National Quality Improvement Initiative Research Articles

Abstract 4136995: Veterans Affairs (VA) Lipid Optimization Reimagined Quality Improvement Program (VALOR-QI) in Veterans with Atherosclerotic Cardiovascular Disease (ASCVD) at the San Juan VA

ASCVD is the principal cause of morbidity and mortality for Veterans in the VA Healthcare System. San Juan VA is one of 50 VA sites participating in a national quality improvement initiative called the VALOR QI: VA Lipid Optimization Reimagined Quality Improvement Project. Is a collaborative project between the U.S. Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of positively impacting Veterans’ cardiovascular (CV) health. VA sites work with an AHA QI consultant to develop and deploy a local quality improvement plan to help overcome site specific barriers preventing Veterans from achieving optimal cholesterol levels. The program’s objectives include improving clinical pathways and processes to impact ASCVD management through a Learning Healthcare System model of quality improvement designed to improve the management of dyslipidemia among those with high-risk ASCVD. The hypothesis is that patients who are part of the VALOR QI program will be more successful in reaching LDL-C target. This will help to reduce the risk of ASCVD and mortality for the patients, promoting better management of lipid levels through medications, diet and regular monitoring. As part of the methodology, the patients are enrolled to the program using the criteria of Veterans > 18 years of age with diagnosis of ASCVD and LDL-C > 70 mg/dl or non-HDL > 100 mg/dl. The Healthcare Coach has a full track of their lipid medications, assists the patients with refills, provides educational materials, follows up with their clinical appointments, and emphasizes the importance of having a good compliance with therapy, appointments and diets to maintain the target of LDL-C. Once the patient starts with a new lipid medication, they are followed in 3 months with labs. After reaching the target the patient is followed up closely in 6 months with labs to prevent relapse. The VALOR QI Program started at VA San Juan in June 2023 and, as of May 30, 2024, had directly engaged 282 Hispanic patients. 111 (39.4%) achieved target LDL-C; 268 (95%) have any statin use; 117 (41.5%) are on any non-statin lipid-lowering therapy (LLT); 116 (41%) are on statin plus LLT; 25 (8.9%) are on PCSK9, and 133 (47.2%) received educational materials. In conclusion, this initiative led to target LDL levels in 39% of patients which represents a significant population. As this program is further implemented in our institution, we expect improvement in patient outcomes and prognosis.

Abstract 4142792: VA Lipid Optimization Reimagined Quality Improvement Project (VALOR-QI) at the Dallas VA

The Dallas VA is one of the 50 VA sites participating in a national quality improvement initiative called VALOR-QI: VA Lipid Optimization Reimagined Quality Improvement Project. VALOR-QI is a collaborative project between the U.S. Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of positively impacting veterans’ cardiovascular (CV) health. As part of the program, VA sites work with an AHA QI Consultant to develop and deploy a local quality improvement plan to help overcome site specific barriers preventing veterans from achieving optimal cholesterol levels. We hypothesize that the QI strategies implemented will positively impact lipid levels and ultimately CV outcomes among high-risk patients. We aim to assess potential barriers to achieving LDL-C <70 mg/dL and develop efficient ways to maintain LDL-C goal. Our approach to the VALOR-QI program at Dallas VA is by enrolling patients with established ASCVD and LDL-C > 70 mg/dL from cardiology, vascular, diabetes, lipid, and independent PharmD clinics. These patients are followed by a health coach every 2- 6 months. Medical adherence is enforced by the health coach ensuring timely refills and reminders. Lifestyle modifications are encouraged via educational materials, referral to dieticians, recreation classes, and tobacco cessation. Patients are also encouraged to sign up for patient portal (my HealtheVet) to access electronic medical records and expedite communication with their healthcare team. The health coach provides individualized counseling regarding lipid lowering treatment and acts as liaison between patients and their providers. VALOR-QI was launched at Dallas VA in Jan 2023. As of May 17 th , 2024, an interim analysis showed that out of 132 veterans engaged, 49 (37.1%) achieved target LDL-C, 66 (50%) received educational material, 4 (3.03%) were referred to dieticians, 10 (7.58%) were referred to recreation programs, and 4 (17.4% of active smokers) were interested in quitting. In conclusion, our VALOR-QI strategy at Dallas VA showed encouraging results, but it is premature to make final conclusions. The support of a health coach showed improved medication adherence, health literacy, and lifestyle modification, thus achieving LDL-C target. Major barriers to achieving target LDL-C were health literacy about high cholesterol, challenges in navigating the health care system, and treatment inertia among patients and providers.

A national quality improvement initiative of gynaecomastia referrals and management in Wales

A national quality improvement initiative of gynaecomastia referrals and management in Wales

Leveraging healthcare standards-based improvement initiatives to support learning and continuous improvement: lessons from implementing the Ideal Clinic programme in Cape Town, South Africa

Abstract Background This paper draws on the experiences of a group of health system leaders and researchers in leading and supporting, respectively, the implementation of the Ideal Clinic Realisation and Maintenance Framework (ICRMF) in Cape Town, South Africa. The ICRMF is a national standards-based quality improvement initiative that seeks to improve the quality of care in public primary healthcare (PHC) facilities. We share lessons learned on how efforts to improve healthcare standards can be leveraged for learning and meaningful system change. Methods A three-pronged approach to improving the implementation of the ICRMF was used in 15 PHC facilities across two sub-districts. The approach included (i) nurturing trust, (ii) changing the ICRMF assessment strategy, and (iii) promoting a collaborative and collective sense-making approach to understanding performance and addressing gaps. Routine ICRMF quantitative data and qualitative feedback from both the ICRMF assessment process and routine management meetings were used to reflect on the experience of using this approach and to draw lessons. The results and conclusions were further confirmed through member-checking. Results We found that using the three-pronged approach, the ICRMF assessments were able to facilitate deep and reflexive conversations about everyday health system challenges facing healthcare delivery in the sub-districts, while encouraging collective sensemaking and collaboration. The ICRMF was often perceived as a compliance-driven exercise with limited value on the actual quality of care. The three-pronged approach helped shift some of these perceptions and improved the experiences of facility managers in implementing the programme. Conclusion When supported by trusting relationships, reflexive processes and multidisciplinary ownership and collaboration, healthcare standards programmes such as the ICRMF can provide powerful avenues for learning and meaningful change. Our limited dataset could not demonstrate if our approach addresses the challenge of maintaining standards or not (which is linked to continuous improvement).

How a Canadian federal organization integrated synoptic reporting and quality improvement tools to drive a national learning health system in cancer surgery.

Accurate and complete surgical and pathology reports are the cornerstone of treatment decisions and cancer care excellence. Synoptic reporting is a process for reporting specific data elements in a specific format in surgical and pathology reports. Since 2007, the Canadian Partnership Against Cancer has led the implementation of synoptic reporting mechanisms across multiple cancer disease sites and jurisdictions across Canada. While the implementation of synoptic reporting has been successful, its use to drive improvements in the quality of cancer care delivery has been lacking. Here we describe the 4-year, national multi-jurisdictional quality improvement initiative to catalyse the use synoptic data to drive cancer system improvements. Resources provided to the jurisdictions included operational funding, training in quality improvement methodology, national forums, expert coaches, and ad hoc monitoring and support. The program emphasized foundational concepts including data literacy, audit and feedback reports, communities of practice, and positive deviance methodology.

Building Tailored Resource Guides to Address Social Risks and Advance Health Equity in the Veterans Health Administration.

Health care organizations, including the Veterans Health Administration (VHA), are increasingly adopting programs to address social determinants of health. As part of a comprehensive social risk screening and referral model, tailored resource guides can support efforts to address unmet social needs. However, limited guidance is available on best practices for the development of resource guides in health care settings. This article describes the development of geographically tailored resource guides for a national VHA quality improvement initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), which aims to systematically screen for and address social needs among veterans. We outline the rationale for using resource guides as a social needs intervention and provide a pragmatic framework for resource guide development and maintenance. We offer guidance based on lessons learned from the development of ACORN resource guides, emphasizing a collaborative approach with VHA social workers and other frontline clinical staff, as well as with community-based organizations. Our how-to guide provides steps for identifying high-yield resources along with formatting considerations to maximize accessibility and usability among patients. Resource guides can serve as a valuable cross-cutting component of health care organizations' efforts to address social needs. We provide a practical approach to resource guide development that may support successful implementation within the VHA and other clinical settings.

Age nine is possible: Improving age 9 HPV initiation through a national quality improvement initiative during the COVID-19 pandemic

ABSTRACT The American Cancer Society collaborated with a range of healthcare partners in 2020–2022 to implement quality improvement clinical interventions with the goal of improving HPV vaccination rates among adolescents’ ages 9–13. 2020 was the first cohort for which partners had been asked to submit HPV rate data for patients’ ages 9–12. At least 80% of the partners across all reported project years were able and willing to report HPV rates for these ages. Partners submitted HPV initiation rates at the beginning and end of the 12-month project year along with project activities, including evidence-based interventions (EBIs) implemented. Mean initiation rates for ages 9–10 significantly increased 4.1% during 2020 compared to non-significant rate increases of 2.6% and 2.0% for ages 11–12 and age 13, respectively. In 2021, ages 9–10 initiation saw a non-significant increase of 2.2%, whereas ages 11–12 and age 13 decreased non-significantly by 0.3% and 0.1%, respectively. The 2022 cohort saw significant initiation rate increases of at least 4% across all ages, potentially a promising result of the myriad back on track HPV vaccination campaigns designed to reverse the damage of the COVID-19 pandemic on adolescent immunizations. These findings demonstrate an effective adaptation of quality improvement in increasing HPV vaccination coverage among younger ages even during a national pandemic.

Current Practices, Perceived Barriers, and Promising Implementation Strategies for Improving Quality of Smoking Cessation Support in Accredited Cancer Programs of the American College of Surgeons.

Persistent smoking is associated with poor outcomes in cancer care. It is strongly recommended that oncology care providers provide cessation support; however, there is limited information about smoking cessation assessment and treatment patterns in routine oncology practice. Leaders of the American College of Surgeons Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (National Accredited Program for Breast Cancer) elected to participate in a national quality improvement initiative (Just ASK) focused on smoking assessment/treatment in cancer care. Online baseline survey responses were received from 762 accredited programs. Most programs reported regularly asking about smoking (89.9%), documenting smoking history and current use (85.8%), and advising patients to quit (71.2%). However, less than half of programs reported documenting a smoking cessation treatment plan (41.7%). Even fewer programs reported regularly assisting patients with quitting (41.3%), providing self-help information (27.2%), providing individual counseling (18.2%), and referring patients to an affiliated tobacco treatment program (26.1%) or external Quitline (28.5%). Very few programs reported regularly prescribing medications (17.6%). Principal barriers to tobacco treatment delivery were lack of staff training (68.8%), lack of designated specialists (61.9%), perceived patient resistance (58.3%), lack of available resources (53.3%), competing clinical priorities (50.9%), inadequate program funding (40.6%), insufficient staff time (42.4%), and inadequate reimbursement (31.0%). Although programs reported a high rate of smoking assessment, critical gaps in advising and assisting patients with cessation were found. Improving equitable delivery of smoking assessment/treatment in cancer care will require addressing key organizational and provider barriers for implementation of best practices.

A national heart failure initiative is associated with improved use of quadruple guideline-directed medical therapy

Abstract Background Heart Failure (HF) is projected to impact over 8 million people in the US by 2030. The 2022 AHA/ACC/HFSA Guideline for the Management of HF recommend four foundational medication classes for treating HFrEF patients: RAAS inhibitors, preferably angiotensin receptor/neprilysin inhibitor (ARNi), evidence-based beta-blockers (EBBB), sodium-glucose cotransporter-2 inhibitor (SGLT2i) and mineralocorticoid receptor antagonist (MRA) referred to as Quadruple Guideline-Directed Medical Therapy (Q-GDMT). Q-GDMT has shown an estimated 73% relative and 26% absolute reduction in all-cause mortality over 2 years. Yet, despite remarkable clinical potential, these therapies are patently underutilized in clinical practice. It is unknown whether an implementation science strategy may enhance adherence to Q-GDMT for HF. Methods IMPLEMENT-HF (IHF) is a national HF quality improvement initiative composed of a multidisciplinary learning collaborative and resource repository across seven U.S regions. IHF promotes adherence to Q-GDMT by focusing on early adoption and rapid adherence to prescribing at hospital discharge and within 30 days post discharge. Multi-disciplinary participation in the learning collaborative includes pharmacy, provider groups, nursing, quality, social services, outpatient clinics and others. Shared interventions to promote Q-GDMT include formulary changes (e.g., adding SGLT2i), optimizing electronic health record tools (disease-specific order sets, dot phrases), clinician education, and user-friendly patient resources to address medication access. IHF sites receive educational materials, including webinars, learning modules, pocket guideline booklets, and reminder cards to reinforce Q-GDMT. IHF participating hospitals collect Q-GDMT data at discharge and at 30 days post discharge in Get With The Guidelines®-Heart Failure (GWTG-HF). These data were analyzed from baseline (Q1 Q2 2021 aggregate) through Q3 2022. Results Data from 71 IHF participating sites of 13,858 HFrEF patient hospitalization episodes (median age 69, 34% females, median LVEF 24%), demonstrated Q-GDMT prescription at discharge increased from 14% at baseline to 47% in Q3 2022 (p value <0.001). 30-day post discharge data from 52 IHF sites demonstrated an increase in Q-GDMT from 9% at baseline to 58% in Q3 2022 (p value <0.001) as seen in Figure 1. Conclusions Among sites participating in IHF, the use of an implementation science strategy suggest a rapid increase in prescribing Q-GDMT for eligible HFrEF patients at discharge and 30-days post discharge. This multi-region quality improvement initiative demonstrates the potential for this learning collaborative model to drive improvement in adherence to Q-GDMT prescribing, using shared implementation strategies to overcome barriers. Ongoing study will assess continued compliance and clinical outcomes with Q-GDMT beyond the timeframe of this analysis.Quadruple Medication Therapy baseline-Q3

ACCESS TO HEART FAILURE SERVICES IN CANADA: FINDINGS OF THE HEART & STROKE NATIONAL HEART FAILURE RESOURCES AND SERVICES INVENTORY.

The rising incidence of Heart Failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched a HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted between 2020-2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, services and processes across acute care hospitals and related ambulatory settings. HF-RaSIs was completed by 501 acute care hospitals and urgent care centers, representing 94.7% of all HF hospitalizations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centers with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to brain natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present in 108 sites (21.6%), and 81 sites (16.2%) had dedicated inpatient interdisciplinary HF teams. There were 141 HF clinics (28.1% of all sites); of these, 57 (40.4%) had average wait times from referral to first appointment of > 2 weeks. Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.

Water quality improvement and existing challenges in the Pearl River Basin, China

This study highlights the effectiveness of a national water quality improvement initiative on water quality in the Pearl River Basin. The dynamic characteristics of surface water quality in the Pearl River Basin from 2006 to 2018 were analyzed, and the effects of driving factors, including economy, population, land use, water resources, forestry, industry, energy and animal husbandry on water quality were determined. There was a significant improvement in the overall water quality of the Pearl River basin (except Guangzhou) by controlling the discharge of wastewater pollutants and emphasizing environmental protection of forests and disposal of domestic waste. That is particularly evident from the exponential decrease of GDP normalized ammonium (NH4+-N) and COD concentrations. The modeling of water quality and driving factors indicates water quality in the Pearl River Basin was closely related to industrial pollution control investment, afforested area, innocuous disposal capacity of domestic garbage, vegetable sown area, use of natural gas, ecological water consumption, production of sulfuric acid and mutton yields. The improvement in water quality occurred at a time when GDP was increasing providing evidence that economic development and environmental protection can occur through appropriate environmental investment. It is worth noting that although water quality in Guangzhou has improved, nitrogen pollution resulting from domestic sewage and industrial pollutants remains a severe challenge for water quality in this region.

Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach

The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative. Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work. Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers. Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.

Use of narcotics and sedatives among very preterm infants in neonatal intensive care units in China: an observational cohort study.

Narcotics and sedatives are widely used in neonatal intensive care units for very preterm infants. This study aimed to describe the current use of narcotics and/or sedatives among very preterm infants in Chinese neonatal intensive care units, with an emphasis on infants on invasive mechanical ventilation, and to investigate the association of exposure to narcotics and/or sedatives with neonatal outcomes. This was a retrospective observational cohort study that enrolled all infants born at 24+0-31+6 weeks and admitted to 57 tertiary neonatal intensive care units in the Chinese Neonatal Network in 2019. A multivariate logistic regression model was used to assess the association between narcotics and/or sedatives exposure and major neonatal outcomes. Among 9,442 very preterm infants enrolled, 1,566 (16.6%) received at least one dose of narcotics or sedatives, 111 (1.2%) received only narcotics, 1,301 (13.8%) received sedatives solely, and 154 (1.6%) received both narcotics and sedatives during their hospital stay. Of 4,172 very preterm infants who underwent invasive mechanical ventilation, 1,117 (26.8%) received at least one dose of narcotics or sedatives, with 883 (21.2%) only received sedatives. Significant site variation of narcotics/sedatives use existed among hospitals, with the application rate ranging from 0-72.5% in individual hospital. The narcotics and/or sedatives use by very preterm infants was independently associated with increased risks for periventricular leukomalacia, severe retinopathy of prematurity, and bronchopulmonary dysplasia. Narcotic and/or sedative administration is relatively conservative for very preterm infants in Chinese neonatal intensive care units, with significant variation among hospitals. Since narcotic and sedative use might be related to adverse neonatal outcomes, a pressing and developing need for national quality improvement initiatives is seen with respect to pain/stress management for very preterm infants.

National VQI Initiative Associated With Improved Prescription of Statin and Antiplatelet Medications Across Racial and Ethnic Groups

In 2017, the Vascular Quality Initiative announced the first national initiative intended to improve prescription of antiplatelets and statins. We hypothesized that this national quality initiative would be associated with an increase in prescription of these medications and a decrease in previously noted racial disparities in evidence-based medical management. A retrospective analysis using VQI data from the suprainguinal bypass, infrainguinal bypass, and peripheral vascular intervention modules from January 2015 through July 2022 was performed. Inclusion criteria were center participation during the entire study period, age over 18 years, and no documented contraindication to statin or antiplatelet therapy. Exclusion criteria were acute limb ischemia or inpatient death. Frequency of statin prescription by racial group prior to and following announcement of the national initiative were compared. Multivariable logistic regression was performed separately for statin and antiplatelet prescription at discharge. Finally, a time series analysis was performed to assess changes in disparities over time. Overall, 202,900 patients were included, of whom 149,059 identified as White, 35,871 identified as Black or African American, 11,039 identified as Latinx/Hispanic, 2015 identified as Asian, 1031 identified as Indigenous (including American Indian, Alaskan Native, Native Hawaiian, or other Pacific Islander), and 3861 were designated unknown or other, including patients who identified with more than one race. Almost all racial and ethnic groups had a statistically significant improvement in the frequency of any statin prescription and new statin prescription (Table). Moreover, while the difference between groups was statistically significant prior to announcement of the national quality improvement initiative (P < .001), there was no statistically significant difference between groups after (P = .05). On adjusted analysis, following the national quality improvement initiative, patients had an increased odds of both statin (odds ratio [OR], 1.5; P < .001; 95% confidence interval [CI], 1.4-1.6), new statin (OR, 1.4; P < .001; 95% CI, 1.4-1.5), nonaspirin antiplatelet (OR, 1.5, P < .001; 95% CI, 1.5-1.6), and new nonaspirin antiplatelet prescription (OR, 1.5, P < .001; 95% CI, 1.5-1.6). There was no statistically significant difference in the odds of new aspirin prescription. A time series analysis demonstrated continued improvement of statin prescription for all racial and ethnic groups, with a convergence around 90% (Figure). The first national VQI quality initiative was associated with a reduction in the disparities in statin prescription and nonaspirin antiplatelet prescription across all ethnic groups. These findings highlight the impact VQI-based national quality initiatives may have on racial and ethnic disparities in medical management.TableStatin prescription at dischargeAny statin prescriptionNew statin prescriptionPre-Post-DifferenceP valuePre-Post-DifferenceP valueWhite80.5%88.2%+7.8%.00126%37.8%+11.8%.001Black or African American79.7%88.2%+8.6%.00129.8%42.2%+12.4%.001Latinx/Hispanic82%87.7%+5.7%.00131.9%38.9%+7%.001Unknown or other77.6%86.6%+9%.00127.2%38.7%+11.5%.001Asian83.8%87%+3.2%.0527.9%37.9%+10%.05Indigenous (including American Indian, Alaskan Native, Native Hawaiian, or other Pacific Islander)77.2%86.5%+9%.00133.3%39.5%+6.2%.33 Open table in a new tab

Development and Demonstration of Tobacco Treatment Measures for Cancer Registries: Novel Metrics for Quality Improvement.

Individuals undergoing cancer treatment have better outcomes when they discontinue tobacco use. Few cancer centers systematically provide evidence-based cessation services. As part of a national quality improvement initiative [Cancer Center Cessation Initiative (C3i)], we collaborated with our cancer registry to develop and implement two tobacco treatment metrics for tracking the provision of behavioral support and pharmacotherapy. Post-development, the tobacco treatment metrics were integrated into the registry for all future patients. We used means and frequencies to summarize tobacco treatment for cases treated between 2017 and 2019, coinciding with the timeframe of C3i participation. Of 17,735 cancer cases reviewed, both measures were captured on 17,654 (99.5%) of patients, with 3,091 (17.4%) identified as users of tobacco. Across the 3 years, 557 (18%) of individuals who used tobacco received either tobacco cessation pharmacotherapy or behavioral support; with 478 (15.5%) receiving behavioral counseling, 352 (11.4%) receiving pharmacotherapy, and 273 (8.8%) receiving both-considered gold standard care. Tobacco treatment varied substantially across cancer types. The odds of receiving gold standard care were 2.37 times greater in 2019 compared with 2017. (OR, 2.37; 95% confidence interval, 1.63-3.46; P < 0.0001). The new metrics demonstrated high completion rates and their potential to track quality improvement efforts over time. They identified suboptimal treatment reach, but a potential increase in treatment over time and greater treatment among tobacco-related versus nontobacco-related cancers. Continued tobacco use worsens cancer care outcomes. Integrating measures into cancer registries is a viable option for tracking tobacco treatment and cessation in the context of cancer care.

Preventable harm in the Canadian organ donation and transplantation system: a descriptive study of missed organ donor identification and referral

PurposeDeceased organ donation is predicated on timely identification and referral (IDR) of potential organ donors. Many Canadian provinces have legislated mandatory referral of potential deceased donors. Untimely or missed IDRs are safety events where best or expected practice has not occurred causing preventable harm to patients and denying families the opportunity of donation at end of life (EOL) as well as denying transplant waitlist patients access to lifesaving organs.MethodsWe requested donor definitions and data to calculate IDR, consent, and approach rates from all Canadian organ donation organizations (ODOs) for 2016–2018. We then estimated the number of missed IDR patients who were eligible for approach (safety events) and the associated preventable harm to patients at EOL and on transplant waitlists.ResultsAnnually, there were 63–76 missed IDR patients eligible for approach (3.6–4.5 per million population [PMP]) from four ODOs—three with mandatory referral legislation. Applying each ODO’s approach and consent rates for the corresponding year, there were 37–41 missed donors (2.4 donor PMP) annually. Assuming three transplants per donor, the theoretical number of missed transplants would be 111–123 (6.4–7.3 transplants PMP) annually.ConclusionsData from four Canadian ODOs show that missed IDR safety events resulted in important preventable harm measured by a lost opportunity for donation of 2.4 donors PMP annually and 354 potentially missed transplants between 2016 and 2018. Given that 223 patients died on Canada’s waitlist in 2018, national donor audits and quality improvement initiatives to optimize IDR are essential to reduce preventable harm to these vulnerable populations.

Defining targets to improve care delivery for T4 larynx squamous cell carcinoma.

United States oncology trends consistently demonstrate that nearly half of T4a larynx carcinoma patients are treated with larynx preservation, despite national guidelines favoring laryngectomy. This study identifies clinical decision-making drivers and defines patient subsets that should become targets for care improvement. Retrospective analysis of patients with cT4 squamous cell carcinoma of the larynx from US National Cancer Database 2005-2016. Demographic data and survival rates between clinical pathways were compared. Survival was estimated by Kaplan-Meier method with statistical comparisons assessed by log-rank test. Of 11,556 patients with cT4 disease, laryngectomy (TL) was the initial treatment for 4627 (40%) patients. Larynx preservation via chemoradiation (CRT) occurred for 4307 patients. TL and CRT patients had similar Charlson-Deyo comorbidity indices and insurance status. TL patients had higher total tumor size, lower N3 rates and were more often seen at academic institutions (p < .0001). N0 surgery patients with adjuvant treatment demonstrated superior median survival (MS) compared to CRT (surgery + radiation MS: 69 months, surgery + chemoradiation MS: 66, CRT MS: 37.7), p < .0001. MS for N1/N2 disease patients was 56.5months for surgery + radiation and 35.5months for surgery + CRT, superior to CRT, MS 30.8months, p < .0001. Tri-modality N3 patients with up front surgery had similar MS compared to CRT (surgery + chemoradiation 21.3months vs. CRT 16.1), p=.95. National quality improvement initiatives are needed to promote guideline adherence and improve survival in advanced larynx cancer. Targets for such initiatives should be patients with limited or no nodal disease burden, that meet clear T4a imaging criteria. Level IV, non-randomized controlled cohort.

Abstract 12170: A National Heart Failure Initiative is Associated With Improved Use of Guideline-Directed Medical Therapies

Background: Heart Failure (HF) is projected to impact over 8 million people by 2030. Guideline-Directed Medical Therapy (GDMT) reduces mortality and morbidity, but many eligible patients are not receiving the recommended medications. The 2022 ACC/AHA/HFSA Guideline for the Management of HF highlight the importance of SGLT2i and ARNi, which continue to be underused in eligible HFrEF patients. Methods: IMPLEMENT-HF (I-HF), a national HF quality improvement initiative focusing on early adoption of GDMT, aims to improve use of SGLT2i and ARNi for HFrEF patients. I-HF creates a transformative learning collaborative and resource repository across seven U.S regions to promote education and adherence to GDMT, that includes sharing models of clinical care, targeted training, resource development, and quality improvement consultation. Participation in a learning collaborative allows for sharing of interventions, such as adding SGLT2i on formulary, optimizing EHR tools for GDMT (best practice alerts, disease-specific order sets, dot phrases), provider education, and patient resources to address medication affordability. Sites receive educational materials, including webinars, pocket guideline booklets, and guideline reminder cards to reinforce GDMT. Participating hospitals collect GDMT data in Get With The Guidelines®-Heart Failure (GWTG-HF). ARNi and SGLT2i at discharge was analyzed from baseline (Q1 &amp; Q2 2021 aggregate) through Q1 2022. Results: Data from 62 sites (16,533 HF patient records) showed that use of ARNi at hospital discharge increased from baseline 46% to 58% in Q1 2022, +12%, p value &lt;0.001. SGLT2i use at discharge increased from 8% to 26%, +18%, p value &lt;0.001 (Figure 1). Conclusions: Among centers participating in the I-HF initiative, early findings suggest there has been a rapid increase in use of SGLT2i and ARNi at discharge for HFrEF patients. Further study is needed to assess post-discharge GDMT use, adherence, and clinical outcomes.

Association of Race and Ethnicity With Oral Anticoagulation and Associated Outcomes in Patients With Atrial Fibrillation

Oral anticoagulation (OAC) is underprescribed in underrepresented racial and ethnic group individuals with atrial fibrillation (AF). Little is known of how differential OAC prescribing relates to inequities in AF outcomes. To compare OAC use at discharge and AF-related outcomes by race and ethnicity in the Get With The Guidelines-Atrial Fibrillation (GWTG-AFIB) registry. This retrospective cohort analysis used data from the GWTG-AFIB registry, a national quality improvement initiative for hospitalized patients with AF. All registry patients hospitalized with AF from 2014 to 2020 were included in the study. Data were analyzed from November 2021 to July 2022. Self-reported race and ethnicity assessed in GWTG-AFIB registry. The primary outcome was prescription of direct-acting OAC (DOAC) or warfarin at discharge. Secondary outcomes included cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality postdischarge. Outcomes adjusted for patient demographic, clinical, and socioeconomic characteristics as well as hospital factors. Among 69 553 patients hospitalized with AF from 159 sites between 2014 and 2020, 863 (1.2%) were Asian, 5062 (7.3%) were Black, 4058 (5.8%) were Hispanic, and 59 570 (85.6%) were White. Overall, 34 113 (49.1%) were women; the median (IQR) age was 72 (63-80) years, and the median (IQR) CHA2DS2-VASc score (calculated as congestive heart failure, hypertension, age 75 years and older, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, and sex category) was 4 (2-5). At discharge, 56 385 patients (81.1%) were prescribed OAC therapy, including 41 760 (74.1%) receiving DOAC. OAC prescription at discharge was lowest in Hispanic patients (3010 [74.2%]), followed by Black patients (3935 [77.7%]) Asian patients (691 [80.1%]), and White patients (48 749 [81.8%]). Black patients were less likely than White patients to be discharged while taking any anticoagulant (adjusted odds ratio, 0.75; 95% CI, 0.68-0.84) and DOACs (adjusted odds ratio, 0.73; 95% CI, 0.65-0.82). In 16 307 individuals with 1-year follow up data, bleeding risks (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.53-2.83), stroke risks (aHR, 2.07; 95% CI, 1.34-3.20), and mortality risks (aHR, 1.22; 95% CI, 1.02-1.47) were higher in Black patients than White patients. Hispanic patients had higher stroke risk (aHR, 2.02; 95% CI, 1.38-2.95) than White patients. In a national registry of hospitalized patients with AF, compared with White patients, Black patients were less likely to be discharged while taking anticoagulant therapy and DOACs in particular. Black and Hispanic patients had higher risk of stroke compared with White patients; Black patients had a higher risk of bleeding and mortality. There is an urgent need for interventions to achieve pharmacoequity in guideline-directed AF management to improve overall outcomes.

Payer-Related Sources of Variation in Febrile Infant Management Before and After a National Practice Standardization Initiative.

Sources of variation within febrile infant management are incompletely described. In 2016, a national standardization quality improvement initiative, Reducing Excessive Variation in Infant Sepsis Evaluations (REVISE) was implemented. We sought to: (1) describe sociodemographic factors influencing laboratory obtainment and hospitalization among febrile infants and (2) examine the association of REVISE on any identified sources of practice variation. We included febrile infants ≤60 days of age evaluated between December 1, 2015 and November 30, 2018 at Pediatric Health Information System-reporting hospitals. Patient demographics and hospital characteristics, including participation in REVISE, were identified. Factors associated with variation in febrile infant management were described in relation to the timing of the REVISE initiative. We identified 32 572 febrile infants in our study period. Pre-REVISE, payer-type was associated with variation in laboratory obtainment and hospitalization. Compared with those with private insurance, infants with self-pay (adjusted odds ratio [aOR] 0.43, 95% confidence interval [95% CI] 0.22-0.5) or government insurance (aOR 0.67, 95% CI 0.60-0.75) had lower odds of receiving laboratories, and self-pay infants had lower odds of hospitalization (aOR 0.38, 95% CI 0.28-0.51). Post-REVISE, payer-related disparities in care remained. Disparities in care were not associated with REVISE participation, as the interaction of time and payer was not statistically different between non-REVISE and REVISE centers for either laboratory obtainment (P = .09) or hospitalization (P = .67). Payer-related care inequalities exist for febrile infants. Patterns in disparities were similar over time for both non-REVISE and REVISE-participating hospitals. Further work is needed to better understand the role of standardization projects in reducing health disparities.