Dataset Information

Outcomes of Veterans Undergoing TAVR Within Veterans Affairs Medical Centers: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

ABSTRACT:

Objectives

This study sought to describe clinical and procedural characteristics of veterans undergoing transcatheter aortic valve replacement (TAVR) within U.S. Department of Veterans Affairs (VA) centers and to examine their association with short- and long-term mortality, length of stay (LOS), and rehospitalization within 30 days.

Background

Veterans with severe aortic stenosis frequently undergo TAVR at VA medical centers.

Methods

Consecutive veterans undergoing TAVR between 2012 and 2017 were included. Patient and procedural characteristics were obtained from the VA Clinical Assessment, Reporting, and Tracking system. The primary outcomes were 30-day and 1-year survival, LOS >6 days, and rehospitalization within 30 days. Logistic regression and Cox proportional hazards analyses were performed to evaluate the associations between pre-procedural characteristics and LOS and rehospitalization.

Results

Nine hundred fifty-nine veterans underwent TAVR at 8 VA centers during the study period, 860 (90%) by transfemoral access, 50 (5%) transapical, 36 (3.8%) transaxillary, and 3 (0.3%) transaortic. Men predominated (939 of 959 [98%]), with an average age of 78.1 years. There were 28 deaths within 30 days (2.9%) and 134 at 1 year (14.0%). Median LOS was 5 days, and 141 veterans were rehospitalized within 30 days (14.7%). Nonfemoral access (odds ratio: 1.74; 95% confidence interval [CI]: 1.10 to 2.74), heart failure (odds ratio: 2.51; 95% CI: 1.83 to 3.44), and atrial fibrillation (odds ratio: 1.40; 95% CI: 1.01 to 1.95) were associated with increased LOS. Atrial fibrillation was associated with 30-day rehospitalization (hazard ratio: 1.79; 95% CI: 1.22 to 2.63).

Conclusions

Veterans undergoing TAVR at VA centers are predominantly elderly men with significant comorbidities. Clinical outcomes of mortality and rehospitalization at 30 days and 1-year mortality compare favorably with benchmark outcome data outside the VA.

SUBMITTER: Hall PS

PROVIDER: S-EPMC8505267 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:Background Effective transitions from the procedural to outpatient setting are essential to ensure high-quality cardiovascular care across health care systems, particularly among patients undergoing invasive cardiac procedures. We evaluated the association of postprocedural follow-up visits and antiplatelet prescriptions with clinical outcomes among patients undergoing percutaneous coronary intervention for stable angina at community or Veterans Affairs (VA) hospitals. Methods and Results Patients who actively received care within the VA Healthcare System and underwent percutaneous coronary intervention for stable angina at a community or VA hospital between October 1, 2015, and September 30, 2019, were identified. We compared mortality for patients receiving community or VA care, and among subgroups of community-treated patients by the presence of a postprocedural follow-up visit within 30 days or prescription for antiplatelet (P2Y12) medication within 120 days of the procedure. Among 12 837 patients who survived the first 30 days, 5133 were treated at community hospitals, and 7704 were treated in the VA. Prescriptions for antiplatelet therapy were less common for those treated in the community (85%) compared with the VA at 1 year (95%; hazard ratio [HR], 0.46; 95% CI, 0.44-47). Compared with VA-treated patients, the hazards for death were similar for patients treated in the community with a follow-up visit (HR, 1.17; 95% CI, 0.97-1.40) or with a fill for an antiplatelet therapy (HR, 1.08; 95% CI, 0.90-1.30). However, patients treated in the community without a follow-up visit had an 86% (HR, 1.86; 95% CI, 1.40-2.48) increased hazard of death, and those without antiplatelet prescription fill had a 144% increased hazard of death (HR, 2.44; 95% CI, 1.85-3.21) compared with all VA-treated patients. Conclusions Patients treated at community facilities have a decreased chance of receiving antiplatelet prescriptions after percutaneous coronary intervention with a concordant increased hazard of mortality, emphasizing the importance of transitions of care across health care systems when assessing cardiovascular quality.

Project description:ImportancePeer review is recommended for quality assessment in all cardiac catheterization programs, but, to our knowledge, the content of peer reviews and the potential for quality improvement has not been described.ObjectiveTo characterize the quality improvement content of cardiac catheterization peer reviews.Design, setting, and participantsThis quality improvement study used retrospective case review of diagnostic angiography and percutaneous coronary intervention procedures to characterize the major adverse event review process of the US Department of Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program from January 1, 2012, to December 31, 2016. Data review and analysis took place from November 2017 to August 2018.Main outcomes and measuresPercentage of peer reviews reporting substandard care and opportunities for quality improvement.ResultsA total of 196 643 diagnostic coronary angiograms and 62 576 percutaneous coronary interventions were performed in the Department of Veterans Affairs. Of these, 168 (0.1%) were triggered for review because of a self-reported major adverse event during the procedure. Of 152 cases with complete peer review data, care was adjudicated as not meeting the standard of care in 25 cases (16.4%). Concerns about operator judgment were identified in 46 cases (30.3%), about case selection in 26 (17.1%), about trainee supervision in 21 (13.8%), and about technical performance in 46 (30.3%). Reviewers made recommendations to improve operator performance in 63 cases (41.4%) and catheterization laboratory or hospital processes in 58 (38.2%).Conclusions and relevanceWhile substandard care is infrequently identified in peer review of catheterization laboratory complications in the Department of Veterans Affairs, the process often generates recommendations for quality improvement. Peer review programs should focus on identifying quality improvement opportunities and providing meaningful feedback to operators.

Project description:BACKGROUND:Several antiplatelet medications used during and after percutaneous coronary intervention (PCI) are contraindicated for specific patient groups. A broad assessment of contraindicated medication use and associated clinical outcomes is not well described. METHODS AND RESULTS:Using national Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data for all PCI between 2007 and 2013, we evaluated patients with contraindications to commonly used antiplatelet medications during and after PCI, defined in accordance with package inserts. Adjusted association between contraindicated medication use and outcomes of periprocedural bleeding and 30-day mortality were assessed using Cox proportional hazards with inverse probability weighting. Among 64?294 patients undergoing PCI, 11?315(17.6%) had a contraindication to a common antiplatelet medication and 737 (6.5%) of these patients received a contraindicated medication. In unadjusted analyses, any contraindicated medication use was associated with both increased bleeding and 30-day mortality. In adjusted models, contraindicated abciximab use in patients with thrombocytopenia (hazard ratio, 2.23; 95% confidence interval, 1.58-3.16) and in patients with a previous stroke (hazard ratio, 1.93; 95% confidence interval, 1.37-2.71) remained significantly associated with increased bleeding. Contraindicated abciximab use was not significantly associated with 30-day mortality in adjusted models. Use of eptifibatide in dialysis patients was not significantly associated with an increased risk of bleeding or mortality. CONCLUSIONS:In this national cohort, ?18% of patients undergoing PCI had contraindications to common antiplatelet medications. Approximately 6% of those patients received a contraindicated medication with attendant bleeding risk, although this did not translate into significantly higher risk of 30-day mortality. Continued efforts to reduce contraindicated medication use may help avoid periprocedural complications.

Project description:ImportanceAnatomical scoring systems for coronary artery disease, such as the SYNTAX (Synergy Between Percutaneous Coronary Intervention [PCI] With Taxus and Cardiac Surgery) score, are well established tools for understanding patient risk. However, they are cumbersome to compute manually for large data sets, limiting their use across broad and varied cohorts.ObjectiveTo adapt an anatomical scoring system for use with registry data, allowing facile and automatic calculation of scores and association with clinical outcomes among patients undergoing percutaneous or surgical revascularization.Design, setting, and participantsThis cross-sectional observational cohort study involved procedures performed in all cardiac catheterization laboratories in the largest integrated health care system in the United States, the Veterans Affairs (VA) Healthcare System. Patients undergoing coronary angiography in the VA Healthcare System followed by percutaneous or surgical revascularization within 90 days were observed and data were analyzed from January 1, 2010, through September 30, 2017.Main outcomes and measuresAn anatomical scoring system for coronary artery disease complexity before revascularization was simplified and adapted to data from the VA Clinical Assessment, Reporting, and Tracking Program. The adjusted association between quantified anatomical complexity and major adverse cardiovascular and cerebrovascular events (MACCEs), including death, myocardial infarction, stroke, and repeat revascularization, was assessed for patients undergoing percutaneous or surgical revascularization.ResultsA total of 50 226 patients (49 359 men [98.3%]; mean [SD] age, 66 [9] years) underwent revascularization during the study period, with 34 322 undergoing PCI and 15 904 undergoing coronary artery bypass grafting (CABG). After adjustment, the highest tertile of anatomical complexity was associated with increased hazard of MACCEs (adjusted hazard ratio [HR], 2.12; 95% CI, 2.01-2.23). In contrast, the highest tertile of anatomical complexity among patients undergoing CABG was not independently associated with overall MACCEs (adjusted HR, 1.04; 95% CI, 0.92-1.17), and only repeat revascularization was associated with increasing complexity (adjusted HR, 1.34; 95% CI, 1.06-1.70) in this subgroup.Conclusions and relevanceThese findings suggest that an automatically computed score assessing anatomical complexity can be used to assess longitudinal risk for patients undergoing revascularization. This simplified scoring system appears to be an alternative tool for understanding longitudinal risk across large data sets.

Project description:BACKGROUND:Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization. METHODS:We assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio???3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis. RESULTS:From 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5-56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8-36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6-53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56-2.08) for periprocedural hydration, 1.95 (CI 1.66-2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23-3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n?=?5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38-1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65-2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N?=?1059), 6.2% of cases in 2015 (N?=?128, p?=?<?0.0001)) and no significant change in contrast-minimization (p?=?0.3907). CONCLUSIONS:Among patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.

Project description:ImportanceSocioeconomic factors are associated with worse outcomes after hospitalization, but neither the Centers for Medicare & Medicaid Services (CMS) nor the Veterans Affairs (VA) health care system adjust for socioeconomic factors in profiling hospital mortality.ObjectiveTo evaluate changes in Veterans Affairs medical centers' (VAMCs') risk-standardized mortality rates among veterans hospitalized for heart failure and pneumonia after adjusting for socioeconomic factors.Design, setting, and participantsIn this cross-sectional study, retrospective data were used to assess 131 VAMCs' risk-standardized 30-day mortality rates with or without adjustment for socioeconomic covariates. The study population included 42 892 veterans hospitalized with heart failure and 39 062 veterans hospitalized with pneumonia from January 1, 2012, to December 31, 2014. Data were analyzed from March 1, 2019, to April 1, 2020.Main outcomes and measuresThe primary outcome was 30-day mortality after admission. Socioeconomic covariates included neighborhood disadvantage, race/ethnicity, homelessness, rurality, nursing home residence, reason for Medicare eligibility, Medicaid and Medicare dual eligibility, and VA priority.ResultsThe study population included 42 892 veterans hospitalized with heart failure (98.2% male; mean [SD] age, 71.9 [11.4] years) and 39 062 veterans hospitalized with pneumonia (96.8% male; mean [SD] age, 71.0 [12.4] years). The addition of socioeconomic factors to the CMS models modestly increased the C statistic from 0.77 (95% CI, 0.77-0.78) to 0.78 (95% CI, 0.78-0.78) for 30-day mortality after heart failure and from 0.73 (95% CI, 0.72-0.73) to 0.74 (95% CI, 0.73-0.74) for 30-day mortality after pneumonia. Mortality rates were highly correlated (Spearman correlations of ≥0.98) in models that included or did not include socioeconomic factors. With the use of the CMS model for heart failure, VAMCs in the lowest quintile had a mean (SD) mortality rate of 6.0% (0.4%), those in the middle 3 quintiles had a mean (SD) mortality rate of 7.2% (0.4%), and those in the highest quintile had a mean (SD) mortality rate of 8.8% (0.6%). After the inclusion of socioeconomic covariates, the adjusted mean (SD) mortality was 6.1% (0.4%) for hospitals in the lowest quintile, 7.2% (0.4%) for those in the middle 3 quintiles, and 8.6% (0.5%) for those in the highest quintile. The mean absolute change in rank after socioeconomic adjustment was 3.0 ranking positions (interquartile range, 1.0-4.0) among hospitals in the highest quintile of mortality after heart failure and 4.4 ranking positions (interquartile range, 1.0-6.0) among VAMCs in the lowest quintile. Similar findings were observed for mortality rankings in pneumonia and after inclusion of clinical covariates.Conclusions and relevanceThis study suggests that adjustments for socioeconomic factors did not meaningfully change VAMCs' risk-adjusted 30-day mortality rates for veterans hospitalized for heart failure and pneumonia. The implications of such adjustments should be examined for other quality measures and health systems.