Thomas J. Glorioso

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.

Influence of Nonindex Hospital Readmission on Length of Stay and Mortality

Importance: Hospitals and health care systems face increasing accountability for postdischarge outcomes of patients, but it is unclear how frequently hospital readmissions in particular occur at a different hospital than the index hospitalization and whether this is associated with worse outcomes. Objective: Describe the prevalence of nonindex 30-day readmissions in a nationally representative sample of all payers and associations with outcomes. Design: Secondary retrospective analysis of the 2013 Nationwide Readmissions Database. Setting: Nonfederal hospitals from 21 states representing half of hospitalizations in the United States annually. Participants: Our overall sample included all adults discharged alive from an inpatient stay with 30 days of follow-up; we also created 3 additional cohorts: patients with Medicare as the payer (Medicare cohort), patients discharged to home health or skilled nursing facilities after discharge (postacute care cohort), and Medicare patients with any of the current Hospital Readmission Reduction Program’s penalized conditions (readmission penalty cohort). Exposure: Readmission within 30 days to “index” hospital (where index stay occurred) or “nonindex” hospital. Main Outcome(s) and Measure(s): In-hospital mortality and length of stay during the readmission. Results: The weighted overall sample included 22,884,505 hospital discharges from 2004 unique hospitals. The overall 30-day readmission rate was 11.9%, of these, 22.5% occurred at a nonindex hospital. Readmissions to nonindex facilities were associated with increased odds of in-hospital mortality (odds ratio, 1.21; 95% confidence interval, 1.17–1.25) and longer hospital length of stay (hazard ratio for hospital discharge, 0.87; 95% confidence interval, 0.86–0.88) in the overall sample and in the 3 cohorts. Conclusions and Relevance: Nonindex readmissions are common and associated with worse outcomes; the common findings across cohorts highlight the importance for hospitals and care systems participating in value-based payment models. Hospitals and care systems should invest in improved methods for real-time identification and intervention for these patients.

Effect of Chronic Kidney Disease on Mortality in Patients Who Underwent Lower Extremity Peripheral Vascular Intervention

It is known that chronic kidney disease (CKD) is associated with increased postoperative morbidity and mortality in patients with peripheral artery disease who underwent lower extremity surgical revascularization; however, outcomes after peripheral vascular intervention (PVI) are less well established. This study sought to determine the impact of CKD on adverse outcomes in patients with peripheral artery disease who underwent PVI. Using data from the Veteran Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified a cohort of 755 patients who underwent lower extremity PVI from June 2005 to August 2010 at 33 sites. The outcomes of interest were mortality, progression to dialysis, myocardial infarction, limb amputation, and stroke. Kaplan-Meier survival analysis and Cox proportional hazard frailty models assessed the association between CKD and adverse outcomes. Of the patients who underwent lower extremity PVI, 201 patients (27%) had CKD. The presence of CKD was associated with decreased survival (5-year survival probability of CKD compared with non-CKD: 49.9% [41.6% to 59.9%] vs 80.1% [76.2% to 84.1]), which persisted after risk adjustment (HR 1.57; 95% confidence interval 1.13 to 2.19). In addition, there was a significant association between CKD and progression to dialysis (HR 6.62; 95% confidence interval 2.25 to 19.43). In contrast, there was no association between CKD and re-hospitalization for myocardial infarction, limb amputation, or stroke. In conclusion, CKD is present in 1 of 4 patients who underwent PVI and is associated with increased risk of mortality and progression to dialysis.

Comparative Outcomes After Percutaneous Coronary Intervention Among Black and White Patients Treated at US Veterans Affairs Hospitals

Importance Current comparative outcomes among black and white patients treated with percutaneous coronary intervention (PCI) in the Veterans Affairs (VA) health system are not known. Objective To compare outcomes between black and white patients undergoing PCI in the VA health system. Design, Setting, and Participants This study compared black and white patients who underwent PCI between October 1, 2007, and September 30, 2013, at 63 VA hospitals using data recorded in the VA Clinical Assessment, Reporting, and Tracking System for Cardiac Catheterization Laboratories (CART-CL) program. A generalized linear mixed model with a random intercept for site assessed the relative difference in odds of outcomes between black and white patients. The setting was integrated institutionalized hospital care. Excluded were all patients of other races or those with multiple listed races and those with missing data regarding race or the diagnostic cardiac catheterization. The dates of analysis were January 7, 2016, to April 17, 2017. Exposure Percutaneous coronary intervention at a VA hospital. Main Outcomes and Measures The primary outcome was 1-year mortality. Secondary outcomes were 30-day all-cause readmission rates, 30-day acute kidney injury, 30-day blood transfusion, and 1-year readmission rates for myocardial infarction. In addition, variations in procedural and postprocedural care were examined, including the use of intravascular ultrasound, optical coherence tomography, fractional flow reserve measurements, bare-metal stents, postprocedural medications, and radial access. Results A total of 42 391 patients (13.3% black and 98.4% male; mean [SD] age, 65.2 [9.1] years) satisfied the inclusion and exclusion criteria. In unadjusted analyses, black patients had higher rates of 1-year mortality (7.1% vs 5.9%, P < .001) as well as secondary outcomes of 30-day acute kidney injury (20.8% vs 13.8%, P < .001), 30-day blood transfusion (3.4% vs 2.7%, P < .01), and 1-year readmission rates for myocardial infarction (3.3% vs 2.7%, P = .01) compared with white patients. After adjustment for demographics, comorbidities, and procedural characteristics, odds for 1-year mortality (odds ratio, 1.04; 95% CI, 0.90-1.19) were not different between black and white patients. There were also no differences in secondary outcomes with the exception of a higher rate of adjusted 30-day acute kidney injury (odds ratio, 1.22; 95% CI, 1.10-1.36). Conclusions and Relevance While black patients had a higher rate of mortality than white patients in unadjusted analyses, race was not independently associated with 1-year mortality among patients undergoing PCI in VA hospitals.

Factors associated with rhythm control treatment decisions in patients with atrial fibrillation—Insights from the NCDR PINNACLE registry

Background Decisions to use rhythm control in atrial fibrillation (AF) should generally be dictated by patient factors, such as quality of life, heart failure, and other comorbidities. Whether or not other factors affect decisions about the use of rhythm control, and catheter ablation in particular, is unknown. Methods A cohort of all patients diagnosed with nonvalvular AF were identified from the National Cardiovascular Data Registry’s Practice Innovation and Clinical Excellence (PINNACLE) AF registry of US outpatient cardiology practices during the study period from May 1, 2008, to December 31, 2014. Overall and practice‐specific rates of rhythm control (cardioversion, antiarrhythmic drug therapy, or catheter ablation) were assessed. We assessed patient and practice factors associated with rhythm control and determined the relative contribution of patient, practice, and unmeasured practice factors with its use. Results Among 511,958 PINNACLE AF patients, 22.3% were treated with rhythm control and 2.9% underwent catheter ablation. Significant practice variation in rhythm control was present (median rate of rhythm control across practices 22.8%, range 0.2%‐62.9%). Significant patient factors associated with rhythm control therapy included white (vs nonwhite) race (odds ratio [OR] 2.43, P < .001), private (vs nonprivate) insurance (OR 1.04, P < .001), and whether a patient was seen by an electrophysiologist (OR 1.77, P < .001). In an analysis of the relative contribution of patient, practice, and unmeasured practice factors with rhythm control, the contribution of unmeasured practice factors (95% range OR 0.29‐3.44) exceeded that of either patient (95% range OR 0.46‐2.30) or practice (95% range OR 0.15‐2.77) factors. Conclusions One in 5 AF patients in the PINNACLE registry received rhythm control, and 1 in 50 received catheter ablation, suggesting that rhythm control may be underused. A variety of measured and unmeasured practice factors unrelated to patient characteristics play a disproportionate role in the use of rhythm control treatment decisions. Understanding the drivers of these decisions may identify inappropriate treatment variation and better inform optimal use of these therapies.

SIGNIFICANT VARIATION IN ATRIAL FIBRILLATION TREATMENT STRATEGIES: INSIGHTS FROM THE VETERAN’S HEALTH ADMINISTRATION

The incidence of atrial fibrillation (AF) is increasing and there are several strategies for AF treatment. However, our knowledge of secular trends and variation in treatment patterns for AF is poorly defined. From the Veterans Health Administration (VHA) inpatient treatment files, we identified