Optimal Level Research Articles

Enhanced performance and robustness in anti-lock brake systems using barrier function-based integral sliding mode control

Abstract In anti-lock brake systems (ABS), the primary goal of the controller is to maximize vehicle deceleration by maintaining the slip ratio at an optimal level. This work presents a fresh approach that enhances ABS performance by integrating a sliding mode controller with a barrier function. This method combines integral sliding mode control with adaptive laws informed by barrier functions, effectively managing external disturbances and uncertainties in inertia. A significant benefit of this approach is that it does not require prior knowledge of the upper limits of these uncertainties and disturbances, thanks to the barrier function-based sliding mode control. The system state is initially aligned with the switching manifold, ensuring robust compensation for any uncertainties and disturbances right from the start of braking. During the sliding mode phase, dynamic properties are finely tuned to ensure that the system’s performance remains consistent. The effectiveness and reliability of the proposed controller have been demonstrated through numerical simulations conducted in MATLAB/Simulink, proving its capability across a range of road conditions.

Development of wind power plants to increase the fulfilment ratio of renewable energy in Taiwan using system dynamics modelling

ABSTRACT This research aims to improve wind energy development by addressing environmental challenges and market dynamics. To achieve this, a system dynamics model was used to analyze the complex relationships between various factors, including wind energy production, electricity demand, costs, and government policies. The study focuses on increasing the fulfilment ratio and reducing the price of wind energy. By simulating different scenarios, researchers explored the potential impact of expanding wind farm capacity through the addition of onshore and offshore turbines. The research also investigates the role of government incentives, particularly the feed-in tariff (FIT), in stimulating investment in wind energy. The findings suggest that a higher FIT can significantly boost profitability, attract more investment, and accelerate the expansion of wind farm capacity. The optimal FIT level of 5.5 NTD/KWh is projected to lead to a 6.7% annual growth rate and substantial profits by 2040.

Postharvest CO2 treatment and cold storage for Drosophila suzukii (Diptera: Drosophilidae) fruit infestation control.

The invasive pest, spotted wing drosophila (Drosophila suzukii (Matsumura, 1931)or SWD), damages various soft-skinned fruits, severely impacting orchards and vineyards economically. Current sorting practices in commercial production may overlook early-stage SWD infestations, as visible signs take a few days to appear. Our study focused on managing SWD infesting fruits (blueberry, cherry, and raspberry) without visible signs using an artificial atmosphere with elevated CO2 and low temperature. We hypothesized that these factors affect SWD survival and possibly interact, with potential variations among different soft- or stone-fruit species or varieties. High CO2 concentrations and cold storage both negatively affected SWD development. A 24-h 100% CO2 fumigation, without cold storage, significantly reduced SWD infestations in all 3 fruit species studied. On the other hand, 10% CO2 without cold storage did not cause a significant infestation reduction in cherries. Cold storage alone was too slow to be considered effective. Concurrent low-temperature treatment and CO2 treatment reduced the insecticidal efficacy of CO2 fumigation. Optimal fruit sanitation was achieved with a 3-h 100% CO2 treatment at ambient temperature before cold storage. Raspberries were the most suitable host for SWD development, with over a 5-fold higher SWD development compared to blueberries and over 50 times more than in cherries. We discussed the observed interactions between CO2 fumigation and chilling and suggested a simple postharvest SWD management protocol using optimal CO2 levels, exposure times, and chilling periods-achievable without complex equipment.

Are area-level socioeconomic inequalities in obesity moderated by neighbourhood greenery?

Reducing socioeconomic inequalities in obesity is a public health priority. Limited research exists on the role of neighbourhood environmental attributes in mitigating these inequalities. However, it has been shown that neighbourhoods with more greenery tend to have lower levels of socioeconomic inequalities in non-obesity health outcomes. We examined whether neighbourhood greenery moderates the association of area-level socioeconomic status (SES) with waist circumference. Data from 3,261 middle-aged and older adults who participated in a national cohort study conducted in Australia (2011-12) were used. The outcome was objectively measured waist circumference. For area-level SES, a composite index of disadvantage based on census data was used. We used two measures of neighbourhood greenery: mean greenness and geographic size of greenspace. They were assessed using the Normalized Difference Vegetation Index (NDVI) within 0.5, 1, and 2km radius buffers around participants' homes. The mean NDVI value within each buffer area was used for the former, and the geographic size of the area with NDVI ≥ 0.6 (dense greenery) was used for the latter. There was a significant negative association between area-level SES and waist circumference: one standard deviation higher score in the area-level SES indicator (less disadvantage) was associated with 1.76cm (95% CI: -2.68, -0.83) lower waist circumference. Analyses stratified by greenery levels found similar significant associations in the areas with low and high levels of greenery but not in the areas with medium levels of greenery for both greenery measures within 1km and 2km buffers. Consistent with previous studies, our study found that participants living in disadvantaged suburbs were likely to have a larger waist circumference than those living in advantaged suburbs. However, we also found that such socioeconomic inequalities in obesity were mitigated in the areas with medium levels of greenery for this sample of Australian adults. Our findings suggest that there may be an optimum level of greenery where inequalities in obesity are alleviated. Further research is needed to understand the mechanisms underlying these findings.

Exploring the scope and depth of digitalisation in times of crisis: Implications for SME resilience

This article investigates the role of digitalisation in bolstering small- and medium-sized enterprises (SMEs) during crises. Drawing on data from 245 North American SMEs, we examine the impact of digital technology adoption on firm resilience. The findings reveal nuanced relationships: both the depth (Digital Depth) and scope (Digital Scope) of digitalisation exhibit curvilinear associations with resilience (Profit Outlook), suggesting optimal levels for maximum benefits. Moreover, digital depth moderates the relationship between digital scope and resilience, highlighting their interactive role in enhancing adaptive capacities. This research employs a quantitative approach to explore how SMEs can leverage digital tools for resilience. Notably, it highlights the importance of strategic digital investments tailored to industry dynamics for resilience enhancement illustrating the study underscores the practical significance of digital integration for SMEs, indicating its potential to not only restore pre-crisis performance but also foster sustainable growth in the aftermath of disruption.

The optimal energy level of virtual monochromatic imaging in Dual-energy CT arthrography of the wrist.

To suggest an optimal energy level of virtual monochromatic images (VMIs) in dual-energy CT arthrography of the wrist. This retrospective study included 53 patients with wrist CT arthrography. Conventional polychromatic images and VMIs at four energy levels (40 to 70 keV at 10 keV intervals) were obtained. Image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured, and qualitative analysis of image quality and diagnostic confidence was performed. For each patient, an energy level with the best image quality was chosen by consensus. Comparisons of quantitative and qualitative parameters between VMI sets were performed. The image noise of bone and muscle were increased with decreasing energy level (p < 0.001). The noise of contrast was highest on 60 keV VMI. SNR and CNR (between contrast and muscle) were increased with decreasing energy level and were markedly increased between 60 and 50 keV (p < 0.001). The 60 keV VMI demonstrated the highest image quality and diagnostic confidence, chosen as the best diagnostic image (n = 31/53). Given that the attenuation of the contrast material was low on the conventional image, the optimal energy level of the best VMI tended to be low. Wrist dual-energy CT arthrography with VMIs at 60 keV or less could improve image quality and diagnostic performance by increasing SNR and CNR in cases with low contrast attenuation. Wrist dual-energy CT arthrography with VMIs at variable keV could be utilised to enhance SNR and CNR, thereby achieving diagnostic images of high quality.

Spanish Translation, Adaptation and Psychometric Analysis of a Short Version of the Intercultural Sensitivity Scale in Chilean Public Workers.

Chile has been facing socio-cognitive, affective and cultural tensions and changes due to the constant increase of the migrant population in Chile over the last two decades. This means that local public policy workers must interact and achieve effective communication with migrant users living in their territories. Intercultural sensitivity is understood as the affective dimension of intercultural communication. This dimension facilitates the awareness that people differ in their behaviors, perceptions and feelings during intercultural communication processes, promoting acceptance and respect towards these differences. The aim of this paper was to analyze the factor structure, psychometric properties and invariance of the Intercultural Sensitivity scale (Chen & Starosta, 2000) in a sample of Chilean workers. The sample consists of 337 workers from five municipalities in two regions of Chile. The sample has a mean age of 42.8years (SD = 10.4), and 62.9% report being female. To determine the factor structure, an unweighted least squares (ULS) parameter estimation method was used, which is recommended for relatively small sample sizes, as is the case in this study. The overall structure of the original scale, although showing adequate indicators in a confirmatory factor analysis, presented serious conflicts in the covariance matrix used. Therefore, the 5-factor structure seen in other studies is disconfirmed. Because of this, it was decided to construct an abbreviated version, but reducing the limitations encountered during the validation process. The final result is a 4-dimensional structure, corresponding to four of the original dimensions, with a total of 13 items. The goodness-of-fit indices (CFI, TLI, RMSEA and SRMR) had optimal levels. The Manifest and Subtle Prejudice scale was used for its divergent validity, presenting all the dimensions of the instrument, and its total score, inverse and significant correlations with manifest prejudice, subtle prejudice, and total prejudice, as expected.

The impact of Life's Essentials 8 on sarcopenia prevalence among adults in the United States.

Sarcopenia is closely associated with cardiovascular disease. We aimed to examine the association of Life's Essential 8 (LE8), the recently updated measurement of cardiovascular health (CVH), with the presence of sarcopenia among US adults. This population-based cross-sectional study used data from the National Health and Nutrition Examination Survey in 2005-2006 and 2011-2018, and included adults aged 20 years or older. LE8 score was measured according to American Heart Association definitions. Sarcopenia was measured according to the National Institutes of Health definition, the ratio of appendicular skeletal muscle mass (ASM) to body mass index (BMI). Multivariable logistic and restricted cubic spline models were used to assess the associations between LE8 and sarcopenia. Among the 11,078 participants, 1021 (9.22 %) were diagnosed with sarcopenia. After adjusting for potential confounders, higher LE8, health behavior and health factors scores were associated with reduced odds ratios (OR) of sarcopenia (OR for per 10 scores increase in LE8, 0.65; 95 % CI 0.61-0.70; OR for per 10 scores increase in health behaviors score, 0.90; 95 % CI 0.84-0.97; OR for per 10 scores increase in health factors score, 0.67; 95 % CI 0.63-0.71). A non-linear dose-response relationship was observed between LE8 scores, health factors scores, and sarcopenia. The inversed association between LE8 score and sarcopenia was significantly stronger among males and participants with a high school education or above. LE8 was negatively associated with the prevalence of sarcopenia in a nonlinear fashion. Promoting adherence to optimal CVH levels may benefit to reduce the risk of sarcopenia.

Optimal levels of sleep, sedentary behaviour, and physical activity needed to support cognitive function in children of the early years.

Sleep, sedentary behaviour, physical activity, and the composition of these movement behaviours across the 24-h day are associated with cognitive function in early years children. This study used a Goldilocks day compositional data analysis approach to identify the optimal duration of sleep, sedentary behaviour, light physical activity, and moderate-to-vigorous physical activity associated with desired cognitive function outcomes in early years children. This cross-sectional study included 858 children aged 2.8-5.5 years from the Sleep and Activity Database for the Early Years. 24-h movement behaviours (sleep, sedentary behaviour, light physical activity, moderate-to-vigorous physical activity) were measured using ActiGraph accelerometers. Cognitive function was measured using three tasks from the Early Years Toolbox: visual-spatial working memory, response inhibition, and expressive vocabulary. A Goldilocks day compositional data analysis approach was used in R software to identify the optimal time-use compositions associated with the best 10% of the cognitive function scores. The movement behaviour composition and the relative time spent in sleep and sedentary behaviour but not different intensities of physical activity were significantly associated with working memory (P ≤ 0.01). The movement behaviour composition and relative time spent in sleep, sedentary behaviour, and different intensities of physical activity were not significantly associated with response inhibition or expressive vocabulary (P > 0.2). Therefore, optimal time use was only determined for working memory. Optimal daily durations for working memory were observed with 11:00 (hr:min) of sleep, 5:42 of sedentary behaviour, 5:06 of light physical activity, and 2:12 of moderate-to-vigorous physical activity. Working memory was the only cognitive function outcome related to the 24-h movement behaviour composition. Optimal sleep for working memory was consistent with current recommended durations, while optimal moderate-to-vigorous physical activity greatly exceeded minimal recommended levels. Optimal sedentary behaviour was longer and light physical activity was shorter than the sample average.

The Effects of Vitamin D Deficiency on Physical Fitness and Sport Performance – A Review

Introduction: Deficiency or insufficiency of vitamin D affects all individuals, of both sexes and all ages, and consequently brings a series of negative health consequences for them. This deficiency seems to be a very widespread problem in the population in general and also among physically active individuals and particulary in athletes. Currently, the insufficiency of vitamin D is a problem appearing worldwide. While in the population the main source of deficiencies are insufficient exposure to the sun and deficiency in the food diet, in individuals who participate in physical activity and sports it seems that the main factors are high use and depletion of reserves from muscle and adipose tissue. Vitamin D deficiency has an important role not only in bone and muscle health, but also negatively affects physical fitness and sports performance. Therefore, continuing measurement and monitoring of free vitamin D and/or its bioavailable 25(OH)D metabolites is the best way to determine the true vitamin D status for preventive reasons or supplementation in all individuals. Objectives: This review aims to highlight the current situation of the status of vitamin D, especially in subjects participate in physical activity and sports, and its importance and role in the health of athletes and in sports performance. Methods: For this review, we used the database in Scopus and PubMed, searching with key words: vitamin D deficiency - vitamin D status - elite athletes - sports performance. Full articles in English, published from 2016 to 2024, that evidenced the association between vitamin D status and health outcomes and sports performance were included. Results and Conclusions: The results of the study showed that the deficiency of vitamin D in the general population, but also in those who are actively involved in sports and even elite sports, is present at worrying levels. In different groups and populations, the deficiency factors are partly different, but the results show that the lack of food in the diet today constitutes one of the main factors that has almost taken the same weight as insufficient exposure to the sun. For physically active subjects and those involved in various types of sports, deficiencies are present at an unpredictably high rate, putting in serious danger in some cases the lives of the athletes. This comes from a low attention regarding the deficiencies of this vitamin, compared to other elements that are usually taken in the form of supplements in sports. The results show that maintaining an optimal level of vitamin D affects not only the bone and muscle health, the optimal physical fitness of physically active individuals, but also the health and improvement of sports performance (not only physical) of athletes. Therefore, the measurement, monitoring, ensuring a balanced food diet and supplementing with this vitamin, if needed, should accompany the entire course and activity of the subjects of this category in a strict and consistent manner.

An Interval Fuzzy Programming Approach to Solve a Green Intermodal Routing Problem for Timber Transportation Under Uncertain Information

This study investigates an intermodal routing problem for transporting wood from a storage yard of the timber harvest area to a timber mill, in which the transfer nodes in the intermodal transportation network have multiple service time windows. To improve the environmental sustainability of timber transportation, a carbon tax policy is employed in the routing to reduce the carbon emissions. Uncertain information on the capacities and carbon emission factors of the transportation activities in the intermodal transportation network is modeled using interval fuzzy numbers to enhance the feasibility of the routing optimization in the actual timber transportation. Based on the above consideration, an interval fuzzy nonlinear optimization model is established to handle the specific routing problem. Model defuzzification and linearization are then conducted to obtain an equivalent formulation that is crisp and linear to make the global optimum solution attainable. A numerical experiment is conducted to verify the feasibility of the proposed model, and it reveals the influence of the optimization level and service time windows on the routing optimization, and it confirms that intermodal transportation is suitable for timber transportation. This experiment also analyzes the feasibility of a carbon tax policy in reducing the carbon emissions of timber transportation, and it finds that the performance of this policy is determined by the optimization level given by the timber mill and is not always feasible in all cases. For the case where a carbon tax policy is infeasible, this study proposes a bi-objective optimization that can use Pareto solutions to balance the economic and environmental objectives as an alternative. The bi-objective optimization further shows the relationship between lowering the transportation costs, reducing the carbon emissions, and enhancing the reliability on capacity and budget by improving the optimization level. The conclusions provide managerial insights that can help the timber mill and intermodal transportation operator organize cost-efficient, low-carbon, and reliable intermodal transportation for timber distribution, and support sustainable forest logistics.

Community-level Knowledge, Attitudes, and Practices regarding Cardiovascular Diseases and Modifiable Risk Factors in India.

Assessment of knowledge, attitudes, and practices regarding cardiovascular diseases (CVD) and cardiovascular risk factors (CVRF) is critical to inform CVD prevention strategies, but limited community-level data exist from developing countries. To assess the knowledge, attitudes, and practices regarding CVD and CVRF and acceptability of non-physician health workers and text-message based reminders to guide CVD prevention strategies in India. We conducted a telephone-based survey nested in the on-going Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) cohort in Delhi and Chennai, India between January 2021 to February 2021. We randomly selected people with CVRF, but no established CVD and those with existing CVD from the CARRS cohort (n=502 participants) and assessed their 1) knowledge of CVD symptoms and risk factors, 2) attitude towards non-physician health workers (NPHW) facilitated care and text-messages for healthy lifestyle, and 3) practices regarding monitoring of CVRF. We performed logistic regression analyses to investigate the factors associated with KAP. We interviewed 502 participants (283 with CVRF and 219 with CVD); 45.8% were female, and mean age (SD) was 48.1 (11.2) years. The knowledge of heart attack symptoms, stroke symptoms, and CVRF (>75% correct answers) were: 12.9%, 20.7%, and 17.3%, respectively. Individuals with CVRF had 2.5 times lower knowledge of CVD symptoms compared to those with existing CVD. Acceptability of NPHW-facilitated care and text-messages for healthy lifestyle was 60% and 84%, respectively. The knowledge of CVD symptoms and risk factors is below optimal levels, particularly among individuals at high risk of CVD, unskilled workers, those with lower levels of education and income. Innovative use of NPHW along with mHealth tools could potentially offer solutions to reduce the burden of CVD.

Optimizing Nutrient Management for Enhanced Performance in Kadiri Lepakshi Groundnut

The study was conducted to determine the optimal fertilizer levels for Kadiri Lepakshi groundnut. The experiment consists of eight treatments and was laid out in randomized complete block design with three replications. The present investigation was conducted at Integrated Farming System demonstration plot, ZARS, UAS, GKVK, Bengaluru Karnataka, during the summer of 2022 and Kharif 2023. Five plants from the sampling area were randomly selected and observations on growth and yield parameters were recorded at 30, 60 and 90 days after sowing (DAS) and at harvest. The results revealed that among the various nutrient levels, application of 100 % RDF combined with Phosphogypsum @ 750 kg ha-1 and Borax @ 10 kg ha-1 resulted in significantly higher values for plant height (32.95 cm), number of branches per plant (12.60) and dry matter production at harvest. This treatment also led to a substantial increase in the total number of pods per plant (59) and filled pods per plant (48) in groundnut, performing on par with the treatment that included 100% RDF, Gypsum @ 750 kg ha-1 and Borax @ 10 kg ha-1 (with 57 and 44 pods, respectively) when compared to other treatments. The similar trend was observed with respect to pod yield (2327 kg ha-1), kernel yield (1580 kg ha-1), and haulm yield (3594 kg ha-1). So, the application of 100% RDF with Phosphogypsum @ 750 kg ha-1 and Borax @ 10 kg ha-1 significantly enhanced growth attributes (plant height, branches per plant, and dry matter production) and yield parameters (pods per plant, filled pods, pod yield, kernel yield, and haulm yield) in groundnut. This indicates that Phosphogypsum is an effective source of calcium and sulfur for boosting groundnut yield.

Association of life's essential 8 with chronic obstructive pulmonary disease: a population-based analysis of NHANES 2007-2018.

Chronic obstructive pulmonary disease (COPD) is closely linked to cardiovascular diseases. We aimed to investigate the association between Life's Essential 8 (LE8), the newly established measurement to assess cardiovascular health (CVH), and COPD among U.S. general adults. This study extracted the National Health and Nutrition Examination Survey (2007-2018) data. Multivariate logistic regression models were used to examine the associations between LE8 and COPD. A restricted cubic spline regression model was used to explore the dose-response relationships between LE8 scores and COPD. In addition, subgroup and sensitivity analyses were performed to assess the robustness of our results. Our study included 19,774 participants representing 145.2million non-institutionalized U.S. population aged ≥ 20 years. The overall age-adjusted prevalence of COPD was 4.5%. After adjusting for the potential covariates, LE8 was inversely associated with COPD [adjusted odds ratio (AOR) = 0.169, 95% CI: 0.115, 0.249], exhibiting a nonlinear dose-response relationship (P for nonlinearity < 0.05). Similar trends in the associations of health behavior score (AOR = 0.300, 95% CI: 0.223, 0.404) and health factor score (AOR = 0.603, 95% CI: 0.426, 0.852) with COPD were also identified. Furthermore, higher LE8 metric scores of nicotine exposure and sleep health were associated with a lower prevalence of COPD. LE8 was inversely associated with spirometric/self-reported COPD in a nonlinear trend, primarily driven by the nicotine exposure metric of LE8. Adhering to LE8 guidelines, especially smoking cessation, to sustain optimal CVH levels may be beneficial to alleviate the burden of COPD.

Effects of Flavonoids in Fructus Aurantii Immaturus on Carcass Traits, Meat Quality and Antioxidant Capacity in Finishing Pigs

This experiment aimed to explore the effects of flavonoids in Fructus Aurantii Immaturus (FFAI) on carcass traits, meat quality, and the antioxidant capacity of finishing pigs. The results indicated that the addition of an appropriate amount of FFAI into their diet could significantly reduce the backfat thickness and perirenal fat percentage of finishing pigs, as well as the drip loss, water-holding capacity, shear force, and the levels of lactate, glucose-6-phosphate, glucose, ATP, phosphofructokinase, and pyruvate in the longissimus dorsi (LD) muscle. It also elevated the levels of flavor amino acids such as glutamate, serine, and threonine, and enriched the composition of flavor substances, including benzene and octanal, which significantly contributed to the enhancement of pork flavor. Furthermore, it enhanced the expression levels of MyHC I and MyHC IIa. In summary, the appropriate addition of FFAI to the diet could improve the carcass traits, meat quality, and antioxidant capacity of finishing pigs. The optimal level of FFAI supplementation is 0.12%.

Consideration of the role of protein quality in determining dietary protein recommendations

The quality of a dietary protein refers to its ability to provide the EAAs necessary to meet dietary requirements. There are 9 dietary amino acids that cannot be metabolically produced in the body and therefore must be consumed as part of the diet to avoid adverse metabolic consequences. These essential amino acids (EAAs) serve a variety of roles in the body. The amount and profile of the dietary EAAs relative to the individual EAA requirements and the digestibility of the dietary protein are the key factors that determine its quality. Currently the Digestible Indispensable Amino Acid Score (DIAAS) is the best available approach to quantifying protein quality. The most prominent metabolic role of dietary EAAs is to stimulate protein synthesis by serving as signals to activate molecular mechanisms responsible for the initiation of protein synthesis and, most importantly, to provide the necessary precursors for the synthesis of complete proteins. Current dietary recommendations generally do not consider protein quality. Accounting for protein quality in dietary patterns can be accomplished while staying within established ranges for dietary protein consumption. Poor protein quality can be compensated for to some extent by eating more low-quality protein, but to be effective (“complementary”) the limiting EAA must differ between the low-quality protein and the base diet to which it is being supplemented. Adding a high-quality protein to a dietary pattern based on low-quality protein is more effective in meeting EAA goals than increasing the amount of low-quality protein, even if the low-quality proteins are complementary. Further, reliance entirely on low-quality protein food sources, particularly in circumstances that may benefit from a level of dietary EAAs greater than minimal requirements, is likely to include excessive caloric consumption. While protein consumption in high-income nations is generally perceived to be adequate or even excessive, assessment of dietary patterns indicates that a significant percentage of individuals may fall short of meeting optimal levels of EAA consumption, especially in circumstances such as aging in which the optimal EAA consumption is greater than basal values for healthy young individuals. The case is made that protein quality is an important consideration in meeting EAA requirements.

Abstract 4140167: Lipid Management among US Veterans with Prevalent Atherosclerotic Cardiovascular Disease (ASCVD) * Veteran Affairs Lipid Optimization Reimagined Quality Improvement Program (VALOR-QI)

ASCVD is the most prevalent form of cardiovascular disease and the main cause of morbidity and mortality for Veterans in the VA healthcare system. Management of cholesterol is one of the most effective approaches for reducing CV disease, however, over two-thirds of Veterans with ASCVD are not optimally managed. Veterans with ASCVD are at high risk for recurrent CV events and can benefit greatly from more effective management of their low-density lipoprotein (LDL-C) cholesterol. The reasons for the current undertreatment of dyslipidemia in Veterans with ASCVD are multifaceted, including factors such as low disease awareness among the patients, patient’s preference, statin intolerance, and poor adherence to medications. Purpose: VALOR-QI is a collaborative effort between the U.S. Department of Veterans Affairs (VA) and the American Heart Association (AHA) with the goal of positively impacting Veterans’ cardiovascular health. Method: This project targets at risk veterans over 18 years of age, with ASCVD and LDL-C ≥70 mg/dl or non-HDL-C ≥100 mg/dl identified across 50 VA medical centers nationwide. 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. Health coaches at these centers aid in lipid optimization through patient counseling, medication adherence support, appointment reminders, and referrals to a nutritionist or clinical pharmacist as required. The plan’s effectiveness will be assessed by tracking LDL-C goal achievement rates, LDL-C changes with therapy use, and veteran demographics. Our primary endpoints are for over 30% of veterans to reach the LDL-C target and a significant drop (around 10%) from baseline in veterans with ASCVD and LDL-C not at target. Best practices are shared among sites using the PDSA implementation science model. Results: As of May 2024, 182 patients at the Hines VA are engaged in the project. Among them, 84.8% are on lipid-lowering therapy, 83.1% are on statins (with 57.9% on a high intensity dose), and 11.3% are on dual therapy with a statin plus an additional medication (PCSK9 inhibitor or ezetimibe). So far, 59.5% of enrolled patients reached their LDL-C cholesterol target of &lt;70 mg/dl. Conclusion: Lipid lowering strategies with collaboration of patients, network providers, dieticians and health coaches improved lipid control in veterans with ASCVD.

Abstract 4136978: Six-month Changes in Lipid Management in the Veterans Affairs Lipid Optimization Reimagined Quality Improvement (VALOR-QI) Program

Background: US Veterans have a high burden of cardiovascular disease (CVD). While cholesterol management is one of the most effective approaches for reducing CVD burden, over two-thirds of Veterans with atherosclerotic cardiovascular disease (ASCVD) are not optimally managed. Aims: To evaluate LDL-C monitoring, lipid lowering therapy (LLT) use, and LDL-C levels at baseline and six-months for Veterans in the Veterans Affairs Lipid Optimization Reimagined Quality Improvement (VALOR-QI) Program. Methods: VALOR-QI is a national quality improvement collaboration between the US Department of Veterans Affairs and the American Heart Association (AHA) with the goal of improving lipid management among Veterans with ASCVD. To assess and address barriers to achieving optimal lipid levels, Clinical Champions, Health Care Coaches, and participating providers from 50 VA sites work with AHA QI Consultants. Eligible Veterans (those with an ASCVD diagnosis at two outpatient or one inpatient visit or one ASCVD procedure) were considered engaged in VALOR-QI if they had a qualifying appointment with a participating provider during the program. We examined rates of LDL-C monitoring and LLT use at baseline (start of site monitoring) and 6 months after. Among Veterans who were in the program ≥6 months and had &gt;1 LDL-C measure, we investigated percent meeting an LDL-C goal of &lt;70 mg/dL at their first LDL-C (closest to their first visit with priority given to labs within 365 days before their first visit) and follow-up LDL-C (closest to 6 months after entering the program) and mean LDL-C change (paired t-test). Results: Six months after starting VALOR-QI, sites had a 41% increase in LDL-C monitoring and a 6% increase in LLT use. Among 29,610 Veterans engaged in the program ≥6 months with at least two lipid labs [mean (SD) age 71.0 (9.3) years, 95% men, 72% white race], the proportion who met the LDL-C goal &lt;70 mg/dL increased from 44% at their first measure to 51% at 6-month follow-up. Among these Veterans, we observed a mean LDL-C decrease of 5.1 mg/dL (95% CI: -5.50, -4.78). Conclusion: We observed an increase in lipid monitoring and LLT use and improved LDL-C at 6-month follow-up among US Veterans engaged in VALOR-QI.

Abstract 4140140: Cardiology Follow-Up as a Determinant of LDL-C Management Success in Secondary Cardiovascular Prevention

Managing low-density lipoprotein (LDL) cholesterol is crucial for secondary cardiovascular prevention. Despite ACC/AHA recommendations for maintaining LDL below 70 mg/dL, achieving this target remains suboptimal. This study investigates the impact of consistent cardiologist involvement on LDL cholesterol management. Methods: We conducted a multicenter, cross-sectional cohort study within the Steward Healthcare System in Massachusetts, analyzing data from 10,211 patients hospitalized from January 2019 to March 2024. This study offers a detailed snapshot of data across the study period, capturing both recent and long-standing cases identified through ICD codes for conditions like NSTEMI, CAD, STEMI, or CABG, specifically as markers for secondary cardiovascular prevention. We utilized the most recent LDL cholesterol measurements for our analysis and compared the distribution of lipid-lowering medications across groups. Notably, follow-ups with cardiologists outside our network were not tracked, potentially omitting relevant data. Statistical analysis employed the Chi-square test for categorical variables and binary logistic regression to adjust for confounders. Results: showed that patients with regular cardiology visits more often achieved LDL levels below 70 mg/dL (57.45% vs. 46.67%; OR 1.54, 95% CI: 1.42-1.68; P&lt;0.0001). These patients also had lower mean LDL levels (68.72 ± 27.02) compared to those without cardiology follow-up (75.82 ± 30.27; P&lt;0.0001). Higher usage of PCSK9 inhibitors and non-statin medications was noted among the visiting group, with an adjusted OR of 1.43 (95% CI: 1.29-1.59; P&lt;0.0001). Conclusion: Our study shows that cardiologist involvement significantly enhances cholesterol management in CAD patients, as evidenced by a higher proportion achieving optimal LDL levels and more aggressive use of lipid-lowering medications. Despite these benefits, some patients discontinue their follow-ups with cardiologists after coronary events, shifting cholesterol management to primary care providers (PCPs). This transition often results in less aggressive treatment strategies, evidenced by elevated LDL levels in patients lacking recent cardiology care. To sustain effective cholesterol management and stringent LDL targets, long-term follow-up with a cardiologist is crucial. Furthermore, equipping PCPs with the necessary tools and protocols to adopt more aggressive treatment approaches could bridge the care gap when specialist visits are infrequent.

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 &gt; 18 years of age with diagnosis of ASCVD and LDL-C &gt; 70 mg/dl or non-HDL &gt; 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.