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Julia M. Akeroyd - One of the best experts on this subject based on the ideXlab platform.
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Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease—Perspective from the Veterans Affair Healthcare System
Cardiovascular Drugs and Therapy, 2021Co-Authors: Xiaoming Jia, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Michelle T. Lee, Mahmoud Rifai, Chayakrit Krittanawong, Michael E. Matheny, Glenn Gobbel, Neil J. StoneAbstract:Purpose Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. Methods We assessed facility-Level Variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-Level Variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. Results Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p
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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7
Cardiovascular Drugs and Therapy, 2021Co-Authors: Dhruv Mahtta, David J. Ramsey, Julia M. Akeroyd, Michelle T. Lee, Chayakrit Krittanawong, Safi U. Khan, Preetika Sinh, Mahboob Alam, Kirk N. Garratt, Richard S. SchofieldAbstract:Purpose We investigated facility-Level Variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. Methods Using the 2014–2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males
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facility Level Variation in cardiac stress test use among patients with diabetes findings from the veterans affairs national database
Diabetes Care, 2020Co-Authors: Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Khurram NasirAbstract:Cardiac stress testing in patients with diabetes mellitus (DM) is a topic of much debate (1,2). The clinical heterogeneity and varied interpretation of atypical symptoms in this population may lead to significant Variation in cardiac stress testing with downstream implications in health care expenditure. We evaluated facility-Level Variation in cardiac stress test use among patients with DM across the Veterans Affairs (VA) health care system. We identified patients with DM aged ≥18 years with a primary care clinic visit during VA fiscal year 2014 at one of the 130 VA facilities and associated clinics. Patient demographics and medical history were identified using clinical data sources and ICD-9-CM codes. We calculated diagnostic cost group relative risk score (DCG-RRS), a validated surrogate for overall illness burden. Facility-Level cardiac stress test use was defined as the number of stress tests performed per facility per 100 patients with DM in the preceding 365 days. Stress testing modalities evaluated included exercise treadmill test, stress echocardiography, and SPECT/PET MPI (myocardial perfusion imaging [single photon emission computed tomography or positron emission tomography]). Facilities with <10 studies/year were excluded. Median risk ratio (MRR), a well-established measure of facility-Level Variation (3), was derived by constructing multivariable hierarchical modified regression models adjusted for patient clustering and modeled patient characteristics as filter effects within each facility and individual facilities as a random effect (4). Unadjusted and adjusted MRRs (adjustment for patient, provider, and facility-Level variables) were calculated for overall stress testing and individual stress modalities. MRR represents the likelihood of two …
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facility Level Variation in cardiac stress test utilization among patients with diabetes mellitus findings from the veterans affairs national database
Journal of the American College of Cardiology, 2020Co-Authors: Dhruv Mahtta, Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Stephen W. Waldo, Khurram Nasir, Ihab Hamzeh, Islam Y Elgendy, Mouaz H AlmallahAbstract:Cardiac stress testing in diabetics has been a topic of much debate. We assessed facility-Level Variation in stress test utilization among patients with diabetes mellitus (DM) with hopes of identifying mechanisms to curtail inefficiencies and improve care. We used 2013–2014 nationwide VA
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Facility-Level Variation in Stress Test Utilization in Veterans With Ischemic Heart Disease
JACC: Cardiovascular Imaging, 2019Co-Authors: Nishant R. Shah, Christie M. Ballantyne, Sarah T. Ahmed, David E. Winchester, David J. Ramsey, Julia M. Akeroyd, Stephen W. Waldo, Richard S. Schofield, Laura A. PetersenAbstract:Quantifying facility-Level Variation in cardiac stress test utilization is important for healthcare systems seeking to improve the efficiency and quality of cardiovascular care. Limited registry and payer data suggest such Variation may be wide [(1,2)][1], but benchmark data from a single, large
David J. Ramsey - One of the best experts on this subject based on the ideXlab platform.
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Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease—Perspective from the Veterans Affair Healthcare System
Cardiovascular Drugs and Therapy, 2021Co-Authors: Xiaoming Jia, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Michelle T. Lee, Mahmoud Rifai, Chayakrit Krittanawong, Michael E. Matheny, Glenn Gobbel, Neil J. StoneAbstract:Purpose Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. Methods We assessed facility-Level Variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-Level Variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. Results Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p
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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7
Cardiovascular Drugs and Therapy, 2021Co-Authors: Dhruv Mahtta, David J. Ramsey, Julia M. Akeroyd, Michelle T. Lee, Chayakrit Krittanawong, Safi U. Khan, Preetika Sinh, Mahboob Alam, Kirk N. Garratt, Richard S. SchofieldAbstract:Purpose We investigated facility-Level Variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. Methods Using the 2014–2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males
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facility Level Variation in cardiac stress test use among patients with diabetes findings from the veterans affairs national database
Diabetes Care, 2020Co-Authors: Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Khurram NasirAbstract:Cardiac stress testing in patients with diabetes mellitus (DM) is a topic of much debate (1,2). The clinical heterogeneity and varied interpretation of atypical symptoms in this population may lead to significant Variation in cardiac stress testing with downstream implications in health care expenditure. We evaluated facility-Level Variation in cardiac stress test use among patients with DM across the Veterans Affairs (VA) health care system. We identified patients with DM aged ≥18 years with a primary care clinic visit during VA fiscal year 2014 at one of the 130 VA facilities and associated clinics. Patient demographics and medical history were identified using clinical data sources and ICD-9-CM codes. We calculated diagnostic cost group relative risk score (DCG-RRS), a validated surrogate for overall illness burden. Facility-Level cardiac stress test use was defined as the number of stress tests performed per facility per 100 patients with DM in the preceding 365 days. Stress testing modalities evaluated included exercise treadmill test, stress echocardiography, and SPECT/PET MPI (myocardial perfusion imaging [single photon emission computed tomography or positron emission tomography]). Facilities with <10 studies/year were excluded. Median risk ratio (MRR), a well-established measure of facility-Level Variation (3), was derived by constructing multivariable hierarchical modified regression models adjusted for patient clustering and modeled patient characteristics as filter effects within each facility and individual facilities as a random effect (4). Unadjusted and adjusted MRRs (adjustment for patient, provider, and facility-Level variables) were calculated for overall stress testing and individual stress modalities. MRR represents the likelihood of two …
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facility Level Variation in cardiac stress test utilization among patients with diabetes mellitus findings from the veterans affairs national database
Journal of the American College of Cardiology, 2020Co-Authors: Dhruv Mahtta, Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Stephen W. Waldo, Khurram Nasir, Ihab Hamzeh, Islam Y Elgendy, Mouaz H AlmallahAbstract:Cardiac stress testing in diabetics has been a topic of much debate. We assessed facility-Level Variation in stress test utilization among patients with diabetes mellitus (DM) with hopes of identifying mechanisms to curtail inefficiencies and improve care. We used 2013–2014 nationwide VA
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Facility-Level Variation in Stress Test Utilization in Veterans With Ischemic Heart Disease
JACC: Cardiovascular Imaging, 2019Co-Authors: Nishant R. Shah, Christie M. Ballantyne, Sarah T. Ahmed, David E. Winchester, David J. Ramsey, Julia M. Akeroyd, Stephen W. Waldo, Richard S. Schofield, Laura A. PetersenAbstract:Quantifying facility-Level Variation in cardiac stress test utilization is important for healthcare systems seeking to improve the efficiency and quality of cardiovascular care. Limited registry and payer data suggest such Variation may be wide [(1,2)][1], but benchmark data from a single, large
Brahmajee K Nallamothu - One of the best experts on this subject based on the ideXlab platform.
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temporal trends and hospital Level Variation of inhospital cardiac arrest incidence and outcomes in the veterans health administration
American Heart Journal, 2017Co-Authors: Steven M Bradley, Paul S. Chan, Theodore J Iwashyna, Peter J Kaboli, Lee A Kamphuis, Brahmajee K NallamothuAbstract:Background Despite significant attention to resuscitation care by hospitals, national data on trends in the incidence and survival of patients with inhospital cardiac arrest (IHCA) are limited. Objective To determine trends and hospital-Level Variation in the incidence and outcomes associated with IHCA. In exploratory analyses, we evaluated the relationship between hospital-Level IHCA incidence and outcomes with general hospital-wide quality improvement activities. Design, setting, and participants Retrospective cohort study of 2,205,123 hospitalizations at 101 Veterans Health Administration (VHA) hospitals between 2008 and 2012. Main outcomes Risk- and reliability-adjusted hospital-Level IHCA incidence and survival to hospital discharge. Results A total of 8821 (0.40%) IHCA occurred between 2008 and 2012, with no significant change in risk-adjusted incidence over this time ( P = .77). Hospital-Level IHCA incidence varied substantially across facilities, with a median hospital incidence of 4.0 per 1000 hospitalizations and a range from 1.4 to 11.8 per 1000 hospitalizations. Overall, survival to discharge after IHCA was 31.2%. Risk-adjusted odds of survival increased over the study period (2012 vs 2008, OR: 1.49, 95% CI: 1.27, 1.75) but survival varied substantially across facilities from 20.3% to 45.4%. General hospital quality improvement activities were inconsistently associated with IHCA incidence and survival. Conclusions Within the VHA, the incidence and outcomes of IHCA showed important trends over time but varied substantially across hospitals with no consistent link to general hospital quality improvement activities. Identification of specific resuscitation practices at hospitals with low incidence and high survival of IHCA may guide further improvements for inhospital resuscitation.
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abstract 116 temporal trends and hospital Level Variation in the incidence and 30 day mortality of in hospital cardiac arrest within the veterans health administration
Circulation-cardiovascular Quality and Outcomes, 2015Co-Authors: Steven M Bradley, Paul S. Chan, Theodore J Iwashyna, Kyle Kepreos, Brahmajee K NallamothuAbstract:Background: Improving the quality of in-hospital cardiac arrest (IHCA) care within the Veterans Health Administration (VHA) has received significant attention. Yet there are no national VHA data on the incidence and mortality outcomes of IHCA to guide or evaluate these efforts. We sought to determine overall trends and hospital-Level Variation in the incidence and 30-day mortality of IHCA within the VHA. Methods: Among 2,731,295 patients hospitalized at 115 VHA hospitals between 2008 and 2012, we defined IHCA using specific ICD-9 procedure codes for cardiac arrest and cardiopulmonary resuscitation. Among patients suffering IHCA, we used the VA Vital Status file to identify 30-day mortality from hospital admission. A severity of illness score was used to account for case-mix and determined from a logistic multivariate adaptive regression spline (MARS) model fit to our mortality outcome with covariates for age, race, gender, admission diagnosis category, 29 comorbid conditions, and 11 lab values drawn within 24 hours of admission. Hospital-Level IHCA incidence and 30-day mortality rates were compared using empirical Bayes random effects estimates from multi-Level regression models after risk- and reliability-adjustment. Results: 8,565 (0.3%) patients suffered IHCA between 2008 and 2012 and there was no significant trend in the rate of IHCA over this time period. The hospital-Level incidence of IHCA varied and was statistically significantly higher than the median rate at 38 (34%) hospitals and significantly lower at 24 (21%) hospitals (Figure A, p<0.05 without adjustment for multiple comparisons). Among patients suffering IHCA, the overall 30-day mortality rate was 68.6% and the risk-adjusted 30-day mortality rate decreased from 71.2% in 2008 to 66.1% in 2012 (p for trend <0.01). Hospital-Level 30-day mortality was significantly higher than the median rate at 5 (4%) hospitals and significantly lower at 7 (6%) hospitals (Figure B). Conclusions: Within the VHA, the incidence of IHCA has remained stable while 30-day mortality has improved. However, hospital-Level Variation in IHCA incidence and mortality rates suggest Variation in care processes related to IHCA and a target for future investigation to improve patient outcomes. ![][1] [1]: /embed/graphic-1.gif
Dhruv Mahtta - One of the best experts on this subject based on the ideXlab platform.
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Facility-Level Variation in Reported Statin-Associated Side Effects Among Patients with Atherosclerotic Cardiovascular Disease—Perspective from the Veterans Affair Healthcare System
Cardiovascular Drugs and Therapy, 2021Co-Authors: Xiaoming Jia, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Michelle T. Lee, Mahmoud Rifai, Chayakrit Krittanawong, Michael E. Matheny, Glenn Gobbel, Neil J. StoneAbstract:Purpose Statin-associated side effects (SASEs) can limit statin adherence and present a potential barrier to optimal statin utilization. How standardized reporting of SASEs varies across medical facilities has not been well characterized. Methods We assessed facility-Level Variation in SASE reporting among patients with atherosclerotic cardiovascular disease receiving care across the Veterans Affairs (VA) healthcare system from October 1, 2014, to September 30, 2015. The facility rates for SASE reporting were expressed as cases per 1000 patients with ASCVD. Facility-Level Variation was determined using hierarchical regression analysis to calculate median rate ratios (MRR [95% confidence interval]) by first using an unadjusted model and then adjusting for patient, provider, and facility characteristics. Results Of the 1,248,158 patients with ASCVD included in our study across 130 facilities, 13.7% had at least one SASE reported. Individuals with a history of SASE were less likely to be on a statin at follow-up compared with those without SASE (72.0% vs 80.8%, p
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Significant Facility-Level Variation in Utilization of and Adherence with Secondary Prevention Therapies Among Patients with Premature Atherosclerotic Cardiovascular Disease: Insights from the VITAL (Veterans wIth premaTure AtheroscLerosis) Registry7
Cardiovascular Drugs and Therapy, 2021Co-Authors: Dhruv Mahtta, David J. Ramsey, Julia M. Akeroyd, Michelle T. Lee, Chayakrit Krittanawong, Safi U. Khan, Preetika Sinh, Mahboob Alam, Kirk N. Garratt, Richard S. SchofieldAbstract:Purpose We investigated facility-Level Variation in the use and adherence with antiplatelets and statins among patients with premature and extremely premature ASCVD. Methods Using the 2014–2015 nationwide Veterans wIth premaTure AtheroscLerosis (VITAL) registry, we assessed patients with premature (age at first ASCVD event: males
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facility Level Variation in cardiac stress test use among patients with diabetes findings from the veterans affairs national database
Diabetes Care, 2020Co-Authors: Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Dhruv Mahtta, Khurram NasirAbstract:Cardiac stress testing in patients with diabetes mellitus (DM) is a topic of much debate (1,2). The clinical heterogeneity and varied interpretation of atypical symptoms in this population may lead to significant Variation in cardiac stress testing with downstream implications in health care expenditure. We evaluated facility-Level Variation in cardiac stress test use among patients with DM across the Veterans Affairs (VA) health care system. We identified patients with DM aged ≥18 years with a primary care clinic visit during VA fiscal year 2014 at one of the 130 VA facilities and associated clinics. Patient demographics and medical history were identified using clinical data sources and ICD-9-CM codes. We calculated diagnostic cost group relative risk score (DCG-RRS), a validated surrogate for overall illness burden. Facility-Level cardiac stress test use was defined as the number of stress tests performed per facility per 100 patients with DM in the preceding 365 days. Stress testing modalities evaluated included exercise treadmill test, stress echocardiography, and SPECT/PET MPI (myocardial perfusion imaging [single photon emission computed tomography or positron emission tomography]). Facilities with <10 studies/year were excluded. Median risk ratio (MRR), a well-established measure of facility-Level Variation (3), was derived by constructing multivariable hierarchical modified regression models adjusted for patient clustering and modeled patient characteristics as filter effects within each facility and individual facilities as a random effect (4). Unadjusted and adjusted MRRs (adjustment for patient, provider, and facility-Level variables) were calculated for overall stress testing and individual stress modalities. MRR represents the likelihood of two …
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facility Level Variation in cardiac stress test utilization among patients with diabetes mellitus findings from the veterans affairs national database
Journal of the American College of Cardiology, 2020Co-Authors: Dhruv Mahtta, Nishant R. Shah, Sarah T. Ahmed, David J. Ramsey, Julia M. Akeroyd, Stephen W. Waldo, Khurram Nasir, Ihab Hamzeh, Islam Y Elgendy, Mouaz H AlmallahAbstract:Cardiac stress testing in diabetics has been a topic of much debate. We assessed facility-Level Variation in stress test utilization among patients with diabetes mellitus (DM) with hopes of identifying mechanisms to curtail inefficiencies and improve care. We used 2013–2014 nationwide VA
Paul S. Chan - One of the best experts on this subject based on the ideXlab platform.
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temporal trends and hospital Level Variation of inhospital cardiac arrest incidence and outcomes in the veterans health administration
American Heart Journal, 2017Co-Authors: Steven M Bradley, Paul S. Chan, Theodore J Iwashyna, Peter J Kaboli, Lee A Kamphuis, Brahmajee K NallamothuAbstract:Background Despite significant attention to resuscitation care by hospitals, national data on trends in the incidence and survival of patients with inhospital cardiac arrest (IHCA) are limited. Objective To determine trends and hospital-Level Variation in the incidence and outcomes associated with IHCA. In exploratory analyses, we evaluated the relationship between hospital-Level IHCA incidence and outcomes with general hospital-wide quality improvement activities. Design, setting, and participants Retrospective cohort study of 2,205,123 hospitalizations at 101 Veterans Health Administration (VHA) hospitals between 2008 and 2012. Main outcomes Risk- and reliability-adjusted hospital-Level IHCA incidence and survival to hospital discharge. Results A total of 8821 (0.40%) IHCA occurred between 2008 and 2012, with no significant change in risk-adjusted incidence over this time ( P = .77). Hospital-Level IHCA incidence varied substantially across facilities, with a median hospital incidence of 4.0 per 1000 hospitalizations and a range from 1.4 to 11.8 per 1000 hospitalizations. Overall, survival to discharge after IHCA was 31.2%. Risk-adjusted odds of survival increased over the study period (2012 vs 2008, OR: 1.49, 95% CI: 1.27, 1.75) but survival varied substantially across facilities from 20.3% to 45.4%. General hospital quality improvement activities were inconsistently associated with IHCA incidence and survival. Conclusions Within the VHA, the incidence and outcomes of IHCA showed important trends over time but varied substantially across hospitals with no consistent link to general hospital quality improvement activities. Identification of specific resuscitation practices at hospitals with low incidence and high survival of IHCA may guide further improvements for inhospital resuscitation.
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Practice-Level Variation in Statin Use Among Patients With Diabetes: Insights From the PINNACLE Registry.
Journal of the American College of Cardiology, 2016Co-Authors: Yashashwi Pokharel, Kensey Gosch, Vijay Nambi, Paul S. Chan, Mikhail Kosiborod, William J. Oetgen, John A. Spertus, Christie M. Ballantyne, Laura A. Petersen, Salim S. ViraniAbstract:Statins reduce cardiovascular disease (CVD) and mortality risk in patients with diabetes [(1)][1]. Practice-Level Variation in statin use among diabetic patients in cardiology practices is unknown. Accordingly, we examined practice-Level Variation in statin therapy among 40- to 75-year-old patients
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abstract 116 temporal trends and hospital Level Variation in the incidence and 30 day mortality of in hospital cardiac arrest within the veterans health administration
Circulation-cardiovascular Quality and Outcomes, 2015Co-Authors: Steven M Bradley, Paul S. Chan, Theodore J Iwashyna, Kyle Kepreos, Brahmajee K NallamothuAbstract:Background: Improving the quality of in-hospital cardiac arrest (IHCA) care within the Veterans Health Administration (VHA) has received significant attention. Yet there are no national VHA data on the incidence and mortality outcomes of IHCA to guide or evaluate these efforts. We sought to determine overall trends and hospital-Level Variation in the incidence and 30-day mortality of IHCA within the VHA. Methods: Among 2,731,295 patients hospitalized at 115 VHA hospitals between 2008 and 2012, we defined IHCA using specific ICD-9 procedure codes for cardiac arrest and cardiopulmonary resuscitation. Among patients suffering IHCA, we used the VA Vital Status file to identify 30-day mortality from hospital admission. A severity of illness score was used to account for case-mix and determined from a logistic multivariate adaptive regression spline (MARS) model fit to our mortality outcome with covariates for age, race, gender, admission diagnosis category, 29 comorbid conditions, and 11 lab values drawn within 24 hours of admission. Hospital-Level IHCA incidence and 30-day mortality rates were compared using empirical Bayes random effects estimates from multi-Level regression models after risk- and reliability-adjustment. Results: 8,565 (0.3%) patients suffered IHCA between 2008 and 2012 and there was no significant trend in the rate of IHCA over this time period. The hospital-Level incidence of IHCA varied and was statistically significantly higher than the median rate at 38 (34%) hospitals and significantly lower at 24 (21%) hospitals (Figure A, p<0.05 without adjustment for multiple comparisons). Among patients suffering IHCA, the overall 30-day mortality rate was 68.6% and the risk-adjusted 30-day mortality rate decreased from 71.2% in 2008 to 66.1% in 2012 (p for trend <0.01). Hospital-Level 30-day mortality was significantly higher than the median rate at 5 (4%) hospitals and significantly lower at 7 (6%) hospitals (Figure B). Conclusions: Within the VHA, the incidence of IHCA has remained stable while 30-day mortality has improved. However, hospital-Level Variation in IHCA incidence and mortality rates suggest Variation in care processes related to IHCA and a target for future investigation to improve patient outcomes. ![][1] [1]: /embed/graphic-1.gif
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practice Level Variation in use of recommended medications among outpatients with heart failure insights from the ncdr pinnacle program
Circulation-heart Failure, 2013Co-Authors: Pamela N Peterson, Paul S. Chan, John A. Spertus, Fengming Tang, Philip G Jones, Justin A Ezekowitz, Larry A Allen, Frederick A Masoudi, Thomas M MaddoxAbstract:Background —The objective of this study is to examine practice-Level Variation in rates of guideline-recommended treatment for outpatients with heart failure and reduced ejection fraction (HFREF), and to examine the association between treatment Variation and practice site, independent of patient factors. Methods and Results —Cardiology practices participating in the NCDR PINNACLE registry from July 2008 - December 2010 were evaluated. Practice rates of treatment with angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) and beta blockers (BB) and an optimal combined treatment measure were determined for patients with HFREF and no documented contraindications. Multivariable hierarchical regression models were adjusted for demographics, insurance status and comorbidities. A median rate ratio (MRR) was calculated for each therapy, which describes the likelihood that the treatment of a patient with given comorbidities would differ at two randomly selected practices. We identified 12,556 patients from 45 practices. The unadjusted practice-Level prescription rates ranged from 44% to 100% for ACEI/ARB (median 85%; interquartile range [IQR] 75%-89%), from 49%-100% for BB (median of 92%; IQR 83%-95%) and from 37%-100% for optimal combined treatment (median of 79%; IQR 66%-85%). The adjusted MRR was 1.11 (95% confidence interval [CI] 1.08-1.18) for ACEI/ARB therapy, 1.08 (95% CI 1.05-1.15) for BB therapy and 1.17 (1.13-1.26) for optimal combined treatment. Conclusions —Variation in the use of guideline-recommended medications for patients with HFREF exists in the outpatient setting. Addressing practice-Level differences may be an important component of improving quality of care for patients with HFREF.
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practice Level Variation in warfarin use among outpatients with atrial fibrillation from the ncdr pinnacle program
American Journal of Cardiology, 2011Co-Authors: Paul S. Chan, Thomas M Maddox, Fengming Tang, Sarah A Spinler, John A. SpertusAbstract:Warfarin is a complex but highly effective treatment for decreasing thromboembolic risk in atrial fibrillation (AF). We examined contemporary warfarin treatment rates in AF before the expected introduction of newer anticoagulants and extent of practice-Level Variation in warfarin use. Within the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence program from July 2008 through December 2009, we identified 9,113 outpatients with AF from 20 sites who were at moderate to high risk for stroke (congestive heart failure, hypertension, age, diabetes, stroke score >1) and would be optimally treated with warfarin. Using hierarchical models, the extent of site-Level Variation was quantified with the median rate ratio, which can be interpreted as the likelihood that 2 random practices would differ in treating "identical" patients with warfarin. Overall rate of warfarin treatment was only 55.1% (5,018 of 9,913). Untreated patients and treated patients had mean congestive heart failure, hypertension, age, diabetes, stroke scores of 2.5 (p = 0.38) and similar rates of heart failure, hypertension, diabetes mellitus, and previous stroke, suggesting an almost "random" pattern of treatment. At the practice Level, however, there was substantial Variation in treatment ranging from 25% to 80% (interquartile range for practices 50 to 65), with a median rate ratio of 1.31 (1.22 to 1.55, p <0.001). In conclusion, within the Practice Innovation and Clinical Excellence registry, we found that warfarin treatment in AF was suboptimal, with large Variations in treatment observed across practices. Our findings suggest important opportunities for practice-Level improvement in stroke prevention for outpatients with AF and define a benchmark treatment rate before the introduction of newer anticoagulant agents.
