Site-level Variation Research Articles

Methodological influence on detecting temperature effects on growth variability in juvenile Atlantic salmon

In the context of warming freshwater habitats, protection of Atlantic salmon populations requires an understanding of the effects of temperature on somatic growth during the juvenile life stage. However, quantifying the effect of temperature on growth is challenging given differences among methodologies, metrics of growth, and their underlying assumptions. Using short term studies (2000–2002) in two Canadian populations of wild Atlantic salmon (Margaree and Miramichi rivers), we investigate whether different hierarchical modeling approaches influence the derivation of temperature-growth relationships, by contrasting seasonal growth trajectories (von Bertalanffy; VBGF) to size-at-age data models built with instantaneous growth rates. Size-at-age data analysed seasonally with the VBGF framework failed to detect an effect of temperature, whereas instantaneous growth rates from the same dataset were strongly related to temperature metrics. However, instantaneous growth rates cannot be used to extrapolate predictions into meaningful metrics for fisheries management (e.g., size at the end of the growing season). Nevertheless, we show that size at the end of the growing season can be predicted with VBGF models accounting for site-level variation, which in turn are related to temperature metrics, as observed for instantaneous growth rates. Taken together, these results show that combining these two approaches (size-at-age, growth rates) can circumvent their intrinsic drawbacks and reveal essential ecological patterns that may otherwise remain undetected. In cases where instantaneous growth rates are not available, relating predicted size-at-age from hierarchical VBGF to temperature provides an interesting alternative for detecting subtle environmental effects, even if the VBGF parameters or its residuals are unrelated to temperature metrics.

National Variability in Pacemaker Implantation Rate Following TAVR: Insights From the STS/ACC TVT Registry

BackgroundAlthough permanent pacemaker (PPM) implantation is a common complication of transcatheter aortic valve replacement (TAVR), hospital variation and change in PPM implantation rates are ill defined. ObjectivesThe aim of this study was to determine hospital-level variation and temporal trends in the rate of PPM implantation following TAVR. MethodsUsing the American College of Cardiology/Society of Thoracic Surgeons TVT (Transcatheter Valve Therapy) Registry, temporal changes in variation of in-hospital and 30-day PPM implantation were determined among 184,452 TAVR procedures across 653 sites performed from 2016 to 2020. The variation in PPM implantation adjusted for valve type by annualized TAVR volume was determined, and characteristics of sites below, within, and above the 95% boundary were identified. A series of stepwise multivariable hierarchical models were then fit, and the median OR was used to measure variation in pacemaker rates among sites. ResultsFrom 2016 to 2020, the overall rate of PPM implantation was 11.3%, with wide variation across sites (range: 0%-36.4%); rates trended lower over time. Adjusted for annualized volume, there were 34 sites with PPM implantation rates above the 95th percentile CI and 28 with rates below, with wide variation among the remaining sites. After adjusting for patient-level covariates, there was variation among sites in the probability of PPM implantation (median OR: 1.39; 95% CI: 1.35-1.43, P < 0.001); although some of the variation was explained by the addition of valve type, residual variation in PPM implantation rates persisted in additional models incorporating site-level covariates (annualized volume, region, teaching status, hospital beds, etc). ConclusionsAlthough PPM implantation rates have decreased over time, substantial site-level variation remains even after accounting for observed patient characteristics and site-level factors. As there are numerous outlier sites both above and below the 95% confidence limit, dissemination of best practices from high-performing sites to low-performing sites and guideline-based education may be important quality improvement initiatives to reduce rates of this common complication.

The impact of co-occurring mental health problems on referral to and initiation of treatment among youth under probation supervision: Findings from a cluster randomized trial

IntroductionMany youth under community supervision have substance use and co-occurring mental health issues. Yet, access to treatment is limited, and many programs cannot address co-occurring disorders. This study examines how co-occurring symptoms among youth on probation affect referral to and initiation of treatment. We hypothesize that both referral and initiation rates will be lower for youth with any co-occurring indicators. MethodsThis study collected administrative data from 14 sites in three states between March 2014 and November 2017 using JJ-TRIALS, a cluster randomized trial. Among 8552 youth in need of treatment (screened as having a substance use problem, drug possession arrest, positive drug test, etc.), 2069 received a referral to treatment and 1630 initiated treatment among those referred. A co-occurring indicator (n = 2828) was based on symptoms of an internalizing and/or externalizing issue. Descriptive analyses compared referral and initiation by behavioral health status. Two-level mixed effects logistic regression models estimated effects of site-level variables. ResultsAmong youth in need with co-occurring internal, external, or both indicators, only 16 %, 18 %, and 20 % were referred to treatment and of those referred, 63 %, 69 %, and 57 % initiated treatment, respectively. Comparatively, 27 % and 83 % of youth with a substance use only indicator were referred and initiated treatment respectively. Multi-level multivariate models found that, contrary to our hypothesis, co-occurring-both (p = 0.00, OR 1.44) and co-occurring-internal indicators (p = 0.06, OR 1.25) predicted higher referral but there were no differences in initiation rates. However, there was substantial site-level variation. ConclusionsYouth on probation in need of substance use treatment with co-occurring issues have low referral rates. Behavioral health status may influence youth referral to treatment depending on where a youth is located. Depending on the site, there may be a lack of community programs that can adequately treat youth with co-occurring issues and reduce unmet service needs.

The influence of environmental context on community composition in artificial rockpools associated with seawalls

Artificial structures have become widespread features of coastal marine environments, and will likely proliferate further over the coming decades. These constitute new hard substrata in the marine environment which provide a fundamentally different habitat than natural shores. Eco-engineering solutions aim to ameliorate these differences by combining ecological knowledge and engineering criteria in the construction and modification of artificial substrata. Vertipools™ are artificial bolt-on rockpools intended for deployment on seawalls, where they have been shown to provide biodiversity benefits. In this study, a total of 32 Vertipools were retrofitted on eight seawalls in different environmental contexts (estuarine vs marine and urban vs rural) along the Irish Sea coastline, and were exposed to the environment for a period of two years. After two years, there were no differences in species richness, species-abundance distributions, diversity, or community composition between the specific environmental contexts examined here. Site-level variation was significant, and communities on Vertipools deployed in marine contexts were more variable in general than those in estuarine contexts. Community composition differed significantly between structural sections of the Vertipools, indicating that different sections provide specific microhabitats for colonisation. This study indicates that Vertipools provide biodiversity benefits in a variety of environmental contexts, and therefore are broadly viable as an eco-engineering solution.

Physician Variation and the Impact of Payment Model in Cardiac Imaging.

The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%. We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.

Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study

Approximately 1800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020, allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls. Retrospective observational cohort study across 9 OTPs, geographically dispersed, in the National Institute of Drug Abuse (NIDA) Clinical Trials Network. Newly enrolled patients between April 15 and October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, control period) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and adverse events including emergency department visits, hospitalizations, and overdose. 821 individuals were newly admitted in the post-COVID and year-ago control periods, average age of 38.3 (SD 11.1), 58.9% male. The only difference across pre- and post-reform groups was the prevalence of psychostimulant use disorder (25.7% vs 32.9%, p=0.02). Retention was non-inferior (60.0% vs 60.1%) as were hazards of adverse events in the aggregate (X2 (1)=0.55, p=0.46) in the post-COVID period. However, rates of month-level opioid use were higher among post-COVID intakes compared to pre-COVID controls (64.8% vs 51.1%, p<0.001). Moderator analyses accounting for stimulant use and site-level variation in take-home schedules did not change findings. Policies allowing for extended take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use while in care. Relaxed guidelines were not associated with measurable increased harms and findings could inform future studies with prospective trials. USDHHSNIDACTNUG1DA013035-15.

Trends and site-level variation of novel cardiovascular medication utilization among patients admitted for heart failure or coronary artery disease in the US Veterans Affairs System: 2017-2021

We assessed trends in novel cardiovascular medication utilization in US Veterans Affairs (VA) for angiotensin receptor-neprilysin inhibitors (ARNI), sodium-glucose cotransporter-2 Inhibitors (SGLT2i), and glucagon-like peptide-1 receptor agonists (GLP-1 RA). We retrospectively identified cohorts from 114 VA hospitals with admission for prevalent 1) systolic heart failure (HF, N=82,375) or 2) coronary artery disease and diabetes (CAD+T2D, N=74,209). Site-level data for prevalent filled prescriptions were assessed at hospital admission, discharge, or within 6 months of discharge. Variability among sites was estimated with median odds ratios (mOR), and within-site Pearson correlations of utilization of each medication class were calculated. Site- and patient-level characteristics were compared by high-, mixed-, and low-utilizing sites. ARNI and SGTL2i use for HF increased from <5% to 20% and 21%, respectively, while SGTL2i or GLP-1 RA use for CAD+T2D increased from <5% to 30% from 2017 to 2021. Adjusted mOR and 95% confidence intervals for ARNI, SGTL2i for HF, and SGTL2i or GLP-1 RA for CAD+T2D were 1.73 (1.64-1.91), 1.72 (1.59-1.81), and 1.53 (1.45-1.62), respectively. Utilization of each medication class correlated poorly with use of other novel classes (Pearson <0.38 for all). Higher patient volume, number of beds, and hospital complexity correlated with high-utilizing sites. Utilization of novel medications has increased over time but remains suboptimal for US Veterans with HF and CAD+T2D, with substantial site-level heterogeneity despite a universal medication formulary and low out-of-pocket costs for patients. Future work should include further characterization of hospital- and clinician-level practice patterns to serve as targets to increase implementation.

A Mixed-Methods Investigation Examining Site-Level Variation in Reach Out and Read Implementation.

Reach Out and Read (ROR) is an evidence-based early childhood intervention that has been implemented at scale, yet description of ROR implementation is inconsistent. This study engages implementation science to examine ROR delivery and site-level variation. As part of an ongoing clinical trial, we conducted a mixed-methods study in 3 community health centers (CHCs) that serve low-income Latino families. We integrated quantitative parent survey data, qualitative data from monthly key informant interviews with ROR site leaders over 1 year, and in-depth interviews with 18 additional clinicians. At enrollment, parents reported whether they received a children's book, guidance on reading, and modeling from clinicians. We analyzed quantitative data using descriptive statistics, and qualitative data iteratively engaging emergent and a priori codes drawn from the Template for Intervention Description and Replication Checklist. Three hundred Latino parents (mean age: 31; 75% ≤HS education) completed surveys. The mean child age was 8 months. Overall, most parents reported receiving a book (84%) and guidance (73%), but fewer experienced modeling (23%). Components parents received varied across CHCs. Two themes emerged to explain the variation observed: 1) differences in the perceived purpose of shared reading and book delivery aligned with variation in implementation, and 2) site-level barriers affected what components were implemented. Because of substantive variation in ROR implementation across sites, systematic descriptions using established frameworks and corresponding measurement to characterize ROR implementation may enhance our understanding of mechanisms underlying ROR's effects, which clinicians and policymakers can use to maximize ROR's impact.

PO-04-224 PRACTICE VARIATION AFTER AMBULATORY ECG DETECTION OF NON-SUSTAINED VENTRICULAR TACHYCARDIA IN THE NON-CARDIAC PATIENT

Non-sustained ventricular tachycardia (NSVT) is frequently identified in patients without known cardiac disease. However, current practice guidelines for NSVT largely draw from expert opinion or studies of heart failure or coronary artery disease. These guidelines may have limited applicability to the non-cardiac patient. With limited guideline support, there is likely to be wide variation in care. We sought to examine practice variation after detection of NSVT on ambulatory ECG monitoring. We performed a retrospective cohort study using data from the Veterans Health Administration, the largest integrated health system in the U.S. We included patients who received a Zio® Patch between 11/18/2011 and 6/23/2020 and excluded those with history of arrhythmias, atherosclerotic disease, or heart failure. We defined NSVT as at least 1 VT episode ≥3 beats but <30s in duration. We determined healthcare utilization and medication prescription within 90 days of the Ziopatch, and examined site-level variation in care. We performed mixed-effects logistic regressions to evaluate the association of patient characteristics and site NSVT volume >/= 75th percentile with diagnostic testing or cardiology care. We analyzed 58279 patients (59±15 years, 16% female, 74% white) without known cardiac disease, of whom 18792 (32.2%) had NSVT. We matched 18263 NSVT patients (97.2%) to 89 unique sites for the site-level analysis. There was substantial site-level variation in the proportion of patients with echocardiograms, coronary angiograms, stress testing, cardiology care, and prescriptions filled within 90 days of Ziopatch (Figure). After adjusting for baseline characteristics and medications, we only found significant associations between Charlson Comorbidity Index and echocardiogram use (odds ratio [OR]: 0.95, 95% confidence interval [CI]:0.91-0.99, p=0.008), age and stress testing (OR 0.92, 95% CI: 0.88-0.95, p<0.0001), and high-volume sites and cardiology care (OR 1.83, 95% CI: 1.16-2.89, p=0.01). In patients without known cardiac disease referred for ambulatory ECG monitoring, NSVT is common. However, there is wide variation in care after detection of NSVT, which was not effectively accounted for by patient factors or site volume. This may reflect a fundamental lack of actionable evidence on management of NSVT in patients without other cardiac disease. Clinical trials and high-quality retrospective studies are needed to fill this crucial evidence gap.

Recruitment Strategies of a Decentralized Randomized Placebo Controlled Clinical Trial: The Canagliflozin Impact on Health Status, Quality of Life and Functional Status in Heart Failure (CHIEF-HF) Trial

There has been growing Interest in patient-centered clinical trials using mobile technologies to reduce the need for in-person visits. The CHIEF-HF trial was designed as a double-blind, randomized, fully decentralized clinical trial (DCT) that identified, consented, treated, and followed participants without any in-person visits. Patient-reported questionnaires were the primary outcome, which were collected by a mobile application. To inform future DCTs, we sought to describe the strategies used in successful trial recruitment. This paper describes the operational structure and novel strategies employed in a completely DCT by summarizing the recruitment, enrollment, engagement, retention, and follow-up processes used in the execution of the trial at 18 centers. A total of 18 sites contacted 130,832 potential participants, of which 2,572 (2.0%) opened a hyperlink to the study website, completed a brief survey, and agreed to be contacted for potential inclusion. Of these, 1,333 were eligible and 658 consented with 182 screen-failures, primarily due to baseline Kansas City Cardiomyopathy Questionnaire scores not meeting inclusion criteria, resulting in 476 participants being enrolled (18.5%). There was significant site-level variation in the number of patients invited (median = 2,976; range 73-46,920) and in those agreeing to be contacted (median = 2.4%; range 0.05% - 16.4%). At the highest enrolling site, patients contacted by electronic medical record portal messaging were more likely to successfully opt-into the study than those contacted by email alone (7.8% vs 4.4%). CHIEF-HF used a novel design and operational structure to test the efficacy of a therapeutic treatment but marked variability across sites and strategies in recruiting participants was observed. While this approach may be advantageous for clinical research across a broader range of therapeutic areas, further optimizing recruitment efforts is warranted. NCT04252287: https://clinicaltrials.gov/ct2/show/NCT04252287.

Optimizing Shared Decision Making about Hydroxyurea in Young Children with Sickle Cell Anemia

Introduction: The National Heart, Lung, and Blood Institute (NHLBI) recommends hydroxyurea (HU) be offered to all children with sickle cell anemia (SCA) age >9 months via shared decision-making (SDM). However, HU remains underutilized, largely due to parental concerns about safety and potential long-term effects. SDM was recommended because it can decrease parental uncertainty as families clarify their values/preferences and understand scientific evidence about HU. Funded by the Patient-Centered Outcomes Research Institute (PCORI), the Engage HU study (NCT03442114) compared two methods for optimizing SDM for HU in young children with SCA: the American Society of Hematology's (ASH) HU clinician pocket guide (usual care condition) and a HU SDM toolkit (toolkit condition) created by the research team. This study aimed to compare the impact of these on caregiver decisional uncertainty and caregiver perception of clinician use of SDM. Methods: Engage HU was a prospective, multi-site intervention trial with a unidirectional crossover design in which each clinic began enrolling in the usual care condition and then one-by-one crossed over to the toolkit condition. Inclusion criteria included children ages 0-5 years followed at 12 SCA centers in the US who were candidates for HU and whose caregivers had not decided about HU therapy within 3 months prior to enrollment. After receiving a flyer/letter, eligible caregivers were approached in clinic or by phone. Caregivers completed an e-consent form. Study visits were conducted in-person or via telehealth. Primary endpoints were caregiver decisional uncertainty (Decisional Conflict Scale-DCS) and caregiver perception of clinician use of SDM (Dyadic OPTION scale-OPTION). Lower scores on the DCS indicate less decisional uncertainty and higher scores on the OPTION indicate that the clinician demonstrated more SDM behaviors (e.g., asked about caregiver preferences/values). All survey data were collected using paper surveys or electronically via REDCap™. Data were analyzed using linear regression models in Stata version 17 for each main outcome of interest (DCS and OPTION Total Scores). Our primary predictor was group (toolkit versus usual care). The model was estimated using full information maximum likelihood estimation on the full analysis sample (N=132) to account for missing data. We also accounted for site-level variation, when the sites crossed from usual care to toolkit (i.e., the cluster), when data were collected (0=pre-COVID, 1=during COVID), and the impact of COVID-19 on caregivers (assessed using the COVID-19 Exposure and Family Impact Survey [CEFIS]). Results: A total of 176 caregivers of eligible children consented. Twelve SCA clinical sites participated; however, four sites were terminated early due to staff turnover or low accrual. Mean caregiver age was 30.19 (SD=6.97); most identified as female (93.1%), Black/African American (89.3%), or Mixed race (6.1%), and mothers (90.8%). Most children had HbSS (94.7%). Preliminary analyses were conducted on 132 caregivers with complete data (n=85 Usual Care; n=47 Toolkit). Regression analyses showed that participants in the toolkit condition had significantly lower DCS Total scores (i.e., lower decisional conflict) than those in usual care condition (b=-7.33, 95% CI=-13.3 to 1.31, p=.017). In addition, significant differences were found on the DCS subscales (see Table 1). Similarly, participants in the toolkit condition had significantly higher OPTION Total scores (i.e., parents reported that the clinician exhibited more SDM behaviors) than those in usual care (b=2.38, 95% CI=0.44 to 4.34, p=.016). Conclusions: Use of the HU toolkit compared to the usual care approach significantly improved SDM between providers and caregivers of children with SCA; however, given site team turnover, lower than expected accrual, and study interruption due to the COVID-19 pandemic, additional research is needed to confirm these preliminary findings. Future studies should also seek to identify context-specific factors (e.g., clinic processes) that are key to successful implementation of SDM with both younger and older children with SCA. This project was supported by an award fromPCORI contract number CDR-1609-36055 (PI: Crosby).Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Abstract 05: Hospital Variation In Epinephrine Administration Prior To Defibrillation For Cardiac Arrest Due To Shockable Rhythm

Background: Contrary to guidelines, we recently found that epinephrine administration before first defibrillation for in-hospital cardiac arrest (IHCA) due to a shockable rhythm is not uncommon. However, the extent to which the above practice varies across hospitals and its association with hospital-level survival is unknown. Methods: Using 2000-19 data from the Get With The Guidelines ® -Resuscitation (GWTG-R) registry, we identified 57,816 adult patients (521 sites) with an index IHCA due to an initial shockable rhythm who received at least 1 defibrillation prior to achieving return of spontaneous circulation. We constructed multivariable hierarchical regression models to examine site-level variation in epinephrine before first defibrillation and its association with hospital survival. Results: Overall, the median rate of epinephrine before defibrillation was 18.8% and varied markedly across hospitals (range: 0%-70.6%, median odds ratio [OR] 1.50; 95% C.I. 1.43 - 1.57). Compared to hospitals in the lowest quartile (Q1) for epinephrine before defibrillation, hospitals in the highest quartile (Q4) were more likely to be major teaching hospitals and have more hospital beds. After adjusting for baseline variables, the median risk-standardized survival was 42.5% (IQR: 39.2%-46.0%). Compared to Q1 hospitals (epinephrine first rate of 0-12.4%), there was a stepwise decline in risk-standardized survival at hospitals with higher rates of epinephrine before first defibrillation: Q2: RR 0.95 [0.90-0.99]; Q3: RR 0.91 [0.87-0.96]; Q4: RR 0.81 [0.77-0.86]; P value for trend &lt;0.001. Conclusions: For patients with shockable IHCA, there is marked hospital variation in epinephrine administration prior to first defibrillation, and this practice is associated with lower rates of survival to discharge. Hospital efforts to prioritize immediate defibrillation for patients with shockable IHCA are urgently needed.

A Quality Collaborative Study of the Concordance of Electrodiagnostic Scores and Clinical Severity in Carpal Tunnel Syndrome.

Electrodiagnostic studies are commonly used to diagnose carpal tunnel syndrome. However, these examinations are prone to false-positive and false-negative values. The authors evaluated the agreement of electrodiagnostic study severity, clinical assessment scores, and probability of carpal tunnel syndrome [Six-Item Carpal Tunnel Syndrome Evaluation Tool (CTS-6) scores. This was a retrospective cohort study of 609 patients with carpal tunnel syndrome (941 hands). Data were collected from nine hand surgery practices in the Michigan Collaborative Hand Initiative for Quality in Surgery. Goodman and Kruskal gamma statistics (γ) measured the agreement between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 scores. The authors performed cumulative logistic regression with mixed effects to evaluate the association among electrodiagnostic study severity, clinical assessments, and patient characteristics. The concordance between electrodiagnostic study severity and CTS-6 scores was γ = 0.31 (95 percent CI, 0.21 to 0.40), with an accuracy of 43 percent. The concordance between electrodiagnostic study severity and clinical assessment scores was γ = 0.66 (95 percent CI, 0.58 to 0.74), with an accuracy of 58 percent. Wide site-level variation in the γ coefficient between electrodiagnostic studies and clinical assessment scores and between electrodiagnostic studies and CTS-6 was seen. Male sex, increasing age, and increasing body mass index were significantly associated with increased odds of electrodiagnostic study severity. Wide practice-level variation underscores the variability in diagnostic testing accuracy. Physicians should consider patient characteristics (e.g., sex, age, body mass index) when assessing carpal tunnel syndrome severity. Diagnostic, II.

Patient Symptoms and Stress Testing After Elective Percutaneous Coronary Intervention in the Veterans Affairs Health Care System

Up to 60% of patients in the US receive a stress test within 2 years of percutaneous coronary intervention (PCI), prompting concerns about the possible overuse of stress testing. To examine the proportion of patients who underwent stress testing within 2 years of elective PCI, proportion of patients who had symptoms that were consistent with coronary artery disease (CAD), timing of stress testing, and site-level variation in stress testing among symptomatic and asymptomatic patients. This cohort study used administrative claims data and clinical records from the US Department of Veterans Affairs (VA) Clinical Assessment, Reporting, and Tracking program. Patients who underwent stress testing within 2 years of elective PCI for stable CAD between November 1, 2013, and October 31, 2015, at 64 VA facilities were included in the analysis. Patients who received stress testing for staging purposes, cardiac rehabilitation evaluation, or preoperative testing before high-risk surgery were excluded. Data were analyzed from June to December 2020. The main outcome was the proportion of patients who underwent stress testing and had symptoms that were consistent with obstructive CAD, using definitions from the 2013 clinical practice guideline (Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease). Secondary outcomes were the timing of stress testing (assessed using a cumulative incidence curve) and site-level variation in stress testing (assessed using multilevel logistic regression models). A total of 3705 consecutive patients (mean [SD] age 66.3 [7.6] years; 3656 men [98.7%]; 437 Black individuals [11.8%], 3175 White individuals [85.7%], and 93 individuals [2.5%] of other races and ethnicities [Asian, Hispanic or Latinx, or unknown]) had elective PCI. Of these patients, 916 (24.7%) received a stress test within 2 years, among whom 730 (79.7%) had symptoms that were consistent with obstructive CAD at the time of stress testing. Visual inspection of a cumulative incidence curve for stress testing showed no rapid increases in stress testing at 6 months or 1 year after PCI, which might coincide with routine clinical visits. The proportion of symptomatic patients who underwent stress testing at each VA site ranged from 67.7% to 100%, with no significant site-level variation in stress testing. Results of this study suggest that most veterans who underwent stress testing within 2 years after elective PCI had symptoms that were consistent with obstructive CAD. Therefore, measuring low-value stress testing using only administrative claims data may overestimate its prevalence, and concerns about overuse of post-PCI stress testing may be overstated.

Fish community surveys in eelgrass beds using both eDNA metabarcoding and seining: implications for biodiversity monitoring in the coastal zone

Marine Protected Areas (MPAs) have been adopted globally as a tool to combat biodiversity loss and restore marine ecosystems. Successful application of MPAs will be predicated on the ability to monitor biodiversity in a synoptic and noninvasive manner. Environmental DNA (eDNA) methods have important advantages over traditional biodiversity survey methods for monitoring conservation areas. To evaluate the efficacy of eDNA metabarcoding for fish biodiversity monitoring, we sampled 19 coastal eelgrass (Zostera marina) beds in Canada, as eelgrass beds are known for high biodiversity and significant conservation value. At each site, beach seines were used to survey fish and water samples were collected contemporaneously for eDNA metabarcoding. In total, beach seining caught 32 672 individuals across 59 fish taxa, and eDNA detected 129 fish taxa. eDNA captured site-level variation and detected higher species richness at both site and regional levels compared to seining. eDNA abundance had a positive association with capture abundance. Collectively these results highlight how eDNA metabarcoding offers an efficient approach for monitoring fish biodiversity in coastal eelgrass beds, thus providing a valuable and noninvasive tool for MPA planning and coastal monitoring.

Achievement and quality measure attainment in patients hospitalized with atrial fibrillation: Results from The Get With The Guidelines – Atrial Fibrillation (GWTG-AFIB) registry

The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) Registry uses achievement and quality measures to improve the care of patients with atrial fibrillation (AF). We sought to evaluate overall and site-level variation in attainment of these measures among sites participating in the GWTG-AFIB Registry. From the GWTG-AFIB registry, we included patients with AF admitted between 1/3/2013 and 6/30/2019. We described patient-level attainment and variation in attainment across sites of 6 achievement measures with 1) defect-free scores (percent of patients with all eligible measures attained), and 2) composite opportunity scores (percent of all eligible patient measures attained). We also described attainment of 11 quality measures at the patient-level. Among 80,951 patients hospitalized for AF (age 70±13 years, 47.0% female; CHA2DS2-VASc 3.6±1.8) at 132 sites. Site-level defect-free scores ranged from 4.7% to 85.8% (25th, 50th, 75th percentile: 32.7%, 52.1%, 64.4%). Composite opportunity scores ranged from 39.4% to 97.5% (25th, 50th, 75th: 68.1%, 80.3%, 87.1%). Attainment was notably low for the following quality measures: 1) aldosterone antagonist prescription when ejection fraction ≤35% (29% of those eligible); and 2) avoidance of antiplatelet therapy with OAC in patients without coronary/peripheral artery disease (81% of those eligible). Despite high overall attainment of care measures across GWTG-AFIB registry sites, large site variation was present with meaningful opportunities to improve AF care beyond OAC prescription, including but not limited to prescription of aldosterone antagonists in those with AF and systolic dysfunction and avoidance of non-indicated adjunctive antiplatelet therapy.

Abstract 13686: Variation in Time in Therapeutic Range for Cooling for Out-of-Hospital Cardiac Arrest

Introduction: For comatose survivors of out-of-hospital cardiac arrest (OHCA), targeted temperature management (TTM) is strongly recommended with a goal temperature of 32-36C for a period of at least 24 hours. However, adherence to this target in clinical practice remains unknown. We developed time-in-therapeutic range (TTR) as a treatment metric for patients receiving TTM and evaluated patient- and site-level variation in TTR. Methods: We used data from the Resuscitation Outcomes Consortium-CCC trial which included patients with OHCA across 10 North American sites during 2011-2015. We identified patients who underwent TTM for &gt;12 hours. Serial temperature measures were evaluated between hypothermia start and end times with temperatures between consecutive measures imputed using a linear interpolation method. TTR was defined as percent of time between 32C and 36C during TTM (Fig A). Site was defined based on trial clusters, which represented hospitals served by the same EMS agency. Site-level variation in TTR&lt;90% was evaluated in hierarchical logistic regression using median odds ratio (OR), after adjustment for patient-level factors. Results: A total of 2,695 patients across 49 clusters were included with a median of 45 (IQR: 34 - 52) patients per cluster. The median duration of hypothermia was 23 (IQR: 21 - 24) hours with a median time outside therapeutic range of 0.9 (IQR: 0.0 - 4.2) hours. The median TTR was 96.1% but 1,654 (61%) patients had at least one temperature outside the therapeutic range and 991 (37%) patients had a TTR &lt;90%. There was large variation across sites in the proportion of patients with TTR&lt;90%, ranging from 10% to 68%, with a median OR of 1.74 (Fig B). Conclusions: Within a large randomized controlled trial, more than 1 in 3 OHCA patients treated with TTM had a TTR &lt;90%, with large variation in TTR across sites. These findings highlight an urgent need to focus on improving quality of TTM in clinical practice.

PD38-07 ANTIBIOTIC PROPHYLAXIS PRIOR TO OUTPATIENT UROLOGIC PROCEDURES: OUTCOMES FROM A DEPARTMENT-WIDE QUALITY IMPROVEMENT PROJECT

You have accessJournal of UrologyHealth Services Research: Quality Improvement & Patient Safety III (PD38)1 Sep 2021PD38-07 ANTIBIOTIC PROPHYLAXIS PRIOR TO OUTPATIENT UROLOGIC PROCEDURES: OUTCOMES FROM A DEPARTMENT-WIDE QUALITY IMPROVEMENT PROJECT Matthew Buck, Justin Nguyen, Alejandro Abello, Michael Leapman, Jaime Cavallo, and Patrick Kenney Matthew BuckMatthew Buck More articles by this author , Justin NguyenJustin Nguyen More articles by this author , Alejandro AbelloAlejandro Abello More articles by this author , Michael LeapmanMichael Leapman More articles by this author , Jaime CavalloJaime Cavallo More articles by this author , and Patrick KenneyPatrick Kenney More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002048.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract infections (UTI) are a common complication following office-based lower urinary tract procedures. While the American Urological Association Best Practice Statement provides guidelines on antibiotic prophylaxis in this setting, significant variability remains in practice. We assessed the effects of operationalizing a standardized approach to antibiotic use for outpatient lower tract procedures through a nursing-driven algorithm. METHODS: In February 2019, we implemented a clinical decision-support algorithm based on the Best Practice Statement within a regional healthcare network including five practice sites across two states. Covered procedures were outpatient cystourethroscopies with or without manipulation and urodynamic testing. Antibiotic selection was based on an algorithm consisting of established patient risk factors. Nursing staff assessed risk factors and administered single dose 3g oral fosfomycin for eligible patients. We evaluated the impact of our protocol in reducing site-level variation in antibiotic use, abnormal urinalysis, and rates of UTI. RESULTS: 12,909 patients were seen from January 2018 to December 2020, with 7,711 falling under the antibiotic protocol. We observed a reduction in the variation of antibiotic administration post-protocol (difference in SD = -10.55, p < 0.001), accompanied by an overall decrease in antibiotic use rate (- 9.4%, p < 0.001). Changes varied by site, with the pre-intervention highest utilizer experiencing a decrease (absolute percent change – 30.70%, relative percent change -60.99%) and the lowest utilizer experiencing an increase (absolute percentage change +14.92%, relative percentage change +46.83). Antibiotic use rate changes were not accompanied by a change in abnormal urinalysis (+2.69%, p = 0.437) or urinary tract infection ( +0.04%, p = 0.652). CONCLUSIONS: Operationalizing a standardized nurse-driven antibiotic prophylaxis pathway for office based cystoscopy reduced practice-level variation in antibiotic administration across a regional healthcare system. Changes in antibiotic practices were not associated with measurable changes in overall rates of UTI. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e664-e665 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Buck More articles by this author Justin Nguyen More articles by this author Alejandro Abello More articles by this author Michael Leapman More articles by this author Jaime Cavallo More articles by this author Patrick Kenney More articles by this author Expand All Advertisement Loading ...

A hierarchical modelling approach to estimating humpback whale abundance from sand lance abundance

The primary prey of humpback whales in the southwestern Gulf of Maine is sand lance. Despite this established relationship, we lack models to further understand the influence of sand lance on humpback whales or to predict humpback abundance or distribution in response to climate-related changes in sand lance abundance or distribution. We used a subset of long-term standardized survey data (2013–2019) from Stellwagen Bank National Marine Sanctuary and a Bayesian hierarchical modeling approach to explore the influence of sand lance on humpback whales at multiple spatial and temporal scales while accounting for sampling variability and propagating uncertainty. We developed zero-inflated Poisson mixed effects models for both sand lance and humpbacks, using modelled sand lance abundance as a predictor in the whale model. Results showed a statistically clear positive correlation between sand lance and humpback whales. Regional mean abundances of both species increased from north to south, though site-level variation within regions showed more variability. Results suggest annual variation in abundance of both species, with potentially different influences. We demonstrate one management application of our method by examining entanglement risk for humpback whales. Whale aggregations were more likely to occur in a high density area of fixed fishing gear that overlaps with an area of higher sand lance abundance. Our work suggests that humpback whale distribution in the larger Gulf of Maine may be impacted by climate-related fluctuations in sand lance abundance. Predicting future distributions of humpback whales is important for ecosystem-based management, including mitigation of human impacts, and our work serves as a foundation for further model development.

Composite Metric for Benchmarking Site Performance in Transcatheter Aortic Valve Replacement: Results From the STS/ACC TVT Registry.

Transcatheter aortic valve replacement (TAVR) is a transformative therapy for aortic stenosis. Despite rapid improvements in technology and techniques, serious complications remain relatively common and are not well described by single outcome measures. The purpose of this study was to determine whether there is site-level variation in TAVR outcomes in the United States using a novel 30-day composite measure. We performed a retrospective cohort study using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry to develop a novel ranked composite performance measure that incorporates mortality and serious complications. The selection and rank order of the complications for the composite was determined by their adjusted association with 1-year outcomes. Sites with risk-adjusted outcomes significantly more or less frequent than the national average based on a 95% probability interval were classified as performing worse or better than expected. The development cohort consisted of 52 561 patients who underwent TAVR between January 1, 2015, and December 31, 2017. Based on associations with 1-year risk-adjusted mortality and health status, we identified 4 periprocedural complications to include in the composite risk model in addition to mortality. Ranked empirically according to severity, these included stroke, major, life-threatening or disabling bleeding, stage III acute kidney injury, and moderate or severe perivalvular regurgitation. Based on these ranked outcomes, we found that there was significant site-level variation in quality of care in TAVR in the United States. Overall, better than expected site performance was observed in 25/301 (8%) sites, performance as expected was observed in 242/301 sites (80%), and worse than expected performance was observed in 34/301 (11%) sites. Thirty-day mortality; stroke; major, life-threatening, or disabling bleeding; and moderate or severe perivalvular leak were each substantially more common in sites with worse than expected performance as compared with other sites. There was good aggregate reliability of the model. There are substantial variations in the quality of TAVR care received in the United States and 11% of sites were identified as providing care below the average level of performance. Further study is necessary to determine structural, process-related, and technical factors associated with high- and low-performing sites.