Abstract Background Oral anticoagulation (OAC) with warfarin is underused for atrial fibrillation (AF). The availability of direct oral anticoagulants (DOACs) may improve overall OAC rates in AF ...patients, but a large-scale evaluation of their effects has not been conducted. Objectives This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF. Methods Between April 1, 2008 and September 30, 2014, we identified 655,000 patients with nonvalvular AF and a CHA2 DS2 -VASc score of >1 in the National Cardiovascular Data Registry PINNACLE registry. Temporal trends in overall OAC and individual warfarin and DOAC use were analyzed. Multivariable hierarchical logistic regression identified patient factors associated with OAC and DOAC use. Practice variation of OAC and DOAC use was also assessed. Results Overall OAC rates increased from 52.4% to 60.7% among eligible AF patients (p for trend <0.01). Warfarin use decreased from 52.4% to 34.8% (p for trend <0.01), and DOAC use increased from 0% to 25.8% (p for trend <0.01). An increasing CHA2 DS2 -VASc score was associated with higher OAC use (odds ratio OR: 1.06; 95% confidence interval CI: 1.05 to 1.07), but with lower DOAC use (OR: 0.97; 95% CI: 0.96 to 0.98). Significant practice variation was present in OAC use (median odds ratio MOR: 1.52; 95% CI: 1.45 to 1.57) and in DOAC use (MOR: 3.58; 95% CI: 3.05 to 4.13). Conclusions Introduction of DOACs in routine practice was associated with improved rates of overall OAC use for AF, but significant gaps remain. In addition, there is significant practice-level variation in OAC and DOAC use.
A “learning health care system”, as outlined in a recent Institute of Medicine report, harnesses real-time clinical data to continuously measure and improve clinical care. However, most current ...efforts to understand and improve the quality of care rely on retrospective chart abstractions complied long after the provision of clinical care. To align more closely with the goals of a learning health care system, we present the novel design and initial results of the Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking (CART) program—a national clinical quality program for VA cardiac catheterization laboratories that harnesses real-time clinical data to support clinical care and quality-monitoring efforts. Integrated within the VA electronic health record, the CART program uses a specialized software platform to collect real-time patient and procedural data for all VA patients undergoing coronary procedures in VA catheterization laboratories. The program began in 2005 and currently contains data on 434,967 catheterization laboratory procedures, including 272,097 coronary angiograms and 86,481 percutaneous coronary interventions, performed by 801 clinicians on 246,967 patients. We present the initial data from the CART program and describe 3 quality-monitoring programs that use its unique characteristics—procedural and complications feedback to individual labs, coronary device surveillance, and major adverse event peer review. The VA CART program is a novel approach to electronic health record design that supports clinical care, quality, and safety in VA catheterization laboratories. Its approach holds promise in achieving the goals of a learning health care system.
Beyond Medication Prescription as Performance Measures Arnold, Suzanne V., MD, MHA; Spertus, John A., MD, MPH; Masoudi, Frederick A., MD, MSPH ...
Journal of the American College of Cardiology,
11/2013, Letnik:
62, Številka:
19
Journal Article
Recenzirano
Odprti dostop
Objectives The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). Background Current performance ...measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown. Methods We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target defined from seminal clinical trials), moderate (50% to 74% target), or goal (≥75% target). Patients with contraindications were excluded from analyses for that medication. Results Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval CI: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each. Conclusions Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.
Abstract Objectives The aim of this study was to determine whether incomplete revascularization is associated with a higher risk for major adverse cardiovascular events (MACE) and myocardial ...infarction (MI) among patients undergoing noncardiac surgery. Background Patients with coronary artery disease and prior percutaneous coronary intervention (PCI) frequently undergo noncardiac surgery. These patients may have had PCI either on all obstructive lesions (i.e., complete revascularization) or only on some (i.e., incomplete revascularization). Methods Patients were identified using the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. Veterans Affairs and non–Veterans Affairs surgical records were used to link patients who underwent noncardiac surgery within 2 years after stent placement. Incomplete revascularization was defined as a residual stenosis of ≥50% in the left main coronary artery or ≥70% in another major epicardial coronary artery on the basis of operator visual estimate. Results In total, 4,332 patients (34.7%) had incomplete revascularization. A total of 567 MACE occurred within 1 month post-operatively. Patients with incomplete revascularization had an unadjusted 19% increased odds of post-operative MACE, compared with those with complete revascularization (odds ratio: 1.19; 95% confidence interval CI: 1.00 to 1.41). Among the MACE components, post-operative MI appears to contribute the most, with a 37% increased risk for post-operative MI among patients with incomplete revascularization (odds ratio: 1.37; 95% CI: 1.10 to 1.70). After adjustment, there was a significant interaction between time from PCI and outcomes after noncardiac surgery; incomplete revascularization was associated with significantly increased risk for post-operative MI primarily if surgery was performed within 6 weeks after PCI (adjusted odds ratio: 1.84; 95% CI: 1.04 to 2.38). The number of vessels with incomplete revascularization was also associated with an increased risk for post-operative MI: for each additional vessel with incomplete revascularization, there was a 17% increased odds of post-operative MI. Conclusions Incomplete revascularization among patients with coronary artery disease is associated with an increased risk for MI after noncardiac surgery.
Abstract Background Patients with paroxysmal and persistent atrial fibrillation experience a similar risk of thromboembolism. Therefore, consensus guidelines recommend anticoagulant therapy in those ...at risk for thromboembolism irrespective of atrial fibrillation classification. We sought to examine whether there are differences in rates of appropriate oral anticoagulant treatment among patients with paroxysmal vs persistent atrial fibrillation in real-world cardiology practices. Methods We studied 71,316 outpatients with atrial fibrillation and intermediate to high thromboembolic risk (CHADS2 score ≥2) enrolled in the American College of Cardiology PINNACLE Registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient characteristics, we examined whether anticoagulant treatment rates differed between patients with paroxysmal vs persistent atrial fibrillation. Results The majority of outpatients (78.4%, n = 55,905) had paroxysmal atrial fibrillation. In both unadjusted and multivariable adjusted analyses, patients with paroxysmal atrial fibrillation were less frequently prescribed oral anticoagulant therapy than those with persistent atrial fibrillation (50.3% vs 64.2%; adjusted risk ratio RR 0.74; 95% confidence interval CI, 0.72-0.76). Instead, patients with paroxysmal atrial fibrillation were prescribed more frequently only antiplatelet therapy (35.1% vs 25.0%; adjusted RR 1.77; 95% CI, 1.69-1.86) or neither antiplatelet nor anticoagulant therapy (14.6% vs 10.8%; adjusted RR 1.35; 95% CI, 1.26-1.44; P < .0001 for differences across all 3 comparisons). Conclusions In a large, real-world cardiac outpatient population, patients with paroxysmal atrial fibrillation with a moderate to high risk of stroke were less likely to be prescribed appropriate oral anticoagulant therapy and more likely to be prescribed less effective or no therapy for thromboembolism prevention.
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.
Because the ACC/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are currently unavailable in North America are discussed in the ...text without a specific COR. For studies performed in large numbers of subjects outside North America, a writing committee reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACC/AHA target population to determine whether the findings should inform a specific recommendation.\n Sabik Content Reviewer--ACC Surgeons' Scientific Council Cleveland Clinic--Department Chair, Thoracic and Cardiovascular Surgery Edwards Lifesciences Medtronic None Abbott Laboratoriesdagger Edwards Lifesciencesdagger None Vikas Saini Content Reviewer The Lown Institute--President None None None None Frank W. Sellke Content Reviewer--ACC/AHA Task Force on Practice Guidelines Brown Medical School and Lifespan--Chief of Cardiothoracic Surgery None None The Medicines Company None William S. Weintraub Content Reviewer Christiana Care Health System--Section Chief, Cardiology Bristol-Myers Squibb Daiichi-Sankyo Eli Lilly None None None Christopher J. White Content Reviewer Ochsner Health System--Director, John Ochsner Heart and Vascular Institute None None None St. Jude Medical (DSMB) Sankey V. Williams Content Reviewer--ACP University of Pennsylvania Health System--Professor of General Medicine None None None None Poh Shuan Daniel Yeo Content Reviewer--AIG Tan Tock Seng Hospital, Department of Cardiology--Cardiologist None None None Boston Scientificdagger Merckdagger Schering-Ploughdagger * No reviewer had a relevant ownership, partnership, or principal position to report.
Abstract Background Stenosis of saphenous vein grafts (SVGs) after coronary artery bypass grafting (CABG) is common and often requires percutaneous coronary interventions (PCI) for treatment. ...However, data for the effectiveness of drug-eluting stents (DES) versus bare-metal stents (BMS) in SVG-PCI are unclear. Objectives This study sought to examine the association between DES versus BMS used during SVG PCI and clinical outcomes in the national Veterans Affairs integrated healthcare system. Methods We studied a national cohort of 2,471 post-CABG veterans undergoing SVG-PCI between 2008 and 2011 at all Veterans Affairs hospitals and compared clinical outcomes of between those receiving DES and BMS. Clinical outcomes included procedural complications, myocardial infarction (MI), and all-cause mortality. Comparisons were made in a propensity-matched cohort using Cox proportional hazards regression models. Results DES were used in 1,549 SVG-PCI patients (63%) and the use of DES increased progressively with each calendar year (50% in 2008 to 69% in 2011). Incidence of procedural complications was low and comparable in both groups (2.8% among BMS vs. 2.3% among DES patients; p = 0.54). During long-term (>2 years) follow-up, use of DES was associated with lower mortality than BMS (hazard ratio HR: 0.72; 95% confidence interval CI: 0.57 to 0.89) and similar rates of MI (HR: 0.94; 95% CI: 0.71 to 1.24) in the propensity-matched cohort. Conclusions In a national cohort of veterans, we observed widespread and increasing use of DES during SVG-PCI. In long-term follow-up, compared with BMS, DES use was safe and effective in SVG-PCI patients.
Cardiovascular Care Facts Masoudi, Frederick A., MD, MSPH; Ponirakis, Angelo, PhD; Yeh, Robert W., MD ...
Journal of the American College of Cardiology,
11/2013, Letnik:
62, Številka:
21
Journal Article
Recenzirano
Odprti dostop
Objectives The aim of this report was to characterize the patients, participating centers, and measures of quality of care and outcomes for 5 NCDR (National Cardiovascular Data Registry) programs: 1) ...ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry–GWTG (Get With The Guidelines) for acute coronary syndromes; 2) CathPCI Registry for coronary angiography and percutaneous coronary intervention; 3) CARE (Carotid Artery Revascularization and Endarterectomy) Registry for carotid revascularization; 4) ICD Registry for implantable cardioverter defibrillators; and the 5) PINNACLE (Practice INNovation And CLinical Excellence) Registry for outpatients with cardiovascular disease (CVD). Background CVD is a leading cause of death and disability in the United States. The quality of care for patients with CVD is suboptimal. National registry programs, such as NCDR, permit assessments of the quality of care and outcomes for broad populations of patients with CVD. Methods For the year 2011, we assessed for each of the 5 NCDR programs: 1) demographic and clinical characteristics of enrolled patients; 2) key characteristics of participating centers; 3) measures of processes of care; and 4) patient outcomes. For selected variables, we assessed trends over time. Results In 2011 ACTION Registry–GWTG enrolled 119,967 patients in 567 hospitals; CathPCI enrolled 632,557 patients in 1,337 hospitals; CARE enrolled 4,934 patients in 130 hospitals; ICD enrolled 139,991 patients in 1,435 hospitals; and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers). Data on performance metrics and outcomes, in some cases risk-adjusted with validated NCDR models, are presented. Conclusions The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes.
Abstract Background Oral anticoagulation (OAC), rather than aspirin, is recommended in patients with atrial fibrillation (AF) at moderate to high risk of stroke. Objectives This study sought to ...examine patient and practice-level factors associated with prescription of aspirin alone compared with OAC in AF patients at intermediate to high stroke risk in real-world cardiology practices. Methods The authors identified 2 cohorts of outpatients with AF and intermediate to high thromboembolic risk (CHADS2 score ≥2 and CHA2 DS2 -VASc ≥2) enrolled in the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient and practice characteristics, the authors examined the prevalence and predictors of aspirin alone versus OAC prescription in AF patients at risk for stroke. Results Of 210,380 identified patients with CHADS2 score ≥2 on antithrombotic therapy, 80,371 (38.2%) were treated with aspirin alone, and 130,009 (61.8%) were treated with warfarin or non-vitamin K antagonist OACs. In the cohort of 294,642 patients with CHA2 DS2 -VASc ≥2, 118,398 (40.2%) were treated with aspirin alone, and 176,244 (59.8%) were treated with warfarin or non-vitamin K antagonist OACs. After multivariable adjustment, hypertension, dyslipidemia, coronary artery disease, prior myocardial infarction, unstable and stable angina, recent coronary artery bypass graft, and peripheral arterial disease were associated with prescription of aspirin only, whereas male sex, higher body mass index, prior stroke/transient ischemic attack, prior systemic embolism, and congestive heart failure were associated with more frequent prescription of OAC. Conclusions In a large, real-world cardiac outpatient population of AF patients with a moderate to high risk of stroke, more than 1 in 3 were treated with aspirin alone without OAC. Specific patient characteristics predicted prescription of aspirin therapy over OAC.
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