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Kleidon TM, Schults J, Gibson V, Roebuck DJ, Peirce D, Royle R, Ware RS, Byrnes J, Andresen E, Cattanach P, Dean A, Pitt C, Ramstedt M, McBride CA, Hall S, Rickard CM, Ullman AJ. Securement to Prevent Noncuffed Central Venous Catheter Dislodgement in Pediatrics: The SECURED Superiority Randomized Clinical Trial. JAMA Pediatr 2024:2821063. [PMID: 39008311 PMCID: PMC11250368 DOI: 10.1001/jamapediatrics.2024.2202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/14/2024] [Indexed: 07/16/2024]
Abstract
Importance Catheter dislodgement is a common complication for children with tunneled or peripherally inserted noncuffed central venous catheters (CVCs). A subcutaneous anchor securement system (SASS) may reduce this risk compared with traditional adhesive securement. Objective To compare dislodgement of noncuffed CVCs secured with SASS with dislodgement of noncuffed CVCs secured with sutureless securement devices (SSDs). Design, Setting, and Participants The SECURED (Securing Central Venous Catheters to Prevent Dislodegment) trial was a pragmatic, multicenter, superiority randomized clinical trial with an internal pilot and was conducted from August 5, 2020, to August 30, 2022, at 2 Australian quaternary pediatric hospitals. Data analysis was performed in January 2023. Patients aged 0 to 18 years requiring a noncuffed CVC (≥3F catheter) were eligible for inclusion. Follow-up duration was 8 weeks or until device removal. Interventions Patients were randomly assigned 1:1 to receive an SASS or SSD, stratified by hospital and catheter type. Only 1 catheter was studied per patient. Main Outcomes and Measures The primary outcome was dislodgement (partial or total), defined as movement of the catheter tip by greater than 1 cm (change in external catheter length) at any point during catheter dwell. Dislodgement, reported as a risk ratio (RR), was estimated using a generalized linear model with binomial family and log link. Secondary outcomes were reported as incidence rate ratios and were analyzed using Poission regression. Outcomes reported as mean differences (MDs) were analyzed using linear regression. Results Of 310 randomized patients, 175 patients (56.5%) were male and median (IQR) patient age was 48 (16-120) months. A total of 307 patients had a catheter device inserted, of which 153 (49.8%) were SASS and 154 (50.2%) were SSD, and were included in the intention-to-treat (ITT) analysis. Device dislodgement was lower with SASS (8 dislodgements in 153 patients [5.2%]) compared with SSD (35 dislodgements in 154 patients [22.7%]) (RR, 0.23; 95% CI, 0.11-0.48; P < .001). The per-protocol analysis was consistent with the ITT analysis. Partial dislodgement accounted for most dislodgement events, including 6 partial dislodgements in the SASS group (3.9%) and 30 partial dislodgements in the SSD group (19.5%) (RR, 0.18; 95% CI, 0.08-0.42). This contributed to fewer complications during dwell in the SASS group (37 reported complications [24.2%]) vs the SSD group (60 reported complications [39.0%]) (RR, 0.62; 95% CI, 0.44-0.87). Staff reported greater difficulty removing devices anchored with SASS vs SSD (mean [SD], 29.1 [31.3] vs 5.3 [17.0], respectively; MD, 23.8; 95% CI, 16.7-31.0). However, use of SASS resulted in reduced per-participant health care costs of A$36.60 (95% credible interval, 4.25-68.95; US $24.36; 95% credible interval, 2.83-45.89). Conclusions and Relevance In the SECURED trial, noncuffed CVCs secured with SASS had fewer dislodgements compared with SSDs, with a lower cost per patient and an acceptable safety profile. Future efforts should be directed at SASS implementation at the health service level. Trial Registration anzctr.org.au Identifier: ACTRN12620000783921.
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Affiliation(s)
- Tricia M. Kleidon
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Jessica Schults
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Australia
- Medical School, University of Western Australia, Crawley, Australia
| | - Victoria Gibson
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Derek J. Roebuck
- Department of Medical Imaging, Perth Children’s Hospital, Perth, Australia
- Medical School, University of Western Australia, Crawley, Australia
| | - Deborah Peirce
- Department of Medical Imaging, Perth Children’s Hospital, Perth, Australia
| | - Ruth Royle
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia
| | - Robert S. Ware
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, School of Medicine and Dentistry, Griffith University, Nathan, Australia
| | - Elizabeth Andresen
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Paula Cattanach
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Anna Dean
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Colleen Pitt
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Malanda Ramstedt
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
| | - Craig A. McBride
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Stephanie Hall
- National Health and Medical Research Council Centre for Research Excellence in Wiser Wound Care, Griffith University, Southport, Australia
| | - Claire M. Rickard
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, Australia
- Herston Infectious Diseases Institute, Metro North Health, Brisbane, Australia
- National Health and Medical Research Council Centre for Research Excellence in Wiser Wound Care, Griffith University, Southport, Australia
| | - Amanda J. Ullman
- Children’s Health Queensland Hospital and Health Service, Brisbane, Australia
- School of Nursing, Midwifery, and Social Work, The University of Queensland, Brisbane, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
- National Health and Medical Research Council Centre for Research Excellence in Wiser Wound Care, Griffith University, Southport, Australia
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Beaver K, Naranjo D, Doll J, Maynard C, Taylor L, Plomondon M, Waldo S, Helfrich CD, Rao SV. Design and baseline results of a coaching intervention for implementation of trans-radial access in percutaneous coronary intervention. Contemp Clin Trials 2021; 111:106606. [PMID: 34710590 DOI: 10.1016/j.cct.2021.106606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/18/2021] [Accepted: 10/21/2021] [Indexed: 10/20/2022]
Abstract
Trans-radial artery access (TRA) for cardiac catheterization and percutaneous coronary intervention has many advantages over trans-femoral artery access (TFA), but implementation has been slow. The steep learning curve, logistical issues, and radiation exposure have been documented as barriers to implementation. Although many cardiac catheterization laboratories have overcome these barriers, we lack evidence on effective implementation strategies. Our objective is to test a team-based coaching intervention that targets the learning curve and other barriers to increase use of TRA. We use a stepped-wedge cluster-randomized trial to test a coaching intervention in Department of Veterans Affairs cardiac catheterization laboratories. The coaching intervention comprises team-based didactic instruction with live observation at a TRA-proficient lab, followed by a visit from a cardiologist and catheterization laboratory nurse coaching team. Interview and survey data are collected from participants to test and adapt an implementation science framework known as the Promoting Action on Research Implementation in Health Services (PARIHS) framework. This study is designed to test the effectiveness of the coaching intervention on TRA implementation, inform changes to the coaching intervention itself, and test and adapt the PARIHS framework in practice. While the benefits of TRA, including increased clinical efficiency, patient comfort, and reduced patient complications, are well understood, the underlying drivers of TRA adoption and sustained practice are not. Findings from this trial can inform future research to facilitate change in the cardiac catheterization laboratory.
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Affiliation(s)
- Kristine Beaver
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America.
| | - Diana Naranjo
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Jacob Doll
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Charles Maynard
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Leslie Taylor
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Mary Plomondon
- Department of Veterans Affairs Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, United States of America; Clinical Assessment Reporting and Tracking Program, Department of Veterans Affairs Office of Quality and Patient Safety, 810 Vermont Avenue NW, Washington, DC 20420, United States of America
| | - Stephen Waldo
- Department of Veterans Affairs Eastern Colorado Health Care System, 1055 Clermont St, Denver, CO 80220, United States of America; Clinical Assessment Reporting and Tracking Program, Department of Veterans Affairs Office of Quality and Patient Safety, 810 Vermont Avenue NW, Washington, DC 20420, United States of America
| | - Christian D Helfrich
- Department of Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way S-152, Seattle, WA 98018, United States of America
| | - Sunil V Rao
- Department of Veterans Affairs Durham Health Care System, 508 Fulton Street Durham, NC 27705, United States of America
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Kleidon TM, Schults JA, Wainwright C, Mihala G, Gibson V, Saiyed M, Byrnes J, Cattanach P, Macfarlane F, Graham N, Shevill E, Ullman AJ. Comparison of midline catheters and peripherally inserted central catheters to reduce the need for general anesthesia in children with respiratory disease: A feasibility randomized controlled trial. Paediatr Anaesth 2021; 31:985-995. [PMID: 34053159 DOI: 10.1111/pan.14229] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The optimal intravenous device for antibiotic administration for children with respiratory disease is uncertain. We assessed the feasibility of a randomized controlled trial comparing midline catheters with peripherally inserted central catheters. METHODS Prospective, two-arm, feasibility randomized controlled trial in an Australian tertiary, pediatric hospital. Random assignment of 110 children (<18 years) to receive (i) midline catheter and (ii) peripherally inserted central catheters. Primary outcome was feasibility (eligibility, recruitment, retention, protocol adherence, and acceptability), and the primary clinical outcome was general anesthesia requirement for intravenous catheter insertion. SECONDARY OUTCOMES insertion time, treatment delays, infusion efficiency, device failure, complications, and cost. RESULTS There was 80% recruitment, 100% retention, no missing data, and high patient/staff acceptability. Mean patient experience assessed on a 0-10 numeric rating scale was 8.0 peripherally inserted central catheters and 9.0 (midline catheters), respectively. Participant eligibility was not achieved (49% of screened patients) and moderate protocol-adherence across groups (89% peripherally inserted central catheters vs. 76% midline catheter). Insertion of midline catheter for pulmonary optimization reduced the requirement for general anesthesia compared to peripherally inserted central catheters (10% vs. 69%; odds ratio = 0.01, 95% confidence interval: 0.00-0.09). Midline catheters failed more frequently (18.1 vs. 5.5 peripherally inserted central catheters per 1000 catheter-days); however, this reduced over trial duration. Midline catheter insertion compared to peripherally inserted central catheters saved AUD$1451 per pulmonary optimization episode. CONCLUSIONS An efficacy trial is feasible with expanded eligibility criteria and intensive staff training when introducing a new device. Midline catheter for peripherally compatible infusions is acceptable to patients and staff, might negate the need for general anesthesia and results in significant cost savings.
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Affiliation(s)
- Tricia M Kleidon
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia
| | - Jessica A Schults
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia
| | - Claire Wainwright
- Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
| | - Gabor Mihala
- Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Victoria Gibson
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia
| | - Masnoon Saiyed
- School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Joshua Byrnes
- School of Medicine, Griffith University, Nathan, Qld, Australia.,Menzies Health Institute Group, Centre for Applied Health Economics, Nathan, Qld, Australia
| | - Paula Cattanach
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia
| | - Fiona Macfarlane
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Nicolette Graham
- Department of Pharmacy, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Elizabeth Shevill
- Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
| | - Amanda J Ullman
- Department of Anesthesia and Pain Management, Vascular Assessment and Management Service (VAMS, Queensland Children's Hospital, South Brisbane, Qld, Australia.,Menzies Health Institute Queensland, Alliance for Vascular Access Teaching and Research Group, Southport, Qld, Australia.,School of Nursing and Midwifery, Griffith University, Nathan, Qld, Australia.,Child Health Research Centre, Queensland Children's Hospital, The University of Queensland and Respiratory Medicine, South Brisbane, Qld, Australia
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Hulme W, Sperrin M, Kontopantelis E, Ratib K, Ludman P, Sirker A, Kinnaird T, Curzen N, Kwok CS, De Belder M, Nolan J, Mamas MA. Increased Radial Access Is Not Associated With Worse Femoral Outcomes for Percutaneous Coronary Intervention in the United Kingdom. Circ Cardiovasc Interv 2017; 10:e004279. [PMID: 28196898 DOI: 10.1161/circinterventions.116.004279] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 12/08/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The radial artery is increasingly adopted as the primary access site for cardiac catheterization because of patient preference, lower bleeding rates, cost effectiveness, and reduced risk of mortality in high-risk patient groups. Concerns have been expressed that operators/centers have become increasingly unfamiliar with transfemoral access. The aim of this study was to assess whether a change in access site practice toward transradial access nationally has led to worse outcomes in percutaneous coronary intervention procedures performed through the transfemoral access approach. METHODS AND RESULTS Using the British Cardiovascular Intervention Society (BCIS) database, a retrospective analysis of 235 250 transfemoral access percutaneous coronary intervention procedures was undertaken in all 92 centers in England and Wales between 2007 and 2013. Recent femoral proportion and recent femoral volume were determined, and in-hospital vascular complications and 30-day mortality were evaluated. After case-mix adjustment, no independent association was observed between 30-day mortality for cases undertaken through the transfemoral access and center femoral proportion, the risk-adjusted odds ratio for recent femoral proportion was nonsignificant (odds ratio, 0.99; 95% confidence interval, 0.97-1.02; P=0.472 per 0.1 increase in proportion), and similarly recent femoral volume (per 100 procedures) was not found to be significant (odds ratio, 1.00; 95% confidence interval, 0.98-1.01; P=0.869). The in-hospital vascular complication rate was 1.0%, and this outcome was not significantly associated with recent femoral proportion after risk-adjustment (odds ratio, 0.97; 95% confidence interval, 0.94-1.00; P=0.060 per 0.1 increase in proportion). CONCLUSIONS The outcome gains achieved by the national adoption of radial access are not associated with a loss of femoral proficiency, and centers should be encouraged to continue to adopt radial access as the default access site for percutaneous coronary intervention wherever possible in line with current best evidence.
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Affiliation(s)
- William Hulme
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Matthew Sperrin
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Evangelos Kontopantelis
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Karim Ratib
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Peter Ludman
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Alex Sirker
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Tim Kinnaird
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Nick Curzen
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Chun Shing Kwok
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Mark De Belder
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - James Nolan
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.)
| | - Mamas A Mamas
- From the Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, United Kingdom (W.H., M.S., E.K., M.A.M.); Royal Stoke Hospital, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (K.R., C.S.K., J.N., M.A.M.); Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.); St. Bartholomew's Hospital, University College London Hospitals, United Kingdom (A.S.); University Hospital of Wales, Cardiff, United Kingdom (T.K.); Faculty of Medicine, University Hospital Southampton, University of Southampton, United Kingdom (N.C.); Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom (C.S.K., M.A.M.); and The James Cook University Hospital, Middlesborough, United Kingdom (M.D.B.).
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