Anne Lambert-Kerzner

Site-Level Variation in and Practices Associated With Dabigatran Adherence

IMPORTANCE Unlike warfarin, which requires routine laboratory testing and dose adjustment, target-specific oral anticoagulants like dabigatran do not. However, optimal follow-up infrastructure and modifiable site-level factors associated with improved adherence to dabigatran are unknown. OBJECTIVES To assess site-level variation in dabigatran adherence and to identify site-level practices associated with higher dabigatran adherence. DESIGN, SETTING, AND PARTICIPANTS Mixed-methods study involving retrospective quantitative and cross-sectional qualitative data. A total of 67 Veterans Health Administration sites with 20 or more patients filling dabigatran prescriptions between 2010 and 2012 for nonvalvular atrial fibrillation were sampled (4863 total patients; median, 51 patients per site). Forty-seven pharmacists from 41 eligible sites participated in the qualitative inquiry. EXPOSURE Site-level practices identified included appropriate patient selection, pharmacist-driven patient education, and pharmacist-led adverse event and adherence monitoring. MAIN OUTCOMES AND MEASURES Dabigatran adherence (intensity of drug use during therapy) defined by proportion of days covered (ratio of days supplied by prescription to follow-up duration) of 80% or more. RESULTS The median proportion of patients adherent to dabigatran was 74% (interquartile range [IQR], 66%-80%). After multivariable adjustment, dabigatran adherence across sites varied by a median odds ratio of 1.57. Review of practices across participating sites showed that appropriate patient selection was performed at 31 sites, pharmacist-led education was provided at 30 sites, and pharmacist-led monitoring at 28 sites. The proportion of adherent patients was higher at sites performing appropriate selection (75% vs 69%), education (76% vs 66%), and monitoring (77% vs 65%). Following multivariable adjustment, association between pharmacist-led education and dabigatran adherence was not statistically significant (relative risk [RR], 0.94; 95% CI, 0.83-1.06). Appropriate patient selection (RR, 1.14; 95% CI, 1.05-1.25), and provision of pharmacist-led monitoring (RR, 1.25; 95% CI, 1.11-1.41) were associated with better patient adherence. Additionally, longer duration of monitoring and providing more intensive care to nonadherent patients in collaboration with the clinician improved adherence. CONCLUSIONS AND RELEVANCE Among nonvalvular atrial fibrillation patients treated with dabigatran, there was variability in patient medication adherence across Veterans Health Administration sites. Specific pharmacist-based activities were associated with greater patient adherence to dabigatran.

Temporal Trends in Percutaneous Coronary Intervention Appropriateness: Insights from the Clinical Outcomes Assessment Program

Background— It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. Methods and Results— We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 (P=0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% (P<0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P=0.03). Conclusions— In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness.Background— It is unknown whether the appropriate use of percutaneous coronary intervention (PCI) has improved over time and whether trends in PCI appropriateness have been accompanied by changes in the use of PCI. Methods and Results— We applied appropriate use criteria to determine the appropriateness of all 51 872 PCI performed in Washington State from 2010 through 2013. We evaluated the number of PCIs performed from 2006 through 2013 to provide a comparator period that preceded statewide appropriateness assessment beginning in 2010. Between 2010 and 2013, the overall number of PCI decreased by 6.8% (13 267 PCIs in 2010 to 12 193 in 2013) with a 43% decline in the number of PCIs for elective indications (3818 PCIs in 2010 to 2193 PCIs in 2013). The decline in the use of elective PCI was significantly larger after the onset of statewide PCI appropriateness assessment in 2010 ( P =0.03). The proportion of elective PCIs classified as appropriate increased from 26% in 2010 to 38% in 2013, whereas the proportion of inappropriate PCIs decreased from 16% to 13% ( P <0.001 for trends). Significant improvements in the proportion of inappropriate PCI were limited to the tertile of hospitals with the largest decline in PCIs classified as inappropriate (25% in 2010 to 12% in 2013; P =0.03). Conclusions— In Washington State, the use of PCI for elective indications has decreased over time with concurrent improvements in PCI appropriateness. However, improvements in PCI appropriateness were limited to a minority of hospitals. Understanding processes at these high-performing hospitals may inform efforts to improve PCI appropriateness. # CLINICAL PERSPECTIVE {#article-title-19}

Patient-Centered Adherence Intervention After Acute Coronary Syndrome Hospitalization

Background— Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications. Methods and Results— To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care. Conclusions— If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.

Perspectives of patients on factors relating to adherence to post-acute coronary syndrome medical regimens

Purpose Poor adherence to cardioprotective medications after acute coronary syndrome (ACS) hospitalization is associated with increased risk of rehospitalization and mortality. Clinical trials of multifaceted interventions have improved medication adherence with varying results. Patients’ perspectives on interventions could help researchers interpret inconsistent outcomes. Identifying factors that patients believe would improve adherence might inform the design of future interventions and make them more parsimonious and sustainable. The objective of this study was to obtain patients’ perspectives on adherence to medical regimens after experiencing an ACS event and their participation in a medication adherence randomized control trial following their hospitalization. Patients and methods Sixty-four in-depth interviews were conducted with ACS patients who participated in an efficacious, multifaceted, medication adherence randomized control trial. Interview transcripts were analyzed using the constant comparative approach. Results Participants described their post-ACS event experiences and how they affected their adherence behaviors. Patients reported that adherence decisions were facilitated by mutually respectful and collaborative provider–patient treatment planning. Frequent interactions with providers and medication refill reminder calls supported improved adherence. Additional facilitators included having social support, adherence routines, and positive attitudes toward an ACS event. The majority of patients expressed that being active participants in health care decision-making contributed to their health. Conclusion Our findings demonstrate that respectful collaborative communication can contribute to medication adherence after ACS hospitalization. These results suggest a potential role for training health-care providers, including pharmacists, social workers, registered nurses, etc, to elicit and acknowledge the patients’ views regarding medication treatment in order to improve adherence. Future research is needed with providers to understand how they elicit and acknowledge patients’ views, particularly in the face of nonadherence, and with patients to understand how to empower them to share their opinions with their providers.

Cognitive dysfunction and poor health literacy are common in veterans presenting with acute coronary syndrome: insights from the MEDICATION study.

Background Patient nonadherence to cardiac medications following acute coronary syndrome (ACS) is associated with increased risk of recurrent events. However, the prevalence of cognitive dysfunction and poor health literacy among ACS patients and their association with medication nonadherence are poorly understood. Methods We assessed rates of cognitive dysfunction and poor health literacy among participants of a clinical trial that tested the effectiveness of an intervention to improve medication adherence in patients hospitalized with ACS. Of 254 patients, 249 completed the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) survey, an assessment of risk for poor literacy, and the St Louis University Mental Status (SLUMS) exam, a tool assessing for neurocognitive deficits, during ACS hospitalization. We assessed if SLUMS or REALM-R scores were associated with medication adherence. Results Based on SLUMS score, 14% of patients were categorized as having dementia, and 52% with mild neurocognitive disorder (MNCD). Based on REALM-R score of ≤6, 34% of patients were categorized as at risk for poor health literacy. There was no association between poor health literacy and medication nonadherence. Of those with MNCD, 35.5% were nonadherent, compared to 17.5% with normal cognitive function and 6.7% with dementia. In multivariable analysis, cognitive dysfunction was associated with medication nonadherence (P=0.007), mainly due to an association between MNCD and nonadherence (odds ratio =12.2, 95% confidence interval =1.9 to 243; P=0.007). Cognitive status was not associated with adherence in patients randomized to the intervention. Conclusion Cognitive dysfunction and risk for poor health literacy are common in patients hospitalized with ACS. We found an association between MNCD and medication nonadherence in the usual care group but not in the intervention group. These findings suggest efforts to screen for MNCD are needed during ACS hospitalization to identify patients at risk for nonadherence and who may benefit from an adherence intervention.

Evaluation of the Veterans Health Administration's Specialty Care Transformational Initiatives to Promote Patient-Centered Delivery of Specialty Care: A Mixed-Methods Approach

INTRODUCTION Veterans Affairs Office of Specialty Care (OSC) launched four national initiatives (Electronic-Consults [e-Consults], Specialty Care Access Networks-Extension for Community Healthcare Outcomes [SCAN-ECHO], Mini-Residencies, and Specialty Care Neighborhood) to improve specialty care delivery and funded a center to evaluate the initiatives. METHODS The evaluation, guided by two implementation frameworks, provides formative (administrator/provider interviews and surveys) and summative data (quantitative data on patterns of use) about the initiatives to OSC. RESULTS Evaluation of initiative implementation is assessed through CFIR (Consolidated Framework for Implementation Research)-grounded qualitative interviews to identify barriers/facilitators. Depending on high or low implementation, factors such as receiving workload credit, protected time, existing workflow/systems compatibility, leadership engagement, and access to information/resources were considered implementation barriers or facilitators. Findings were shared with OSC and used to further refine implementation at additional sites. Evaluation of other initiatives is ongoing. CONCLUSIONS The mixed-methods approach has provided timely information to OSC about initiative effect and impacted OSC policies on implementation at additional sites.

Variability of Antithrombotic Dosing Among Veterans Presenting With Acute Coronary Syndrome

Background Antithrombotic therapy for acute coronary syndrome (ACS) patients is recommended by clinical practice guidelines. Appropriate dosing of antithrombotic therapy is necessary to ensure effectiveness and safety and is an American College of Cardiology/American Heart Association ST elevated myocardial infarction/non‐ST elevated myocardial infarction performance measure. This study describes the variability in dosing of unfractionated heparin (UH) and low‐molecular‐weight heparin (LMWH) in an integrated health care system with electronic medical records and computerized physician order entry (CPOE). Methods and Results This was a mixed‐methods study of veterans presenting with ACS at 135 Veterans Health Administration hospitals from 2009 to 2011. Patients hospitalized with ACS and received antithrombotic therapy were included (n=36 682). The cohort was 98% male with an average age of 66 years and median body mass index (BMI) of 28.6. The average percentage of patients by hospital who received an above‐recommended dose of either antithrombotic was 7.5% and ranged 0% to 32.0%. By individual therapy, the average percentage of patients by hospital who received an above‐recommended dose of UH was 1.2% and LMWH was 12.9%. Risk‐adjusted analyses demonstrated that older age and higher BMI were associated with lower risk for receiving a dose above recommended levels. Additionally, there was an association between antithrombotic ordered by a resident and higher risk of the patient receiving an above‐recommended dose. Qualitative interviews supported the quantitative findings by highlighting the need to use current patient weight and the need to adequately train providers on the use of CPOE to improve antithrombotic dosing. Conclusion This study found wide hospital variability in dosing of antithrombotics above the recommended level for patients treated for ACS.

Assessment of attitudes towards future implementation of the “Surgical Risk Preoperative Assessment System” (SURPAS) tool: a pilot survey among patients, surgeons, and hospital administrators

BackgroundRisk assessment in surgery is essential to guide treatment decisions but is highly variable in practice. Providing formal preoperative risk assessment to surgical teams and patients may optimize understanding of risk. Implementation of the Surgical Risk Preoperative Assessment System (SURPAS), an innovative real time, universal, preoperative tool providing individualized risk assessment, may enhance informed consent and reduce adverse outcomes. To ensure optimal development and implementation of SURPAS we performed an in-depth pre-implementation evaluation of SURPAS at an academic tertiary referral center in Colorado.MethodsFour focus groups with 24 patients, three focus groups with 29 surgical providers and clinic administrators, and five individual interviews with administrative officials were conducted to elicit their perspectives about the development and implementation of SURPAS. Qualitative data collection and analyses, utilizing a Matrix Analysis approach were used to explore insights regarding SURPAS.ResultsParticipants were positive about SURPAS and provided suggestions to improve and address concerns regarding it. For healthcare personnel three major themes emerged: 1) The SURPAS tool - Important work especially for high risk patients, yet not a substitute for clinical judgment; 2) Benefits of SURPAS to the risk assessment process - Improves the processes, enhances patients’ participation in shared decision-making process, and creates a permanent record; and 3) Facilitators and barriers of implementation of SURPAS - Easy to incorporate into clinical practice in spite of surgical providers’ resistance to adoption of new technology. For patients three major themes emerged: 1) Past experience of preoperative risk assessment discussions – Patients were not made aware of possible complications that occurred; 2) The SURPAS tool - All patients liked SURPAS and believed having printed material would be useful to guide discussions and facilitate remembering conversations with the providers; and 3) Potential concerns with having risk assessment information – Patients were mixed in deciding to have an operation with high risks.ConclusionsSystematically capturing data from the beginning of the implementation process from key stakeholders (patients, surgical providers, clinical staff, and administrators) that includes adaptations to the tool and implementation process will help to inform pragmatic approaches for implementing the SURPAS tool in various settings, scaling-up, and sustaining it.

Assessment of barriers and facilitators in the implementation of appropriate use criteria for elective percutaneous coronary interventions: a qualitative study

BackgroundThe use of inappropriate elective Percutaneous Coronary Intervention (PCI) has decreased over time, but hospital-level variation in the use of inappropriate PCI persists. Understanding the barriers and facilitators to the implementation of Appropriate Use Criteria (AUC) guidelines may inform efforts to improve elective PCI appropriateness.MethodsAll hospitals performing PCI in Washington State were categorized by their use of inappropriate elective PCI in 2010 to 2013. Semi-structured, qualitative telephone interviews were then conducted with 17 individual interviews at 13 sites in Washington State to identify barriers and facilitators to the implementation of the AUC guidelines. An inductive and deductive, team-based analytical approach, drawing primarily on Matrix analysis was performed to identify factors affecting implementation of the AUC.ResultsSpecific facilitators were identified that supported successful implementation of the AUC. These included collaborative catheterization laboratory environments that allow all staff to participate with questions and opinions; ongoing AUC education with catheterization laboratory teams and referring providers; internal AUC peer review processes; interventional cardiologist be directly involved with the pre-procedural review process; checklist-based algorithms for pre-procedural documentation; systems redesign to include insurance companies; and AUC educational information with patients. Barriers to implementation of the AUC included external pressures, such as competition for patients, and the lack of shared medical records with sites that referred patients for coronary angiography.ConclusionsThe identified facilitators enabled sites to successfully implement the AUC. Catheterization laboratories struggling to successfully implement the AUC may consider utilizing these strategies to improve their processes to improve patient selection for elective PCI.

Adaptation of Lean Six Sigma Methodologies for the Evaluation of Veterans Choice Program at 3 Urban Veterans Affairs Medical Centers

Objective: The Veterans Health Administration (VHA) is adapting to meet the changing needs of our Veterans. VHA leaders are promoting quality improvement strategies including Lean Six Sigma (LSS). This study used LSS tools to evaluate the Veterans Choice Program (VCP), a program that aims to improve access to health care services for eligible Veterans by expanding health care options to non-VHA providers. Research Design: LSS was utilized to assess the current process and efficiency patterns of the VCP at 3 VHA Medical Centers. LSS techniques were used to assess data obtained through semistructured interviews with Veterans, staff, and providers to describe and evaluate the VCP process by identifying wastes and defects. Results: The LSS methodology facilitated the process of targeting priorities for improvement and constructing suggestions to close identified gaps and inefficiencies. Identified key process wastes included inefficient exchange of clinical information between stakeholders in and outside of the VHA; poor dissemination of VCP programmatic information; shortages of VCP-participating providers; duplication of appointments; declines in care coordination; and lack of program adaptability to local processes. Recommendations for improvement were formulated using LSS. Conclusions: This evaluation illustrates how LSS can be utilized to assess a nationally mandated health care program. By focusing on stakeholder, staff, and Veteran perspectives, process defects in the VCP were identified and improvement recommendations were made. However, the current LSS language used is not intuitive in health care and similar applications of LSS may consider using new language and goals adapted specifically for health care.