Salt Lake City Veterans Affairs Research Articles

UNMET NEEDS OF OLDER FEMALE VETERANS AND GENDER DIFFERENCES USING THE PROSPECTIVE HERO CARE SURVEY DATA

Abstract Aging female Veterans face unique healthcare needs which are yet to be well-described. We analyzed round one data from HERO CARE, a prospective survey, to describe the medical, psychological, and social unmet needs of female Veterans and compare them with those of male Veterans. We received survey responses from 8,056 community-dwelling Veterans (227 (2.8%) females and 7,829 (97.2%) males) from San Antonio, Palo Alto, Miami, Salt Lake City Veterans Affairs (VA) Medical Centers, and Veteran Integrated Service Network 8 in July 2021. We compared difference in needs between the female and male respondents using chi-square tests and difference in age in years using t-tests. Respondents were classified as having an unmet need if they responded that they needed “a little” or “a lot more help” for specific needs. Female respondents were 74.3 (SD: 14.5) years-old on average, and 7.9% Hispanic, 15.4% non-Hispanic Black, 72.7% non-Hispanic White. Male respondents were older 80.3 (SD: 9.8) years-old on average (p< 0.01), with no significant difference in race/ethnicity. Female Veterans reported unmet needs in ADLs (14.1%), IADLs (40.1%), nursing tasks (7.1%), pain management (17.6%), communicating with the healthcare team (10.6%), and social needs like legal or housing (16.3%). All unmet needs were like those of male Veterans (all p>0.05). Among female Veterans, 20.1% screened positive for anxiety (GAD-2 score >2) and 22.8% for depression (PHQ-2 score >2), compared to male Veterans: 15.2% (p< 0.01) and 21.6% (p=0.41), respectively. Routine assessment of aging female Veterans, specifically focusing on mental health and IADLs, may better address their needs.

Women's Health Provider Perspectives on Reproductive Services Provision in the Veterans Health Administration.

Women veterans are a fast-growing population in the Veterans Health Administration (VHA), and ensuring reproductive service availability is a VHA priority. As such, we sought to explore barriers and facilitators to VHA reproductive service provision across a catchment area from women's health providers' perspectives. We performed a mixed-methods study, including semistructured, qualitative provider interviews with a quantitative survey on training, comfort, and knowledge of reproductive services. All women's health providers and their support staff from the Salt Lake City Veterans Affairs Medical Center and nine VHA community-based outpatient clinics were asked to participate. We conducted qualitative interviews and knowledge surveys with providers and staff to explore training, care processes, and improvement opportunities in reproductive service provision. We completed descriptive analyses of all of the quantitative data and used an open, iterative process to analyze provider interviews for emergent themes. We interviewed 15 providers (7 advanced practice nurses, 4 registered nurses, and 4 physicians) across nine sites (50% response rate). The commonly identified barriers included provider training and staffing, scheduling/referral processes, inconsistent services/supplies, and lack of veteran awareness of reproductive services. Facilitators included prior non-VHA reproductive health experience among providers, invested support staff, and the integrated VHA health system. Addressing barriers to VHA reproductive healthcare provision may overcome reproductive service variations related to clinic location and improve reproductive health outcomes for women veterans.

Military Injuries-Understanding Posttraumatic Epilepsy, Health, and Quality-of-Life Effects of Caregiving: Protocol for a Longitudinal Mixed Methods Observational Study.

BackgroundVeterans with posttraumatic epilepsy (PTE), particularly those with comorbidities associated with epilepsy or traumatic brain injury (TBI), have poorer health status and higher symptom burden than their peers without PTE. One area that has been particularly poorly studied is that of the role of caregivers in the health of veterans with PTE and the impact caring for someone with PTE has on the caregivers themselves.ObjectiveIn this study, we aim to address the following: describe and compare the health and quality of life of veterans and caregivers of veterans with and without PTE; evaluate the change in available supports and unmet needs for services among caregivers of post-9/11 veterans with PTE over a 2-year period and to compare support and unmet needs with those without PTE; and identify veteran and caregiver characteristics associated with the 2-year health trajectories of caregivers and veterans with PTE compared with veterans without PTE.MethodsWe conducted a prospective cohort study of the health and quality of life among 4 groups of veterans and their caregivers: veterans with PTE, nontraumatic epilepsy, TBI only, and neither epilepsy nor TBI. We will recruit participants from previous related studies and collect information about both the veterans and their primary informal caregivers on health, quality of life, unmet needs for care, PTE and TBI symptoms and treatment, relationship, and caregiver experience. Data sources will include existing data supplemented with primary data, such as survey data collected at baseline, intermittent brief reporting using ecological momentary assessment, and qualitative interviews. We will make both cross-sectional and longitudinal comparisons, using veteran-caregiver dyads, along with qualitative findings to better understand risk and promotive factors for quality of life and health among veterans and caregivers, as well as the bidirectional impact of caregivers and care recipients on one another.ResultsThis study was approved by the institutional review boards of the University of Utah and Salt Lake City Veterans Affairs and is under review by the Human Research Protection Office of the United States Army Medical Research and Development Command. The Service Member, Veteran, and Caregiver Community Stakeholders Group has been formed and the study questionnaire will be finalized once the panel reviews it. We anticipate the start of recruitment and primary data collection by January 2022.ConclusionsNew national initiatives aim to incorporate the caregiver into the veteran’s treatment plan; however, we know little about the impact of caregiving—both positive and negative—on the caregivers themselves and on the veterans for whom they provide care. We will identify specific needs in this understudied population, which will inform clinicians, patients, families, and policy makers about the specific impact and needs to equip caregivers in caring for veterans at home.International Registered Report Identifier (IRRID)PRR1-10.2196/30975

A multifaceted quality improvement intervention to improve management of alcohol withdrawal on a general medicine ward: impact on benzodiazepine use

Objective: To measure the effects of a quality improvement intervention on length of stay and benzodiazepine use among patients admitted for alcohol use disorder. Methods: This retrospective cohort study was performed at the Salt Lake City Veterans Affairs Medical Center. Patients 18 years and older admitted to a general medical ward with a diagnosis of alcohol related disorders who were treated for alcohol withdrawal were included. The baseline cohort included patients admitted over 12 months. The post-intervention cohort included patients admitted over 12 months. Primary outcomes were total benzodiazepine dose and length of stay. Secondary outcomes included episodes of delirium tremens and seizures. Results: Total benzodiazepine dose decreased significantly over the intervention period. Length of stay also decreased. No episodes of delirium tremens or seizures were observed. Conclusions: A quality improvement intervention directed at general medicine inpatients admitted for alcohol withdrawal was associated with reductions in total benzodiazepine administration and length of stay.

How We Do It: Salt Lake City Veterans Affairs Medical Center Transitional Pain Service

How We Do It: Salt Lake City Veterans Affairs Medical Center Transitional Pain Service

2218. Feasibility of Automated Prediction of Drug Resistance in Pneumonia in the Veteran Population.

BackgroundTo enhance antimicrobial decision-making in community-onset pneumonia, several manually calculable clinical scores have been proposed to predict drug-resistant organisms (DRPs), most commonly methicillin-resistant Staphylococcus aureus or Pseudomonas aeruginosa. The Drug Resistance in Pneumonia (DRIP) score includes 10 features that can be calculated by providers at the bedside but is potentially automatically extractable from an electronic health record (EHR). We aimed to explore the feasibility of calculating an automated “eDRIP” score from the EHR in the Veteran’s Affairs (VA) population.MethodsWe extracted patient characteristics, features relevant to the DRIP score, and detection of DRPs among all inpatient admissions for pneumonia between August 29, 2010 and July 31, 2013 at VA hospitals nationwide using EHR data from the VA corporate data warehouse. We calculated an eDRIP score for each admission. We compared the prevalence of each electronically extracted feature to that reported in a separate study of manually extracted factors performed at the Salt Lake City VA by Babbel et al, and to the original DRIP score validation cohort from Webb et al.ResultsAmong 101,462 pneumonia admissions across 114 VA hospitals, 4% had a DRP detected on culture, 25% had an eDRIP ≥ 4, and 50% received broad-spectrum antibiotics. The Salt Lake City VA demonstrated slightly lower prevalence of eDRIP factors than the national population (table). Within the Salt Lake City VA, the EHR cohort and manually extracted Babbel cohort demonstrated similar prevalence of detected DRP’s, DRIP ≥ 4, and 8 of 10 features involved in the DRIP score (table). The eDRIP identified fewer hospitalizations with poor functional status and residence in long-term facilities.ConclusionIn a large population of veterans admitted for community-onset pneumonia, automated extraction of an eDRIP score from the EHR was promising, though in need of revision. While some extracted features had similar prevalence to manual review, others differed by a factor of 10 or more, which may reflect issues with data extraction. Further work is needed to optimize feature extraction and compare electronic to manual DRIP scores to determine its utility within the VA population. Disclosures All authors: No reported disclosures.

2886 A Quality Improvement Curriculum for First Year Gastroenterology Fellows Associated With Improved Efficiency in the Endoscopy Unit

INTRODUCTION: A teaching endoscopy unit is a dynamic setting, with many interrelated parts. Its fundamental mission is to provide quality care to patients while facilitating the development of physician learners. This requires that teaching cases be safe and effective, but also timely. We implemented a Quality Improvement (QI) curriculum in the Salt Lake City Veterans Affairs GI Endoscopy Unit with a focus on workflow efficiency. METHODS: We implemented a year-long quality improvement curriculum in the Endoscopy Unit. This was carried out by rotating first-year fellows and faculty mentors with input from technical and nursing staff. Initial efforts were aimed at identifying areas of inefficiency. Pre-intervention data was collected from fifty eight appointments over three months using recording sheets. Time points were noted as patients underwent each phase of their GI procedures with moderate sedation (e.g. appointment, check-in, intake, consent, in-room, scope in). Forty three appointments were analyzed, while fifteen were incomplete and were omitted. Our primary measure was patient check-in time to patient in-room time. Procedures were defined as “on-time,” only if this interval was thirty minutes or less. After data collection confirmed our perceived area of inefficiency, we made formal modifications to process inputs and quantified their effect over two months. A total of thirty six appointments were included in the post-intervention analysis. Eight appointments were incomplete and were omitted. RESULTS: At the time of initial data collection, a total of 14% of procedures began “on-time.” We considered multiple changes to workflow inputs. These included modifications to the check-in process, variations in the order and location of consent, utilization of workstations-on-wheels as well as novel communication methods between Unit staff. However, the chosen intervention was a formal posting which detailed the roles and responsibilities of each member of the Endoscopy Unit. This was communicated with the support of departmental leadership. Post-intervention, a total of 61% procedures began “on-time.” Overall, the initiative was associated with a 47% improvement over a five-month period. CONCLUSION: Increasing emphasis is being placed on healthcare efficiency and productivity, even in the academic setting. In this collaborative initiative, we demonstrate that implementation of a first year fellows QI curriculum is associated with a significant improvement in the timeliness of endoscopic procedures.

An initiative using informatics to facilitate clinical research planning and recruitment in the VA health care system.

BackgroundRandomized clinical trials are the gold standard for evaluating healthcare interventions and, more generally, add to the medical knowledge related to the treatment, diagnosis and prevention of diseases and conditions. Recent literature continues to identify health informatics methods that can help improve study efficiency throughout the life cycle of a clinical trial. Electronic medical record (EMR) data provides a mechanism to facilitate clinical trial research during the study planning and execution phases, and ultimately, can be utilized to enhance recruitment. The Department of Veterans Affairs (VA) has a strong history of clinical and epidemiological research with over four decades of data collected from Veterans it has served nationwide. The VA Informatics and Computing Infrastructure (VINCI) provides VA research investigators with a nationwide view of high-value VA patient data. Within VA, the Cooperative Studies Program (CSP) Network of Dedicated Enrollment Sites (NODES) is a consortium of nine sites that are part of an embedded clinical research infrastructure intended to provide systematic site-level solutions to issues that arise during the conduct of VA CSP clinical research. This paper describes the collaboration initiated by the Salt Lake City (SLC) node site to bring informatics and clinical trials together to enhance study planning and recruitment within the VA.MethodsThe SLC VA Medical Center physically houses both VINCI and a node site and the co-location of these two groups prompted a natural collaboration on both a local and national level. One of the functions of the SLC NODES is to enhance recruitment and promote the success of CSP projects. VINCI supports these efforts by providing VA researchers access to potential population pools. VINCI can provide 1) feasibility data during study planning, and 2) active patient lists during recruitment. The process for CSP study teams to utilize these services involves regulatory documentation, development of queries, revisions to the initial data request, and ongoing communications with several key study personnel including the requesting research team, study statisticians, and VINCI data managers.ResultsThe early efforts of SLC NODES and VINCI aimed to provide patient lists exclusively to the SLC CSP study teams for the following purposes: 1) increasing recruitment for trials that were struggling to meet their respective enrollment goals, and 2) decreasing the time required by study coordinators to complete chart review activities. This effort was expanded to include multiple CSP sites and studies. To date, SLC NODES has facilitated the delivery of these VINCI services to nine active CSP studies.ConclusionThe ability of clinical trial study teams to successfully plan and execute their respective trials is contingent upon their proficiency in obtaining data that will help them efficiently and effectively recruit and enroll eligible participants. This collaboration demonstrates that the utilization of a model that partners two distinct entities, with similar objectives, was effective in the provision of feasibility and patient lists to clinical trial study teams and facilitation of clinical trial research within a large, integrated healthcare system.

The Utility of Repeat Blood Cultures for Bacteremic Urinary Tract Infections and Associated Durations of Therapy

BackgroundUrinary tract infections (UTIs) are common among hospitalized patients with 10–40% of cases complicated by bacteremia. Recent literature suggests limited utility in repeating blood cultures for non-Staphylococcus aureus bacteremia; however, clinicians often repeat blood cultures to document clearance prior to selecting definitive therapy for bacteremias. Additionally, comparative data evaluating treatment duration for bacteremic UTIs are lacking and clinical practice guidelines do not address optimal duration for bacteremic UTIs. We aimed to evaluate local practice patterns and utility of repeat blood cultures and their influence on treatment durations for bacteremic UTIs.MethodsWe identified patients with bacteremia from a urinary source at the Salt Lake City Veterans Affairs (VA) hospital from a previously compiled cohort of inpatients with bacteremia from any source between November 2013 and October 2015. Demographic and clinical information including presence of comorbidities, source of infection, number of repeat blood cultures collected, repeat blood culture positivity, planned duration of antibiotic therapy and recurrent bacteremia with the same organism within 30 days of discharge were collected by manual chart review.ResultsFifty-three bacteremic UTIs were included during the study period. Ninety-four percent of patients were male with a median age of 77. Repeat blood cultures were drawn in 77% (41/53) of cases; however, only 7% (3/41) of repeats were positive, all with Enterococcus faecalis. Median duration of therapy was 14 days (IQR 14, 15), with a longer mean duration in patients with repeat blood cultures as compared with not (15 vs.. 12 days, P = 0.03). Two patients had recurrent bacteremia with the same organism within 30 days; both with negative repeat blood cultures at the time of initial bacteremia and undetected metastatic complications.ConclusionPatients with bacteremic UTIs are at low risk of persistent bacteremia. Repeat blood cultures are of low utility, specifically with Gram-negative organisms, and may lead to prolonged durations of therapy. The impact of reducing repeat blood culture collection on outcomes, length of stay, and antibiotic durations warrants further evaluation.Disclosures All authors: No reported disclosures.

The Bone Health Team: A Team-Based Approach to Improving Osteoporosis Care for Primary Care Patients.

Background: Significant improvements in secondary prevention of osteoporotic fractures have been noted with fracture liaison services. However, similar models for the primary prevention of such fractures have not been reported. Objective: To determine the impact of a Bone Health Team (BHT) on osteoporosis screening and treatment rates in U.S. veterans in primary care practices. Design: Historical cohort study of a primary care–based intervention of a BHT from February 2013 to February 2015. Setting: Community-based outpatient clinics of the Salt Lake City Veterans Affairs Health Care System. Participants: Men aged 70 years and older and women aged 65 years and older. Intervention: Enrollment in the BHT. Measurements: Rates of dual energy x-ray absorptiometry (DXA) completion, chart diagnosis of osteoporosis or osteopenia, completion of vitamin D measurement, and initiation of fracture reducing medication. Results: Our cohort consisted of 7644 individuals, 975 of whom were exposed to the BHT and 6669 of whom were not. Comparison of patients exposed to the BHT versus non-exposed subjects demonstrated a substantial increase in all outcome measures studied. Hazard ratios (HRs) from multivariable cox proportional hazard models were: measurement of vitamin D, HR = 1.619 (P < .001); chart diagnosis of osteopenia, HR = 37.00 (P < .001); chart diagnosis of osteoporosis, HR = 16.38 (P < .001); osteoporosis medication, HR = 17.03 (P < .001); and completion of DXA, HR = 139.9 (P < .001). Conclusions and Relevance: The implementation of a dedicated BHT produced significantly increased rates of intermediate osteoporosis outcome measures in US veterans in primary care practices. Additional research describing medication adherence rates and cost-effectiveness is forthcoming.

Evaluation of the Effectiveness of a Patient-Centered Educational Mailer Designed to Improve Statin Adherence: A Pragmatic Trial.

Background:Patients with high total cholesterol have increased risk of cardiovascular disease. National Cholesterol Education Program (NCEP) and American Heart Association (AHA) guidelines recommend cholesterol lowering with statin medications; however, statin adherence remains poor. We hypothesized that patient-centered education on the 10-year risk for each of the major constituents of cardiovascular disease would increase statin adherence and achievement of the low-density lipoprotein cholesterol (LDL-C) goal.Methods:Veterans within the Salt Lake City Veterans Affairs (VA) Medical Center initiating statin therapy from October 2008 to December 2011 were randomized in a pragmatic design to receive either an educational mailer or usual care. The mailer outlined their 10-year global cardiovascular risk, separated into coronary heart disease, stroke, and congestive heart failure. The study was unblinded and followed an intention-to-treat analysis where outcome measures were obtained during normal care process. The primary outcome measure was the achievement of the LDL-C goal during the 12-month follow-up.Results:Two hundred and seven patients were randomly assigned to either the intervention arm (95) or the control arm (112). No differences in the proportion of patients meeting the LDL-C goal were detected during 12-months [Relative Risk (RR): 0.95 (95 percent confidence interval (CI): 0.77–1.17)] or 18-months [RR: 1.03 (95 percent CI: 0.84, 1.25)]. Patients in the intervention arm had higher adherence on average, e.g., intervention patients were more likely to have 70 percent or more days of statin therapy compared to patients who received standard care—though this did not reach statistical significance—RR: 1.33 (95 percent CI: 1.00, 1.78). There were no statistical differences in cardiovascular outcomes or mortality.Conclusion:Patient education mailers sent to patients starting statin treatment did not have a clear impact on LDL-C goal achievement or adherence to statin therapy.

"Mini-Residency" in Musculoskeletal Care: a National Continuing Professional Development Program for Primary Care Providers.

A cost-effective professional development program enhancing musculoskeletal (MSK) skills of physicians and allied health providers working in primary care settings has been reported at a single site. This article describes the first 2years of the national expansion and implementation of a 3-day "MSK Mini-residency." Faculty from Veterans Affairs (VA) medical centers worked in partnership with national program faculty from the Salt Lake City VA to present an intensive, integrated, multidisciplinary program to strengthen the skills of primary care providers in evaluating and managing MSK conditions common in primary care. Course assessments included written surveys and a two-station observed structured clinical examination (OSCE) evaluating the physical examination of the shoulder and knee. In the first 2years of the program, 13 VA facilities participated. Two hundred twenty-seven health care providers, including 135 physicians, were trained. Two hundred seven participants (91%) completed all pre- and post-course written assessments and the two-station OSCE. The MSK Mini-residency program is an effective and well-received mixed-method educational initiative to strengthen the skills of primary care physicians and other health care providers in evaluating and managing patients with MSK complaints and to document their competence in performing physical examinations of the shoulder and knee. The 2-year experience in implementation suggests that this model of educational partnerships is a feasible approach to disseminating innovative educational programs in a way that preserves curricular consistency yet is adaptable to local needs.

Mini-Residency in Musculoskeletal Care: An Interprofessional, Mixed-Methods Educational Initiative for Primary Care Providers.

A structured educational effort to train primary care providers (PCPs) to perform joint injections has been projected to be cost effective. The US Department of Veterans Affairs (VA) is developing a national continuing professional development program to train PCPs in the evaluation and management of patients with common musculoskeletal conditions. The objective of this pilot project was to confirm initial projections of cost effectiveness and to inform further efforts to develop this program on a national scale. The Salt Lake City VA served as the national hub for this pilot project. The initial phase included 19 providers, who participated in a weeklong mixed-methods course. Evaluation was conducted by the VA Employee Education System. Assessments included anonymous surveys, structured telephone interviews, and a review of de-identified procedure codes. The survey response rate was 100%, with uniformly positive results. All participants recommended the expansion of this program. The mean number of joint injections performed each month increased from 0.3 (precourse) to 3.5 (postcourse), congruent with prior analyses projecting program cost effectiveness. The musculoskeletal mini-residency is a well-received program, with early evidence of cost effectiveness and impact aligned with course objectives. This pilot program is a foundation for efforts in the national dissemination of this initiative.

Use of a Polytetrafluoroethylene (GORE-TEX) Bolster to Close the Renal Parenchymal Defect During Open Partial Nephrectomy

Numerous surgical techniques have been described to facilitate closure of the renal parenchymal defect. We sought to describe the operative technique and define the safety and efficacy of using an expanded polytetrafluoroethylene (GORE-TEX; WL Gore and Associates, Flagstaff, AZ) bolster to aid in closure of the renal parenchymal defect at the time of open partial nephrectomy (OPN). A retrospective review of 175 patients who underwent an OPN using an expanded polytetrafluoroethylene (ePTFE) bolster at the Huntsman Cancer Hospital, University of Utah and Salt Lake City Veterans Affairs Medical Center from March 2005 to February 2013 was conducted. Postoperative complications occurring within 90 days were graded using the Clavien grading system. Overall, 57 patients (32.6%) experienced a postoperative complication. Fifteen patients (8.5%) had a Clavien ≥ grade-III complication. Ten patients (5.7%) received blood transfusions. Urine leak requiring intervention occurred in 2 patients (1.1%). Delayed hemorrhage requiring nephrectomy and pseudoaneurysm formation were rare, occurring in 1 patient each (0.6%). Infection of the ePTFE material occurred in 2 patients (1.1%). In both cases, it was explanted without requiring nephrectomy. The use of an ePTFE bolster is an effective and safe method of closing the renal parenchymal defect after OPN with an acceptable 90-day postoperative complication rate and a low risk of infection.

Results of an Investigator-Initiated Single-Blind Split-Face Comparison of Photodynamic Therapy and 5% Imiquimod Cream for the Treatment of Actinic Keratoses

Topical photodynamic therapy (PDT) with aminolevulinic acid (ALA) and 5% imiquimod cream are effective therapies for the treatment of actinic keratoses (AKs), but no split-face studies directly comparing these treatment options are available in the literature. To compare the efficacy and tolerability of ALA-PDT and imiquimod 5% cream for the treatment of AKs. Sixty-one patients were enrolled from the Salt Lake City Veterans Affairs Hospital; 51 completed the study and were included in the analysis. All patients were randomized to receive half of a sachet of imiquimod 5% cream twice weekly on half of their face and two sessions of PDT with 20% solution of ALA applied for 1hour to the other side of the face. The 75% AK clearance rate was 34.6% for ALA-PDT and 25% for imiquimod 5% cream (p=.30). The mean reduction in AK count was 59.2% for ALA-PDT and 41.4% for imiquimod 5% cream (p=.002). Dermatology Life Quality Index (DLQI) scores were assessed for each treatment modality at week 4 and were 1.95 and 1.38, respectively (p=.20). The sample size was small, and patients applied a small amount of imiquimod 5% cream (half a sachet) to a large surface area. There was no statistically significant difference in treatment response when the 100% or 75% clearance rate cutoff was used, but our secondary outcome suggests that two sessions of ALA-PDT is superior to imiquimod 5% cream for the treatment of AKs. There was no statistically significant difference in effect on quality of life as assessed using the DLQI.

Usefulness of Adjusting for Clinical Covariates to Improve the Ability of B-Type Natriuretic Peptide to Distinguish Cardiac from Noncardiac Dyspnea

Certain clinical characteristics affect brain natriuretic peptide (BNP) levels independently of clinical heart failure (HF). However, it is unclear how to adjust the diagnostic cutoffs of BNP for these variables. We hypothesized that adjusting for important covariates would improve the diagnostic accuracy of BNP for HF in the emergency room setting. We included patients presenting with dyspnea at the Salt Lake City Veterans Affairs Medical Center. Physicians unaware of the BNP values adjudicated the outcome as dyspnea due to HF or noncardiac dyspnea. Subgroup analyses and logistic regression analysis were used to adjust the BNP cutoffs. The mean age of the study population (n = 335) was 72 +/- 11 years. A BNP of 100 pg/ml had a sensitivity of 91%, and a BNP of 400 pg/ml had a specificity of 92%. The covariates age, history of atrial fibrillation, creatinine, and body mass index affected BNP levels independently of HF. The subgroup-specific BNP cutoff that maintained 91% sensitivity was 184 pg/ml for patients > or =75 years, 150 pg/ml for those with atrial fibrillation, and 449 pg/ml for patients with a creatinine > or =2 mg/dl. These subgroup-specific cutoffs improved specificity compared to a cutoff of 100 pg/ml. The regression model that adjusted BNP improved the reclassification of patients as having cardiac or noncardiac dyspnea compared to the conventional BNP cutoffs. Of the patients without HF, 11% were correctly reclassified as having noncardiac dyspnea (p = 0.003). In conclusion, adjusting BNP levels for clinical covariates improves its diagnostic performance.

Use of National Surgical Quality Improvement Program Data as a Catalyst for Quality Improvement

Semiannually, the National Surgical Quality Improvement Program (NSQIP) provides its participating sites with observed-to-expected (O/E) ratios for 30-day postoperative mortality and morbidity. At each reporting period, there is typically a small group of hospitals with statistically significantly high O/E ratios, meaning that their patients have experienced more adverse events than would be expected on the basis of the population characteristics. An important issue is to determine which actions a surgical service should take in the presence of a high O/E ratio. This article reviews case studies of how some of the Department of Veterans Affairs and private-sector NSQIP participating sites used the clinically rich NSQIP database for local quality improvement efforts. Data on postoperative adverse events before and after these local quality improvement efforts are presented. After local quality improvement efforts, wound complication rates were reduced at the Salt Lake City Veterans Affairs medical center by 47%, surgical site infections in patients undergoing intraabdominal surgery were reduced at the University of Virginia by 36%, and urinary tract infections in vascular patients were reduced at the Massachusetts General Hospital by 74%. At some sites participating in the NSQIP, notably the Massachusetts General Hospital and the University of Virginia, the NSQIP has served as the basis for surgical service-wide outcomes research and quality improvement programs. The NSQIP not only provides participating sites with risk-adjusted surgical mortality and morbidity outcomes semiannually, but the clinically rich NSQIP database can also serve as a catalyst for local quality improvement programs to significantly reduce postoperative adverse event rates.

State of the art immunosuppressive regimens

From the Division of Cardiology, University of Utah Medical Center and the Salt Lake City Veterans Affairs Medical Center, Salt Lake City, UT, USA