Performance Measures In Patients Research Articles

INTERSESSION REPEATABILITY OF READING PERFORMANCE MEASURES IN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

To assess the intersession repeatability of reading performance measures in patients with previously treated neovascular age-related macular degeneration and good best-corrected visual acuity (≥20/40 Snellen). Ninety-one patients (91 eyes) with a diagnosis of previously treated neovascular age-related macular degeneration and good best-corrected visual acuity (≥20/40 Snellen) were prospectively enrolled. Reading performance metrics were assessed using Radner charts, and these measurements were repeated after 7 days to obtain the intersession repeatability. To test repeatability, we calculated the intraclass correlation coefficient, the 95% coefficient of repeatability, and the coefficient of variation for each reading parameter: 1) reading acuity (RA-LogRAD); 2) maximal reading speed-words per minute; 3) RA score (RA score-LogRAD); and 4) critical print size-LogRAD. Mean ± standard deviation best-corrected visual acuity was 0.13 ± 0.01 logMAR [range: 0.00-0.30 logMAR]. The intraclass correlation coefficient values indicated a good reliability for all the analyzed metrics (0.901 for RA; 0.859 for max reading speed; 0.906 for RA score; and 0.868 for critical print size). The coefficient of repeatability was 0.2 LogRAD for RA, 63.2 words per minute for max reading speed, 0.2 LogRAD for RA score, and 0.2 LogRAD for critical print size. Coefficient of variation was 5.5% for RA, 8.9% for max reading speed, 5.8% for RA score, and 6.9% for critical print size. Reading performance metrics are characterized by good values of intersession repeatability in patients with neovascular age-related macular degeneration with good best-corrected visual acuity. Our findings may grant the employment of such measures in trials assessing the visual outcome in these patients.

Kinesiophobia contributes to worse functional and patient-reported outcome measures in Achilles tendinopathy: a systematic review.

To assess the effect of kinesiophobia or fear of reinjury on patient-reported outcome measures and physical performance measures in patients with chronic Achilles tendinopathy (AT). Three databases were systematically screened for studies from inception to May 22nd, 2023 for literature investigating the impact of kinesiophobia on PROMs or physical performance metrics in AT. The authors adhered to the PRISMA and R-AMSTAR guidelines as well as the Cochrane Handbook for Systematic Reviews of Interventions. Data on demographics, pain, level of activity, self-reported injury severity, quality of life, single-leg hop performance, and heel-raise performance were recorded. Data was presented primarily in a narrative summary fashion. The MINORS score was used for all studies to perform a quality assessment of included studies. Six studies comprising 705 patients were included in this review. Variations of the Tampa Scale of Kinesiophobia (TSK-11 or TSK-17) were used in all studies. TSK scores were strongly correlated with the Pain Catastrophizing Score (PCS) and Visual Analogue Scale (VAS) scores and were correlated with decreased Victorian Institute of Sports Assessment Achilles (VISA-A) and Foot and Ankle Outcome Scores Quality of Life (FAOS-QoL) subscale scores. Kinesiophobia was associated with heel raise completion with conflicting evidence on correlations with hop test performance. Increased kinesiophobia scores (> 35 points), measured by TSK are associated with worse PROMs, including increased pain, decreased quality of life, increased self-reported severity, and is also associated with poorer physical performance measures in patients with AT. IV.

ATA2023Annual Conference & ExpoMarch 4–6, 2023San Antonio, Texas

ATA2023Annual Conference & ExpoMarch 4–6, 2023San Antonio, Texas

Longitudinal Changes in MRI Muscle Morphometry and Composition in People With Inclusion Body Myositis.

Limited data suggest that quantitative MRI (qMRI) measures have potential to be used as trial outcome measures in sporadic inclusion body myositis (sIBM) and as a noninvasive assessment tool to study sIBM muscle pathologic processes. Our aim was to evaluate changes in muscle structure and composition using a comprehensive multiparameter set of qMRI measures and to assess construct validity and responsiveness of qMRI measures in people with sIBM. This was a prospective observational cohort study with assessments at baseline (n = 30) and 1 year (n = 26). qMRI assessments include thigh muscle volume (TMV), inter/intramuscular adipose tissue (IMAT), muscle fat fraction (FF), muscle inflammation (T2 relaxation time), IMAT from T2* relaxation (T2*-IMAT), intermuscular connective tissue from T2* relaxation (T2*-IMCT), and muscle macromolecular structure from the magnetization transfer ratio (MTR). Physical performance assessments include sIBM Physical Functioning Assessment (sIFA), 6-minute walk distance, and quantitative muscle testing of the quadriceps. Correlations were assessed using the Spearman correlation coefficient. Responsiveness was assessed using the standardized response mean (SRM). After 1 year, we observed a reduction in TMV (6.8%, p < 0.001) and muscle T2 (6.7%, p = 0.035), an increase in IMAT (9.7%, p < 0.001), FF (11.2%, p = 0.030), connective tissue (22%, p = 0.995), and T2*-IMAT (24%, p < 0.001), and alteration in muscle macromolecular structure (ΔMTR = -26%, p = 0.002). A decrease in muscle T2 correlated with an increase in T2*-IMAT (r = -0.47, p = 0.008). Deposition of connective tissue and IMAT correlated with deterioration in sIFA (r = 0.38, p = 0.032; r = 0.34, p = 0.048; respectively), whereas a decrease in TMV correlated with a decrease in quantitative muscle testing (r = 0.36, p = 0.035). The most responsive qMRI measures were T2*-IMAT (SRM = 1.50), TMV (SRM = -1.23), IMAT (SRM = 1.20), MTR (SRM = -0.83), and T2 relaxation time (SRM = -0.65). Progressive deterioration in muscle quality measured by qMRI is associated with a decline in physical performance. Inflammation may play a role in triggering fat infiltration into muscle. qMRI provides valid and responsive measures that might prove valuable in sIBM experimental trials and assessment of muscle pathologic processes. This study provides Class I evidence that qMRI outcome measures are associated with physical performance measures in patients with sIBM.

Effects of a Low-Intensity Walking Intervention on Walking Performance Measures in Patients with Peripheral Artery Disease

The purpose of this study was to examine the effects of a low-intensity (pain-free) walking intervention on walking performance and self-report measures in patients with peripheral arterial disease (PAD). Thirty-three participants who experienced intermittent claudication were assigned to either a walking group (n = 18) or a comparison group (n = 15). The walking group performed a structured walking program (pain-free walking, 5 days per week for 12 weeks). The comparison group maintained their usual daily activities. Tests of walking performance included a treadmill test (pain-free, functional and maximal walking distances were measured) and the 6-minute walk test. Self-perception of walking ability was determined using the walking impairment questionnaire. Circulatory measures were obtained from the ankle-brachial index, (ABI). Participants were assessed at the beginning (Week 1) and end of the study (Week 12). Members of the walking group significantly increased their walking performance and self-perception of walking ability, whereas the ABI remained the same. These results show that participation in a 12-week, low-intensity (pain-free) exercise program can enhance physical performance, perception of walking ability and maintain the ABI suggesting that a home-based exercise program is a viable alternative to traditional exercise programs prescribed for patients with symptomatic PAD. Keywords: peripheral artery disease, exercise, walking performance, ankle-brachial index, walking impairment questionnaire

Validation of Physical Performance Tests in Individuals with Advanced Knee Osteoarthritis.

Individuals with advanced osteoarthritis (OA) of the knee experience significant impairments in balance and in essential physical functions such as walking and rising from a chair. There is limited evidence on valid outcome measures to capture these impairments. We sought to examine the construct validity of three physical performance measures in patients with advanced knee OA: a gait speed (GS) test, the Short Physical Performance Battery (SPPB), and the Timed Up and Go (TUG) test. We designed a cross-sectional clinical measurement study in which patients with advanced knee OA completed two self-reported measures: the Knee Injury and Osteoarthritis Outcome Score-Physical Function Shortform (KOOS-PS) and a four-part numeric pain rating scale (Q-NPRS). They were also administered the GS test, TUG test, and SPPB. Convergent and divergent construct validity were assessed by examining relationships between the GS test, the SPPB, the TUG test, the KOOS-PS, and the Q-NPRS and calculating Pearson correlation coefficients (r). The scores for the GS, TUG test, and SPPB were compared with established normative values for age-matched healthy controls. Forty-four subjects (mean age, 66.9 ± 8.1 years) participated in the study. The GS test showed low concordance with the SPPB component tests and the TUG test. The relationships between the physical performance measures and the self-reported measures were low. The scores for the GS test, TUG test, and SPPB in our sample were significantly worse when compared with age-matched normative values, indicating impairments in physical performance. These results advance the understanding of the validity of the GS test, TUG test, and SPPB in demonstrating the impairments in physical performance that patients with advanced knee OA experience in walking, balancing, and rising from a chair. Future research should examine the reproducibility and responsiveness of the GS test, TUG test, and SPPB in patients with advanced knee OA, in order to facilitate the integration of these measures into clinical practice.

Adherence to fluid resuscitation guidelines and outcomes in patients with septic shock: Reassessing the “one-size-fits-all” approach

ObjectiveThe Surviving Sepsis Campaign and Centers for Medicare and Medicaid Services (CMS) Severe Sepsis and Septic Shock Management Bundle (SEP-1) recommend rapid crystalloid infusion (≥30 mL/kg) for patients with sepsis-induced hypoperfusion or septic shock. We aimed to assess compliance with this recommendation, factors associated with non-compliance, and how compliance relates to mortality. DesignRetrospective, observational study. Setting1136-bed academic and 235-bed community hospital (January 2015–June 2016). PatientsPatients with septic shock. InterventionsCrystalloid infusion (≥30 mL/kg) within 6 h of identification of septic shock as required by CMS. MeasurementsAssociations with compliance and how compliance associates with mortality; odds ratios (OR) and 95% confidence intervals (CI) reported. Main resultsOverall, 1027 septic shock patients were included. Of these, 486 (47.3%) met the 6-hour 30 ml/kg fluid requirement. Compliance was lower in patients with congestive heart failure (CHF) (40.9%), chronic kidney disease (CKD) (42.3%) or chronic liver disease (38.5%) and among those that were identified in the inpatient setting (35.4%) rather than in the emergency department (51.7%). When adjusting for relevant covariates, compliance (compared to non-compliance) was not associated with in-hospital mortality: OR 1.03 CI 0.76–1.41. ConclusionsThese findings question a “one-size-fits-all” approach to fluid administration and performance measures for patients with sepsis.

Abstract WP388: Improvement of Adherence to Performance Measures in Patients With Acute Ischemic Stroke by Using Automatic Extraction of Electronic Medical Records: Baseline Characteristics of the Network of Shanghai Stroke Service System (4S)

Introduction: Several stroke quality control and outcome projects have demonstrated the success in improving stroke care quality through structured process. However, Chinese healthcare systems are challenged with its overwhelming numbers of patients, limited resources and large regional disparities. This study aims to Improve quality of stroke care to address regional disparities. Methods: The Shanghai Stroke Service System (4S) was established as a regional network for stroke care quality improvement in Shanghai. The 4S registry uses a web-based database that automatically extracts data from structured electronic medical records. Thirty-six hospitals including 10 regional stroke centers and 25 district stroke centers. Registry began enrolling all patients with diagnosed acute ischemic stroke (AIS) in 2017. Primary outcome is to evaluate the differences in quality metrics performance before and after the implementation structured quality improvement process. Results: Among 14461 patients with AIS registered, patient’s average age was 73 years old with 4958 women (34.2%) in 2017. Compared to the data from the previous registry, web-based database enrolled more patients (3175 in 2014, 4815 in 2015, 12387 in 2016, p&lt;0.001). With the best use of resource(Table1), AIS patients in 4S were more likely to receive performance measures than those of previous registry (composite measure 83%, Figure 1A). A trend of gradually decreased hospital mortality and rate of unplanned re-admission within 30 days was observed in 4S hospitals (Figure 1B). Conclusions: The study has helped to identify areas stroke care deficiencies and improvement. Despite of challenges of healthcare in China, 4S proved the feasibility and potentially effective as a regional stroke network model for quality improvement. This model could be duplicated at other large cities or regions in China. Clinicaltrials.gov Identifier NCT02735226

Balancing measures: identifying unintended consequences of diabetes quality performance measures in patients at high risk for hypoglycemia.

To determine if changes in overtreatment rates were associated with changes in undertreatment rates. Pre-test/post-test study used cross-sectional administrative data from calendar years (CYs) 2013 and 2016. The Veterans Health Administration. Patients with diabetes at risk for hypoglycemia (n = 171 875 and 166 703 in 2013 and 2016, respectively). Observational study of extant initiatives to reduce overtreatment. Overtreatment rate of diabetes defined at the proportion of patients in the group at high risk for hypoglycemia with A1c < 7.0%. Undertreatment defined as A1C > 9%. There was marked variation in overtreatment rates; for A1c < 7%, overtreatment rates ranged from 26.4% to 58.2% and 26.2% to 49.2% at the facility level in 2013 and 2016, respectively. The mean (±standard deviation (SD)) facility-level overtreatment rates fell from 40.3 (±5.3)% in 2013 to 37.75 (±4.70)% in 2016 (P < 0.001, paired t-test). Facility undertreatment rates ranged from 5.8% to 16.9% and 6.8% to 18.7% at the facility level in 2013 and 2016, respectively. The mean (±SD) undertreatment rate rose from 10.3 (±2.2)% in 2013 to 11.0 (±2.4)% in 2016 (P ≤ 0.001, paired t-test). However, change at individual facilities ranged from a decrease of 4.6% to an increase of 7.2%. Within year correlations were stronger than between year correlations. Overtreatment defined as A1c < 7 in this population inversely correlated strongly with undertreatment (r = -0.653, P < 0.001). Promotion of overtreatment reduction may be associated with an increase in undertreatment in patients with diabetes. Unintended consequence should be considered when implementing and evaluating quality measures and systems should include balancing measures to identify potential unintended harms.

Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China

In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. ClinicalTrials.gov Identifier: NCT02212912.

Guideline-adherence regarding critical time intervals in the German Chest Pain Unit registry.

Since 2008, the German Cardiac Society certified 256 Chest Pain Units (CPUs). Little is known about adherence to recommended performance measures in patients with suspected acute coronary syndrome (ACS) presenting to CPUs. We investigated guideline-adherence regarding critical time intervals and selected performance measures in German Chest Pain Units. From 2008 to 2014, 23,804 consecutive patients with suspected ACS were prospectively enrolled in the Chest Pain Unit registry of the German Cardiac Society. Median time from symptom onset to first medical contact was 2 h in patients with ST-elevation myocardial infarction (STEMI) and 4 h in patients with unstable angina and non-STEMI (NSTEMI). In patients with STEMI, median time from hospital admission to percutaneous coronary intervention (PCI) was 40 min and median time from first medical contact to PCI was 1 h 35 min. Primary PCI was performed in 94.7% of patients with STEMI, 70.0% of patients with NSTEMI and 37.4% of patients with unstable angina. PCI was performed during the first 24 h in 79.5% of patients with NSTEMI and the first 72 h in 89.0% of patients with unstable angina. Electrocardiograms were performed in 99.5% after a median of 6 min after admission and obtained within 10 min in 71%. Interestingly, 56.1% of patients were found to have non-ACS diagnoses, underlining the importance of access to additional diagnostic modalities including echocardiography, stress testing or computed tomography. Guideline-adherence regarding critical time intervals and primary PCI rates is good in German Chest Pain Units. More than half of patients admitted with suspected ACS had non-ACS diagnoses. Improvements in pre-hospital time delays through public awareness programmes are warranted.

Electronic health records and outpatient cardiovascular disease care delivery: Insights from the American College of Cardiology’s PINNACLE India Quality Improvement Program (PIQIP)

BackgroundThere has been a push toward implementation of electronic health records (EHRs) in federally-funded hospitals under the current policies initiated by the Indian government, with a lack of evidence supporting their adoption. We analyzed data from the American College of Cardiology’s PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP) to evaluate the association between EHR use and quality of cardiovascular disease care in India. Methods and ResultsBetween 2011–2016, we collected data on performance measures for patients with coronary artery disease (CAD), heart failure (HF) and atrial fibrillation (AF) among 17 participating practices in PIQIP. There were 19,035 patients with CAD, 9,373 patients with HF, and 1,127 patients with AF. Documentation of co-morbidity burden in patients with CAD was lower among practices with EHR—hypertension (49.8% vs. 52.1%, p=0.003), diabetes (34.9% vs. 38.3%, p<0.001), and hyperlipidemia (0.2 vs. 3.9%, p<0.001). On the contrary, documentation of medication prescription was higher in CAD patients seen at practices with EHR—aspirin (63.2% vs. 17.8%, p<0.001), clopidogrel (41.7% vs. 27.4%, p<0.001), beta-blockers (61.4% vs. 9.8%, p<0.001), and ACE-i or ARBs (53.9% vs. 16.4%, p<0.001). Similarly, documentation of receipt of beta-blockers (43.8% vs. 10.7%, p<0.001), ACE-i or ARBs (40.8% vs. 16.1%, p<0.001), and beta-blockers+ACE-i or ARBs (36.4% vs. 3.6%, p<0.001) was also significantly higher in patients with HF seen at practices with EHR. Among patients with AF, documentation of oral anticoagulation use was significantly higher among EHR practices—warfarin (42.5% vs. 26.1%, p<0.001). ConclusionsDocumentation of receipt of guideline-directed medical therapy in CAD, HF, and AF was significantly higher in practices with EHRs in India compared with sites without EHRs. Our findings shed a spotlight on the value of EHRs in future health care policy-making in India with regard to widespread adoption of EHRs in primary and advanced specialty care settings across public and private sectors.

Assessment of quality performance measures in patients with acute coronary syndromes: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS), a nationwide registry.

Registries are a powerful tool to assess specific performance measurements and quality of care in acute coronary syndromes (ACSs). In Portugal, ProACS is a nationwide registry of ACS that has been active for the past 15years, and our objective was to assess specific quality indicators for the treatment of ACS. Descriptive analysis of data from ProACS registry in specific quality indicators previously defined by international scientific societies. A total of 45,141 patients were included since 2002, 43.5% with ST-segment elevation myocardial infarction. In ST-segment elevation myocardial infarction, reperfusion rates, particularly by primary angioplasty, have increased dramatically with 85% being submitted to any form of reperfusion presently. In-hospital time delays are, however, suboptimal, particularly in patients admitted first to hospitals without catheterization facilities. For non-ST elevation ACS, invasive strategy also showed important improvements, with more than 80% of patients being submitted to catheterization. Although there was also improvement in the use of guideline recommended medication, particularly statins, it is also suboptimal, requiring additional specific interventions. The quality of care of ACS improved dramatically in the last 15years in Portugal, with major improvements in hospital mortality. It is, however, suboptimal in specific points that have been identified and that require additional measures.

Performance verification of a plasma-based PD-L1 test that reliably measures mRNA expression from patients with NCSLC.

156 Background: The detection of circulating nucleic acids using non-invasive blood-draws has become highly relevant to clinical testing. In this study we report on the development of a blood-based PD-L1 test for immunotherapy selection. Methods: We have previously reported on the analytic performance of a droplet digital™ PCR (ddPCR) assay for circulating cytokeratin 19 and PD-L1. Using a variable threshold based on a logistic regression score for the blood assay and a 1% IHC (immunohistochemistry) tissue cut-off, concordance was 80% (n = 16). Positive calls for the blood-based PD-L1 assay ranged from 2 to 124 copies. In this study we focused on variables that could impact concordance of the blood assay and tissue results. Criteria included droplet counts for tissue and blood mRNA transcripts and tumor proportion score (TPS) for the tissue IHC assay (22C3 pharmDx). Results: We examined the correlation between PD-L1 in formalin-fixed paraffin-embedded (FFPE) tissue by IHC, mRNA expression in serial cut FFPE sections, and in matched plasma samples collected at the time of tissue resection. Five cases were assayed to confirm PD-L1 positivity by tissue. We successfully recovered RNA from serial tissue sections for each case and detected PD-L1 levels ranging from 6 to 1272 copies. Plasma samples were available for four of the cases for circulating RNA evaluation, and we were successful in detecting PD-L1 in all cases (copy range 32-138). While all four cases contained detectible PD-L1 mRNA in tissue and circulation, we observed little concordance between these levels in tissue and blood. Conclusions: We have developed methods to measure the dynamic range of PD-L1 from plasma. We have shown feasibility of these methods by evaluating key immune and cancer-specific RNAs. The current study demonstrates that although the development of quantitative assays for mRNA in blood is possible, concordance with traditional clinical tissue assays such as IHC may not be a useful validation measure. We have initiated prospective validation studies that will continue to evaluate PD-L1 expression by IHC and in the blood-based assay, and will also monitor patient performance measures in response to immunotherapy.

Implementation of an emergency department atrial fibrillation and flutter pathway improves rates of appropriate anticoagulation, reduces length of stay and thirty-day revisit rates for congestive heart failure.

An evidence-based emergency department (ED) atrial fibrillation and flutter (AFF) pathway was developed to improve care. The primary objective was to measure rates of new anticoagulation (AC) on ED discharge for AFF patients who were not AC correctly upon presentation. This is a pre-post evaluation from April to December 2013 measuring the impact of our pathway on rates of new AC and other performance measures in patients with uncomplicated AFF solely managed by emergency physicians. A standardized chart review identified demographics, comorbidities, and ED treatments. The primary outcome was the rate of new AC. Secondary outcomes were ED length of stay (LOS), referrals to AFF clinic, ED revisit rates, and 30-day rates of return visits for congestive heart failure (CHF), stroke, major bleeding, and death. ED AFF patients totalling 301 (129 pre-pathway [PRE]; 172 post-pathway [POST]) were included; baseline demographics were similar between groups. The rates of AC at ED presentation were 18.6% (PRE) and 19.7% (POST). The rates of new AC on ED discharge were 48.6 % PRE (95% confidence interval [CI] 42.1%-55.1%) and 70.2% POST (62.1%-78.3%) (20.6% [p<0.01; 15.1-26.3]). Median ED LOS decreased from 262 to 218 minutes (44 minutes [p<0.03; 36.2-51.8]). Thirty-day rates of ED revisits for CHF decreased from 13.2% to 2.3% (10.9%; p<0.01; 8.1%-13.7%), and rates of other measures were similar. The evidence-based pathway led to an improvement in the rate of patients with new AC upon discharge, a reduction in ED LOS, and decreased revisit rates for CHF.

Abstract 134: Implementation of Home-Based Cardiac Rehabilitation in the VA

Objective: Referral to cardiac rehabilitation (CR) is one of nine performance measures for patients with ischemic heart disease (IHD), but fewer than 20% of eligible patients participate in the United States. Home-based CR programs (available in the United Kingdom, Australia, and Canada) have similar effects on morbidity and mortality as traditional (facility-based) CR, but they are not currently available or reimbursed in the US. We sought to determine whether implementing home-based programs could increase CR participation among patients with IHD. Methods: Using electronic health records from 134 VA medical centers, we identified 106,277 veterans hospitalized for acute myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting between 2010 and 2015. We compared the proportion of eligible patients who participated in CR at 13 VA hospitals that offered referral to either home-based CR or facility-based CR vs. 121 VA hospitals that offered referral to only facility-based CR (usual care). Results: The number of VA medical centers offering home-based CR increased from 2 in 2010 to 13 in 2015. Among the 20,949 eligible patients hospitalized at VA medical centers that implemented home-based CR between 2010 and 2015, CR participation increased from 11% to 26% (Figure). Among the 85,328 eligible patients hospitalized at VA medical centers that did not offer home-based CR, CR participation increased from only 8% to 11%. Conclusion: Among eligible patients with IHD, participation in CR more than doubled at VA medical centers that implemented home-based CR programs between 2010 and 2015, whereas participation increased by only 3% at VA medical centers that did not implement home-based CR programs. Home-based CR is an effective way of engaging patients who may otherwise decline to participate in CR.

Abstract 060: Association of Body Mass Index With Risk Factor Optimization and Guideline Directed Medical Therapy in Veterans With Cardiovascular Disease

Background: Obesity is an epidemic in the United States and has been linked to the development of cardiovascular diseases (CVD) including atherosclerosis, heart failure and hypertension. However, obesity has been associated with better survival once CVD is established and has been referred to as the “obesity paradox”. Medical management and risk factor optimization are recommended for patients with all forms of CVD. The association of body mass index (BMI) with performance measure compliance is not known. Methods: In a large national cohort, we identified 1,242,015 patients with CVD receiving care in 130 Veterans Affairs facilities between 10/1/2013 and 9/30/2014. CVD was defined as the presence of ischemic heart disease, peripheral artery disease, or ischemic cerebrovascular disease. We assessed the frequency of compliance with performance measures in patients divided into 5 groups: underweight (BMI &lt;18.5 Kg/m 2 ), normal BMI (18.5-24.9 Kg/m 2 ), overweight (25-29.9 Kg/m 2 ), obese (30-39.9 Kg/m 2 ), and extremely obese (&gt;=40 Kg/m 2 ). We compared compliance with hypertension control (BP &lt;140/90 mmHg), diabetes control (HbA1C &lt;=9% among diabetics), use of statin, and use of antiplatelet therapy among the 5 groups. A composite of all 4 measures (BP control, statin use, antiplatelet use, HbA1C &lt;=9% among diabetics) termed optimal medical therapy (OMT) was also compared among the groups. Multivariable logistic regression was performed with normal BMI as the referent category. Results (Table): Underweight comprised 12,623 (1.1%), normal BMI 230,471 (20.5%), overweight 413,590 (36.8%), obese 404,105 (36%), and extremely obese 61,778 (5.5%). Compliance with risk factor control (hypertension and diabetes control) was higher in the underweight and normal BMI group and lowest in the extremely obese group. However, statin and antiplatelet use was lowest in the underweight group and highest in the obese and extremely obese groups. Overall, only 32.7%-45.5% received OMT (i.e. met the composite measure) and was highest in the overweight group. Conclusions: Compliance with OMT was low in all patients. Patients that were underweight and extremely obese were least likely to receive OMT. Our results suggest potential for improvement in OMT for all CVD patients especially those that are underweight and extremely obese.

Abstract WP275: Much Work to Do: Analysis of Potential Performance Measures for Patients Transferred for Acute Endovascular Thrombectomy

Background: Potential performance measures to assess care of acute ischemic stroke patients transferred from initial hospitals to interventional centers for thrombectomy include: 1) door-in to door-out (DIDO) time (time from arrival to discharge at first hospital, and 2) first imaging at referral hospital to first arterial access at endovascular hospital (FIFA) (time from qualifying CT/MR imaging at initial hospital to arterial puncture at endovascular hospital). Methods: In a prospectively maintained registry, we analyzed consecutive patients transferred from regional referral hospitals to receive thrombectomy at an academic medical center, January 2015 to March 2016. Results: Among 35 patients, transferred from 10 referral hospitals, with documented time intervals, mean age was 52.8 (±12.2), 37% female, mean NIHSS 12.3 (±8.3). Initial hospital imaging was NCCT alone in 49%, and NCCT with CTA or MRA in 51%. Overall, 20 (57%) received IV tPA at the initial hospital, and 14 (40%) thrombectomy at the interventional hospital. Door-in door-out times were median 153 min (IQR 99-220). For candidate target DIDO performance metric intervals: &lt;60m was achieved in 6%; &lt;90m in 20%. Interfacility travel was by air in 34% (median distance 65, IQR 50-65, miles] and ground in 66% (median 16, IQR 12-16, miles), and travel times were similar for air v ground, 58 min (IQR 37-87) v 51 min (IQR 40-70), p=0.52. First (outside) imaging to first arterial access times were median 261 min (IQR 190-315). For candidate target FIFA performance metric intervals: &lt;90m (SNIS “ideal”) was achieved in 3%; &lt;120m in 6%. Additional intervals were: onset to first door, 52 min (IQR 33-156); onset to second door, 304 min (IQR 240-434); onset to puncture, 355 min (IQR 312-447); and onset to substantial reperfusion, 412 min (IQR 342-529). Conclusion: Substantial opportunities exist to expedite thrombectomy for patients presenting to referral hospitals and transferred to interventional centers. National programs to improve achievement of DIDO and FIFA performance measure targets would benefit acute stroke patients in developing regional acute stroke care networks

Gender disparities in cardiovascular care access and delivery in India: Insights from the American College of Cardiology's PINNACLE India Quality Improvement Program (PIQIP)

BackgroundLimited data are available to assess whether access to and quality of cardiovascular disease (CVD) care are comparable among men and women in India. We analyzed data from the American College of Cardiology's PINNACLE (Practice Innovation and Clinical Excellence) India Quality Improvement Program (PIQIP) to evaluate gender disparities in CVD care delivery. Methods and resultsBetween 2011 and 2015, we collected data on performance measures for patients with coronary artery disease (CAD) (n=14,010), heart failure (HF) (n=11,965) and atrial fibrillation (AF) (n=496) in PIQIP, among 17 participating practices.The total number of women was 31,796 (32.0%). Women had fewer total encounters compared to men during the study interval (mean number of encounters=2.59 vs. 2.82 for women and men, respectively, p≤0.001). Women were significantly younger (48.9years vs. 51.5years, p≤0.01), but had a higher co-morbidity burden compared to men — hypertension (62.0% vs. 45.6%, p≤0.01), diabetes (39.4% vs. 35%, p≤0.01), and hyperlipidemia (3.7% vs. 3.1%, p=0.19). On the contrary, the guideline-directed medication prescriptions were strikingly lower in women with CAD compared to men — aspirin (38% vs. 50.4%, p≤0.001), aspirin or thienopyridine combination (46.9% vs. 57.2%, p≤0.001), and beta-blockers (36.8% vs. 47.8%, p≤0.001). Similarly, among women with ejection fraction ≤40%, the use of guideline-directed medical therapy was significantly lower compared to men for beta-blockers (30.8% vs. 37.0%, p≤0.001), angiotensin-converting enzyme inhibitors (ACE-i) or angiotensin receptor blockers (ARBs) (29.3% vs. 34.9%, p≤0.001), and beta-blockers/ACE-i or ARBs (24.6% vs. 31.0%, p≤0.001). Among patients with atrial fibrillation and CHADS2 score≥2, more women were on oral anticoagulation (19.6% vs. 14.6%, p=0.34), although this was not significantly different, and the overall number of patients with atrial fibrillation was low. ConclusionsDespite a significantly higher co-morbidity burden in women, we found fewer women receiving guideline-directed medical therapy for CVD compared with men. If such disparities are confirmed in the larger Indian population, it is important to find potential causes for, and seek solutions to narrow this gap.

Abstract 164: Home-Based Cardiac Rehabilitation Improves Access for Rural Veterans

Objective: Referral to cardiac rehabilitation (CR) is one of nine performance measures for patients with ischemic heart disease (IHD), but fewer than 10% of eligible Veterans participate. Home-based CR programs may improve participation in CR, particularly for rural Veterans who do not live near traditional facility-based programs. We sought to compare referral to, participation in, and completion of CR in rural and urban Veterans. Methods: We established The Healthy Heart Program, a home-based CR program, to increase participation in CR programs and provide an alternative to facility-based CR programs for Veterans with IHD. Between August 2013 and May 2015, 574 patients were referred to CR during hospitalization for myocardial infarction, coronary revascularization, valve surgery, angina, or as an outpatient with heart failure. We used the Rural-Urban Commuting Areas (zip code) system to categorize urban and rural Veterans. We then compared the proportions of urban vs. rural Veterans who were referred to, enrolled in, and completed home-based CR. Results: Overall, 52% (94/181) of rural and 51% (202/393) of urban Veterans agreed to enroll in CR. Rural Veterans were more likely to be married (50% vs. 41%, p=0.02) and have undergone coronary artery bypass surgery (30% vs. 20%, p=0.03). Among 296 patients who agreed to enroll, 82% chose home-based and 18% chose facility-based CR (p&lt;0.001). Rural Veterans were more likely than urban Veterans to choose home-based CR (95% vs. 76%; p&lt;0.001). Among 243 patients who enrolled in home-based CR, rural Veterans were more likely to complete at least 9 weeks of home-based CR (67% vs. 53%; p=0.031) and less likely to withdraw (33% vs. 47%, p=0.031). After adjustment for demographics and clinical indication, rural Veterans had 49% greater odds of enrolling in (odds ratio 1.49, 95% confidence interval 1.03, 2.14; p=0.034) and 80% greater odds of completing home-based CR (OR 1.80, 95% CI 1.20, 2.71; p=0.004). Conclusion: The majority of Veterans who were interested in CR chose a home-based over a facility-based program. Rural Veterans were more likely to choose home-based CR and to complete CR. Home-based CR is an effective way of engaging patients who may otherwise decline to participate in CR, especially for rural Veterans.