Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment: a randomized clinical trial

IMPORTANCE

Most patients with asthma take fewer than half of prescribed doses of controller medication. Interventions to improve adherence have typically been costly, impractical, and at best only minimally successful.

OBJECTIVE

To test a speech recognition (SR) intervention to improve adherence to pediatric asthma controller medication.

DESIGN, SETTING, AND PARTICIPANTS

The Breathe Well study was a 24-month pragmatic randomized clinical trial. The study was conducted within Kaiser Permanente Colorado, a large, group-model health maintenance organization. A total of 1187 children aged 3 to 12 years with a persistent asthma diagnosis and prescription for an inhaled corticosteroid were randomized to the computerized SR intervention or usual care condition and followed up for 24 months between October 2009 and February 2013.

INTERVENTIONS

Speech recognition telephone calls to parents in the intervention condition were triggered when an inhaled corticosteroid refill was due or overdue. Calls were automatically tailored with medical and demographic information from the electronic health record and from parent answers to questions in the call regarding recent refills or a desire to receive help refilling, learn more about asthma control, or speak with an asthma nurse or pharmacy staff member.

MAIN OUTCOMES AND MEASURES

Adherence to pediatric asthma controller medication, measured as the medication possession ratio over 24 months.

RESULTS

In the intention-to-treat analysis, inhaled corticosteroid adherence was 25.4% higher in the intervention group than in the usual care group (24-month mean [SE] adherence, 44.5% [1.2%] vs 35.5% [1.1%], respectively; P < .001). Asthma-related urgent care events did not differ between the 2 groups. The intervention effect was consistent in subgroups stratified by age, sex, race/ethnicity, body mass index, and disease-related characteristics.

CONCLUSIONS AND RELEVANCE

The intervention's significant impact on adherence demonstrates strong potential for low-cost SR adherence programs integrated with an electronic health record. The absence of change in urgent care visits may be attributable to the already low number of asthma urgent care visits within Kaiser Permanente Colorado. Application of electronic health record-leveraged SR interventions may reduce health care utilization when applied in a population with less-controlled asthma.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00958932.

Barriers to calling 911 and learning and performing cardiopulmonary resuscitation for residents of primarily Latino, high-risk neighborhoods in Denver, Colorado

STUDY OBJECTIVE

Individuals in neighborhoods composed of minority and lower socioeconomic status populations are more likely to have an out-of-hospital cardiac arrest event, less likely to have bystander cardiopulmonary resuscitation (CPR) performed, and less likely to survive. Latino cardiac arrest victims are 30% less likely than whites to have bystander CPR performed. The goal of this study is to identify barriers and facilitators to calling 911, and learning and performing CPR in 5 low-income, Latino neighborhoods in Denver, CO.

METHODS

Six focus groups and 9 key informant interviews were conducted in Denver during the summer of 2012. Purposeful and snowball sampling, conducted by community liaisons, was used to recruit participants. Two reviewers analyzed the data to identify recurrent and unifying themes. A qualitative content analysis was used with a 5-stage iterative process to analyze each transcript.

RESULTS

Six key barriers to calling 911 were identified: fear of becoming involved because of distrust of law enforcement, financial, immigration status, lack of recognition of cardiac arrest event, language, and violence. Seven cultural barriers were identified that may preclude performance of bystander CPR: age, sex, immigration status, language, racism, strangers, and fear of touching someone. Participants suggested that increasing availability of tailored education in Spanish, increasing the number of bilingual 911 dispatchers, and policy-level changes, including CPR as a requirement for graduation and strengthening Good Samaritan laws, may serve as potential facilitators in increasing the provision of bystander CPR.

CONCLUSION

Distrust of law enforcement, language concerns, lack of recognition of cardiac arrest, and financial issues must be addressed when community-based CPR educational programs for Latinos are implemented.

Nonobstructive coronary artery disease and risk of myocardial infarction

IMPORTANCE

Little is known about cardiac adverse events among patients with nonobstructive coronary artery disease (CAD).

OBJECTIVE

To compare myocardial infarction (MI) and mortality rates between patients with nonobstructive CAD, obstructive CAD, and no apparent CAD in a national cohort.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of all US veterans undergoing elective coronary angiography for CAD between October 2007 and September 2012 in the Veterans Affairs health care system. Patients with prior CAD events were excluded.

EXPOSURES

Angiographic CAD extent, defined by degree (no apparent CAD: no stenosis >20%; nonobstructive CAD: ≥1 stenosis ≥20% but no stenosis ≥70%; obstructive CAD: any stenosis ≥70% or left main [LM] stenosis ≥50%) and distribution (1, 2, or 3 vessel).

MAIN OUTCOMES AND MEASURES

The primary outcome was 1-year hospitalization for nonfatal MI after the index angiography. Secondary outcomes included 1-year all-cause mortality and combined 1-year MI and mortality.

RESULTS

Among 37,674 patients, 8384 patients (22.3%) had nonobstructive CAD and 20,899 patients (55.4%) had obstructive CAD. Within 1 year, 845 patients died and 385 were rehospitalized for MI. Among patients with no apparent CAD, the 1-year MI rate was 0.11% (n = 8, 95% CI, 0.10%-0.20%) and increased progressively by 1-vessel nonobstructive CAD, 0.24% (n = 10, 95% CI, 0.10%-0.40%); 2-vessel nonobstructive CAD, 0.56% (n = 13, 95% CI, 0.30%-1.00%); 3-vessel nonobstructive CAD, 0.59% (n = 6, 95% CI, 0.30%-1.30%); 1-vessel obstructive CAD, 1.18% (n = 101, 95% CI, 1.00%-1.40%); 2-vessel obstructive CAD, 2.18% (n = 110, 95% CI, 1.80%-2.60%); and 3-vessel or LM obstructive CAD, 2.47% (n = 137, 95% CI, 2.10%-2.90%). After adjustment, 1-year MI rates increased with increasing CAD extent. Relative to patients with no apparent CAD, patients with 1-vessel nonobstructive CAD had a hazard ratio (HR) for 1-year MI of 2.0 (95% CI, 0.8-5.1); 2-vessel nonobstructive HR, 4.6 (95% CI, 2.0-10.5); 3-vessel nonobstructive HR, 4.5 (95% CI, 1.6-12.5); 1-vessel obstructive HR, 9.0 (95% CI, 4.2-19.0); 2-vessel obstructive HR, 16.5 (95% CI, 8.1-33.7); and 3-vessel or LM obstructive HR, 19.5 (95% CI, 9.9-38.2). One-year mortality rates were associated with increasing CAD extent, ranging from 1.38% among patients without apparent CAD to 4.30% with 3-vessel or LM obstructive CAD. After risk adjustment, there was no significant association between 1- or 2-vessel nonobstructive CAD and mortality, but there were significant associations with mortality for 3-vessel nonobstructive CAD (HR, 1.6; 95% CI, 1.1-2.5), 1-vessel obstructive CAD (HR, 1.9; 95% CI, 1.4-2.6), 2-vessel obstructive CAD (HR, 2.8; 95% CI, 2.1-3.7), and 3-vessel or LM obstructive CAD (HR, 3.4; 95% CI, 2.6-4.4). Similar associations were noted with the combined outcome.

CONCLUSIONS AND RELEVANCE

In this cohort of patients undergoing elective coronary angiography, nonobstructive CAD, compared with no apparent CAD, was associated with a significantly greater 1-year risk of MI and all-cause mortality. These findings suggest clinical importance of nonobstructive CAD and warrant further investigation of interventions to improve outcomes among these patients.

Initiation of oral contraceptives and changes in blood pressure and body mass index in healthy adolescents

OBJECTIVES

To describe changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI) associated with initiation and continued use of combined oral contraceptives (COCs) in healthy adolescents.

STUDY DESIGN

This observational, matched cohort study was conducted in 2 large health systems. Utilizing claims and electronic medical records, we identified adolescents 14-17.9 years of age initiating medium-dose COCs (containing 30 or 35 (μg of ethinyl estradiol or equivalent and a progestin) between July 1, 2007 and December 31, 2009 with a baseline and at least 1 follow-up blood pressure (BP) and BMI. COC-users were matched 1:2 by age, race/ethnicity, and site to controls (COC-nonusers). All BPs and BMIs recorded during outpatient visits starting 1 month prior to COC initiation (index date for controls), through December 31, 2010 were collected. Mixed model linear regression with random intercepts and slopes were then used to estimate changes in SBP, DBP, and BMI over time.

RESULTS

The 510 adolescent COC-users and 912 controls did not differ significantly by age, race/ethnicity, insurance, and baseline SBP, DBP, or BMI. After adjusting for baseline values, over a median of 18 months follow-up, COC-users had an decrease in SBP of 0.07 mm Hg/mo, and controls had an increase of 0.02 mm Hg/mo (P = .65). Similarly, DBP decreased by 0.007 mm Hg/mo in COC-users vs 0.006 mm Hg/mo in controls (P = .99). BMI increased by 0.04 (kg/m(2))/mo in COC-users vs 0.025 (kg/m(2))/mo in controls (P = .09).

CONCLUSIONS

These data should provide reassurance to patients and providers regarding the lack of significant associations between COC-use and BMI or BP changes in adolescents.

Multiple cluster analysis for the identification of high-risk census tracts for out-of-hospital cardiac arrest (OHCA) in Denver, Colorado

BACKGROUND

Prior research has shown that high-risk census tracts for out-of-hospital cardiac arrest (OHCA) can be identified. High-risk neighborhoods are defined as having a high incidence of OHCA and a low prevalence of bystander cardiopulmonary resuscitation (CPR). However, there is no consensus regarding the process for identifying high-risk neighborhoods.

OBJECTIVE

We propose a novel summary approach to identify high-risk neighborhoods through three separate spatial analysis methods: Empirical Bayes (EB), Local Moran's I (LISA), and Getis Ord Gi* (Gi*) in Denver, Colorado.

METHODS

We conducted a secondary analysis of prospectively collected Emergency Medical Services data of OHCA from January 1, 2009 to December 31, 2011 from the City and County of Denver, Colorado. OHCA incidents were restricted to those of cardiac etiology in adults ≥18 years. The OHCA incident locations were geocoded using Centrus. EB smoothed incidence rates were calculated for OHCA using Geoda and LISA and Gi* calculated using ArcGIS 10.

RESULTS

A total of 1102 arrests in 142 census tracts occurred during the study period, with 887 arrests included in the final sample. Maps of clusters of high OHCA incidence were overlaid with maps identifying census tracts in the below the Denver County mean for bystander CPR prevalence. Five census tracts identified were designated as Tier 1 high-risk tracts, while an additional 7 census tracts where designated as Tier 2 high-risk tracts.

CONCLUSION

This is the first study to use these three spatial cluster analysis methods for the detection of high-risk census tracts. These census tracts are possible sites for targeted community-based interventions to improve both cardiovascular health education and CPR training.

Personalised physician learning intervention to improve hypertension and lipid control: randomised trial comparing two methods of physician profiling

PURPOSE

To assess the impact of personalised physician learning (PPL) interventions using simulated learning cases on control of hypertension and dyslipidaemia in primary care settings.

METHODS

A total of 132 primary care physicians, 4568 eligible patients with uncontrolled hypertension, and 15 392 eligible patients with uncontrolled dyslipidaemia were cluster-randomised to one of three conditions: (a) no intervention, (b) PPL-electronic medical record (EMR) intervention in which 12 PPL cases were assigned to each physician based on observed patterns of care in the EMR in the previous year, or (c) PPL-ASSESS intervention in which 12 PPL cases were assigned to each physician based on their performance on four standardised assessment cases. General and generalised linear mixed models were used to account for clustering and to model differences in patient outcomes in the study arms.

RESULTS

Among patients with uncontrolled hypertension at baseline, 49.1%, 46.6% and 47.3% (p=0.43) achieved blood pressure (BP) targets at follow-up. Among patients with uncontrolled dyslipidaemia at baseline, 37.5%, 37.3% and 38.1% (p=0.72) achieved low density lipoprotein cholesterol targets at follow-up in PPL-EMR, PPL-ASSESS and the control group, respectively. Although systolic (BP) (p<0.001) and lipid (p<0.001) values significantly improved during the study, the group-by-time interaction term showed no differential change in systolic BP values (p=0.51) or lipid values (p=0.61) among the three study arms. No difference in intervention effect was noted when comparing the PPL-EMR with the PPL-ASSESS intervention (p=0.47).

CONCLUSIONS

The two PPL interventions tested in this study did not lead to improved control of hypertension or dyslipidaemia in primary care clinics during a mean 14-month follow-up period. This null result may have been due in part to substantial overall improvement in BP and lipid control at the study sites during the study.

TRIAL REGISTRATION NUMBER

NCT00903071.

The HANDDS program: a systematic approach for addressing disparities in the provision of bystander cardiopulmonary resuscitation

The current paradigm of bystander cardiopulmonary resuscitation (CPR) blankets a community with training. Recently, the authors have found that high-risk neighborhoods can be identified, and CPR training can be targeted in the neighborhoods in which it is most needed. This article presents a novel method and pilot implementation trial for the HANDDS (identifying High Arrest Neighborhoods to Decrease Disparities in Survival) program. The authors also seek to describe example methods in which the HANDDS program is being implemented in Denver, Colorado. The HANDDS program uses a simple three-step approach: identify, implement, and evaluate. This systematic conceptual framework uses qualitative and quantitative methods to 1) identify high-risk neighborhoods, 2) understand common barriers to learning and performing CPR in these neighborhoods, and 3) implement and evaluate a train-the-trainer CPR Anytime intervention designed to improve CPR training in these neighborhoods. The HANDDS program is a systematic approach to implementing a community-based CPR training program. Further research is currently being conducted in four large metropolitan U.S. cities to examine whether the results from the HANDDS program can be successfully replicated in other locations.

Cost-effectiveness evaluation of a home blood pressure monitoring program

OBJECTIVES

To evaluate the health system cost of a home blood pressure monitoring (HBPM) program versus usual care in an integrated healthcare system.

STUDY DESIGN

This cost-effectiveness analysis was based upon a previously completed randomized controlled trial of 348 hypertensive patients, in which mean systolic blood pressure (BP) was lowered 21 versus 8 mm Hg in the HBPM and usual care groups, respectively, and BP control was achieved in 54% versus 35% of patients (P < .001).

METHODS

This analysis compared direct costs from the health plan perspective, including clinic visits, e-mail and telephone encounters, laboratory tests, medications, hospitalizations, and emergency department visits between the 2 groups. Primary outcomes were the incremental hypertension care-related cost of HBPM per mm Hg lowering of systolic BP per patient, per additional BP controlled, and per life-year gained.

RESULTS

Median hypertension-related cost per patient over 6 months was $455 in the HBPM group and $179 for usual care (P < .001). This increase was attributable to additional e-mail and telephone encounters, greater antihypertensive medication use, additional laboratory monitoring, and the BP monitor. Median total cost per patient was $1530 and $1283 for the HBPM and usual care groups, respectively (P = .034). The HBPM program increased hypertension-related expenditures by $20.50 per mm Hg lowering of systolic BP, $1331 per additional patient achieving BP control at 6 months, and $3330 per life-year gained.

CONCLUSIONS

The HBPM program requires investment in outpatient encounters, medications, and laboratory monitoring, but produces significantly improved BP control.

Lipid screening in children and adolescents in community practice: 2007 to 2010

BACKGROUND

Integrated guidelines on cardiovascular health and risk reduction in children issued in 2011 newly recommended universal screening for dyslipidemia in children at 9 to 11 years and 17 to 21 years.

METHODS AND RESULTS

We determined the frequency and results of lipid testing in 301 080 children and adolescents aged 3 to 19 enrolled in 3 large US health systems in 2007 to 2010 before the 2011 guidelines were issued. Overall, 9.8% of the study population was tested for lipids. The proportion tested varied by body mass index percentile (5.9% of normal weight, 10.8% of overweight, and 26.9% of obese children) and age (8.9% of 9- to 11-year olds and 24.3% of 17- to 19-year olds). In normal weight individuals, 2.8% of 9- to 11-year olds and 22.0% of 17- to 19-year olds were tested. In multivariable models, age and body mass index category remained strongly associated with lipid testing. Sex, race, ethnicity, and blood pressure were weakly associated with testing. Abnormal lipid levels were found in 8.6% for total cholesterol, 22.5% for high-density lipoprotein-cholesterol, 12.0% for non-high-density lipoprotein-cholesterol, 8.0% for low-density lipoprotein-cholesterol, and 21% for triglycerides (age, 10-19 years). There was a strong and graded association of abnormal lipid levels with body mass index, particularly for high-density lipoprotein-cholesterol and triglycerides (2- to 6-fold higher odds ratio in obese when compared with that in normal weight children).

CONCLUSIONS

Lipid screening was uncommon in 9- to 11-year olds and was performed in a minority of 17- to 19-year olds during 2007 to 2010. These data serve as a benchmark for assessing change in practice patterns after the new recommendations for pediatric lipid screening and management.

Impact of hypertension on healthcare costs among children

OBJECTIVES

Despite the significant prevalence of elevated blood pressure (BP) and body mass index (BMI) in children, few studies have assessed their combined impact on healthcare costs. This study estimates healthcare costs related to BP and BMI in children and adolescents.

STUDY DESIGN

Prospective dynamic cohort study of 71,617 children aged 3 to 17 years with 208,800 child years of enrollment in integrated health systems in Colorado or Minnesota between January 1, 2007, and December 31, 2011.

METHODS

Generalized linear models were used to calculate standardized annual estimates of total, inpatient, outpatient, and pharmacy costs, outpatient utilization, and receipt of diagnostic and evaluation tests associated with BP status and BMI status. Results: Total annual costs were significantly lower in children with normal BP ($736, SE = $15) and prehypertension ($945, SE = $10) than children with hypertension ($1972, SE = $74) (P <.001, each comparison), adjusting for BMI. Total annual cost for children below the 85th percentile of BMI ($822, SE = $8) was significantly lower than for children between the 85th and 95th percentiles ($954, SE = $45) and for children at or above the 95th percentile ($937, SE = $13) (P <.001, each), adjusting for HT.

CONCLUSIONS

This study shows strong associations of prehypertension and hypertension, independent of BMI, with healthcare costs in children. Although BMI status was also statistically significantly associated with costs, the major influence on cost in this large cohort of children and adolescents was BP status. Costs related to elevated BMI may be systematically overestimated in studies that do not adjust for BP status.

Abstract 317: Outcomes after Primary Prevention Implantable Cardioverter Defibrillator Placement: Results of the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators

Background: Implantable cardioverter defibrillators (ICDs) are commonly used for the primary prevention of sudden cardiac death. Controversies persist, however, about outcomes in representative cohorts and in clinically important patient subgroups. Observational studies of outcomes following primary prevention ICD implantation are typically limited to relatively restricted cohorts (e.g. Medicare) or with short follow up.

Methods: In the Cardiovascular Research Network (CVRN), we conducted a study in 7 integrated health care delivery systems to identify patients undergoing primary prevention ICD implantation for left ventricular systolic dysfunction between 2006-2010. Baseline procedural and clinical data were obtained from the NCDR ICD Registry; longitudinal data to ascertain outcomes after implantation were obtained through clinical health system data from the CVRN Virtual Data Warehouse. We assessed the occurrence of complications at 90 days and mortality, all-cause hospitalization, and heart failure hospitalization up to 5 years after implantation in clinical strata designated a priori. Multivariable models accounting for clustering of patients within site were used to assess the relationship between clinical variables and each outcome. Clinical variables of interest (Table) were included in all models; additional variables were assessed with forward selection to account for possible confounders.

Results: Among 2953 eligible patients, median age was 69 years and 26% were women Coexisting conditions, including hypertension (74%), atrial fibrillation (32%), COPD (20%), and diabetes (42%), were common. Overall event rates (per 1000 patient years) were 110 for death, 438 for any hospitalization, and 58 for heart failure hospitalization. The association between clinically important variables and outcomes are shown in the Table.

Conclusions: In a diverse population of patients undergoing ICD implantation in contemporary practice we identified specific clinical variables associated with adverse outcomes. These data can inform prognosis in clinical care and guide the design of future trials of this therapy.

Abstract 271: Anti-coagulation and Ischemic Stroke Risk in Patients with Chronic Kidney Disease and Atrial Fibrillation: Insights from the Kaiser Permanente Colorado Atrial Fibrillation Registry

Background: There is uncertainty about the benefits of anticoagulation therapy for stroke reduction in CKD patients with atrial fibrillation. Accordingly, we assessed the association between anticoagulation use and stroke risk in CKD patients with atrial fibrillation.

Methods: The Kaiser Permanente Colorado Atrial Fibrillation Registry is comprised of patients with incident atrial fibrillation between January 1, 2006 and June 30, 2012 from Kaiser Permanente Colorado. Incident atrial fibrillation was defined by ICD-9 codes 427.31 (Atrial Fibrillation) or 427.32 (Atrial Flutter) and without a diagnosis in the prior year. Patients with mitral valve replacement, renal transplant, or use of anticoagulants other than warfarin were excluded. CKD status was determined by ICD-9 codes or by two consecutive outpatient laboratory results with estimated glomerular filtration rate < 60 ml/min/1.73m2 by the CKD-EPI equation. The primary outcome was ischemic stroke identified by ICD-9 codes and validated by chart review. We assessed the association between warfarin use and ischemic stroke in patients with and without CKD using Cox proportional hazards models adjusted for CHA2DS2-VASc score and an interaction for warfarin use and CKD.

Results: Of 5,728 patients with incident atrial fibrillation, 2,070 (36.1%) had CKD. Patients with CKD were older, more likely to be female, had a higher CHA2DS2-VASc score, and were more likely to receive warfarin than those without CKD (see Table). During a mean follow up of 2.6 years (SD 1.8 years), stroke occurred in 49 (2.4%) patients with CKD and 83 (2.3%) patients without CKD. In multivariable analysis adjusting for CHA2DS2-VASc score, warfarin use was associated with lower hazard of stroke (HR 0.36; 95% CI 0.24 - 0.53). When stratified by CKD status, warfarin use remained associated with lower hazard of stroke in CKD (HR 0.35; 95% CI 0.18 - 0.66) and non CKD (HR 0.36; 95% CI 0.22 - 0.60) patients.

Conclusion: 1 in 3 patients with atrial fibrillation have CKD. There were similar reductions in the risk of stroke associated with warfarin use for CKD and non-CKD patients. These findings reinforce current clinical practice guidelines, which recommend warfarin use based on thromboembolic risk without consideration for CKD status.

Hospital-level variation in use of cardiovascular testing for adults with incident heart failure: findings from the cardiovascular research network heart failure study

OBJECTIVES

This study aimed to characterize the use of cardiovascular testing for patients with incident heart failure (HF) hospitalization who participated in the National Heart, Lung, and Blood Institute sponsored Cardiovascular Research Network (CVRN) Heart Failure study.

BACKGROUND

HF is a common cause of hospitalization, and testing and treatment patterns may differ substantially between providers. Testing choices have important implications for the cost and quality of care.

METHODS

Crude and adjusted cardiovascular testing rates were calculated for each participating hospital. Cox proportional hazards regression models were used to examine hospital testing rates after adjustment for hospital-level patient case mix.

RESULTS

Of the 37,099 patients in the CVRN Heart Failure study, 5,878 patients were hospitalized with incident HF between 2005 and 2008. Of these, evidence of cardiovascular testing was available for 4,650 (79.1%) patients between 14 days before the incident HF admission and ending 6 months after the incident discharge. We compared crude and adjusted cardiovascular testing rates at the hospital level because the majority of testing occurred during the incident HF hospitalization. Of patients who underwent testing, 4,085 (87.9%) had an echocardiogram, 4,345 (93.4%) had a systolic function assessment, and 1,714 (36.9%) had a coronary artery disease assessment. Crude and adjusted testing rates varied markedly across the profiled hospitals, for individual testing modalities (e.g., echocardiography, stress echocardiography, nuclear stress testing, and left heart catheterization) and for specific clinical indications (e.g., systolic function assessment and coronary artery disease assessment).

CONCLUSIONS

For patients with newly diagnosed HF, we did not observe widespread overuse of cardiovascular testing in the 6 months following incident HF hospitalization relative to existing HF guidelines. Variations in testing were greatest for assessment of ischemia, in which testing guidelines are less certain.

The quality of antiplatelet and anticoagulant medication administration among ST-segment elevation myocardial infarction patients transferred for primary percutaneous coronary intervention

BACKGROUND

Timely and appropriate use of antiplatelet and anticoagulant therapies has been shown to improve outcomes among ST-segment elevation myocardial infarction (STEMI) patients but has not been well described in patients transferred for primary percutaneous coronary intervention (PCI).

METHODS

We examined 16,801 (26%) transfer and 47,329 direct-arrival STEMI patients treated with primary PCI at 441 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals. Medication use was compared between transfer and direct-arrival patients to determine if these therapies were delayed or dosed in excess.

RESULTS

Although transfer patients were more likely to receive antiplatelet and anticoagulant therapies before catheterization, they had longer delays to initiation of heparin (35 vs. 25 minutes), clopidogrel (119 vs. 84 minutes), and glycoprotein IIb/IIIa inhibitor (107 vs. 60 minutes, P < .0001 for both). Administration of low-molecular-weight heparin and glycoprotein IIb/IIIa inhibitor at the STEMI-referring hospital was associated with longer delays to reperfusion compared with deferred administration at the STEMI-receiving hospital, whereas early use of unfractionated heparin was not. Among treated patients, those transferred were more likely to receive excess heparin dosing (adjusted odds ratio [OR] 1.28 [95% CI 1.04-1.58] for unfractionated heparin, adjusted OR 1.54 [95% CI 1.09-2.18] for low-molecular-weight heparin) and are associated with higher risks of major bleeding complications (adjusted OR 1.10, 95% CI 1.03-1.17).

CONCLUSIONS

ST-segment elevation myocardial infarction patients transferred for primary PCI in community practice are at risk for delayed and excessively dosed antithrombotic therapy, highlighting the need for continued quality improvement to maximize the appropriate use of these important adjunctive therapies.

Prevalence of obesity and extreme obesity in children aged 3-5 years

BACKGROUND

Early childhood adiposity may have significant later health effects. This study examines the prevalence and recognition of obesity and severe obesity among preschool-aged children.

METHODS

The electronic medical record was used to examine body mass index (BMI), height, sex and race/ethnicity in 42,559 children aged 3-5 years between 2007 and 2010. Normal or underweight (BMI < 85th percentile); overweight (BMI 85th-94th percentile); obesity (BMI ≥ 95th percentile); and severe obesity (BMI ≥ 1.2 × 95th percentile) were classified using the 2000 Centers for Disease Control and Prevention growth charts. Provider recognition of elevated BMI was examined for obese children aged 5 years.

RESULTS

Among 42,559 children, 12.4% of boys and 10.0% of girls had BMI ≥ 95th percentile. The prevalence was highest among Hispanics (18.2% boys, 15.2% girls), followed by blacks (12.4% boys, 12.7% girls). A positive trend existed between increasing BMI category and median height percentile, with obesity rates highest in the highest height quintile. The prevalence of severe obesity was 1.6% overall and somewhat higher for boys compared with girls (1.9 vs. 1.4%, P < 0.01). By race/ethnicity, the highest prevalence of severe obesity was seen in Hispanic boys (3.3%). Among those aged 5 years, 77.9% of obese children had provider diagnosis of obesity or elevated BMI, increasing to 89.0% for the subset with severe obesity.

CONCLUSIONS

Obesity and severe obesity are evident as early as age 3-5 years, with race/ethnic trends similar to older children. This study underscores the need for continued recognition and contextualization of early childhood obesity in order to develop effective strategies for early weight management.

Initial persistence with antihypertensive therapies is associated with depression treatment persistence, but not depression

The purpose of this study was to examine the relationship between the presence of clinical depression and persistence to drug therapy treatment for depression with early nonpersistence to antihypertensive therapies in a large, diverse cohort of newly treated hypertension patients. Using a hypertension registry at Kaiser Permanente Northern California, the authors conducted a retrospective cohort study of 44,167 adults (18 years and older) with hypertension who were new users of antihypertensive therapy in 2008. We used multivariate logistic regression analysis to model the relationships between the presence of clinical depression and early nonpersistence (defined as failing to refill the first prescription within 90 days after the end of the first fill days' supply) to antihypertensive therapies, controlling for sociodemographic and clinical risk factors. Within the group of 1484 patients who had evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, the authors examined the relationship between drug therapy treatment for depression and 6-month persistence with antidepressant therapy with early nonpersistence with antihypertensive therapies. No association was found between the presence of clinical depression and early nonpersistence to antihypertensive therapies after adjustment for individual demographic and clinical characteristics and neighborhood-level socioeconomic status. However, among the subset of 1484 patients with documented evidence of clinical depression in the 12 months prior to the initiation of antihypertensive therapy, being prescribed and persistence with antidepressant therapy was strongly associated with lower odds of early nonpersistence to antihypertensive medications (odds ratio, 0.64; confidence interval, 0.42-0.96). In an integrated delivery system, the authors found that treatment for depression was associated with higher levels of antihypertensive persistence. Improving quality of depression care in patients with comorbid hypertension may be an important strategy in decreasing cardiovascular disease risk in these patients.

Severe obesity in children: prevalence, persistence and relation to hypertension

Background

Newer approaches for classifying gradations of pediatric obesity by level of body mass index (BMI) percentage above the 95^th percentile have recently been recommended in the management and tracking of obese children. Examining the prevalence and persistence of severe obesity using such methods along with the associations with other cardiovascular risk factors such as hypertension is important for characterizing the clinical significance of severe obesity classification methods.

Methods

This retrospective study was conducted in an integrated healthcare delivery system to characterize obesity and obesity severity in children and adolescents by level of body mass index (BMI) percentage above the 95^th BMI percentile, to examine tracking of obesity status over 2–3 years, and to examine associations with blood pressure. Moderate obesity was defined by BMI 100-119% of the 95^th percentile and severe obesity by BMI ≥120% × 95^th percentile. Hypertension was defined by 3 consecutive blood pressures ≥95^th percentile (for age, sex and height) on separate days and was examined in association with obesity severity.

Results

Among 117,618 children aged 6–17 years with measured blood pressure and BMI at a well-child visit during 2007–2010, the prevalence of obesity was 17.9% overall and was highest among Hispanics (28.9%) and blacks (20.5%) for boys, and blacks (23.3%) and Hispanics (21.5%) for girls. Severe obesity prevalence was 5.6% overall and was highest in 12–17 year old Hispanic boys (10.6%) and black girls (9.5%). Subsequent BMI obtained 2–3 years later also demonstrated strong tracking of severe obesity. Stratification of BMI by percentage above the 95^th BMI percentile was associated with a graded increase in the risk of hypertension, with severe obesity contributing to a 2.7-fold greater odds of hypertension compared to moderate obesity.

Conclusion

Severe obesity was found in 5.6% of this community-based pediatric population, varied by gender and race/ethnicity (highest among Hispanics and blacks) and showed strong evidence for persistence over several years. Increasing gradation of obesity was associated with higher risk for hypertension, with a nearly three-fold increased risk when comparing severe to moderate obesity, underscoring the heightened health risk associated with severe obesity in children and adolescents.

Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure

BACKGROUND

Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown.

METHODS AND RESULTS

Using electronic data from 3 health systems 2005 to 2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for heart failure with reduced ejection fraction who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years, and 37.1% were women. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Preinitiation K was >5.0 mmol/L in 1.4% and Cr>2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of postinitiation K testing (c-statistic, 0.67).

CONCLUSIONS

Although laboratory monitoring before MRA initiation for heart failure with reduced ejection fraction is common, laboratory monitoring after MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.

Natural history of left ventricular ejection fraction in patients with heart failure

BACKGROUND

Patients with heart failure (HF) are typically designated as having reduced or preserved ejection fraction (HFREF, HFPEF) because of the importance of left ventricular ejection fraction (LVEF) on therapeutic decisions and prognosis. Such designations are not necessarily static, yet few data exist to describe the natural history of LVEF over time.

METHODS AND RESULTS

We identified 2413 patients from Kaiser Permanente Colorado with a primary discharge diagnosis of HF between January 1, 2001, and December 31, 2008, who had ≥2 LVEF measurements separated by ≥30 days. We used multi-state Markov modeling to examine transitions among HFREF, HFPEF, and death. We observed a total of 8183 transitions. Women were more likely than men to transition from HFREF to HFPEF (hazard ratio, 1.85; 95% confidence interval, 1.38-2.47). Patients who were adherent to β-blockers were more likely to transition from HFREF to HFPEF (hazard ratio, 1.53; 95% confidence interval, 1.10-2.13) compared with patients who were nonadherent to β-blockers, whereas angiotensin-converting enzyme or angiotensin II receptor blocker adherence was not associated with LVEF transitions. Patients who had a previous myocardial infarction were more likely to transition from HFPEF to HFREF (hazard ratio, 1.75; 95% confidence interval, 1.26-2.42).

CONCLUSIONS

In this cohort of patients with HF, LVEF is a dynamic factor related to sex, coexisting conditions, and drug therapy. These findings have implications for left ventricular systolic function ascertainment in patients with HF and support evidence-based therapy use, especially β-blockers.

Patterns of care and persistence after incident elevated blood pressure

BACKGROUND AND OBJECTIVE

Screening for hypertension in children occurs during routine care. When blood pressure (BP) is elevated in the hypertensive range, a repeat measurement within 1 to 2 weeks is recommended. The objective was to assess patterns of care after an incident elevated BP, including timing of repeat BP measurement and likelihood of persistently elevated BP.

METHODS

This retrospective study was conducted in 3 health care organizations. All children aged 3 through 17 years with an incident elevated BP at an outpatient visit during 2007 through 2010 were identified. Within this group, we assessed the proportion who had a repeat BP measured within 1 month of their incident elevated BP and the proportion who subsequently met the definition of hypertension. Multivariate analyses were used to identify factors associated with follow-up BP within 1 month of initial elevated BP.

RESULTS

Among 72,625 children and adolescents in the population, 6108 (8.4%) had an incident elevated BP during the study period. Among 6108 with an incident elevated BP, 20.9% had a repeat BP measured within 1 month. In multivariate analyses, having a follow-up BP within 1 month was not significantly more likely among individuals with obesity or stage 2 systolic elevation. Among 6108 individuals with an incident elevated BP, 84 (1.4%) had a second and third consecutive elevated BP within 12 months.

CONCLUSIONS

Whereas >8% of children and adolescents had an incident elevated BP, the great majority of BPs were not repeated within 1 month. However, relatively few individuals subsequently met the definition of hypertension.

Geographic variation in cardiovascular procedure use among Medicare fee-for-service vs Medicare Advantage beneficiaries

IMPORTANCE

Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.

OBJECTIVE

To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.

MAIN OUTCOMES AND MEASURES

Rates of coronary angiography, PCI, and CABG surgery.

RESULTS

We evaluated a total of 878,339 Medicare Advantage patients and 5,013,650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.

CONCLUSIONS AND RELEVANCE

Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.

Risk factors for adverse outcomes by left ventricular ejection fraction in a contemporary heart failure population

BACKGROUND

Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown.

METHODS AND RESULTS

We identified all members with HF between 2005 and 2008 from 4 integrated healthcare systems in the Cardiovascular Research Network. LVEF was categorized as preserved (LVEF ≥ 50% or normal), borderline (41%-49% or mildly reduced), and reduced (≤ 40% or moderately to severely reduced). We used Cox regression models to identify independent predictors of death and hospitalization by LVEF category. Among 30094 ambulatory adults with HF, mean age was 74 years and 46% were women. LVEF was preserved in 49.5%, borderline in 16.2%, and reduced in 34.3% of patients. During a median follow-up of 1.8 years (interquartile range, 0.8-3.1), 8060 (26.8%) patients died, 8108 (26.9%) were hospitalized for HF, and 20272 (67.4%) were hospitalized for any reason. In multivariable models, nearly all tested covariates performed similarly across LVEF strata for the outcome of death from any cause, as well as for HF-related and all-cause hospitalizations.

CONCLUSIONS

We found that in a large, diverse contemporary HF population, risk assessment was strikingly similar across all LVEF categories. These data suggest that, although many HF therapies are uniquely applied to patients with reduced LVEF, individual prognostic factor performance does not seem to be significantly related to level of left ventricular systolic function.

Chronic kidney disease and outcomes in heart failure with preserved versus reduced ejection fraction: the Cardiovascular Research Network PRESERVE Study

BACKGROUND

There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction (HF-PEF).

METHODS AND RESULTS

We identified a community-based cohort of patients with HF. Electronic medical record data were used to divide into HF-PEF and reduced left ventricular EF on the basis of quantitative and qualitative estimates. Level of CKD was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all-cause). Multivariable Cox regression estimated the adjusted relative-risk of outcomes by level of CKD, separately for HF-PEF and HF with reduced left ventricular EF. We identified 14 579 patients with HF-PEF and 9762 with HF with reduced left ventricular EF. When compared with patients with eGFR between 60 and 89 mL/min per 1.73 m(2), lower eGFR was associated with an independent graded increased risk of death and hospitalization. For example, among patients with HF-PEF, the risk of death was nearly double for eGFR 15 to 29 mL/min per 1.73 m(2) and 7× higher for eGFR<15 mL/min per 1.73 m(2), with similar findings in those with HF with reduced left ventricular EF.

CONCLUSIONS

CKD is common and an important independent predictor of death and hospitalization in adults with HF across the spectrum of left ventricular systolic function. Our study highlights the need to develop new and effective interventions for the growing number of patients with HF complicated by CKD.

Association of single- vs dual-chamber ICDs with mortality, readmissions, and complications among patients receiving an ICD for primary prevention

IMPORTANCE

Randomized trials of implantable cardioverter-defibrillators (ICDs) for primary prevention predominantly used single-chamber devices. In clinical practice, patients often receive dual-chamber ICDs, even without clear indications for pacing. The outcomes of dual- vs single-chamber devices are uncertain.

OBJECTIVE

To compare outcomes of single- and dual-chamber ICDs for primary prevention of sudden cardiac death.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of admissions in the National Cardiovascular Data Registry's (NCDR) ICD registry from 2006-2009 that could be linked to Centers for Medicare & Medicaid Services fee-for-service Medicare claims data. Patients were included if they received an ICD for primary prevention and did not have a documented indication for pacing.

MAIN OUTCOMES AND MEASURES

Adjusted risks of 1-year mortality, all-cause readmission, heart failure readmission, and device-related complications within 90 days were estimated with propensity-score matching based on patient, clinician, and hospital factors.

RESULTS

Among 32,034 patients, 12,246 (38%) received a single-chamber device and 19,788 (62%) received a dual-chamber device. In a propensity-matched cohort, rates of complications were lower for single-chamber devices (3.51% vs 4.72%; P < .001; risk difference, -1.20 [95% CI, -1.72 to -0.69]), but device type was not significantly associated with 1-year mortality (unadjusted rate, 9.85% vs 9.77%; hazard ratio [HR], 0.99 [95% CI, 0.91 to 1.07]; P = .79), 1-year all-cause hospitalization (unadjusted rate, 43.86% vs 44.83%; HR, 1.00 [95% CI, 0.97-1.04]; P = .82), or hospitalization for heart failure (unadjusted rate, 14.73% vs 15.38%; HR, 1.05 [95% CI, 0.99-1.12]; P = .19).

CONCLUSIONS AND RELEVANCE

Among patients receiving an ICD for primary prevention without indications for pacing, the use of a dual-chamber device compared with a single-chamber device was associated with a higher risk of device-related complications and similar 1-year mortality and hospitalization outcomes. Reasons for preferentially using dual-chamber ICDs in this setting remains unclear.

Abstract 301: Chronic Kidney Disease and Outcomes in Heart Failure with Preserved vs. Reduced Ejection Fraction

Background: Patients with chronic kidney disease (CKD) often have heart failure with reduced left ventricular ejection fraction (HF-REF), and previous work has shown that the co-occurrence of those conditions confers a higher rate of poor outcomes than either condition alone. But few studies have examined whether CKD confers a clinically meaningful difference in outcomes among heart failure patients with preserved left ventricular ejection fraction (HF-PEF). Compared to previous work, our study uses more granular renal function estimates and a large, contemporary cohort.

Methods: Using data from the NHLBI-sponsored Cardiovascular Research Network (CVRN), we identified a community-based cohort of patients with HF. Electronic medical record data, including manual review where necessary, were used to classify heart failure type (HF-PEF and HF-REF), based on quantitative and qualitative estimates. Renal function was assessed by estimated glomerular filtration rate (eGFR) and by dipstick proteinuria. We followed patients between 2005 and 2008 for a median of 22.1 months for outcomes of death and hospitalization (HF-specific and all cause). We used Cox regression with time-updated covariates to estimate relative-risk of outcomes by level of CKD, separately for HF-PEF and HF-REF.

Results: We identified 14,579 patients with HF-PEF and 9,762 with HF-REF. Compared to patients with eGFR between 60-89 ml/min/1.73m2, lower eGFR was associated with an independent graded increased risk of death and hospitalization; this relation did not meaningfully differ by type of heart failure. For example, among patients with HF-PEF, compared to patients with eGFR 60-89 ml/min/1.73m2, the relative risk of death was 1.57 (95% CI 1.41, 1.76) for eGFR 15-29 ml/min/1.73m2; for those with HF-REF the same relative risk was 2.15 (95% CI 1.87, 2.48). Results were similar with renal function estimates using dipstick proteinuria.

Conclusions: Renal dysfunction is common among patients with heart failure, and is an important independent predictor of death and hospitalization across the spectrum of left ventricular systolic function. Whether patients with heart failure respond differentially to treatments by level of renal function is not clear; Our study highlights the need to develop new and effective interventions for the growing number of patients with heart failure complicated by CKD.

Contemporary prevalence and correlates of incident heart failure with preserved ejection fraction

BACKGROUND

We assessed the prevalence of preserved left ventricular ejection fraction in patients with incident heart failure and differences in the demographic and clinical characteristics that may differentiate patients presenting with heart failure with preserved versus reduced left ventricular ejection fraction.

METHODS

We identified all patients with newly diagnosed heart failure between 2005 and 2008 from 4 sites in the Cardiovascular Research Network on the basis of hospital discharge and ambulatory visit diagnoses, and assigned a category of preserved, borderline, or reduced left ventricular ejection fraction using data from electronic databases and chart review.

RESULTS

We identified 11,994 patients with incident heart failure; of these, 6210 (51.8%) had preserved left ventricular ejection fraction, 1870 (15.6%) had borderline systolic dysfunction, and 3914 (32.6%) had reduced left ventricular ejection fraction. For those with heart failure with preserved left ventricular ejection fraction, the mean age was 74.7 years and 57.1% were women; for those with borderline systolic dysfunction, the mean age was 71.6 years and 38.4% were women; and for those with reduced left ventricular ejection fraction, the mean age was 69.1 years and 32.6% were women. Compared with white patients, black patients were less likely to have heart failure with preserved systolic function. Those with a history of coronary artery bypass surgery, mitral or aortic valvular disease, atrial fibrillation or flutter, or a diagnosis of hypertension were more likely to have heart failure with preserved systolic function, as were those with a diverse range of noncardiac comorbid conditions, including chronic lung disease, chronic liver disease, a history of a hospitalized bleed, a history of a mechanical fall, a diagnosis of depression, and a diagnosis of dementia. Patients with a history of acute myocardial infarction and a history of ventricular fibrillation or ventricular tachycardia were less likely to have heart failure with preserved left ventricular ejection fraction. Patients with higher systolic blood pressures at baseline and lower low-density lipoprotein levels were more likely to have heart failure with preserved left ventricular ejection fraction, as were those with lower hemoglobin levels and the lowest glomerular filtration rates.

CONCLUSIONS

Heart failure with preserved left ventricular ejection fraction is the most common form of the heart failure syndrome among patients newly presenting with this condition, and women and older adults are especially affected. Evidence-based treatment strategies apply to less than one third of patients with newly diagnosed heart failure.

Abstract 141: Incremental Prognostic Value Of Serial Health Status Measures For Ambulatory Patients With Heart Failure

Background: Existing heart failure (HF) risk models have only moderate performance for adverse outcomes. Whether serial health status measurements can improve risk stratification is unknown.

Methods: In 2007 and again in 2008, we administered Kansas City Cardiomyopathy Questionnaires (KCCQ) to ambulatory Kaiser Permanente Colorado enrollees with a history of HF hospitalization between 2001 and 2007 who survived through 2008. The primary endpoint was hospitalization or death in the 6 months following the 2008 KCCQ administration. C-statistics, integrated discrimination indices (IDI), and net reclassification indices (NRI) were calculated; event rate thresholds for NRI were low (30%).

Results: Survey response rates were 71% in 2007 and 69% in 2008, resulting in a cohort of 629 patients who completed both questionnaires, of which 153 experienced the endpoint. Mean age was 75 years, 51% were women, mean LVEF was 49%, and mean KCCQ score was 69. Compared with a base model using well accepted demographic and clinical covariates (Model 3, Table), the 2008 KCCQ score appropriately reclassified a large percentage of patients (NRI 13.0%). Adding the change in KCCQ did not further improve reclassification (NRI -3.0%).

Conclusions: A recent measure of health status, added to traditional prognostic markers, significantly improved risk stratification among a broad ambulatory HF population. Although important patient-centered outcomes in their own right, temporal trends in health status did not further improve prognostication, as compared with the most recent health status assessment. Thus serial health status assessments provide an ‘up-to-date’ assessment of a patient’s prognoses by focusing on the latest values, rather than previous ones.

Comparison of medication practices in patients with heart failure and preserved versus those with reduced ejection fraction (from the Cardiovascular Research Network [CVRN])

Limited data exist describing the differences in the medical treatment of patients with heart failure with preserved ejection fraction (HF-PEF) from those with heart failure with reduced ejection fraction (HF-REF) in more generalizable population-based cohorts. We studied patients with incident HF diagnosed from 2005 to 2008 from 4 sites participating in the Cardiovascular Research Network. These patients, their medication profile, and left ventricular systolic function status were identified from the hospital discharge and ambulatory visit diagnoses, pharmacy dispensing information, and imaging reports found in the health plan electronic databases and through chart review. The study population consisted of 6,210 patients with newly diagnosed HF-PEF and 3,914 patients with newly diagnosed HF-REF. The mean age of our study population was 73 years, 48% were women, and 74% were white. The patients with HF-REF were less likely to have been treated with various cardiac and HF-related medications before their index HF event; however, they were significantly more likely to have been treated with new cardiac medications and HF therapies after the diagnosis of HF than were the patients with HF-PEF. After controlling for several potentially confounding factors, the patients with HF-PEF were significantly less likely to have been treated with multiple cardiac drug regimens (adjusted odds ratio 0.69, 95% confidence interval 0.59 to 0.81) and multiple HF-related therapies (adjusted odds ratio 0.40, 95% confidence interval 0.38 to 0.42) than were patients with HF-REF. In conclusion, the present results from a large, population-based sample suggest considerable variation in the previous and new use of different cardiac medication classes of drugs in patients with HF-PEF versus HF-REF.

Abstract 44: Lipid Screening In Children And Adolescents In Community Practice 2007-2010

Background: A 2011 guideline on cardiovascular risk reduction in children recommended universal screening for dyslipidemia in children at age 9-11 and again at age 17-21.

Objectives: To ascertain frequency of lipid testing before the guideline was issued in children and adolescents, in predefined age, gender, BMI and race strata.

Methods: Study subjects included 294,369 individuals age 3-19 years enrolled at HealthPartners (Minnesota), Kaiser Permanente Colorado or Kaiser Permanente Northern California in 2007-2010 and with at least one measurement of blood pressure and a height measurement within 90 days. We excluded children with medical conditions (other than obesity) or medications that could have prompted lipid testing. Subjects’ electronic medical records were examined for date and results of the first recorded measurement of total cholesterol and HDL cholesterol (HDL-C). We report descriptive statistics on the proportion of children who received lipid testing and abnormal test results by age, gender, BMI and race/ethnicity group.

Results: The study population was 49.9% female, 12.3% Black, 21.0% Hispanic, 11.4% Asian; 15.3% were overweight (BMI percentile 85-<95) and 14.5% were obese (BMI percentile > 95). Across the 3 sites during the period of observation, 9.7% of youth had at least one lipid screen; rates varied by BMI (5.8% of normal weight, 10.8% of overweight and 27.3% of obese youth). The proportion tested increased steadily with age, ranging from 1.0% of 3-5 year olds, to 8.7% of 9-11 years olds, and to 25.2% of 17-19 year olds. There was relatively little variation in testing by sex and race/ethnicity after adjusting for age and BMI. Among those tested, total cholesterol was elevated ( > 200 mg/dL) in 8.7%, HDL-Cl was low (<40 mg/dL) in 27.5% of boys and in 18.0% of girls, and non-HDL-C was elevated ( > 145 mg/d/L) in 12.0%. The proportion with elevated levels of non-HDL-C was 6.9% in normal weight, 11.5% in overweight and 16.9% of obese children, and was 14.4% in 9-11 year olds and 12.4% in 17-19 year olds.

Conclusion: Before the 2011 guideline, lipid testing was uncommon in 9-11 year old children, but was performed in one quarter of 17-19 year old adolescents. The high proportion of youth with abnormally low HDL-C likely reflects targeted testing of overweight and obese individuals. The proportion of youth with elevated non-HDL-C is closer to that observed in population-based surveillance studies during the same time period. These data serve as a benchmark for assessing change in practice patterns as the new guideline is implemented for pediatric lipid screening and management. They suggest that health care systems will need to assess their capacity to deliver lifestyle interventions in the substantial proportion of youth for whom such services are recommended.

Comparative effectiveness of 2 β-blockers in hypertensive patients

BACKGROUND

Randomized controlled trials have demonstrated the efficacy of selected β-blockers for preventing cardiovascular (CV) events in patients following myocardial infarction (MI) or with heart failure (HF). However, the effectiveness of β-blockers for preventing CV events in patients with hypertension has been questioned recently, but it is unclear whether this is a class effect.

METHODS

Using electronic medical record and health plan data from the Cardiovascular Research Network Hypertension Registry, we compared incident MI, HF, and stroke in patients who were new β-blocker users between 2000 and 2009. Patients had no history of CV disease and had not previously filled a prescription for a β-blocker. Cox proportional hazards regression was used to examine the associations of atenolol and metoprolol tartrate with incident CV events using both standard covariate adjustment (n = 120,978) and propensity score-matching methods (n = 22,352).

RESULTS

During follow-up (median, 5.2 years), there were 3517 incident MI, 3272 incident HF, and 3664 incident stroke events. Hazard ratios for MI, HF, and stroke in metoprolol tartrate users were 0.99 (95% CI, 0.97-1.02), 0.99 (95% CI, 0.96-1.01), and 0.99 (95% CI, 0.97-1.02), respectively. An alternative approach using propensity score matching yielded similar results in 11,176 new metoprolol tartrate users, who were similar to 11,176 new atenolol users with regard to demographic and clinical characteristics.

CONCLUSIONS

There were no statistically significant differences in incident CV events between atenolol and metoprolol tartrate users with hypertension. Large registries similar to the one used in this analysis may be useful for addressing comparative effectiveness questions that are unlikely to be resolved by randomized trials.

Longitudinal study of implantable cardioverter-defibrillators: methods and clinical characteristics of patients receiving implantable cardioverter-defibrillators for primary prevention in contemporary practice

BACKGROUND

Implantable cardioverter-defibrillators (ICDs) are increasingly used for primary prevention after randomized, controlled trials demonstrating that they reduce the risk of death in patients with left ventricular systolic dysfunction. The extent to which the clinical characteristics and long-term outcomes of unselected, community-based patients with left ventricular systolic dysfunction undergoing primary prevention ICD implantation in a real-world setting compare with those enrolled in the randomized, controlled trials is not well characterized. This study is being conducted to address these questions.

METHODS AND RESULTS

The study cohort includes consecutive patients undergoing primary prevention ICD placement between January 1, 2006 and December 31, 2009 in 7 health plans. Baseline clinical characteristics were acquired from the National Cardiovascular Data Registry ICD Registry. Longitudinal data collection is underway, and will include hospitalization, mortality, and resource use from standardized health plan data archives. Data regarding ICD therapies will be obtained through chart abstraction and adjudicated by a panel of experts in device therapy. Compared with the populations of primary prevention ICD therapy randomized, controlled trials, the cohort (n=2621) is on average significantly older (by 2.5-6.5 years), more often female, more often from racial and ethnic minority groups, and has a higher burden of coexisting conditions. The cohort is similar, however, to a national population undergoing primary prevention ICD placement.

CONCLUSIONS

Patients undergoing primary prevention ICD implantation in this study differ from those enrolled in the randomized, controlled trials that established the efficacy of ICDs. Understanding a broad range of health outcomes, including ICD therapies, will provide patients, clinicians, and policy makers with contemporary data to inform decision-making.

Patterns of comorbidity in older adults with heart failure: the Cardiovascular Research Network PRESERVE study

OBJECTIVES

To examine whether the total burden of comorbidity and pattern of co-occurring conditions varies in individuals with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HF-P) or HF with reduced LVEF (HF-R).

DESIGN

Cross-sectional cohort study.

SETTING

Four participating health plans within the National Heart, Lung, and Blood Institute-sponsored Cardiovascular Research Network.

PARTICIPANTS

All members aged 65 and older with HF based on hospital discharge and ambulatory visit diagnoses.

MEASUREMENTS

Participants with a LVEF of 50% or greater were classified as having HF-P. Presence of cardiac and noncardiac comorbidities was obtained from health plan administrative databases.

RESULTS

Of 23,435 individuals identified with HF and LVEF information, 53% (12,407) had confirmed HF-P (mean age 79.6; 60% female). More than three-quarters of the sample had three or more co-occurring conditions in addition to HF, and half had five or more cooccurring conditions. Participants with HF-P had a slightly higher burden of comorbidity than those with HF-R (mean 4.5 vs 4.4, P = .002). Patterns of how specific conditions co-occurred did not vary in participants with preserved or reduced systolic function.

CONCLUSION

There is a high degree of comorbidity and multiple morbidity in individuals with HF. The burden and pattern of comorbidity varies only slightly in individuals with preserved or reduced LVEF.

A Pharmacist-Led, American Heart Association Heart360 Web-Enabled Home Blood Pressure Monitoring Program

Background—

To determine whether a pharmacist-led, Heart360-enabled, home blood pressure monitoring (HBPM) intervention improves blood pressure (BP) control compared with usual care (UC).

Methods and Results—

This randomized, controlled trial was conducted in 10 Kaiser Permanente Colorado clinics. Overall, 348 patients with BP above recommended levels were randomized to the HBPM (n=175) or UC (n=173) groups. There were no statistically significant differences in baseline characteristics between the groups; however, there was a trend toward a higher baseline BP for the HBPM group compared with the UC group (148.8 versus 145.5 mm Hg for systolic BP; 89.6 versus 88.0 mm Hg for diastolic BP). At 6 months, the proportion of patients achieving BP goal was significantly higher in the HBPM group (54.1%) than in the UC group (35.4%; P <0.001). Compared with the UC group, the HBPM group experienced a −12.4-mm Hg larger (95% confidence interval, −16.3 to −8.6) reduction in systolic BP and a −5.7-mm Hg larger (95% confidence interval, −7.8 to −3.6) reduction in diastolic BP. The impact of the intervention on BP reduction was even larger for the subgroup of patients with diabetes mellitus or chronic kidney disease. The HBPM group had more e-mail and telephone contacts and greater medication regimen intensification. The proportion of patients reporting high satisfaction with hypertension care was significantly greater in the HBPM group (58%) than in the UC group (42%), P <0.001.

Conclusions—

A pharmacist-led, Heart360-supported, home BP monitoring intervention led to greater BP reductions, superior BP control, and higher patient satisfaction than UC.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov/ct2/show/NCT01162759 . Unique identifier: NCT01162759.

Patient-identified factors related to heart failure readmissions

BACKGROUND

Although readmission after hospitalization for heart failure has received increasing attention, little is known about its root causes. Prior investigations have relied on administrative databases, chart review, and single-question surveys.

METHODS AND RESULTS

We performed semistructured 30- to 60-minute interviews of patients (n=28) readmitted within 6 months of index heart failure admission. Established qualitative approaches were used to analyze and to interpret data. Interview findings were the primary focus of the study, but patient information and provider comments from chart data were also consulted. Patient median age was 61 years; 29% were nonwhite; 50% were married; 32% had preserved ejection fraction; and median time from discharge to readmission was 31 days. Reasons for readmission were multifactorial and not easily categorized into mutually exclusive reasons. Five themes emerged as reasons cited for hospital readmission: distressing symptoms, unavoidable progression of illness, influence of psychosocial factors, good but imperfect self-care adherence, and health system failures.

CONCLUSIONS

Our study provides the first systematic qualitative assessment of patient perspectives concerning heart failure readmission. Contrary to prior literature and distinct from what we found documented in the medical record, patient experiences were highly heterogeneous, not easily categorized as preventable or not preventable, and not easily attributed to a single cause. These findings suggest that future interventions designed to reduce heart failure readmissions should be multifaceted, should be systemic in nature, and should integrate patient input.

Atrial fibrillation and outcomes in heart failure with preserved versus reduced left ventricular ejection fraction

Background

Atrial fibrillation (AF) and heart failure (HF) are 2 of the most common cardiovascular conditions nationally and AF frequently complicates HF. We examined how AF has impacts on adverse outcomes in HF‐PEF versus HF‐REF within a large, contemporary cohort.

Methods and Results

We identified all adults diagnosed with HF‐PEF or HF‐REF based on hospital discharge and ambulatory visit diagnoses and relevant imaging results for 2005–2008 from 4 health plans in the Cardiovascular Research Network. Data on demographic features, diagnoses, procedures, outpatient pharmacy use, and laboratory results were ascertained from health plan databases. Hospitalizations for HF, stroke, and any reason were identified from hospital discharge and billing claims databases. Deaths were ascertained from health plan and state death files. Among 23 644 patients with HF, 11 429 (48.3%) had documented AF (9081 preexisting, 2348 incident). Compared with patients who did not have AF, patients with AF had higher adjusted rates of ischemic stroke (hazard ratio [HR] 2.47 for incident AF; HR 1.57 for preexisting AF), hospitalization for HF (HR 2.00 for incident AF; HR 1.22 for preexisting AF), all‐cause hospitalization (HR 1.45 for incident AF; HR 1.15 for preexisting AF), and death (incident AF HR 1.67; preexisting AF HR 1.13). The associations of AF with these outcomes were similar for HF‐PEF and HF‐REF, with the exception of ischemic stroke.

Conclusions

AF is a potent risk factor for adverse outcomes in patients with HF‐PEF or HF‐REF. Effective interventions are needed to improve the prognosis of these high‐risk patients.

Benefits of early hypertension control on cardiovascular outcomes in patients with diabetes

OBJECTIVE

To assess the impact of early hypertension (HT) control on occurrence of subsequent major cardiovascular events in those with diabetes and recent-onset HT.

RESEARCH DESIGN AND METHODS

Study subjects were 15,665 adults with diabetes but no diagnosed coronary or cerebrovascular disease at baseline who met standard criteria for new-onset HT. Poisson regression models assessed whether adequate blood pressure control within 1 year of HT onset predicts subsequent occurrence of major cardiovascular events with and without adjustment for baseline Framingham Risk Score (FRS) and other covariates.

RESULTS

Mean age was 51.5 years, and mean blood pressure at HT onset was 136.8/80.8 mmHg. In the year after HT onset, mean blood pressure decreased to 131.4/78.0 mmHg and was <130/80 mmHg in 32.9% of subjects and <140/90 mmHg in 80.2%. Over a mean follow-up of 3.2 years, age-adjusted rates of major cardiovascular events in those with mean 1-year blood pressure measurements of <130/80, 130-139/80-89, and ≥140/90 mmHg were 5.10, 4.27, and 6.94 events/1,000 person-years, respectively (P = 0.004). In FRS-adjusted models, rates of major cardiovascular events were significantly higher in those with mean blood pressure ≥140/90 mmHg in the first year after HT onset (rate ratio 1.30 [95% CI 1.01-1.169]; P = 0.04).

CONCLUSIONS

Failure to adequately control BP within 1 year of HT onset significantly increased the likelihood of major cardiovascular events within 3 years. Prompt control of new-onset HT in patients with diabetes may provide important short-term clinical benefits.

Safety climate and medical errors in 62 US emergency departments

STUDY OBJECTIVE

We describe the incidence and types of medical errors in emergency departments (EDs) and assess the validity of a survey instrument that identifies systems factors contributing to errors in EDs.

METHODS

We conducted the National Emergency Department Safety Study in 62 urban EDs across 20 US states. We reviewed 9,821 medical records of ED patients with one of 3 conditions (myocardial infarction, asthma exacerbation, and joint dislocation) to evaluate medical errors. We also obtained surveys from 3,562 staff randomly selected from each ED; survey data were used to calculate average safety climate scores for each ED.

RESULTS

We identified 402 adverse events (incidence rate 4.1 per 100 patient visits; 95% confidence interval [CI] 3.7 to 4.5) and 532 near misses (incidence rate 5.4 per 100 patient visits; 95% CI 5.0 to 5.9). We judged 37% of the adverse events, and all of the near misses, to be preventable (errors); 33% of the near misses were intercepted. In multivariable models, better ED safety climate was not associated with fewer preventable adverse events (incidence rate ratio per 0.2-point increase in ED safety score 0.82; 95% CI 0.57 to 1.16) but was associated with more intercepted near misses (incidence rate ratio 1.79; 95% CI 1.06 to 3.03). We found no association between safety climate and violations of national treatment guidelines.

CONCLUSION

Among the 3 ED conditions studied, medical errors are relatively common, and one third of adverse events are preventable. Improved ED safety climate may increase the likelihood that near misses are intercepted.

Clinicians' implicit ethnic/racial bias and perceptions of care among Black and Latino patients

PURPOSE

We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships.

METHODS

We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales.

RESULTS

Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98).

CONCLUSIONS

This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

Association of neighborhood characteristics with bystander-initiated CPR

BACKGROUND

For persons who have an out-of-hospital cardiac arrest, the probability of receiving bystander-initiated cardiopulmonary resuscitation (CPR) may be influenced by neighborhood characteristics.

METHODS

We analyzed surveillance data prospectively submitted from 29 U.S. sites to the Cardiac Arrest Registry to Enhance Survival between October 1, 2005, and December 31, 2009. The neighborhood in which each cardiac arrest occurred was determined from census-tract data. We classified neighborhoods as high-income or low-income on the basis of a median household income threshold of $40,000 and as white or black if more than 80% of the census tract was predominantly of one race. Neighborhoods without a predominant racial composition were classified as integrated. We analyzed the relationship between the median income and racial composition of a neighborhood and the performance of bystander-initiated CPR.

RESULTS

Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods.

CONCLUSIONS

In a large cohort study, we found that patients who had an out-of-hospital cardiac arrest in low-income black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods. (Funded by the Centers for Disease Control and Prevention and others.).

A community translational research pilot grants program to facilitate community--academic partnerships: lessons from Colorado's clinical translational science awards

BACKGROUND

National growth in translational research has increased the need for practical tools to improve how academic institutions engage communities in research.

METHODS

One used by the Colorado Clinical and Translational Sciences Institute (CCTSI) to target investments in community-based translational research on health disparities is a Community Engagement (CE) Pilot Grants program. Innovative in design, the program accepts proposals from either community or academic applicants, requires that at least half of requested grant funds go to the community partner, and offers two funding tracks: One to develop new community-academic partnerships (up to $10,000), the other to strengthen existing partnerships through community translational research projects (up to $30,000).

RESULTS AND CONCLUSION

We have seen early success in both traditional and capacity building metrics: the initial investment of $272,742 in our first cycle led to over $2.8 million dollars in additional grant funding, with grantees reporting strengthening capacity of their community- academic partnerships and the rigor and relevance of their research.