematurely by 6 months (p < 0.01 for trend, OR 1.65 CI 1.07 – 2.62 for comparison between quartile 1 and 4).

Conclusion: Premature discontinuation of clopidogrel is associated with adverse outcomes among patients who receive drug eluting stents. Hospitals with higher rates of premature discontinuation of clopidogrel have higher rates of adverse outcomes. Hospital-level interventions to reduce early discontinuation of clopidogrel therapy have the potential to improve outcomes of patients who receive a DES.

Abstract 31: Hyperglycemia During MI Hospitalization Predicts Subsequent Diabetes: Insights from the VA IHD-QUERI Cardiac Care Follow-Up Clinical Study (CCFCS)

Background: Among non-diabetic patients hospitalized with an acute myocardial infarction (AMI), in-hospital hyperglycemia is associated with adverse outcomes. This phenomenon may be due to undiagnosed diabetes (DM), which could have implications for in-hospital screening and post-discharge follow up. While high rates of newly-diagnosed DM have been reported in AMI patients, whether majority of these cases occur among those with in-hospital hyperglycemia is unknown.

Methods: We examined a national cohort of AMI patients hospitalized in the VA between 10/2005 -7/2009, who did not have known DM, were not diagnosed with DM during hospitalization, and survived at least 6 months post-discharge. We assessed rates of inpatient hyperglycemia (defined as mean hospitalization glucose ≥140mg/dL) and DM diagnosis during 6 months after hospitalization (defined as ICD-9 diagnosis codes, prescription of any glucose-lowering medication, or HbA1c value ≥ 6.5%). Predictors of DM diagnosis were assessed using a multivariable logistic regression model.

Results: Among 7875 non-diabetic AMI patients, 484 (6.1%) had inpatient hyperglycemia. Hyperglycemic patients were older, had greater AMI severity and burden of comorbidities, and were more likely to be treated with insulin during hospitalization. Six months following discharge, 100 (20.7%) hyperglycemic patients were diagnosed with DM, compared to 308 (4.2%) normoglycemic patients (p <0.0001). After multivariable adjustment, in-hospital hyperglycemia remained a significant predictor of 6-month DM diagnosis (OR 5.15, 95% CI 3.97, 6.69). Other factors associated with DM diagnosis are listed in the Table.

Conclusions: Elevated glucose during AMI hospitalization is a strong predictor of incident DM, with greater than 1 in 5 non-DM hyperglycemic patients being diagnosed with DM within 6 months after discharge. Our findings suggest that non-DM AMI patients with hyperglycemia warrant formal DM screening during or shortly after AMI hospitalization.

Abstract 257: Practice Variation is a Significant Contributor to Secondary Prevention Medication Use: Insights from the NCDR PINNACLE Program

Background: Secondary prevention medications for eligible CAD patients include antiplatelets, lipid lowering agents, beta-blockers (BB) and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB). However, use of these therapies is variable. The contribution of practice-level factors to variation in medication use is unknown. In addition, the contribution of practice-level factors relative to patient factors is also unknown.

Methods: We evaluated CAD patients in cardiology practices participating in the NCDR PINNACLE program, a national office-based cardiac quality improvement registry, between July 2008 and December 2010. Patients eligible for treatment were grouped by Class I indications for therapy: antiplatelets and lipid lowering agents in all, BBs in post-MI patients, and ACEIs/ARBs in those with diabetes or with reduced left ventricular ejection fraction (≤40%). Mean practice rates of therapy use were calculated. Next, hierarchical regression models assessed the effect of practice on therapy use, adjusted for patient factors, using the median rate ratio (MRR). The MRR compares the likelihood of treatment for identical patients from two randomly selected practices. In general, MRRs ≥ 1.2 indicate significant variation by practice. Finally, the magnitude of contribution of patient factors, expressed in ORs, to variation in therapy use was assessed.

Results: Our cohort consisted of 277,526 patients in 62 practices. The mean practice rate was 80.8% for antiplatelets (range 41.2–100%), 79.5% for lipid lowering agents (range 33.9–100%), 77.6% for BBs (range 35.2–100%), and 73.8% for ACEI/ARBs (range 39.1–100%). Adjusted MRR between practices was 1.19 for antiplatelets, 1.19 for lipid lowering agents, 1.20 for BBs, and 1.19 for ACEIs/ARBs. Almost all patient-level factors were smaller in magnitude than the MRR for practice-level variation (see Table).

Conclusions: Among practices participating in the PINNACLE program, significant variation in guideline recommended treatments among CAD outpatients exists. Practice setting, independent of patient factors, was associated with variation in treatment and was similar in magnitude to most patient factors. Our findings suggest that practice setting is an important contributor to variability in secondary prevention medication use. Accordingly, to improve the use of evidence-based CAD therapies, quality improvement efforts targeting practice-level factors should be evaluated.