Guideline-based Medication Research Articles

Adherence to low back pain clinical guidelines in Australian hospital emergency departments: A public and private comparison

Managing LBP via clinical practice guidelines in healthcare settings is recommended, yet burgeoning evidence suggests adherence is suboptimal in emergency department settings. Whether adherence differs between public and private settings is unknown. A retrospective audit of two Australian emergency departments matched 86 private patients to 86 public patients by age ( ± 5 years), sex (male/female) and LBP duration (first time/history of LBP). Patient charts were reviewed according to the Australian clinical guidelines for the management of LBP. Guidelines were considered individually and via a collective guideline adherence score (GAS). Management GAS was lower in private patients compared to public patients (d [95 %CI]: −0.67 [−0.98, −0.36], P < 0.001). Public patients were more likely to have documentation of guideline-based advice (OR [95 %CI]: 4.4 [2.4, 8.4], P < 0.001) and less likely to be sent for imaging (OR [95 %CI]: 5.0 [2.6, 9.4], P < 0.001). Private patients were more likely to have documented screening for psychosocial risk factors (OR [95 %CI]: 21.8 [9.1, 52.1], P < 0.001) and more likely to receive guideline-based medication prescriptions at patient discharge (OR [95 %CI]: 2.2 [1.2, 4.2], P = 0.013). Differences exist in public and private hospital emergency department guideline adherence. Exploring barriers and facilitators underpinning these differences will assist in guiding future implementation science approaches.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Palestine: Retrospective clinical audit study

ObjectivesTo assess the characteristics of patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with mid-range ejection fraction (HFmrEF), as well as the current application of guideline-directed medical therapy (GDMT) in Palestine. MethodsThis retrospective cohort study involved a population of heart failure (HF) patients who visited cardiology clinics at An-Najah National University Hospital and the National Hospital, Palestine. The primary outcome measures of interest were the proportions of patients prescribed guideline-based cardiovascular medications (GBCMs), such as angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), β-blockers, and mineralocorticoid receptor antagonists (MRAs), and the corresponding optimized doses at ≥ 50 % of targets and the reasons underlying the non-prescription of GDMT. ResultsA total of 70.5%, 56.6%, and 88.6% of patients were on ACEIs/ARBs, MRAs, and β-blockers, respectively. Of all patients, 38.7% were on the triple GDMT regimen. ConclusionLess than half the patients received the triple combination treatment. Age, diabetes mellitus, chronic renal disease, and admission to the hospital for HF all had significant independent relationships with the reduced utilization and inadequate dosage of GDMT.

Referral and Prescription Patterns for Female Patients With Urinary Incontinence.

Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them. To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system. Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates. In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48). Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

The IMPACT of the COVID-19 Pandemic on Prescription Drug Use in Patients with Psoriasis Vulgaris in Germany.

Real-world evidence (RWE) data is increasingly important to generate rapid insights to effectively manage patient populations. Disruptions like the coronavirus disease 2019 (COVID-19) pandemic may negatively impact the choice of medications used for managing chronic diseases such as psoriasis (PSO). Here, we explored the effect of the COVID-19 pandemic on the sales volumes of treatment guideline-based PSO medication in Germany. Patient-level pharmacy dispensing data from the Permea platform, covering approximately 44% of all community pharmacy dispensing in Germany, were analysed from 2019 through to 2021. Patient demographics and PSO indicated medication sales were assessed specifically before and during the pandemic in Germany. We included 6,865,852 sold PSO related drugs from April 2019 to March 2021. Medication sales increased during the pandemic compared with before the pandemic for treatment classes of first-line biological and second-line drugs. The increase was observed across all age groups, but monthly variations could not be detected. Furthermore, we observed increased sales in first-line biological and second-line medications when comparing low to high COVID-19 incidence state. Throughout the COVID-19 pandemic the PSO indicated medication sales increased for first-line biological and second-line treatment. This shows that despite the pandemic impact, there continues to be an increase in sales volume for biologics. Only German federal states with intermittently very high COVID-19 incidences show a stagnation in sales volume. The reasons for this need to be investigated in further studies to possibly gain a better understanding of the concerns and uncertainties of patients with PSO.

443-P: Two-Year Results from a Novel, Patient-Centered, Team-Based Intervention for Patients with Type 2 Diabetes at High Cardiovascular Risk

Background: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of death in patients with type 2 diabetes (T2D). CINEMA is a novel, patient-centered, team-based intervention for patients with T2D/prediabetes with high risk for ASCVD. We present the outcomes from the first 2 years of the CINEMA program. Methods: Patients with T2D or prediabetes at high risk for CV events (established ASCVD, coronary artery calcium &amp;gt;100 AU, chronic heart failure, chronic kidney disease, and/or metabolic syndrome) were included. Linear mixed effects and generalized linear mixed models were used to assess changes in ASCVD risk factors and guideline-based medication prescriptions over time, respectively. Results: From May 2020 to September 2022, 426 patients were enrolled in CINEMA; 47% were women and 37% Black, with mean age 60 yrs, mean BMI 36kg/m2, and 48% with established ASCVD. 54% had ≥ 1 follow up visit with median follow up time of 3 months. There were significant reductions in risk factors including HbA1c (-12.1%), LDL-C (-14.2%), BP (-1.8%), and BMI (-2.2%) (P&amp;lt;0.001 for all). SGLT2 inhibitor and GLP-1 RA prescriptions increased from during follow up (20% to 56% and 17% to 66%, respectively). Conclusion: A multidisciplinary approach to treating patient with type 2 diabetes with the CINEMA program improves ASCVD risk factors and guideline-based medication adherence. Disclosure A.Arafah: None. I.Neeland: Consultant; Nestlé Health Science, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance, Bayer Inc. B.M.Bourges-sevenier: None. Z.Albar: None. C.Sullivan: None. S.G.Al-kindi: None. S.Rajagopalan: Advisory Panel; Novartis, Novo Nordisk, Speaker's Bureau; Novo Nordisk.

Acute heart failure presentation, management and outcomes in cancer patients: a national longitudinal study.

Currently, little evidence exists on survival and quality of care in cancer patients presenting with acute heart failure (HF). To investigate the presentation and outcomes of hospital admission with acute HF in a national cohort of patients with prior cancer. This retrospective, population-based cohort study, identified 221,953 patients admitted to hospital in England for HF during 2012-2018 (12,867 with a breast, prostate, colorectal or lung cancer diagnosis in the previous 10 years). We examined the impact of cancer on 1) HF presentation and in-hospital mortality, 2) place of care, 3) HF medication prescribing, and 4) post-discharge survival, using propensity score weighting and model-based adjustment. HF presentation was similar between cancer and non-cancer patients. A lower percentage of patients with prior cancer were cared for in a cardiology ward (-2.4 percentage point difference [ppd] [95% CI -3.3, -1.6]) or were prescribed ACEi/ARB for HFrEF (-2.1 ppd [-3.3, -0.9]) than non-cancer patients. Survival after HF discharge was poor with median survival of 1.6 years in prior cancer and 2.6 years in non-cancer patients. Mortality in prior cancer patients was driven primarily by non-cancer causes (68% of post-discharge deaths). Survival in prior cancer patients presenting with acute HF was poor, with a significant proportion due to non-cancer causes of death. Despite this, cardiologists were less likely to manage cancer patients with HF. Cancer patients who develop HF were less likely to be prescribed guideline-based HF medications compared with non-cancer patients. This was particularly driven by patients with a poorer cancer prognosis.

Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding

Background and AimsUpper GI bleeding (UGIB) is a common indication for inpatient esophagogastroduodenoscopy (EGD). Guideline adherence improves post-EGD care, including appropriate medication dosing/duration and follow-up procedures that reduce UGIB-related morbidity. We aimed to optimize and standardize post-EGD documentation to improve process and clinical outcomes in UGIB-related care.MethodsWe performed a prospective quality improvement study of inpatient UGIB endoscopies at an academic tertiary referral center during 6/2019–7/2021. Guidelines were used to develop etiology/severity-specific electronic health record note templates. Participants (39 faculty/15 trainees) completed 10-min training in template content/use. We collected pre/post-intervention process data on “Minimal Standard Report” (MSR) documentation including patient disposition, diet, and medications. We also recorded documentation of re-bleed precautions and follow-up procedures. Study outcomes included guideline-based medication prescriptions, ordering of follow-up EGD, and post-discharge re-bleeding. Pre/post-intervention analysis was performed using chi-square tests.ResultsFrom a pre-intervention baseline of 199 patients to 459 patients post-intervention, compliance improved with inpatient PPI (53.4–77.9%, p < 0.001) and discharge PPI (31.3–61.0%, p < 0.001) prescriptions. There was improvement in MSR completion (28.6–42.5%, p < 0.001). Compliance improved with octreotide prescriptions (75.0–93.6%, p = 0.002) and follow-up EGD order (61.3–87.1%, p < 0.001). There was no change in post-discharge re-bleeding. 82.6% of cases used templates.ConclusionsOur project leveraged endoscopy software to standardize documentation, resulting in improved clinical care behavior and efficiency. Our intervention required low burden of maintenance, and sustainability with high utilization over 9 months. Similar endoscopy templates can be applied to other health systems and procedures to improve care.

Multifactorial Effects of Outpatient Cardiac Rehabilitation in Patients with Heart Failure: A Nationwide Retrospective Cohort Study.

Although cardiac rehabilitation (CR) is a strongly recommended therapy, no large study has assessed the effects of outpatient CR in patients with heart failure (HF) in real-world settings. Therefore, this study aimed to investigate the multifactorial effects of outpatient CR in patients with HF using a nationwide database. This nationwide retrospective cohort study was performed using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with acute HF who underwent inpatient CR between April 2014 and March 2020 were included. The association between outpatient CR participation and all-cause mortality, rehospitalisation for HF, use of medical resources, and medical costs was analysed using propensity score matching analysis. Of 250,528 patients, 17,884 (7.1%) underwent outpatient CR. After propensity score matching, the CR (+) group was associated with a reduction in the risk of all-cause mortality (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.60-0.68, p < 0.001) and rehospitalisation for HF compared to the CR (-) group (HR: 0.87, 95% CI: 0.82-0.92, p < 0.001). The proportion of guideline-based medication use for HF at 1 year was higher in the CR (+) group than in the CR (-) group. The total medical costs from the index hospitalisation to 1.5 years after admission were similar between the groups. Outpatient CR participation after discharge from HF was associated with reduced mortality and rehospitalisation for HF without increasing medical costs.

Comparison of immediate changes of repolarization parameters after left bundle branch area pacing and traditional biventricular pacing in heart failure patients.

Comparison of immediate changes of repolarization parameters after left bundle branch area pacing and traditional biventricular pacing in heart failure patients.

Closing gaps in medication taking for secondary prevention of coronary heart disease patients among US adults

BackgroundThe secondary preventive medical remedies used in the U.S. general population, particularly those with numerous co-morbidities, are poorly understood. We aimed to assess health outcomes and the extent of their adherence to guideline-based secondary prevention medications among U.S. coronary heart disease (CHD) patients. MethodsWe analysed information from the U.S. National Health and Nutrition Examination Survey (NHANES) from 1999 to 2018 on people in the United States aged 18 to 85 who had a personal history of coronary heart disease (CHD). Logistic regression analyses were used to identify characteristics related to healthcare access that were linked with not taking any indicated drugs among CHD and other co-morbidity patients in the U.S. ResultsWe gathered 4256 CHD patients aged 18 and above. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), statins, and antiplatelet medications were taken by 50.94%, 48.26%, 53.41 %, and 19.78% of the population, respectively. Surprising, not received recommended drugs was reached up to 21.12%, and taking all four drugs was only 7.64%. In conclusion, the logistic regression analysis revealed that the chance of not taking prescribed drugs increased with age (18–39), race (Hispanic and Non-Hispanic Black), low income, lack of insurance, and the absence of co-morbidities (hypertension, heart failure, and diabetes mellitus). ConclusionsThe gap between the proposed secondary preventative measures and their actual execution remains sizable. In order to achieve ‘Healthy Aging’, a systematic approach for prevention of CHD is urgently needed.

Temporal trends in the treatment and outcomes of patients with acute coronary syndrome according to bleeding risk

Abstract Background High bleeding risk is associated with adverse clinical outcomes in patients with ACS. We aimed to evaluate temporal trends in the treatment and outcomes of ACS patients according to bleeding risk. Methods Included were ACS patients enrolled in the ACSIS survey. Bleeding risk was calculated using the CRUSADE score. Patients were divided into 3 groups according to enrolment period: early (2002–2004), mid (2006–2010) and recent (2012–2018). Each group was further divided into 3 sub-groups according to bleeding risk (low, intermediate and high). The primary endpoints were 30-day MACE and 1-year all-cause mortality. Results Included were 13,058 ACS patients. Patients at high bleeding risk were more frequently treated with guideline-based medications and coronary revascularization regardless of enrollment period. ACS patients at high bleeding risk had higher rates of 30-day MACE and 1-year all-cause mortality in all enrolment periods. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p&amp;lt;0.001), Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p&amp;lt;0.001), and for patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p&amp;lt;0.001) in low, moderate and high bleeding risk group, respectively. Furthermore, among patients enrolled in early period, 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p&amp;lt;0.001), Among patients enrolled in mid period, 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p&amp;lt;0.001), and for patients enrolled in recent period, 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p&amp;lt;0.001) in low, moderate and high bleeding risk group, respectively. These differences remained significant following a multivariate analysis. Conclusions Despite the improvement in the treatment of ACS patients in recent years, high bleeding risk remains a very strong predictor of adverse clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Temporal Trends in the Prevalence, Treatment and Outcomes of Patients with Acute Coronary Syndrome at High Bleeding Risk.

(1) Background: High bleeding risk is associated with adverse outcomes in ACS patients. We aimed to evaluate temporal trends in treatment and outcomes of ACS patients according to bleeding risk. (2) Methods: Included were ACS patients enrolled in ACSIS surveys. Patients were divided into three groups according to enrolment period: early (2002–2004), mid (2006–2010) and recent (2012–2018). Each group was further stratified into three subgroups according to CRUSADE bleeding risk score. The primary endpoints were 30-day MACE and 1-year all-cause mortality. (3) Results: Included were 13,058 ACS patients. High bleeding risk patients were less frequently treated with guideline-based medications and coronary revascularization. They also had higher rates of 30-day MACE and 1-year all-cause mortality regardless of the enrollment period. Among patients enrolled in early period, 30-day MACE rates were 10.8%, 17.5% and 24.3% (p < 0.001) and 1-year all-cause mortality rates were 2%, 7.7% and 23.6% (p < 0.001) in the low, moderate and high bleeding risk groups, respectively. Among patients enrolled in mid period, 30-day MACE rates were 7.7%, 13.4% and 23.5% (p < 0.001) and 1-year all-cause mortality rates were 1.5%, 7.2% and 22.1% (p < 0.001) in low, moderate and high bleeding risk groups, respectively. For patients enrolled in recent period, 30-day MACE rates were 5.7%, 8.6% and 16.2%, (p < 0.001) and 1-year all-cause mortality rates were 2.1%, 6% and 22.4%, (p < 0.001) in low, moderate and high bleeding risk groups, respectively. These differences remained significant following a multivariate analysis. (4) Conclusions: The percentage of patients at high bleeding risk has decreased over the last years. Despite recent improvements in the treatment of ACS patients, high bleeding risk remains a strong predictor of adverse outcomes.

Racial Differences and Social Determinants of Health in Achieving Hypertension Control

ObjectiveTo investigate whether specific social determinants of health could be a “health barrier” toward achieving blood pressure (BP) control and to further evaluate any differences between Black patients and White patients. Patients and MethodsWe conducted a retrospective cohort study of 3305 patients with elevated BP who were enrolled in a hypertension digital medicine program for at least 60 days and followed up for up to 1 year. Patients were managed virtually by a dedicated hypertension team who provided guideline-based medication management and lifestyle support to achieve goal BP. ResultsCompared with individuals without any health barriers, the addition of 1 barrier was associated with lower probability of control at 1 year from 0.73 to 0.60 and to 0.55 in those with 2 or more barriers. Health barriers were more prevalent in Black patients than in those who were White (44.6% [482 of 1081] vs 31.3% [674 of 2150]; P<.001). There was no difference at all in BP control between Black individuals and those who were White if 2 or more barriers were present. ConclusionPatient-related health barriers are associated with BP control. Black patients with poorly controlled hypertension have a higher prevalence of health barriers than their White counterparts. When 2 or more health barriers were present, there was no differences in BP control between White and Black individuals.

Medication Optimization Among People With Type 2 Diabetes Participating in a Continuous Glucose Monitoring-Driven Virtual Care Program: Prospective Study.

BackgroundThe Onduo virtual care program for people with type 2 diabetes (T2D) includes a mobile app, remote lifestyle coaching, connected devices, and telemedicine consultations with endocrinologists for medication management and prescription of real-time continuous glucose monitoring (RT-CGM) devices. In a previously described 4-month prospective study of this program, adults with T2D and baseline glycated hemoglobin (HbA1c) ≥8.0% to ≤12.0% experienced a mean HbA1c decrease of 1.6% with no significant increase in hypoglycemia.ObjectiveThe objective of this analysis was to evaluate medication optimization and management in the 4-month prospective T2D study.MethodsStudy participants received at least 1 telemedicine consultation with an Onduo endocrinologist for diabetes medication management and used RT-CGM intermittently to guide therapy and dosing. Medication changes were analyzed.ResultsOf 55 participants, 48 (87%) had a medication change consisting of a dose change, addition, or discontinuation. Of these, 15 (31%) participants had a net increase in number of diabetes medication classes from baseline. Mean time to first medication change for these participants was 36 days. The percentage of participants taking a glucagon-like peptide-1 receptor agonist increased from 25% (12/48) to 56% (n=27), while the percentages of participants taking a sulfonylurea or dipeptidyl peptidase 4 inhibitor decreased from 56% (n=27) to 33% (n=16) and 17% (n=8) to 6% (n=3), respectively. Prescriptions of other antidiabetic medication classes including insulin did not change significantly.ConclusionsThe Onduo virtual care program can play an important role in providing timely access to guideline-based diabetes management medications and technologies for people with T2D.Trial RegistrationClinicalTrials.gov NCT03865381; https://clinicaltrials.gov/ct2/show/NCT03865381

Abstract 9188: Sex Differences in Cardiovascular Risk and Guideline-Based Preventive Medication Use Among Sudden Death Victims

Introduction: Atherosclerotic cardiovascular disease (ASCVD) is associated with an increased risk of sudden death. Preventive medications are recommended by clinical practice guidelines for those with elevated ASCVD risk. Guidelines are often underutilized and use of preventive medications differs by sex. Methods: Out-of-hospital deaths of adults aged 18-64 were reported by emergency medical services in Wake County, North Carolina from 2013-2015 and underwent adjudication to identify sudden unexpected death cases. A cohort of 1,114 living controls was generated through random sampling from a central electronic health records repository and propensity scores matched to the sudden death victims based on sex and race. A 10-year ASCVD risk was calculated for all subjects with the requisite components and categorized as low (&lt;7.5%), intermediate (7.5%-19.9%), and high (≥20%). Use of preventive medications, specifically aspirin and statin, was assessed. Logistic regression models were fitted to evaluate the association between 10-year ASCVD risk and sudden death both overall and by sex. Odds ratios for males and females were compared in a pairwise fashion using an adjusted Wald test. Results: The average 10-year ASCVD risk was higher among sudden death victims compared to living controls for both males (36.4 ± 22.2 vs. 16.3 ± 16.0, p-value &lt;0.001) and females (20.6 ± 17.9 vs. 7.1 ± 8.4, p-value &lt;0.001). Among intermediate or high 10-year ASCVD risk sudden death victims and controls, aspirin and statin use were low (13-21%). Among those with intermediate or high ASCVD risk, male sudden death victims were less likely than living controls to be prescribed aspirin (p-value 0.007). Comparing sudden death victims to living controls, there was no difference in statin use among males or in aspirin or statin use among females. There was no significant difference in the strength of association between 10-year ASCVD risk categories and sudden death by sex. Conclusions: Although the average 10-year ASCVD risk of sudden death victims is higher than living controls both overall and by sex, the use of aspirin and statin was low and did not differ significantly between victims and controls. Improvements are needed to increase the use of guideline-based preventive medications.

S1292 Optimizing Endoscopy Procedure Documentation Improves Guideline Adherent Care in Upper Gastrointestinal Bleeding

Introduction: Upper GI bleeding (UGIB) is a common indication forced inpatient esophagogastroduodenoscopy (EGD). Outcomes afterwards are often dependent in part by guideline-based post-EGD care. Our aim was to optimize and standardize documentation post-EGD in UGIB to improve clinical care. Methods: National guidelines were used to build optimized etiology- and severity-specific note templates at an academic tertiary referral center. 39 attendings and 15 fellows completed a 10 minute training session in template content & use. We collected pre- and post-intervention on “minimal-standard” (MS) report documentation including patient disposition, diet, & medications. We also recorded documentation of rebleed precautions, and follow-up procedures. Health outcomes measured included guideline-based medication prescriptions, ordering of follow-up EGD if indicated, and clinical cessation of bleeding after discharge. Results: Pre-intervention demonstrated 54% and 36% of 108 patients received guideline-based inpatient and outpatient proton pump inhibitor (PPI), respectively. At baseline, 67.6% were referred for standard-of-care repeat EGD and only 36.1% of reports met MS report criteria. After template implementation, of 309 EGDs for UGIB over 6 months, the templates were used in 72% of cases. Workload was reduced by a mean of 33 “clicks,” 356 free text characters and 2 minutes per report (Figure 1, Panel A). There was a significant improvement in documentation of disposition (63.0% to 74.1%, p=0.028), appropriate PPI use(57.1% to 69.8%, p=0.035), rebleed (22.2% to 44.3%, p< 0.001) recommendations, and MS report completion (27.8% to 40.8%,p=0.016). There was significant improvement in inpatient PPI administered (53.6% to 73.6%, p< 0.001), discharge PPI prescription(35.7% to 54.0%, p=0.004), octreotide regimen(79.2% to 93.2%,p=0.048) and follow-up EGD orde r(67.6% to 86.7%, p< 0.001) (Table 1). Template usage (64%-79%), process (38%-50%) and outcome(67%-95%) metrics remained high over 6 months (Figure 1, Panel B & C). Inpatient PPI compliance(71.7% vs 63.4%; p=0.069) and follow-up EGD orders (85.7% vs 77.3%;p=0.028) were improved with template use. Conclusion: Our project leveraged endoscopy software to standardize efficient provider documentation, resulting in improved clinical care. Our intervention required minimal implementation cost, low burden of maintenance, and sustainability with high utilization rates over 6 months. Similar endoscopy templates can be applied to other health systems and endoscopic procedures to improve the quality of care.Table 1.: Process and outcome metrics pre- vs post- intervention. Statistical analysis using X2 testing.Figure 1.: Panel A: Sample endoscopy documentation template, Upper Gastrointestinal Bleed High Risk Non-Variceal Panel B: Process metrics pre- vs post-intervention of template usage (circle), minimal-standard non-variceal report (square), minimal-standard report (all etiologies) (diamond), and minimal-standard variceal report (triangle) Panel C: Outcome metrics pre- vs post-intervention of compliance with coordinated repeat EGD (circle), inpatient PPI regimen (square) and discharge PPI regimen (triangle).

Population health management of low-density lipoprotein cholesterol via a remote, algorithmic, navigator-executed program

Implementation of guideline-directed cholesterol management remains low despite definitive evidence establishing such measures reduce cardiovascular (CV) events, especially in high atherosclerotic CV disease (ASCVD) risk patients. Modern electronic resources now exist that may help improve health care delivery. While electronic medical records (EMR) allow for population health screening, the potential for coupling EMR screening to remotely delivered algorithmic population-based management has been less studied as a way of overcoming barriers to optimal cholesterol management. In an academically affiliated healthcare system, using EMR screening, we sought to identify 1,000 high ASCVD risk patients not meeting guideline-directed low-density lipoprotein-cholesterol (LDL-C) goals within specific system-affiliated primary care practices. Contacted patients received cholesterol education and were offered a remote, guideline-directed, algorithmic cholesterol management program executed by trained but non-licensed "navigators" under professional supervision. Navigators used telephone, proprietary software and internet resources to facilitate algorithm-driven, guideline-based medication initiation/titration, and laboratory testing until patients achieved LDL-C goals or exited the program. As a clinical effectiveness program for cholesterol guideline implementation, comparison was made to those contacted patients who declined program-based medication management, and received education only, along with their usual care. 1021 patients falling into guideline-defined high ASCVD risk groups warranting statin therapy (ASCVD, type 2 diabetes, LDL ≥ 190 mg/dL, calculated 10-year ASCVD risk ≥7.5%) and not achieving guideline-defined target LDL-C levels and/or therapy were identified and contacted. Among the 698 such patients who opted for program medication management, significant LDL-C reductions occurred in the total cohort (mean -65.4 mg/dL, 45% decrease), and each high ASCVD risk subgroup: ASCVD (-57.2 mg/dL, -48.0%); diabetes mellitus (-53.1 mg/dL, -40.0%); severe hypercholesterolemia (-76.3 mg/dL, -45.7%); elevated ASCVD 10-year risk (-62.8 mg/dL, -41.1%) (P<0.001 for all), without any significant complications. Among 20% of participants with reported statin intolerance, average LDL-C decreased from baseline 143 mg/dL to 85 mg/dL using mainly statins and ezetimibe, with limited PCSK9 inhibitor use. In comparison, eligible high ASCVD risk patients who were contacted but opted for education only, a 17% LDL-C decrease occurred over a similar timeframe, with 80% remaining with an LDL-C over 100 mg/dL. A remote, algorithm-driven, navigator-executed cholesterol management program successfully identified high ASCVD risk undertreated patients using EMR screening and was associated with significantly improved guideline-directed LDL-C control, supporting this approach as a novel strategy for improving health care access and delivery.

Drug Adherence and Long-Term Outcomes in Non-Revascularized Patients Following Acute Myocardial Infarction

This study examined long-term outcomes and adherence to guideline-based medications in non-revascularized acute myocardial infarction (MI) patients undergoing and not undergoing angiography. We analyzed non-revascularized MI patients hospitalized in Alberta, Canada between 2010-2016 and categorized them according to whether they had undergone coronary angiography. Adherence to guideline-based medications was determined by the proportion of days covered (PDC) and subdivided into categories based on PDC: 0% (none), 1-40% (low), 40-79% (intermediate) and ≥ 80% (high). Patients not undergoing angiography were older, less frequently male, and had more comorbidities. Those not receiving angiography had higher rates of 2-year myocardial infarction (9.9% vs 6.1%, p <0.001), heart failure (14.9% vs 6.1%, p <0.001), and mortality (29.4% vs 7.4%, p <0.001). Optimal medial therapy (OMT), defined by high PDC for the combination of lipid-modifying agents, β-blockers and angiotensin converting enzyme-inhibitors/receptor blockers (ACE-I/ARBs), was achieved in 32.9%. Patients not undergoing angiography had lower rates of OMT adherence (p <0.001). In patients not undergoing angiography, high-adherence to lipid-modifying agents (HR 0.70 [95% CI 0.57-0.87]), β-blockers (HR 0.78 [0.62-0.97]), ACE-I/ARBs (HR 0.64 [0.52-0.79]) and OMT (HR 0.56 [0.40-0.77]) was independently associated with lower 2-year mortality. In conclusion, MI patients not receiving angiography had low adherence rates to guideline-based pharmacotherapies and high rates of long-term outcomes, suggesting potential treatment targets to improve prognosis in non-invasively managed MI patients.

Impact of guideline-based medical therapy on malignant arrhythmias and mortality among heart failure patients implanted with a primary prevention ICD/CRTD

Abstract Funding Acknowledgements Type of funding sources: None. Background In contrast with the well-established impact of heart failure (HF) medical treatment reducing HF hospitalizations and improving survival, its impact on ventricular arrhythmia (VA) is based mainly on circumstantial evidence. Aim To evaluate prevalence of HF medical treatment and its impact on VA and overall survival among HF patients implanted with primary prevention ICD/CRTD. Methods Single center retrospective analysis of all HF patients implanted with ICD/CRTD as primary prevention. Patients" indication for implant according to guidelines was confirmed by a senior EP physician. Thereafter, the association of HF medications and dose (% guideline recommended target dose) of beta-blockers (BB), Angiotensin-antagonists (AgA), Mineralocorticoid-antagonsits (MRA), and Anti-Arrhythmic Drugs (AAD) with VA episodes and overall mortality was analyzed, based on patients" medical records and device clinic regular interrogations. Results 186 HF patients qualifying for primary prevention ICD/CRTD implant according to HF and device guidelines, were included. Their mean ± SD age 66.4 ± 12 years, 15.1% female, 79 (42.5%) implanted with an ICD and 107 (57.5%) with CRTD. During 3.8 [2.1;6.7] (median[IQR]) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (medication, % of patients) included: BB (83%), AgA (87%), MRA (59%), and AAD (43.5%). Doses were 25[12.5;50]% of target for BB or AgA and 25[0;50]% of target for MRA. Treatment with &amp;gt;25% target dose of BB was associated with significantly reduced VA incidence. In a multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was significantly and independently associated with reduced VA (HR 0.443 95%CI 0.222-0.885; p = 0.021). Kapkan-Myer analysis for survival without VA according to each medication group dose, supported reduced VA among patients receiving &amp;gt; median dose of BB (Figure 1). Multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment; VA was associated with increased mortality (HR 2.672; 95% CI 1.429-4.999; p = 0.002) while AgA treatment was significantly and independently associated with reduced mortality (HR 0.515; 95% CI 0.285-0.929; p = 0.028). Conclusions In this cohort of real-life HF patients discharged after primary prevention ICD/CRTD implant, most of the patients were prescribed with guideline-based HF medications albeit with low doses. Higher BB dose was associated with reduced VA, while treatment with AgA was associated with improved survival. Abstract Figure. Survival without VA according to HF medi

Association of Guideline-Based Medical Therapy with Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator Device (CRTD).

Aim: Evaluate prevalence of heart failure (HF) medications and their association with ventricular arrhythmia (VA) and survival among patients implanted with primary prevention implantable cardiac defibrillator (ICD)/cardiac resynchronization therapy + defibrillator (CRTD) devices. Methods: Association of treatment and dose (% guideline recommended target) of beta-adrenergic receptor antagonist (BB), angiotensin-antagonists (AngA), and mineralocorticoid-antagonists (MRA), after ICD/CRTD implant with VA and mortality was retrospectively analyzed. Results: Study included 186 HF patients; 42.5% and 57.5% implanted with ICD and CRTD, respectively. During 3.8 (2.1;6.7) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (% of patients) included: BB (83%), AngA (87%), and MRA (59%). Median doses were 25(12.5;50)% of target for all medications. BB treatment >25% target dose was associated with reduced VA incidence. In the multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was associated with reduced VA (hazard ratio (HR) 0.443 95% CI 0.222–0.885; p = 0.021). In the multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment, VA was associated with increased mortality (HR 2.672; 95% CI 1.429–4.999; p = 0.002) and AngA treatment was associated with reduced mortality (HR 0.515; 95% CI 0.285–0.929; p = 0.028). Conclusions: In this cohort of real-life HF patients discharged after ICD/CRTD implant, prevalence of guideline-based HF medications was high, albeit with low doses. Higher BB dose was associated with reduced VA, while AngA was associated with improved survival.