Iso-osmolar versus low-osmolar contrast media and outcomes after percutaneous coronary intervention: Insights from the VA CART Program.

OBJECTIVES: To assess whether contrast media type is associated with outcomes in veterans undergoing percutaneous coronary intervention (PCI). BACKGROUND: There is uncertainty about the impact of iso-osmolar contrast medium (IOCM) versus low-osmolar contrast medium (LOCM) on acute kidney injury (AKI) and other major adverse renal or cardiovascular events (MARCE) after PCI. We assessed the association between contrast media type and MARCE in patients who underwent PCI within the Veterans Administration Healthcare System. METHODS: We reviewed PCIs performed between 2009 and 2019 using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. The primary endpoint was MARCE, a composite of myocardial infarction, stroke, all-cause death, AKI, and dialysis onset at 30 days. RESULTS: The analysis cohort consisted of 50,389 patients of whom 25,555 received LOCM and 24,834 received IOCM. There was significant variation in contrast type across sites. After adjustment for comorbidities, no significant association between contrast media type and MARCE was observed in both site-unadjusted (odds ratio [OR] for IOCM: 0.99; 95% confidence interval [CI]: 0.92-1.08; p = 0.97) and site-adjusted (OR: 1.06; 95% CI: 0.95-1.18; p = 0.30) analyses. Similar results were obtained when contrast volume was imputed or the data was subset to individuals with available contrast volume. CONCLUSION: In a large cohort of veterans undergoing PCI, we found considerable site variation in the type of contrast media used but no significant association between contrast media type and the incidence of MARCE, both before and after adjustment for the site.

Practices to support relational coordination in care transitions: Observations from the VA rural Transitions Nurse Program.

BACKGROUND: Ensuring safe transitions of care around hospital discharge requires effective relationships and communication between health care teams. Relational coordination (RC) is a process of communicating and relating for the purpose of task integration that predicts desirable outcomes for patients and providers. RC can be measured using a validated survey. PURPOSE: The aim of the study was to demonstrate the application of RC practices within the rural Transitions Nurse Program (TNP), a nationwide transitions of care intervention for Veterans, and assess relationships and mechanisms for developing RC in teams. METHODOLOGY/APPROACH: TNP implemented practices expected to support RC. These included creation of a transition nurse role, preimplementation site visits, process mapping to understand workflow, creation of standardized communication templates and protocols, and inclusion of teamwork and shared accountability in job descriptions and annual reviews. We used the RC Survey to measure RC for TNP health care teams. Associations between the months each site participated in TNP, number of Veterans enrolled, and adherence to the TNP intervention were assessed as possible mechanisms for developing high RC using Spearman (rs) correlations. RESULTS: The RC Survey was completed by 44 providers from 11 Veterans Health Administration medical centers. RC scores were high across sites (mean = 4.19; 1-5 Likert scale) and were positively correlated with months participating in TNP (rs = .66) and number of enrollees (rs = .63), but not with adherence to the TNP intervention (rs = .12). PRACTICE IMPLICATIONS: The impact of practices to support RC can be assessed using the RC Survey. Our findings suggest scale-up time is a likely mechanism to the development of high-quality relationships and communication within teams.

Percutaneous coronary intervention in patients with stable coronary artery disease and left ventricular systolic dysfunction: insights from the VA CART program.

BACKGROUND: Revascularization of ischemic cardiomyopathy by coronary artery bypass grafting has been shown to improve survival among patients with left ventricular ejection fraction (LVEF) ≤35%, but the role of percutaneous coronary intervention (PCI) in this context is incompletely described. This study sought to evaluate the effect of PCI on mortality and hospitalization among patients with stable coronary artery disease and reduced left ventricular ejection fraction. METHODS: We performed a retrospective analysis comparing PCI with medical therapy among patients with ischemic cardiomyopathy in the Veterans Affairs Health Administration. Patients with angiographic evidence of 1 or more epicardial stenoses amenable to PCI and LVEF ≤35% were included in the analysis. Outcome data were determined by VA and non-VA data sources on mortality and hospital admission. RESULTS: From 2008 through 2015, a study sample of 4,628 patients was identified, of which 1,322 patients underwent ad hoc PCI. Patients were followed to a maximum of 3 years. Propensity score weighted landmark analysis was used to evaluate the primary and secondary outcomes. The primary outcome of all-cause mortality was significantly lower in the PCI cohort compared with medical therapy (21.6% vs 30.0%, P <.001). The secondary outcome of all-cause rehospitalization or death was also lower in the PCI cohort (76.5% vs 83.8%, P <.001). CONCLUSIONS: In this retrospective analysis of patients with ischemic cardiomyopathy with coronary artery disease amenable to PCI and LVEF ≤35%, revascularization by PCI was associated with decreased all-cause mortality and decreased all-cause death or rehospitalization.

Comparison of rotational and orbital atherectomy for the treatment of calcific coronary lesions: Insights from the VA clinical assessment reporting and tracking (CART) program.

BACKGROUND: Previous studies suggested that pre-treatment of coronary artery calcification (CAC) with rotational atherectomy (RA) prior to stent deployment improved procedural success but was not associated with a concomitant improvement in clinical outcomes. Orbital atherectomy (OA) has demonstrated similar benefits, though there are few data comparing the safety and efficacy of the two modalities. METHODS: Patients who underwent PCI of a native coronary lesion with RA or OA from 2014 to 2018 within the Veterans Affairs Healthcare System were identified. Propensity matched cohorts were generated to compare the clinical and safety outcomes following either RA or OA. The primary endpoint was the rate of 30-day major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause mortality, repeat myocardial infarction, target vessel revascularization, and stroke. RESULTS: We identified 1,091 patients that underwent atherectomy during the study period, 640 (59%) treated with RA and 451 (41%) treated with OA. Among a propensity-matched cohort consisting of 950 patients, there was no significant difference in MACCE for patients who underwent RA or OA (7.1 vs. 8.2%, p = .36). Components of the primary outcome including 30-day mortality, myocardial infarction, target vessel revascularization, and stroke were also similar in the matched cohort. Additionally, procedural complications including perforation, no-reflow, dissection, and in-stent thrombosis were comparable across both treatment strategies. CONCLUSIONS: Both rotational and orbital atherectomy are safe and effective strategies for the treatment of calcified coronary plaque prior to stent deployment, with similarly low rates of peri-procedural adverse events.

Trends in Timing of and Glycemia at Initiation of Second-line Type 2 Diabetes Treatment in U.S. Adults.

OBJECTIVE: Therapeutic inertia threatens the potential long-term benefits of achieving early glycemic control after type 2 diabetes diagnosis. We evaluated temporal trends in second-line diabetes medication initiation among individuals initially treated with metformin. RESEARCH DESIGN AND METHODS: We included data from 199,042 adults with type 2 diabetes in the U.S. Department of Veterans Affairs health care system initially treated with metformin monotherapy from 2005 to 2013. We used multivariable Cox proportional hazards and linear regression to estimate associations of year of metformin monotherapy initiation with time to second-line diabetes treatment over 5 years of follow-up (primary outcome) and with hemoglobin A1c (HbA1c) at the time of second-line diabetes treatment initiation (secondary outcome). RESULTS: The cumulative 5-year incidence of second-line medication initiation declined from 47% among metformin initiators in 2005 to 36% in 2013 counterparts (P < 0.0001) despite a gradual increase in mean HbA1c at the end of follow-up (from 6.94 ± 1.28% to 7.09 ± 1.42%, Ptrend < 0.0001). In comparisons with metformin monotherapy initiators in 2005, adjusted hazard ratios for 5-year initiation of second-line diabetes treatment ranged from 0.90 (95% CI 0.87, 0.92) for 2006 metformin initiators to 0.68 (0.66, 0.70) for 2013 counterparts. Among those receiving second-line treatment within 5 years of metformin initiation, HbA1c at second-line medication initiation increased from 7.74 ± 1.66% in 2005 metformin initiators to 8.55 ± 1.92% in 2013 counterparts (Ptrend < 0.0001). CONCLUSIONS: We observed progressive delays in diabetes treatment intensification consistent with therapeutic inertia. Process-of-care interventions early in the diabetes disease course may be needed to reverse adverse temporal trends in diabetes care.

Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study.

BACKGROUND: Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE: To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS: National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES: The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS: The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS: TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.

Increasing enrolment in a national VA transitions of care programme: a pre-post evaluation of a data dashboard and nudge-based intervention.

BACKGROUND: The rural transitions nurse programme (TNP) is a care coordination intervention for high-risk veterans. An interactive dashboard was used to provide real-time performance metrics to sites as an audit and feedback tool. One-year post implementation, enrolment goals were not met. Nudge emails were introduced to increase TNP veteran enrolment. This study evaluated whether veteran enrolment increased when feedback occurred through a dashboard plus weekly nudge email versus dashboard alone. SETTING/POPULATION: This observational study included veterans who were hospitalised and discharged from four Veterans Health Administration hospitals participating in TNP. METHODS: Veteran enrolment counts between the dashboard phase and dashboard plus weekly nudge email phase were compared. Nudge emails included run charts of enrolment data. The difference of means for weekly enrolment between the two phases were calculated. After 3 months of nudge emails, a survey assessing TNP transitions nurse and physician champion perceptions of the nudge emails was distributed. RESULTS: The average enrolment for the four TNP sites during the ~20-month dashboard only phase was 4.23 veterans/week. The average during the 3-month dashboard plus nudge email phase was 4.21 veterans/week. The difference in means was -0.03 (p=0.73). Adjusting for time trends had no further effect. Four nurses responded to the survey. Two nurses reported neutral and two reported positive perceptions of the nudge emails. CONCLUSION: Drawing attention to metrics, through nudge emails, maintained, but did not increase TNP veteran discharges compared to dashboard feedback alone.

Association of Ischemic Evaluation and Clinical Outcomes Among Patients Admitted With New-Onset Heart Failure.

Background The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new-onset systolic heart failure. Methods and Results Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high-performing (90th percentile) and low-performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90-4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin-converting enzyme inhibitors (75% versus 64%, P<0.001) or beta blockers (92% versus 82%, P<0.001) and subsequently undergo percutaneous (8% versus 0%, P<0.001) or surgical (2% versus 0%, P<0.001) revascularization. Patients with an ischemic evaluation also had a significantly lower adjusted hazard of all-cause mortality (hazard ratio, 0.54; 95% CI, 0.47-0.61) compared with those without an evaluation. Conclusions Ischemic evaluations are underutilized in patients admitted with heart failure and a new reduction in left ventricular systolic function. A focused intervention to increase guideline-concordant care could lead to an improvement in clinical outcomes.

Quantifying the incremental value of deep learning: Application to lung nodule detection.

We present a case study for implementing a machine learning algorithm with an incremental value framework in the domain of lung cancer research. Machine learning methods have often been shown to be competitive with prediction models in some domains; however, implementation of these methods is in early development. Often these methods are only directly compared to existing methods; here we present a framework for assessing the value of a machine learning model by assessing the incremental value. We developed a machine learning model to identify and classify lung nodules and assessed the incremental value added to existing risk prediction models. Multiple external datasets were used for validation. We found that our image model, trained on a dataset from The Cancer Imaging Archive (TCIA), improves upon existing models that are restricted to patient characteristics, but it was inconclusive about whether it improves on models that consider nodule features. Another interesting finding is the variable performance on different datasets, suggesting population generalization with machine learning models may be more challenging than is often considered.

Identification of Emergency Care-Sensitive Conditions and Characteristics of Emergency Department Utilization.

Importance: Monitoring emergency care quality requires understanding which conditions benefit most from timely, quality emergency care. Objectives: To identify a set of emergency care-sensitive conditions (ECSCs) that are treated in most emergency departments (EDs), are associated with a spectrum of adult age groups, and represent common reasons for seeking emergency care and to provide benchmark national estimates of ECSC acute care utilization. Design, Setting, and Participants: A modified Delphi method was used to identify ECSCs. In a cross-sectional analysis, ECSC-associated visits by adults (aged ≥18 years) were identified based on International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes and analyzed with nationally representative data from the 2016 US Nationwide Emergency Department Sample. Data analysis was conducted from January 2018 to December 2018. Main Outcomes and Measures: Identification of ECSCs and ECSC-associated ED utilization patterns, length of stay, and charges. Results: An expert panel rated 51 condition groups as emergency care sensitive. Emergency care-sensitive conditions represented 16 033 359 of 114 323 044 ED visits (14.0%) in 2016. On average, 8 535 261 of 17 886 220 ED admissions (47.7%) were attributed to ECSCs. The most common ECSC ED visits were for sepsis (1 716 004 [10.7%]), chronic obstructive pulmonary disease (1 273 319 [7.9%]), pneumonia (1 263 971 [7.9%]), asthma (970 829 [6.1%]), and heart failure (911 602 [5.7%]) but varied by age group. Median (interquartile range) length of stay for ECSC ED admissions was longer than non-ECSC ED admissions (3.2 [1.7-5.8] days vs 2.7 [1.4-4.9] days; P < .001). In 2016, median (interquartile range) ED charges per visit for ECSCs were $2736 ($1684-$4605) compared with $2179 ($1118-$4359) per visit for non-ECSC ED visits (P < .001). Conclusions and Relevance: This comprehensive list of ECSCs can be used to guide indicator development for pre-ED, intra-ED, and post-ED care and overall assessment of the adult, non-mental health, acute care system. Health care utilization and costs among patients with ECSCs are substantial and warrant future study of validation, variations in care, and outcomes associated with ECSCs.

Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program.

Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.