To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to ...maintain an International Normalized Ratio (INR) within the therapeutic range.
Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.
For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.
Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.
MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.
IntroductionThe Centers for Medicare & Medicaid Services (CMS) is using a new peer group-based payment system to compare hospital performance which classifies hospitals into quintiles based on their ...share of dual eligible beneficiaries for Medicare and Medicaid. This study evaluated the association of percent dual eligibility for Medicare Medicaid with HF quality of care and outcomes.MethodsThis is a retrospective analysis of patients hospitalized for HF using the Get With The Guidelines-HF (GWTG-HF) registry between July, 1 2010 - December 31, 2017. Study endpoints included HF process of care measures, in-hospital mortality, 30-day all-cause or HF readmissions, 30-day all-cause mortality. We included patients aged ≥65 years old with available data on dual eligibility status. Hospitals were divided into quintiles based on their share dual eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models.ResultsA total of 258,995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual eligibility quintile (Q5) tended to care for patients who were younger, more likely female, belong to racial minority groups, or located in rural areas compared with Q1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility (Q5 sites) were associated with lower rates of key process measures including evidence-based beta blocker prescription (aOR0.70, 95% CI 0.52,0.94), measure of left ventricular function (aOR0.39, 95% CI 0.21,0.72), anticoagulation for atrial fibrillation or atrial flutter (aOR0.68, 95% CI 0.51,0.91). Differences in clinical outcomes were seen with higher 30-day all-cause (aOR1.24, 95% CI 1.14,1.35) and HF (aOR1.14, 95% CI 1.03,1.27) readmissions in higher dual eligible Q5 sites compared to Q1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in Q1 vs Q5 hospitals.ConclusionsHigher dual eligibility quintile sites were associated with lower rates of key HF quality of care process measures and higher 30-day all-cause or HF readmissions compared to lower dual eligibility quintile sites.
To determine the effect of patient refusal on racial and sex differences in the use of coronary angiography and in outcomes among elderly patients with acute myocardial infarction.
We included ...Medicare beneficiary patients admitted to hospitals performing coronary angiography from February 1994 through July 1995. In-hospital use and refusal of coronary angiography were determined, and adjusted for patient, hospital, and physician characteristics.
Of 124,691 patients, 53,671 (43%) underwent angiography during hospitalization and 2881 (2.3%) refused. Patients refusing angiography were more likely to be female (odds ratio OR = 1.37; 95% confidence interval CI: 1.23 to 1.53), black (OR = 1.26 vs. whites; 95% CI: 1.02 to 1.56), and older (OR = 2.25 per 10-year increase; 95% CI: 2.05 to 2.43) than patients who underwent angiography. Angiography use was lower in blacks (OR = 0.78; 95% CI: 0.72 to 0.83) than in whites, and lower in women (OR = 0.83; 95% CI: 0.80 to 0.86) than in men. Increased refusal explained 6% (95% CI: -3% to 15%) of the difference in angiography use between whites and blacks, and 16% (95% CI: 10% to 22%) of the difference between men and women. After adjustment for patient characteristics, refusal of angiography was not associated with worse survival at 1 year (OR = 0.99; 95% CI: 0.82 to 1.20).
Among Medicare beneficiaries, elderly female and black patients are more likely to refuse angiography than are male and white patients. However, patient refusal is uncommon and accounts for only a small fraction of the racial and sex differences in use of angiography after myocardial infarction.
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GEOZS, IJS, NUK, OILJ, UL, UM
Abstract only Objective: There is growing interest in the use of networks to facilitate knowledge exchange in health-care settings. The goal of the Dept. of Veterans Affairs (VA) Chronic Heart ...Failure (CHF) QUERI program is to improve the quality of care for heart failure (HF) patients and implement evidence-based practices (EBP) throughout the VA system. One strategy to achieve this goal was to create a VA Heart Failure Provider Network which occurred in 2006. We sought to conduct a formative evaluation of this well-established network to assess its perceived value by the members participating in it to improve HF care for Veterans. Method: Qualitative data was gathered using semi-structured phone interviews with selected HF Network members (n=25). All current members who had been participating in the HF Network for at least six months and hadn’t participated in the phone interview completed a web-based survey (n=878). The survey response rate was 24.9%. The HF Network members include leaders from Central Office, regional and facilities, chiefs of cardiology, physicians, nurses and others from all VA facilities (n=144). Results: Qualitative analysis of interviews showed that members participated in the HF Network to stay informed and maintain or enhance their knowledge in this area. Collaboration within and between VA facilities was frequently mentioned as a facilitator to achieve the goals of the HF Network. Also, many members mentioned that the web-based meetings and conference calls about HF clinics/programs were the most helpful because these methods provided access to new and practical ideas about solving problems and implementing changes in their own facility and to the members stay informed concerning heart failure care. Regarding barriers to greater involvement in HF Network activities, the most commonly noted barrier was lack of resources with members frequently mentioning lack of staff, time and local support. Quantitative findings strongly support the findings. Among the respondents (n=219), 90% of all members reported that the HF Network helped them establish collaborations and/or to network among members of the HF Network at least to a moderate extent. Interestingly, 63.8% of all members also reported that their participation in the HF Network provided them with names of contacts for networking and potential problem solving. 94.1% of the members found attending the web-based meetings and conference calls helpful in learning about barriers and facilitators in setting up or running HF program. Conclusions: Members perceived this social network of heart failure providers as a platform for the exchange of both explicit and tacit knowledge with the goal of improving quality of care for Veterans with heart failure. Implications for Policy or Practice: Social networks offer an effective platform for the implementation of EBP to improve the quality of HF care from local, regional to national levels.
Abstract only Objective: Reducing readmission rates for heart failure (HF) patients is the primary goal of the Department of Veterans Affairs (VA) and its Chronic Heart Failure (CHF) QUERI. Since its ...establishment in 2005 the CHF QUERI has undertaken many initiatives to improve the quality of HF care by providers for Veterans. One such initiative is the development of a comprehensive evidence-based “Heart Failure Toolkit for Providers”. This is a web-based toolkit with links and downloadable PDF documents. It has been developed through collaboration with the members of the CHF QUERI’s Heart Failure (HF) Provider Network along with existing quality tools provided by non-VA organizations. Method: Using a mixed methods approach we gathered quantitative data using a cross-sectional web-based survey from all current members of the HF Network who have been participating in it for at least six months (n=878). The response rate was 24.9%. Qualitative data was gathered from semi-structured phone interviews of selected HF Network members who hadn’t responded to the survey (n=25). Results: Survey finding showed 133 member respondents (61.3%) were aware of the HF Toolkit and all of them had accessed it 1-9 times. Among them 60.9% had recommended and/or sent the link for the toolkit to other providers. These members perceived the toolkit positively in terms of its usability to manage HF patients (96.6%), comprehensiveness of topics (98.3%), layout of web-based toolkit (97.4%) and opportunity to provide feedback about the availability of tools and/or upload other tools (93.0%). These members felt the toolkit helped provide evidence-based care for HF patients (98.0%), helped improve their quality of care (98.1%), helped educate providers about current standards of HF care (99.0%), and can be used by providers in primary care and by teamlets (98.0%) at all types of small/ large and urban/rural facilities (98.0%). Interestingly, qualitative data substantiated these findings. 75% of the members had heard about the HF Toolkit, and 57% of them specifically mentioned the following components as being extremely useful: patient education, guidelines, clinical pathways, order sets and discharge instructions. The organization of the toolkit was cited as a key contributor to its ease of use. Several of the members also appreciated the direct access to information specific to the VA context. Conclusions: VA providers and staff found an online toolkit valuable in the management of heart failure patients. Implications: Evidence-based comprehensive, well-organized and easily accessible resources are helpful for improved outcomes of heart failure patients.
Contrast left ventriculography is a method of measuring left ventricular function usually performed at the discretion of the invasive cardiologist during cardiac catheterization. We sought to ...determine variation in the use of left ventriculography in the Veterans Affairs (VA) Health Care System.
We identified adult patients who underwent cardiac catheterization including coronary angiography between 2000 and 2009 in the VA Health Care System. We determined patient and hospital predictors of the use of left ventriculography as well as the variation in use across VA facilities. Results were validated using data from the VA's Clinical Assessment, Reporting, and Tracking (CART) program. Of 457 170 cardiac catheterization procedures among 336 853 patients, left ventriculography was performed on 263 695 (58%) patients. Use of left ventriculography decreased over time (64% in 2000 to 50% in 2009) and varied markedly across facilities (<1->95% of cardiac catheterizations). Patient factors explained little of the large variation in use between facilities. When the cohort was restricted to those with an echocardiogram in the prior 30 days and no intervening event, left ventriculography was still performed in 50% of cases.
There is large variation in the use of left ventriculography across VA facilities that is not explained by patient characteristics.
The American Heart Association (AHA) convened a meeting to summarize the changing landscape of heart failure (HF), anticipate upcoming challenges and opportunities to achieve coordinated ...identification and treatment, and to recommend areas in need of focused efforts. The conference involved representatives from clinical care organizations, governmental agencies, researchers, patient advocacy groups and public and private healthcare partners, demonstrating the breadth of stakeholders interested in improving care and outcomes for patients with HF. The main purposes of this meeting were to foster dialog and brainstorm actions to close gaps in identifying people with or at risk for HF, and reduce HF-related morbidity, mortality and hospitalizations. This report highlights the key topics covered during the meeting, including 1) identification of patients with or at risk for HF, 2) tracking patients once diagnosed, 3) application of population health approaches to HF, 4) improved strategies for reducing HF hospitalization (not just re-hospitalization), and 5) promoting HF self-management.
Atrial fibrillation (AF) is one of the most common cardiac conditions treated in primary care and specialty cardiology settings, and is associated with considerable morbidity, mortality and cost. ...Catheter ablation, typically by electrically isolating the pulmonary veins and surrounding tissue, is more effective at maintaining sinus rhythm than conventional antiarrhythmic drug therapy and is now recommended as first-line therapy. From a value standpoint, the cost-effectiveness of ablation must incorporate the upfront procedural costs and risks with the benefits of longer term improvements in quality of life (QOL) and healthcare utilisation. Here, we present a primer on cost-effectiveness analysis (CEA), review the data on cost-effectiveness of AF ablation and outline key areas for further investigation.
Patients (pts) have unique perspectives and journeys about living with chronic heart failure that may not be captured by heart failure-related quality of life scores.
To examine predictors of the ...patients' journey in heart failure after controlling for demographic, heart failure and medical history factors.
Using a prospective, cross-sectional design, patients completed a valid and reliable 45-item Patients' Journey in Living with Heart Failure survey of 9 themes (provider-patient symptoms communication; provider-patient communication; self-care/symptom abilities; shared decision-making; receiving heart failure knowledge; feelings related to heart failure; caregiver support; worsening heart failure and advanced care planning /palliative care) and patients' demographic, heart failure and medical history factors. In univariate analyses, factors associated with patient journey total scores (p < 0.1) were considered for backward elimination multivariable models (p< 0.05 for retention). Reference groups reflect the smallest adjusted means.
Of 293 adults, 60.1% were female, mean (SD) age was 61.9 (13.8) years, 65.5% were married/living w someone, 42.3% had heart failure for 5 or more years, 49.8% had poor/fair heath status, 51.9% had New York Heart Association- Functional Class III and 92.5% had a cardiologist provider (non specialist or specialist). Total mean (SD) pt journey standardized score (higher score reflected a more favorable journey) was 75.4 (15.3). By theme, highest scores were for provider-patient communication, 90.1 (18.0) and shared decision-making, 87.3 (15.5); lowest scores were for feelings related to heart failure, 59.0 (24.7) and advanced care planning/palliative care, 56.7 (30.8). Of 14 factors assessed in the total score multivariable model, 5 were retained after backward elimination (Table).
Patients’ heart failure journeys were enhanced by time, social support, higher socioeconomic status, HF specialty provider and higher self-rated health.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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