RESUMO
BACKGROUND: Opioids may play a part in the development of atrial fibrillation (AF). Understanding the relationship between opioid exposure and AF can help providers better assess the risk and benefits of prescribing opioids. OBJECTIVE: To assess the incidence of AF as a function of prescribed opioids and opioid type. DESIGN: We performed unadjusted and adjusted time-updated Cox regressions to assess the association between opioid exposure and incident AF. PARTICIPANTS: The national study sample was comprised of Veterans enrolled in the Veterans Health Administration (VHA) who served in support of post-9/11 operations. MAIN MEASURES: The main predictor of interest was prescription opioid exposure, which was treated as a time-dependent variable. The first was any opioid exposure (yes/no). Secondary was opioid type. The outcome, incident AF, was identified through ICD-9-CM diagnostic codes at any primary care visit after the baseline period. KEY RESULTS: A total of 609,763 veterans (mean age: 34 years and 13.24% female) were included in our study. Median follow-up time was 4.8 years. Within this cohort, 124,395 veterans (20.40%) were prescribed an opioid. A total of 1,455 Veterans (0.24%) were diagnosed with AF. In adjusted time-updated Cox regressions, the risk of incident AF was higher in the veterans prescribed opioids (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.38-1.57). In adjusted time-updated Cox regressions, both immunomodulating and nonimmunomodulating opioid type was associated with increased risk of incident AF (HR: 1.40; 95% CI: 1.25-1.57 and HR: 1.49; 95% CI: 1.39-1.60), compared to no opioid use, respectively. CONCLUSIONS: Our findings suggest opioid prescription may be a modifiable risk factor for the development of AF.
Assuntos
Fibrilação Atrial , Veteranos , Humanos , Feminino , Adulto , Masculino , Analgésicos Opioides/efeitos adversos , Fibrilação Atrial/epidemiologia , Fatores de Risco , PrescriçõesRESUMO
BACKGROUND: Current United States guidelines recommend troponin as the preferred biomarker in assessing for acute coronary syndrome, but recommendations are limited about which patients to test. Variations in troponin ordering may influence downstream health care utilization. METHODS: We performed a cross-sectional analysis of 3,308,131 emergency department (ED) visits in all 121 acute care facilities within the Veterans Health Administration from 2015 to 2017. We quantified the degree to which case mix and facility characteristics accounted for variations in facility rates in troponin ordering. We then assessed the association between facility quartiles of risk-adjusted troponin ordering and downstream resource utilization [inpatient admissions, noninvasive testing (stress tests, echocardiograms), and invasive procedures (coronary angiograms, percutaneous coronary interventions, and coronary artery bypass grafting surgeries)]. RESULTS: The proportion of ED visits with troponin orders ranged from 2.2% to 64.5%, with a median of 37.1%. Case mix accounted for 9.5% of the variation in troponin orders; case mix and differences in facility characteristics accounted for 34.6%. Facilities in the highest quartile of troponin ordering, as compared with those in the lowest quartile, had significantly higher rates of inpatient admissions, stress tests, echocardiograms, coronary angiograms, and percutaneous coronary intervention. CONCLUSIONS: Significant variation in troponin utilization exists across Veterans Health Administration facilities and that variation is not well explained by case mix alone. Facilities with higher rates of troponin ordering were associated with more downstream resource utilization.
Assuntos
Síndrome Coronariana Aguda/diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Troponina/sangue , United States Department of Veterans Affairs/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Estudos Transversais , Grupos Diagnósticos Relacionados , Fidelidade a Diretrizes , Humanos , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Fatores Sexuais , Fatores Socioeconômicos , Estados UnidosRESUMO
Reports indicate that long-term opioid therapy is associated with cardiovascular disease (CVD). Using VA electronic health record data, we measured the impact of opioid use on the incidence of modifiable CVD risk factors. We included Veterans whose encounter was between October 2001 to November 2014. We identified Veterans without CVD risk factors during our baseline period, defined as the date of first primary care visit plus 365 days. The main exposure was opioid prescriptions (yes/no, long-term (i.e. ≥90 days) vs no opioid, and long-term vs short-term (i.e. <90 days)), which was time-updated yearly from the end of the baseline period to February 2015. The main outcome measures were incident CVD risk factors (hypertension, dyslipidemia, diabetes, obesity, and current smoking). After excluding prevalent CVD risk factors, we identified 308,015 Veterans. During the first year of observation, 12,725 (4.1%) Veterans were prescribed opioids, including 2028 (0.6%) with long-term exposure. Compared to patients without opioid use, Veterans with opioid use were more likely to have CVD risk factors. Those with long-term exposure were at higher risk of having hypertension (adjusted average hazards ratio [HR] 1.45, 99% confidence interval [CI] 1.33-1.59), dyslipidemia (HR 1.45, 99% CI 1.35-156), diabetes (HR 1.30, 99% CI 1.07-1.57), current smoking status (HR 1.34, 99% CI 1.24-1.46), and obesity (HR 1.22, 99% CI 1.12-1.32). Compared to short-term exposure, long-term had higher risk of current smoking status (HR 1.12, 99% CI 1.01-1.24). These findings suggest potential benefit to screening and surveillance of CVD risk factors for patients prescribed opioids, especially long-term opioid therapy.
Assuntos
Analgésicos Opioides/efeitos adversos , Doenças Cardiovasculares/epidemiologia , Fatores de Risco de Doenças Cardíacas , Veteranos/estatística & dados numéricos , Adulto , Doenças Cardiovasculares/etiologia , Diabetes Mellitus/etiologia , Registros Eletrônicos de Saúde , Feminino , Humanos , Hipertensão/etiologia , Incidência , Masculino , Medicamentos sob Prescrição , Fatores de Tempo , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
Background and Purpose- In older populations, transient ischemic attack (TIA) and ischemic stroke have been linked to psychological factors, including posttraumatic stress disorder (PTSD). Whether PTSD also increases risk for early incident stroke in young adults is unknown. Methods- We prospectively assessed the incidence of TIA and ischemic stroke in a cohort of 987 855 young and middle-aged Veterans (mean age of 30.29±9.19 years; 87.8% men, 64.4% white) who first accessed care through the Veterans Health Administration from October 2001 to November 2014 and were free of TIA and ischemic stroke at baseline. For each outcome, time-varying multivariate Cox models were constructed to examine the effect of PTSD on incident stroke. We also assessed for effect modification by sex. Additional sensitivity analyses controlled for healthcare utilization. Results- Over a 13-year period, TIA and ischemic stroke were diagnosed in 766 and 1877 patients, respectively. PTSD was diagnosed in 28.6% of the sample during follow-up. In unadjusted analyses, PTSD was significantly associated with new-onset TIA (hazard ratio [HR], 2.02; 95% CI, 1.62-2.52) and ischemic stroke (HR, 1.62; 95% CI, 1.47-1.79). In fully adjusted models, the association between PTSD and incident TIA (HR, 1.61; 95% CI, 1.27-2.04) and ischemic stroke (HR, 1.36; 95% CI, 1.22-1.52) remained significant. The effect of PTSD on ischemic stroke risk was stronger in men than in women (HR, 0.63; 95% CI, 0.47-0.86; P=0.003), but no effect of sex was found for TIA. Conclusions- PTSD is associated with a significant increase in risk of early incident TIA and ischemic stroke independent of established stroke risk factors, coexisting psychiatric disorders, and healthcare utilization. Sex moderated the relationship for adults with ischemic stroke but not TIA. These findings suggest that psychological factors, including PTSD, may be important targets for future age-specific prevention strategies for young adults.
Assuntos
Isquemia Encefálica , Modelos Cardiovasculares , Transtornos de Estresse Pós-Traumáticos , Acidente Vascular Cerebral , Adolescente , Adulto , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Adulto JovemRESUMO
BACKGROUND: Despite strong guideline recommendations for cardiac resynchronization therapy-defibrillator (CRT-D) in select patients, this therapy is underutilized with substantial variation among hospitals, and the association of this variation with outcomes is unknown. OBJECTIVE: The purpose of this study was to assess whether facility variation in CRT-D utilization is associated with differences in hospital-level outcomes. METHODS: We linked Medicare claims data with the National Cardiovascular Data Registry's ICD Registry from 2010 to 2015. We calculated the intraclass correlation coefficient to quantify the degree of variation in patient-level CRT use that can be explained by interfacility variation on a hospital level. To quantify the degree of hospital variation in patient-level outcomes (all-cause mortality, readmissions, and cardiac readmissions) that can be attributed to variations in CRT-D use, we utilized multilevel modeling. RESULTS: The study included 30,134 patients across 1377 hospitals. The median rate of CRT-D implantation in those meeting guideline indications was 89%, but there was a wide variation across hospitals. After adjustment, most of the variation (74%) in hospital rates of CRT-D utilization was attributable to the hospital in which the patient was treated. Differences in hospital CRT-D utilization was associated with 8.76%, 5.26%, and 4.71% of differences in hospital mortality, readmissions, and cardiac readmission rates, respectively (P < .001 for all outcomes). CONCLUSION: There is a wide variation in the use of CRT-D across hospitals that was not explained by case mix. Hospital-level variation in CRT-D utilization was associated with clinically significant differences in outcomes. A measure of CRT-D utilization in eligible patients may serve as a useful metric for quality improvement efforts.
Assuntos
Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Insuficiência Cardíaca , Humanos , Idoso , Estados Unidos/epidemiologia , Medicare , Insuficiência Cardíaca/terapia , Resultado do Tratamento , HospitaisRESUMO
BACKGROUND: Pain and heart failure are highly comorbid. OBJECTIVES: The purpose of this study was to examine differences in pain intensity and pain medication prescriptions among Veterans with comorbid heart failure and pain and those with pain alone. METHODS: The Musculoskeletal Disorder (MSD) cohort includes 5,237,763 Veteran diagnosed with a musculoskeletal disorder between 2000 and 2013. Veterans with comorbid heart failure and back pain (heart failure+, n = 3,950, Mage = 70.5 ± 12) were compared to those with back pain alone (heart failure-, n = 165,290, Mage = 52.1 ± 17.5). RESULTS: In multivariate adjusted models, heart failure+ was associated with a higher likelihood of moderate/severe pain (OR = 1.12; 95% CI 1.04-1.21), a higher likelihood of opioids (OR = 1.63; CI = 1.52-1.75) and/or gabapentin prescriptions (OR = 1.18; CI = 1.02-1.36), but a lower likelihood of NSAID prescriptions (OR = 0.57; CI = 0.50-0.66). CONCLUSIONS: Comorbid cardiovascular and pain conditions present a challenge in clinical management that warrants further study.
Assuntos
Insuficiência Cardíaca , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Dor nas Costas/tratamento farmacológico , Dor nas Costas/epidemiologia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/epidemiologia , Humanos , Pessoa de Meia-Idade , Medição da Dor , PrescriçõesRESUMO
The American College of Cardiology and American Heart Association recently published guidelines narrowing the indications for low-dose aspirin use. The suitability of the electronic health record (EHR) to identify patients for low-dose aspirin deprescribing is unknown. To apply the 3 low-dose aspirin guidelines to EHR data, the guidelines were deconstructed into components from their narrative text and assigned computer-interpretable definitions based on electronic data interchange standards. These definitions were used to search EHR data to identify patients for aspirin deprescribing. To verify EHR records for low-dose aspirin, we then compared the records with a survey of patients' self-reported use of low-dose aspirin. Of the 3 aspirin guidelines, only 1 had a definition suitable for EHR implementation. The other 2 contained difficult-to-implement phrases (e.g., "higher ASCVD risk", "increased bleeding risk"). An EHR search with the single implementable guideline identified 86,555 people for possible aspirin deprescribing (2% of 5,598,604). Only 676 of 1,135 (60%) patients who self-reported taking low-dose aspirin had an active EHR record for low-dose aspirin at that time. Limitations exist when using EHR data to identify patients for possible low-dose aspirin deprescribing such as incomplete EHR capture of and the interpretation of non-specific terminology when translating guidelines into an electronic equivalent. In conclusion, data show many people unnecessarily take low-dose aspirin.
Assuntos
Aspirina/uso terapêutico , Aterosclerose/tratamento farmacológico , Doenças Cardiovasculares/prevenção & controle , Atenção à Saúde/estatística & dados numéricos , Overdose de Drogas/epidemiologia , Prevenção Primária/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: OEF/OIF/OND Veterans have an elevated risk for developing cardiovascular disease (CVD), but research suggests that engagement in CVD preventive behaviors is low even among at-risk individuals. It is critical to understand barriers to prevention engagement among Veterans to inform the development of tailored interventions addressing barriers and reducing CVD incidence. METHOD: The Women Veterans Cohort Study survey of OEF/OIF/OND Veterans (586 women and 555 men) assessed patient, interpersonal, and systems level barriers to CVD risk prevention. Prevalence of barriers was determined, and chi-squares were conducted to examine sex differences. Multivariate logistic regressions were conducted to determine if sex differences remained when adjusting for demographic factors (age, marital status, education, employment status). RESULTS: Despite a low response rate (11.5%), endorsement of barriers was high for both women and men, with most (56.8%) not perceiving themselves to be at CVD risk. More men preferred making no lifestyle change (40.9% vs. 29.1%). More women endorsed lack of confidence (42.4% vs. 36.1%), stress (36.9% vs. 27.8%) and depression (36.9% vs. 27.8%), and inadequate social support (26% vs. 20.9%), along with the belief that their clinician does not perceive them as at risk (57.8% vs. 32%) and has not explained CVD preventive behaviors (19% vs. 12.3%). Multivariate analyses reduced statistical significance of sex differences. CONCLUSIONS: Given the low response rate, testing of efforts-for example, implementation science methods-to assess CVD risk reduction barriers in this population are needed, a task for which the Veterans Health Administration is well suited. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Assuntos
Doenças Cardiovasculares/prevenção & controle , Veteranos/psicologia , Adulto , Estudos de Coortes , Feminino , Humanos , Guerra do Iraque 2003-2011 , Masculino , Prevalência , Estados UnidosRESUMO
BACKGROUND: Diagnostic error is commonly defined as a missed, delayed or wrong diagnosis and has been described as among the most important patient safety hazards. Diagnostic errors also account for the largest category of medical malpractice high severity claims and total payouts. Despite a large literature on the incidence of inpatient adverse events, no systematic review has attempted to estimate the prevalence and nature of harmful diagnostic errors in hospitalised patients. METHODS: A systematic literature search was conducted using Medline, Embase, Web of Science and the Cochrane library from database inception through 9 July 2019. We included all studies of hospitalised adult patients that used physician review of case series of admissions and reported the frequency of diagnostic adverse events. Two reviewers independently screened studies for inclusion, extracted study characteristics and assessed risk of bias. Harmful diagnostic error rates were pooled using random-effects meta-analysis. RESULTS: Twenty-two studies including 80 026 patients and 760 harmful diagnostic errors from consecutive or randomly selected cohorts were pooled. The pooled rate was 0.7% (95% CI 0.5% to 1.1%). Of the 136 diagnostic errors that were described in detail, a wide range of diseases were missed, the most common being malignancy (n=15, 11%) and pulmonary embolism (n=13, 9.6%). In the USA, these estimates correspond to approximately 249 900 harmful diagnostic errors yearly. CONCLUSION: Based on physician review, at least 0.7% of adult admissions involve a harmful diagnostic error. A wide range of diseases are missed, including many common diseases. Fourteen diagnoses account for more than half of all diagnostic errors. The finding that a wide range of common diagnoses are missed implies that efforts to improve diagnosis must target the basic processes of diagnosis, including both cognitive and system-related factors. PROSPERO REGISTRATION NUMBER: CRD42018115186.
Assuntos
Erros de Diagnóstico , Adulto , Hospitalização , Humanos , Pacientes Internados , Segurança do Paciente , PrevalênciaRESUMO
Background Patients undergoing implantable cardioverter-defibrillator (ICD) implantations have high rates of long-term device-related complications and reoperations. Whether physician specialty training is associated with differences in long-term outcomes following ICD implantation is unclear. Methods and Results We linked data from the National Cardiovascular Data Registry ICD Registry with Medicare fee-for-service claims to identify physicians who performed ≥10 index ICDs from 2006 to 2009. We used data from the American Board of Medical Specialties to group the specialty of the implanting physician into mutually exclusive categories: electrophysiologists, interventional cardiologists, general cardiologists, thoracic surgeons, and other specialties. Primary outcomes were long-term device-related complications requiring reoperations or hospitalizations and reoperations for reasons other than complications. We compared the cumulative incidence rates and case-mix adjusted rates of long-term outcomes of index ICD implantations across physician specialties. Our analysis had a median follow-up of 47 months and included 107 966 index ICD implantations. Electrophysiologists had the lowest rates of incident long-term device-related complications (14.1%; interventional cardiologists, 15.3%; general cardiologists, 15.4%; thoracic surgeons, 16.4%; other specialists, 15.2%; P<0.001) and reoperations for reasons other than complications (electrophysiologists, 16.7%; interventional cardiologists, 17.0%; general cardiologists, 18.0%; thoracic surgeons, 18.4%; other specialists, 18.0%; P<0.001). Compared with patients whose ICDs were implanted by electrophysiologists, patients with implantations performed by nonelectrophysiologists were at higher risk of having long-term device-related complications (relative risk for interventional cardiologists: 1.16 [95% CI, 1.08-1.25]; general cardiologists: 1.13 [1.08-1.18]; thoracic surgeons: 1.20 [1.06-1.37]; all P<0.001, but not other specialists: 1.08 [0.99-1.17]; P=0.07). Compared to patients with implantations performed by electrophysiologists, patients with implantations performed by general cardiologists and thoracic surgeons were at higher risk of reoperation for noncomplication causes (relative risk for general cardiologists: 1.10 [1.05-1.15]; thoracic surgeons: 1.16 [1.00-1.33]; both P<0.05). Conclusions Patients with ICD implantations performed by electrophysiologists had the lowest risks of having long-term device-related complications and reoperations for noncomplication causes. Consideration of physician specialty before ICD implantation may represent an opportunity to minimize long-term adverse outcomes.
Assuntos
Competência Clínica , Desfibriladores Implantáveis , Cardioversão Elétrica/tendências , Complicações Pós-Operatórias/cirurgia , Padrões de Prática Médica/tendências , Reoperação/tendências , Especialização/tendências , Idoso , Idoso de 80 Anos ou mais , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Incidência , Masculino , Medicare , Complicações Pós-Operatórias/epidemiologia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
Background Certificate of need ( CON ) regulations are intended to coordinate new healthcare services, limit expansion of unnecessary new infrastructure, and limit healthcare costs. However, there is limited information about the association of CON regulations with the appropriateness and outcomes of percutaneous coronary interventions ( PCI ). The study sought to characterize the association between state CON regulations and PCI appropriateness. Methods and Results We used data from the American College of Cardiology's Cath PCI Registry to analyze 1 268 554 PCI s performed at 1297 hospitals between January 2010 and December 2011. We used the Appropriate Use Criteria to classify PCI procedures as appropriate, maybe appropriate, or rarely appropriate and used Chi-square analyses to assess whether the proportions of PCI s in each Appropriate Use Criteria category varied depending on whether the procedure had been performed in a state with or without CON regulations. Analyses were repeated stratified by whether or not the procedure had been performed in the setting of an acute coronary syndrome ( ACS ). Among 1 268 554 PCI procedures, 674 384 (53.2%) were performed within 26 CON states. The proportion of PCI s classified as rarely appropriate in CON states was slightly lower compared with non- CON states (3.7% versus 4.0%, P<0.01). Absolute differences were larger among non- ACS PCI (23.1% versus 25.0% [ P<0.01]) and were not statistically significantly different in ACS (0.62% versus 0.63% [ P>0.05]). Conclusions States with CON had lower proportions of rarely appropriate PCI s, but the absolute differences were small. These findings suggest that CON regulations alone may not limit rarely appropriate PCI among patients with and without ACS .
Assuntos
Certificado de Necessidades/estatística & dados numéricos , Doença da Artéria Coronariana/cirurgia , Hospitais , Seleção de Pacientes , Intervenção Coronária Percutânea/legislação & jurisprudência , Garantia da Qualidade dos Cuidados de Saúde , Sistema de Registros , Idoso , Estudos Transversais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: To examine the association of dual use of both Veterans Health Administration (VHA) and Medicare benefits with high-risk opioid prescriptions among Veterans aged 65 years and older with a musculoskeletal disorder diagnosis. DATA SOURCES/STUDY SETTING: Data were obtained from the VA Musculoskeletal Disorder (MSD) cohort and national Medicare claims data from 2008 to 2010. STUDY DESIGN: We conducted a retrospective analysis of Veterans enrolled in Medicare to examine the association of dual use with long-term opioid use (>90 days of prescription opioids/year) and overlapping opioid prescriptions. Multivariable logistic regression was performed adjusting for demographic and clinical characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified 21,111 Veterans enrolled in Medicare who entered the MSD cohort in 2008 and received an opioid prescription in 2010. We linked VHA data with Medicare claims data to identify opioid prescriptions for these Veterans in 2010. PRINCIPAL FINDINGS: As compared to Veterans who used only VHA or Medicare, Veterans with dual use of VHA and Medicare were significantly more likely to be prescribed long-term opioid therapy (OR = 4.61 (95 percent CI 4.05-5.25) and were also found to have higher median number of opioid prescriptions and higher odds of overlapping opioid prescriptions in 1 year. Patients reporting moderate-to-severe pain, non-white-race/ethnicity, and higher scoring on the Charlson comorbidity index had significantly higher odds of long-term opioid prescriptions. CONCLUSIONS: Among Veterans aged 65 years or older, dual use of both VHA and Medicare was associated with higher odds of long-term opioid therapy. Our findings suggest there may be benefit to combining VHA and non-VHA electronic health record data to minimize exposure to high-risk opioid prescribing.
Assuntos
Analgésicos Opioides/uso terapêutico , Medicare/estatística & dados numéricos , Doenças Musculoesqueléticas/tratamento farmacológico , United States Department of Veterans Affairs/estatística & dados numéricos , Fatores Etários , Idoso , Analgésicos Opioides/administração & dosagem , Comorbidade , Estudos Transversais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Grupos Raciais , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores Sexuais , Estados UnidosRESUMO
BACKGROUND: The Physician Consortium for Performance Improvement recently proposed percutaneous coronary intervention (PCI)-specific process measures. However, information about hospital performance on these measures and the association of PCI process and outcomes measures are not available. METHODS AND RESULTS: We linked the National Cardiovascular Data Registry (NCDR) CathPCI Registry with Medicare claims data to assess hospital performance on established PCI process measures (aspirin, thienopyridines, and statins on discharge; door-to-balloon time; and referral to cardiac rehabilitation), newly proposed PCI process measures (documentation of contrast dose, glomerular filtration rate, and PCI indication; appropriate indication for elective PCI; and use of embolic protection device), and a composite of all process measures. We calculated weighted pair-wise correlations between each set of process metrics and performed weighted correlation analyses to assess the association between composite measure performance with corresponding 30-day risk-standardized mortality and readmission rates. We reported the variance in risk-standardized 30-day outcome rates explained by process measures. We analyzed 1 268 860 PCIs from 1331 hospitals. For many process measures, median hospital performance exceeded 90%. We found strong correlations between medication-specific process measures (P<0.01) and weak correlations between hospital performance on the newly proposed and established process measures. The composite process measure explained only 1.3% and 2.0% of the observed variation in mortality and readmission rates, respectively. CONCLUSIONS: Hospital performance on many PCI-specific process measures demonstrated little opportunity for improvement and explained only a small percentage of hospital variation in 30-day outcomes. Efforts to measure and improve hospital quality for PCI patients should focus on both process and outcome measures.
Assuntos
Doença das Coronárias/terapia , Intervenção Coronária Percutânea/normas , Avaliação de Processos em Cuidados de Saúde/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Reabilitação Cardíaca/normas , Doença das Coronárias/diagnóstico , Doença das Coronárias/mortalidade , Estudos Transversais , Disparidades em Assistência à Saúde/normas , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Medicare , Alta do Paciente/normas , Readmissão do Paciente/normas , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação Plaquetária/uso terapêutico , Encaminhamento e Consulta/normas , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/normas , Resultado do Tratamento , Estados UnidosRESUMO
Excess dosing of anticoagulant agents has been linked to increased risk of bleeding after percutaneous coronary intervention (PCI) for women compared with men, but these studies have largely included older patients. We sought to determine the prevalence and gender-based differences of excess dosing of anticoagulants including glycoprotein IIb/IIIa inhibitors, bivalirudin, and unfractionated heparin in young patients with acute myocardial infarction who underwent PCI and to examine its association with bleeding. Of 2,076 patients enrolled in the Variation in Recovery: Role of Gender on Outcomes of Young Acute Myocardial Infarction Patients study who underwent PCI, we abstracted doses of unfractionated heparin, bivalirudin, and glycoprotein IIb/IIIa inhibitors administered during PCI from the medical records. At least 47.2% received at least 1 excess dose of an anticoagulant, which did not differ by gender. We used logistic regression to determine the predictors of excess dosing and the association of excess dosing with bleeding. In multivariable analysis, only lower body weight and younger age were significant predictors of excess dosing. Bleeding was higher in young women who received excess dosing versus those who did not (9.3% vs 6.0%, p = 0.03) but was comparable among men (5.2% vs 5.9%, p = 0.69) in univariate analysis. In multivariable analysis, there was a trend to an association between excess dosing and bleeding (odds ratio 1.33, 95% confidence interval 0.92 to 1.91) although not statistically significant. In conclusion, approximately half of the patients received excess dosing of anticoagulant drugs during PCI, which did not vary based on gender. There was a trend toward an association between excess dosing and increased bleeding, although not statistically significant.