Clinical Assessment, Reporting, And Tracking Research Articles

Impact of severity of baseline thrombocytopenia on outcomes after percutaneous coronary interventions: Analysis from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program.

The aim of this study was to evaluate the effect of the degree of severity of baseline thrombocytopenia (TCP) on outcomes after percutaneous coronary intervention (PCI) BACKGROUND: The association of TCP with clinical outcomes among patients undergoing coronary intervention has not been previously evaluated. Using data from the US Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program, we identified patients undergoing PCI between October 1, 2007, to September 30, 2017. The cohort was then stratified by platelet count, as no TCP (platelet count >150,000/mcl), mild TCP (100-150,000/mcl), or moderate-severe TCP (<100,000/mcl) and this was associated with clinical outcomes. The cohort included 80,427 patients (98% male), of which 14.9% (13.2% mild, 1.7% moderate-severe) suffered from TCP at the time of PCI. Compared with mild or no TCP, moderate-severe TCP was associated with increased risk of post-PCI pericardiocentesis (0.6% vs. 0.2% vs. 0.2%, p = 0.018) and in-hospital mortality (1.5% vs. 0.7% vs. 0.7%) without a difference in postprocedure stroke (0.5% vs. 0.3% vs. 0.3%, p = 0.6). Over a median follow-up of 1729 days, time-to-repeat revascularization was significantly shorter in moderate-severe TCP (1080 vs. 1347 vs. 1467 days, p < 0.001) despite lower risk of revascularization. Both mild (adjusted HR: 1.11, 95% CI: 1.07-1.15, p < 0.001) and moderate-severe TCP (HR: 1.55, 95% CI: 1.43-1.69, p < 0.001) were associated with increased all-cause mortality compared with those without TCP. Thrombocytopenia was associated with increased short- and long-term adverse events among patients undergoing PCI. Any degree of TCP was associated with increased long-term all-cause mortality while moderate-severe TCP was also associated with increased risk of periprocedural adverse events.

Impact of Operator Volumes and Experience on Outcomes After Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program

BackgroundRecent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship. ObjectivesTo assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association. MethodsAnnual PCI volumes for facilities and operators within the Veterans Affairs Healthcare System and their relationship with 30-day mortality following PCI were described. The influence of operator lifetime experience on the volume-outcome relationship was assessed. Hierarchical logistic regression was used to adjust for patient and procedural factors. Results57,608 PCIs performed from 2013 to 2018 by 382 operators and 63 institutions were analyzed. Operator annualized PCI volume averaged 47.6 (standard deviation [SD] 49.1) and site annualized volume averaged 189.2 (SD 105.2). Median operator experience was 9.0 years (interquartile range [IQR] 4.0–15.0). There was no independent relationship between operator annual volume, institutional volume, or operator lifetime experience with 30-day mortality (p > 0.10). However, the interaction between operator volume and lifetime experience was associated with a marginal decrease in mortality (odds ratio [OR] 0.9998, 95% CI 0.9996–0.9999). ConclusionsThere were no significant associations between facility or operator-level procedural volume and 30-day mortality following PCI in a nationally integrated healthcare system. There was a marginal association between the interaction of operator lifetime experience, operator annual volume, and 30-day mortality that is unlikely to be clinically relevant, though does suggest an opportunity to explore novel factors that may influence the volume-outcome relationship.

Abstract 16977: Coronary Chronic Total Occlusions: Insights on Upstream Management

Introduction: Percutaneous coronary intervention (PCI) of coronary artery chronic total occlusions (CTO) has increased over time, despite representing higher procedural risk than traditional PCI. While guidelines for stable ischemic heart disease recommend antianginal therapy prior to attempted revascularization, the frequency with which this occurs for CTO PCI remain unknown. We propose to assess the frequency and variability in upstream use of antianginal therapy prior to CTO PCI attempt over time. Methods: This study identified all patients who underwent a CTO PCI attempt from January 2012 to September 2018 across the Veterans Affairs Healthcare System using the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) program. Patients were categorized by upstream management: (A) &lt;2 antianginal medications prescribed in year prior to CTO PCI, (B) ≥ 2 antianginals (C) Stress testing within 3 months of CTO PCI attempt and (D) ≥2 antianginals AND stress testing. Antianginal medications included beta blockers, nitrates, calcium channel blockers, and ranolazine. Multivariable logistic regression was used to estimate the propensity for receiving each category of treatment over time. Results: During the study period, 4250 patients underwent CTO PCI, with 1716 (40%) on ≥2 antianginal medications, 2534 (60%) on &lt;2 antianginals, 1023 (24%) with stress testing, and 338 (8%) on ≥2 antianginals with stress testing. Trends in upstream medical management of patients undergoing CTO PCI were unchanged over each fiscal year (Figure 1A) while odds of preprocedural stress testing decreased across fiscal years (Figure 1B). Conclusions: The majority of patients were on low intensity antianginal medical therapy prior to CTO PCI. Utilization of preprocedural stress testing decreased over time while patterns of upstream medical management remained constant, suggesting an opportunity to improve guideline compliance among patients undergoing attempted CTO PCI.

Abstract 332: Racial Differences in Prescribing of Sodium Glucose Cotransporter-2 Inhibitors and Glucagon-like Peptide-1 Receptor Agonists Among Veterans With Type 2 Diabetes and Coronary Artery Disease: Findings From the Veteran’s Administration Clinical Assessment, Reporting, and Tracking Program

Background: Recent trials have shown improved cardiovascular benefit associated outcomes with sodium glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA) treatment in patients (pts) with type 2 diabetes (T2D) and high cardiovascular (CV) risk. We examined the extent to which this new evidence has been applied in routine clinical care and whether race influenced differences in prescription rates between patients. Methods and results: We used data from the US Department of Veterans Affairs’ Clinical Assessment, Reporting, and Tracking (CART) Program (2015-2017 inclusive). Pts were deemed SGLT2i- or GLP-1RA-eligible based on EMPA-REG OUTCOME and LEADER trial criteria. Rates of use were examined among eligible pts by race/ethnicity in unadjusted and multivariable logistic regression models adjusted for age, insurance type, service connection, and clinical site. From 84 sites, 21,053 patients were eligible for an SGLT2i and 1,520 (7.2%) had one prescribed. Recipients of SGLT2i were younger (65.59 years vs 68.29 years) had a higher mean HbA1c (8.27% vs 8.02%) and were more likely white (86.0 % vs 82.6%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.38; 95% CI 1.05,1.85; p &lt; 0.01. Among 11,913 Veterans eligible for an GLP-1RA, 477 (4.0%) had one prescribed. Recipients were younger (65.84 years vs 68.96 years), had a higher mean HbA1c (8.55% vs 8.09%) and were more likely white (83.6% vs 81.8%). Compared to black pts, whites had higher odds of receiving the medication, OR = 1.43; 95% CI 1.09, 1.92; p = 0.013. Representation of other racial/ethnic groups was insufficient for comparison. Conclusion: Appropriate prescription of SGLT2i or GLP-1RA was less likely among black than white US Veterans at high CV risk. Our results suggest that while overall uptake of these medications has been slow, there are substantial racial differences that exist concerning the prescribing of these medications. In view of these findings, additional research is needed to further investigate both institutional and clinical factors which may adversely affect the prescribing of SGLT2i and GLP-1RA in African American Veterans.

Variation in contrast-associated acute kidney injury prophylaxis for percutaneous coronary intervention: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program

BackgroundContrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization.MethodsWe assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio ≤ 3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis.ResultsFrom 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5–56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8–36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6–53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56–2.08) for periprocedural hydration, 1.95 (CI 1.66–2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23–3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n = 5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38–1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65–2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N = 1059), 6.2% of cases in 2015 (N = 128, p = < 0.0001)) and no significant change in contrast-minimization (p = 0.3907).ConclusionsAmong patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.

A pilot study to assess the learning environment and use of reliability enhancing work practices in VHA cardiac catheterization laboratories.

IntroductionA learning health system (LHS) harnesses data and analytics to learn from clinical encounters to implement the best care with high reliability. The 81 Veterans Health Administration (VHA) cardiac catheterization laboratories (cath lab) are a model LHS. The quality and safety of coronary procedures are monitored and reported by the Clinical Assessment, Reporting and Tracking (CART) Program, which has identified variation in care across cath labs. This variation may be due to underappreciated aspects of LHSs, the learning environment and reliability enhancing work practices (REWPs). Learning environments are the educational approaches, context, and settings in which learning occurs. REWPs are the organizational practices found in high reliability organizations. High learning environments and use of REWPs are associated with improved outcomes. This study assessed the learning environments and use of REWPs in VHA cath labs to examine factors supportive of learning and high reliability.MethodsIn 2018, the learning organization survey‐27 and the REWP survey were administered to 732 cath lab staff. Factor analysis and linear models were computed. Unit‐level analyses and site ranking (high, low) were conducted on cath labs with >40% response rate using Bayesian methods.ResultsSurveys from 40% of cath lab staff (n = 294) at 84% of cath labs (n = 68) were included. Learning environment and REWP strengths across cath labs include the presence of training programs, openness to new ideas, and respectful interaction. Learning environment and REWP gaps include lack of structured knowledge transfer (eg, checklists) and low use of forums for improvement. Survey dimensions matched established factor structures and demonstrated high reliability (Cronbach's alpha >.76). Unit‐level analyses were conducted for 29 cath labs. One ranked as high and four as low learning environments.ConclusionsThis work demonstrates an approach to assess local learning environments and use of REWPs, providing insights for systems working to become a LHS.

Utilization and Outcomes of Measuring Fractional Flow Reserve in Patients With Stable Ischemic Heart Disease

BackgroundThe use and clinical outcomes of fractional flow reserve (FFR) measurement in patients with stable ischemic heart disease (SIHD) are uncertain, as prior studies have been based on selected populations. ObjectivesThis study sought to evaluate contemporary, real-world patterns of FFR use and its effect on outcomes among unselected patients with SIHD and angiographically intermediate stenoses. MethodsThe authors used data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program to analyze patients who underwent coronary angiography between January 1, 2009, and September 30, 2017, and had SIHD with angiographically intermediate disease (40% to 69% diameter stenosis on visual inspection). The authors documented trends in FFR utilization and evaluated predictors using generalized mixed models. They applied Cox proportional hazards models to determine the association between an FFR-guided revascularization strategy and all-cause mortality at 1 year. ResultsA total of 17,989 patients at 66 sites were included. The rate of FFR use gradually increased from 14.8% to 18.5% among all patients with intermediate lesions, and from 44% to 75% among patients who underwent percutaneous coronary intervention. One-year mortality was 2.8% in the FFR group and 5.9% in the angiography-only group (p < 0.0001). After adjustment for patient, site-level, and procedural factors, FFR-guided revascularization was associated with a 43% lower risk of mortality at 1 year compared with angiography-only revascularization (hazard ratio: 0.57; 95% confidence interval: 0.45 to 0.71; p < 0.0001). ConclusionsIn patients with SIHD and angiographically intermediate stenoses, use of FFR has slowly risen, and was associated with significantly lower 1-year mortality.

Temporal Trends and Site Variation in High-Risk Coronary Intervention and the Use of Mechanical Circulatory Support: Insights From the Veterans Affairs Clinical Assessment Reporting and Tracking (CART) Program.

BackgroundPatients undergoing percutaneous coronary intervention (PCI) are older with greater medical comorbidities and anatomical complexity than ever before, resulting in an increased frequency of nonemergent high‐risk PCI (HR‐PCI). We thus sought to evaluate the temporal trends in performance of HR‐PCI and utilization of mechanical circulatory support in the largest integrated healthcare system in the United States.Methods and ResultsA cohort of high‐risk adult patients that underwent nonemergent PCI in the Veterans Affairs Healthcare System between January 2008 and June 2018 were identified by objective clinical, hemodynamic, and anatomic criteria. Temporal trends in the performance of HR‐PCI, utilization of mechanical circulatory support, and site‐level variation were assessed. Of 111 548 patients assessed during the study period, 554 met 3 high‐risk criteria whereas 4414 met at least 2 criteria for HR‐PCI. There was a significant linear increase in the proportion of interventions that met 3 (P<0.001) or at least 2 (P<0.001) high‐risk criteria over time, with rates approaching 1.9% and 11.2% in the last full calendar year analyzed. A minority of patients who met all high‐risk criteria received PCI with mechanical support (15.7%) without a significant increase over time (P=0.193). However, there was significant site‐level variation in the probability of performing HR‐PCI (4.0‐fold higher likelihood) and utilizing mechanical circulatory support (1.9‐fold higher likelihood) between high and low utilization sites.ConclusionsThe proportion of cases categorized as HR‐PCI has increased over time, with significant site‐level variation in performance. The majority of HR‐PCI cases did not utilize mechanical support, highlighting a discrepancy between current recommendations and clinical practice in an integrated healthcare system.

Characteristics of the Quality Improvement Content of Cardiac Catheterization Peer Reviews in the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

Peer review is recommended for quality assessment in all cardiac catheterization programs, but, to our knowledge, the content of peer reviews and the potential for quality improvement has not been described. To characterize the quality improvement content of cardiac catheterization peer reviews. This quality improvement study used retrospective case review of diagnostic angiography and percutaneous coronary intervention procedures to characterize the major adverse event review process of the US Department of Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program from January 1, 2012, to December 31, 2016. Data review and analysis took place from November 2017 to August 2018. Percentage of peer reviews reporting substandard care and opportunities for quality improvement. A total of 196 643 diagnostic coronary angiograms and 62 576 percutaneous coronary interventions were performed in the Department of Veterans Affairs. Of these, 168 (0.1%) were triggered for review because of a self-reported major adverse event during the procedure. Of 152 cases with complete peer review data, care was adjudicated as not meeting the standard of care in 25 cases (16.4%). Concerns about operator judgment were identified in 46 cases (30.3%), about case selection in 26 (17.1%), about trainee supervision in 21 (13.8%), and about technical performance in 46 (30.3%). Reviewers made recommendations to improve operator performance in 63 cases (41.4%) and catheterization laboratory or hospital processes in 58 (38.2%). While substandard care is infrequently identified in peer review of catheterization laboratory complications in the Department of Veterans Affairs, the process often generates recommendations for quality improvement. Peer review programs should focus on identifying quality improvement opportunities and providing meaningful feedback to operators.

Risk of obstructive coronary artery disease and major adverse cardiac events in patients with noncoronary atherosclerosis: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program

Rates of the angiographic end point of oCAD were compared among patients with and without noncoronary atherosclerosis undergoing coronary angiography within the Veterans Health Administration between October 2007 and August 2015. The primary angiographic end point of oCAD was defined as left main stenosis ≥50% or any stenosis ≥70% in 1, 2, or 3 vessels. In patients who proceeded to PCI, the rate of the composite clinical end point of death, myocardial infarction, or stroke was compared among those with concomitant noncoronary atherosclerosis (CVD, PAD, or CVD + PAD) versus isolated CAD. Among 233,353 patients undergoing angiography, 9.6% had CVD, 12.4% had PAD, and 6.1% had CVD + PAD. Rates of oCAD were 57.9% for neither CVD nor PAD, 66.4% for CVD, 73.6% for PAD, and 80.9% for CVD + PAD. Compared with patients without noncoronary atherosclerosis, the adjusted risk of oCAD with CVD, PAD, or CVD + PAD was 1.03 (95% CI 1.02-1.04), 1.10 (95% CI 1.09-1.11), and 1.12 (95% CI 1.11-1.13), respectively. In patients who underwent PCI, the adjusted hazard for death, myocardial infarction, or stroke among those with CVD, PAD, or CVD + PAD was 1.36 (95% CI 1.26-1.45), 1.53 (95% CI 1.45-1.62), and 1.72 (95% CI 1.59-1.86), respectively. In patients undergoing coronary angiography, noncoronary atherosclerosis was associated with increased burden of oCAD and adverse events post-PCI.

Abstract 29: Appropriateness of Percutaneous Coronary Intervention in Patients with Stable Coronary Artery Disease: Department of Veterans Affairs, 2013-2015

Background: Percutaneous coronary intervention (PCI) for patients with stable coronary artery disease is commonly performed in Veterans Affairs (VA) hospitals. However, the appropriateness of these procedures in contemporary practice is unknown. Methods: We performed a multi-center, retrospective study of patients within the VA Clinical Assessment, Reporting, and Tracking (CART) Program with stable coronary artery disease undergoing elective PCI between November 1, 2013, and October 31, 2015. Trained personnel abstracted data on patient symptoms and stress testing results. Using criteria issued by multiple cardiovascular professional societies in 2012, the level of risk indicated by stress testing was adjudicated and PCI appropriateness was assessed. The extent of hospital-level variation in rates of inappropriate PCI was characterized. Results: Of 2622 PCIs at 66 hospitals, 800 (30.5%) were classified as appropriate, 1583 (60.4%) were classified as uncertain, and 239 (9.1%) were classified as inappropriate. Inappropriate PCIs were performed in patients with low-risk ischemia on stress testing (n=223/382, 58.4%), with &lt; 1 classes of antianginal medication (n=235/1936, 12.1%), or without symptoms (n=14/23, 60.9%). Hospital-level variation in the proportion of inappropriate PCIs was observed ( Figure 1: median hospital rate for inappropriate PCI, 9.3%; interquartile range 6.2%-11.8%). Conclusions: In contemporary VA practice, most PCIs were classified as appropriate or uncertain. However, 9.1% were classified as inappropriate with variation across hospitals. These findings may inform ongoing efforts to identify elements of hospital performance and enhance PCI-related quality of care. Figure 1: Hospital-Level Variation in Rates of Inappropriate PCI

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.

Predictors and Outcomes of Staged Versus One-Time Multivessel Revascularization in Multivessel Coronary Artery Disease: Insights From the VA CART Program

ObjectivesThe aim of this study was to determine predictors and outcomes associated with staged percutaneous coronary intervention (PCI) versus one-time multivessel revascularization (OTMVR) in patients with multivessel coronary artery disease. BackgroundPrior observational studies have not evaluated predictors and outcomes of staged PCI versus OTMVR in a heterogenous population of patients with multivessel coronary artery disease who undergo multivessel revascularization. MethodsData from the Veterans Affairs (VA) CART (Clinical Assessment, Reporting, and Tracking) Program were used to evaluate patients who underwent PCI of >2 vessels between October 1, 2007, and September 3, 2014. Associations between individual factors and the decision to perform staged PCI were assessed. Additionally, the impact of measured patient and procedural factors, site factors, and unmeasured site factors on the decision to perform staged PCI was compared. Cox proportional hazards models were used to determine the association between staged PCI and mortality. ResultsA total of 7,599 patients at 61 sites were included. The decision to perform staged PCI was driven by procedural characteristics and unmeasured site factors. Staged PCI was associated with lower risk-adjusted mortality compared with OTMVR (adjusted hazard ratio [HR]: 0.78; 95% confidence interval [CI]: 0.72 to 0.84; p < 0.01). This mortality benefit was observed among the ST-segment elevation myocardial infarction (HR: 0.31; 95% CI: 0.21 to 0.47; p < 0.01), non–ST-segment elevation myocardial infarction (HR: 0.74; 95% CI: 0.64 to 0.87; p < 0.01), unstable angina (HR: 0.75; 95% CI: 0.64 to 0.89; p < 0.01) and stable angina (HR: 0.88; 95% CI: 0.77 to 1.00; p = 0.05) groups. ConclusionsThe decision to pursue staged PCI was driven by procedural characteristics and unmeasured site variation and was associated with lower mortality compared with OTMVR. After adjustment, there was an association between staged PCI and reduced mortality. Given the observational nature of these findings, a randomized trial comparing the 2 is needed to guide practice.

The implications of cocaine use and associated behaviors on adverse cardiovascular outcomes among veterans: Insights from the VA Clinical Assessment, Reporting, and Tracking (CART) Program.

Cocaine use has been associated with adverse cardiovascular outcomes in patients with coronary artery disease (CAD). It is unclear whether this is due to direct effects of cocaine or other factors. Cocaine use is associated with worse outcomes in patients undergoing cardiac catheterization METHODS: We used the Veterans Affairs database to identify veterans undergoing coronary catheterization between 2007 and 2014. We analyzed association between cocaine use and 1-year all-cause mortality, myocardial infarction (MI), and cerebrovascular accident (CVA) among veterans with obstructive CAD (N = 122 035). To explore factors contributing to these associations, we sequentially adjusted for cardiac risk factors, risky behaviors, and clinical conditions directly affected by cocaine. 3082 (2.5%) veterans were cocaine users. Cocaine users were younger (median 58.2 vs 65.3 years; P < 0.001), more likely to be African American (58.9% vs 10.6%; P < 0.001), and had fewer traditional cardiac risk factors. After adjustment for cardiac risk factors, cocaine was associated with increased risk of mortality (HR: 1.23, 95% CI: 1.08-1.39), MI (HR: 1.40, 95% CI: 1.07-1.83), and CVA (HR: 1.88, 95% CI: 1.38-2.57). With continued adjustment, increased CVA risk remained significantly associated with cocaine use, whereas MI risk was mediated by risky behaviors and mortality was fully explained by conditions directly affected by cocaine. Cocaine use is associated with adverse cardiac events in veterans with CAD. Contributors to this association are multifaceted and specific to individual cardiovascular outcomes, including associated risky behaviors and direct effects of cocaine. Effective intervention programs to reduce cardiac events in this population will require multiple components addressing these factors.

Abstract P050: Association Between Glycemic Control and Short-term Mortality Varies Across the Spectrum of Coronary Artery Disease

Background: Diabetes is a significant risk factor for cardiovascular disease, but optimal glycemic control strategies remain unclear. In particular, trials of intensive glycemic control have highlighted a tension between increased mortality risk and macrovascular benefits. In this study we aimed to assess whether the burden of coronary artery disease (CAD) modifies the association between glycemic control and short-term mortality. Methods: We studied veterans with diabetes who underwent elective cardiac catheterization between 2005 and 2013 in a retrospective analysis of data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program. Primary exposures were time-varying HbA1c over two years of follow-up after index catheterization, categorized as &lt;6%, 6-6.49%, 6.5-6.99%, 7-7.99%, 8-8.99%, and &gt;=9%, and burden of CAD, categorized as no CAD, non-obstructive CAD, or obstructive CAD. Primary outcome was two-year all-cause mortality. A total of 17394 participants had, on average, five HbA1c measurements over two years of follow-up. We used multivariable Cox proportional hazards regression to estimate the association between HbA1c and mortality, adjusting for demographic and clinical covariates and CAD burden, and including a term for interaction between HbA1c and CAD burden. Results: In adjusted models with 6.5 ≤ HbA1c ≤ 6.99% as the reference category, HbA1c &lt; 6% was associated with increased risk of mortality (HR 1.55 [1.25, 1.92]), whereas HbA1c categories above 7% were not. We observed significant interaction between glycemic control and CAD burden (interaction p=0.0005); the increased risk of short-term mortality at HbA1c &lt; 6% was limited to individuals with non-obstructive and obstructive CAD (Figure 1). Conclusions: HbA1c below 6% was associated with increased risk of short-term mortality, but only in individuals with CAD. CAD burden may thus inform individualized diabetes management strategies, specifically treatment de-escalation in individuals with any angiographically-defined CAD.

Facility-Level Percutaneous Coronary Intervention Readmission Rates Are Not Associated With Facility-Level Mortality: Insights From the VA Clinical Assessment, Reporting, and Tracking (CART) Program.

BackgroundThirty‐day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility‐level 30‐day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility‐level 30‐day readmission rates are associated with facility‐level mortality. We sought to determine the effect of 30‐day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system.Methods and ResultsWe included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all‐cause mortality rates between patients with and without 30‐day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital‐level readmission rates with hospital‐level 1‐year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30‐day readmission had higher risk‐adjusted mortality (hazard ratio 1.53, 95% CI 1.44–1.63, P<0.0001). Facilities varied widely in 30‐day readmission rates (systemwide range of 6.6–19.4%, median 11.8%, interquartile range 10.0–13.2%); however, adjusted facility‐level readmission rates were not correlated with adjusted 1‐year mortality rates.ConclusionsThirty‐day readmissions after PCI are common and are a significant risk factor for mortality for individual patients even after robust statistical adjustment for clinical confounding. However, lack of correlation between readmission and mortality at the facility level suggests that quality improvement based on facility‐level readmission rates will not modify mortality in this high‐risk group.

Cardiac Electrophysiology Laboratories: A Potential Target for Antimicrobial Stewardship and Quality Improvement?

BACKGROUND Infections following cardiovascular implantable electronic device (CIED) procedures, including pacemaker and implantable cardioverter-defibrillators, are devastating and costly. Preimplantation prophylactic antimicrobials are effective for reducing postprocedural infections. However, routine postprocedural antimicrobials are not associated with improved outcomes, and they may be harmful. Thus, we sought to characterize antimicrobial use patterns following CIED procedures. DESIGN All patients who underwent CIED procedures from October 1, 2007 to September 30, 2013 and had procedural information entered into the VA Clinical Assessment Reporting and Tracking (CART) software program were included in this study. All antibiotic prescriptions lasting more than 24 hours following device implantation or revision were identified using pharmacy databases, and postprocedural antibiotic use lasting more than 24 hours was characterized. RESULTS In total, 3,712 CIED procedures were performed at 34 VA facilities on 3,570 patients with a mean age of 71.7 years (standard deviation [SD], 11.1 years), 98.4% of whom were male. Postprocedural antibiotics >24 hours were prescribed following 1,579 of 3,712 CIED procedures (42.5%). The median duration of therapy was 5 days (interquartile range [IQR], 3-7 days). The most commonly prescribed antibiotic was cephalexin (1,152 of 1,579; 72.9%), followed by doxycycline (118 of 1,579; 7.47%) and ciprofloxacin (93 of 1,579; 5.9%). Vancomycin was used in 73 of 1,579 prescriptions (4.62%). Among the highest quartile of procedural volume, prescribing practices varied considerably, ranging from 3.2% to 77.6%. CONCLUSIONS Nearly 1 in 2 patients received prolonged postprocedural antimicrobial therapy following CIED procedures, and the rate of postprocedural antimicrobial therapy use varied considerably by facility. Given the lack of demonstrated benefit of routine prolonged antimicrobial therapy following CIED procedures, antimicrobial use following cardiac device interventions may be a potential target for quality improvement programs and antimicrobial stewardship. Infect Control Hosp Epidemiol 2016;37:1005-1011.

Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery.

To identify predictors of major adverse cardiovascular outcomes (MACE) among patients with prior percutaneous coronary intervention (PCI) who require noncardiac surgery. Patients with prior PCI who undergo noncardiac surgery have an increased risk of postoperative MACE, but few studies have examined the association of PCI lesion characteristics with subsequent operative risk. Patients were identified using the VA Clinical Assessment, Reporting, and Tracking (CART) program. Patients who underwent noncardiac surgery within 2 years after stent placement were linked to VA and non-VA surgical records. A multivariable logistic regression model was developed to identify predictors of postoperative MACE. Among 12,621 patients with a history of prior PCI who underwent subsequent noncardiac surgery, 570 (4.5%) developed postoperative MACE. The median time from stent placement to surgery was 368 days (IQR 181-528). The strongest predictors of postoperative MACE were urgency of the operation, revised cardiac risk index, the indication for the prior PCI, and timing of the surgery after the PCI. Lesion characteristics independently associated with postoperative MACE included PCI to a distal (AOR 1.43, 95% CI 1.11-1.83) or ostial lesion (AOR 1.52, 95% CI 1.11-2.08), and lesion calcification (AOR 1.29, 95% CI 1.03-1.61), but stent length and target vessel were not independently associated with outcomes. Placement of a bare metal stent was also an independent predictor of MACE after noncardiac surgery (AOR 1.29, 95% CI 1.06-1.57). While patient and operative characteristics are the strongest predictors of MACE after noncardiac surgery, specific lesion characteristics including ostial or distal lesion location and calcification are novel risk factors for postoperative MACE. © 2016 Wiley Periodicals, Inc.

Guideline Recommended Medical Therapy for Cardiovascular Diseases in the Obese: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program.

BackgroundStigma against the obese is well described in health care and may contribute to disparities in medical decision‐making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline‐recommended medications in patients undergoing elective percutaneous coronary intervention.Methods and ResultsUsing data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty‐seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed β‐blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin‐converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants.ConclusionsOver 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline‐indicated medication prescription were <70% among all patients, and across BMI categories, with an association between increased BMI and greater use of guideline‐recommended medications. Our findings offer a possible contribution to the obesity paradox seen in many cardiovascular conditions.

Abstract 316: Using Reference Effect Measures to Identify Sources of Variation in 30-day Readmissions for Percutaneous Coronary Intervention

Background: Multilevel models for non-normal outcomes are widely used in outcomes research to estimate effects of covariates on outcomes, e.g. hospital readmissions following percutaneous coronary intervention (PCI). We refine Reference Effect Measures (REM) to compare effects of individual covariates, sets of covariates and random effects on the same scale (e.g. odds ratio, OR) and present a novel approach for displaying these effects. We illustrate this method by studying these sources of variation in 30-day readmission rates for Veterans Administration (VA) patients undergoing PCI. Methods: We used mixed effects logistic regression with 13 patient and 3 hospital covariates to study 30-day readmission rates in a national cohort of 45,521 VA Clinical Assessment, Reporting and Tracking (CART) patients who received a PCI during 10/2007-9/2012 at 49 VA hospitals. OR was used as a REM to compare percentiles of hospital or patient risk with median hospitals or patients to assess levels of variation. Results: Overall 30-day readmission rate was 11.5% ranging from 6.8% to 17.3% across the 49 sites. The figure below shows effects of individual patient and hospital covariates, combined effects of patient and hospital characteristics (shaded bars), and hospital random variation (shaded curve) for 30-day readmissions. The OR for comparing a 97.5 th percentile hospital with a median hospital, all covariates being equal, was 1.43, which was substantially less than the 2.88 OR found when comparing patients at the same percentile of the combined patient risk distribution. The largest patient covariate effect (congestive heart failure) had an OR of 1.58, equivalent to comparing a 99 th percentile hospital with a median hospital, or an 81 st percentile risk patient to a median risk patient. Combining all hospital characteristics, the OR for a 97.5 th percentile hospital versus a median hospital was 1.16. Conclusions: REMs are simple to compute, interpret and graph, and provide direct comparison on the same scale across random effects and covariates. The methods apply generally to linear, logistic, log, count, and time to event outcomes. These methods showed that patient risk drives 30-day readmission rates for VA PCI patients and the figure provided a new way of visualizing variation across these effects.