Abstract P232: Screening Past B-Type Natriuretic Peptide (BNP) Values to Identify Candidates for Treatment of Systolic Dysfunction

Background: BNP testing is now common though it is not clear if the test results are used to improve patient care. A high BNP may be an indicator that the left ventricular ejection fraction (LVEF) is low (&lt;40%) such that the patient will benefit from life-prolonging therapy. Objective: To determine how often clinicians obtained a measure of LVEF (echocardiography, nuclear) following a high BNP value when the left ventricular ejection fraction (LVEF) was not known to be low (&lt;40%). Methods and Results: We reviewed the medical records of 296 consecutive patients (inpatient or outpatient) with a BNP values of at least 200 pg/ml at a single medical center (tertiary hospital with 8 community clinics). A prior diagnosis of heart failure was made in 65%, while 42% had diabetes, 79% had hypertension, 59% had ischemic heart disease and 31% had chronic lung disease. The mean age was 73 ± 12 years, 75% were white, 10% black, 15% other and the mean BNP was 810 ± 814 pg/ml. The LVEF was known to be &lt; 40% in 84 patients (28%, mean BNP value of 1094 ± 969 pg/ml). Of the remaining 212 patients without a known low LVEF, 161 (76%) had a prior LVEF &gt;=40% ( mean BNP value of 673 ± 635 pg/ml), and 51 (24%) had no prior LVEF documented (mean BNP 775 ± 926 pg/ml). Following the high BNP, a measure of LVEF was obtained (including outside studies documented by the primary care provider) within 6 months in only 53% (113 of 212) of those with an LVEF not known to be low. Of those with a follow-up echocardiogram, the LVEF was &lt;40% in 18/113 (16%) and &gt;=40% in 95/113 (84%). There was no significant difference in mean initial BNP values between those with a follow-up LVEF &lt;40% (872 ± 940pg/ml), &gt;=40% (704 ± 737 pg/ml), or not done (661 ± 649 pg/ml, p=0.5). Conclusions: Follow-up measures of LVEF did not occur in almost 50% of patients with a high BNP where the information may have led to institution of life-prolonging therapy. Of those that did have a follow-up study a new diagnosis of depressesd LVEF was noted in 16%. Screening of existing BNP and LVEF data and may be an efficient strategy to identify patients that may benefit from life-prolonging therapy for heart failure. </jats:p

Abstract 12737: Sex and Race/Ethnic Disparities in the Use of High Potency Statins for Patients With Atherosclerotic Cardiovascular Disease

Background: The November 2013 AHA/ACC prevention guidelines recommend the use of a fixed dose high potency statin (HPS) for patients with established atherosclerotic cardiovascular disease (ASCVD), irrespective of low-density lipoprotein cholesterol levels. We sought to determine how these guidelines are being adopted at the Veterans Affairs (VA) Health System and identify treatment gaps in patient groups. Methods: We examined administrative data from the VA 6 months prior to the index dates of 4/1/2013 and 4/1/2014 to identify patients with at least one outpatient visit for a diagnosis of established ASCVD, defined as coronary heart disease, cerebrovascular disease, or peripheral arterial disease. Statin use was assessed 6 months following the index date, and HPS was defined as atorvastatin 40mg or 80mg, rosuvasatin 20mg or 40mg, and simvastatin 80mg. Patient and facility-level predictors of statin use for secondary prevention were analyzed using multivariate logistic regressions. Results: Our study sample included 507,072 and 489,754 eligible adults with established ASCVD, in 4/1/2013 and 4/1/2014, respectively. The sample consisted of approximately 190,035 (2%) women and 200,461 (19%) non-white patients. HPS use was lowest in Hispanics and Native Americans, though all groups showed an increase over time (Figure 1). After adjustment for clinical and facility characteristics, there was a 40% increase in the use of HPS during the study period [OR=1.4; 95%CI (1.39-1.42)]. However, the racial differences shown in Figure 1 persisted and women were less likely to receive HPS than men (Odds Ratios [OR]=0.85; 95% CI 0.83-0.87). Conclusion: HPS use has increased following release of the ACC/AHA prevention guideline in the VA, though racial and gender disparities persist. Our findings highlight the continued need for targeted efforts to increase HPS use for women and certain minority groups. </jats:p

Abstract 094: Evaluation of Readmission and Survival Rates After Heart Failure Hospitalization in the Veterans Affairs Health Care System Between 2006 and 2013

Objective: Evaluate trends in readmission and mortality rates after heart failure (HF) hospitalization among veterans in the era of improved utilization of guideline directed therapy and nation-wide focus on decreasing hospital readmission rates. Background: In the past decade, a strong emphasis has been placed on decreasing HF readmissions. Concurrently, adherence to guideline directed therapy has improved. A 2002 to 2006 evaluation of the Veterans Affairs Health Care System (VAHCS) showed stagnant HF readmission rates, but declining mortality rates. It is unclear to what extent the recent focus on decreasing readmission and following guidelines has affected these outcomes. Methods: The 30-day mortality and 30-day readmission rates of patients admitted with a first diagnosis of HF from 2006 to 2013 in the VAHCS were assessed for temporal trends. Odds ratios for these outcomes were adjusted for patient demographics, medical history, and laboratory data. Results: This study included 119,261 patients admitted to VAHCS institutions between 2006 and 2013 with a new diagnosis of HF. Among these patients, 116,849 were male, the mean age was 71.1 years, 80,497 were white, 24,753 were black, and 6,548 were Hispanic. During the two years preceding admission, the incidence of renal disease, ischemic heart disease, diabetes, malignancy, hypertension, COPD, CVD, and acute myocardial infarction were 46.1% (54,984 of 119,261), 73.5% (87,640 of 119,261), 56.1% (66,883 of 119,261), 16.2% (19,257 of 119,261), 92.8% (110,687 of 119,261), 53.7% (64,064 of 119,261), 22.9% (27,268 of 119,261), and 26.5% (31,619 of 119,261), respectively. During the study period, the 30-day readmission rate declined from 19.56% (3852 of 19,694) to 13.76% (1420 of 10,317, p &lt; 0.0001) with an adjusted odds ratio of 30-day readmission in 2013 (vs 2006) of 0.66 (95% CI: 0.66 to 0.76) (Figure 1). Conversely, the 30-day mortality rate was stable at 5.62% (1107 of 19,694) in 2006 and 5.30% (547 of 10,317) in 2013 (p = 0.45) with an adjusted odds ratio of 30-day mortality in 2013 (vs 2006) of 1.22 (95% CI: 1.09 to 1.37). This odds ratio was stable from 2007 through 2013. Conclusions: Despite the observed decline in 30-day readmission rates, 30-day mortality rates have been unaffected by the recent focus on preventing readmission and improved guideline adherence. </jats:p

Use of A Community of Practice For The Implementation of Evidence-Based Practices For Heart Failure Within The United States Department of Veterans Affairs

Abstract Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). COPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. Formation: In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established in the United States (US) Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. The CoP has involved a total of 1,341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Examples of CoP activities include discussions of interventions to decrease hospitalization rates and to empower patients and caregivers for self-management. Goals of the CoP include networking facilitation, information dissemination and exchange, collaboration and implementation of EBPs. Assessment: We conceptualized the assessment (formative evaluation) of the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual-level, and its distal and ultimate impacts (outcomes) at the site-level leading to an improved culture of implementation of new/improved EBPs at the system-wide level. The HF Network membership grew steadily over the nine years. Most members were practicing clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%), and others (n = 38, 2.8%). Participation was “active” for 70.9% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership. Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Members, particularly those that consider themselves influential in improving quality of care, noted multiple benefits of membership. These included confirmation of one’s own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programs.</jats:p

Use of a Community of Practice for the Implementation of Evidence-based Practices for Heart Failure Within the United States Department of Veterans Affairs

Abstract Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). COPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities.Formation: In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established in the United States (US) Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. The CoP has involved a total of 1,341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Examples of CoP activities include discussions of interventions to decrease hospitalization rates and to empower patients and caregivers for self-management. Goals of the CoP include networking facilitation, information dissemination and exchange, collaboration and implementation of EBPs.Assessment: We conceptualized the assessment (formative evaluation) of the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual-level, and its distal and ultimate impacts (outcomes) at the site-level leading to an improved culture of implementation of new/improved EBPs at the system-wide level.The HF Network membership grew steadily over the nine years. Most members were practicing clinicians (n=891, 66.4%), followed by administrators (n=342, 25.5%), researchers (n=70, 5.2%), and others (n=38, 2.8%). Participation was “active” for 70.9% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership.Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Members, particularly those that consider themselves influential in improving quality of care, noted multiple benefits of membership. These included confirmation of one’s own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programs.</jats:p

How successful was the use of a community of practice for the implementation of evidence-based practices for heart failure within the United States Department of Veterans Affairs: Insights from a formative evaluation

Abstract Background Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustained over 9 years, and evaluates its value and impact on EBP. Methods In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level. Results The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA Health Care Systems (sites). Most members were practising clinicians (n = 891, 66.4%), followed by administrators (n = 342, 25.5%), researchers (n = 70, 5.2%) and others (n = 38, 2.8%). Participation was assessed to be “active” for 70.6% versus “passive” for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership. Conclusions Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives. </jats:sec

Association between intensity of statin therapy and mortality in patients with atherosclerotic cardiovascular disease

Importance: High-intensity statin therapy is recommended for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Nevertheless, statin therapy in general, and high-intensity statin therapy in particular, is underused in patients with established ASCVD.Objective: To determine the association between all-cause mortality and intensity of statin therapy in the Veterans Affairs health care system.Design, setting, and participants: A retrospective cohort analysis was conducted of patients aged 21 to 84 years with ASCVD treated in the Veterans Affairs health care system from April 1, 2013, to April 1, 2014. Patients who were included had 1 or more International Classification of Diseases, Ninth Revision codes for ASCVD on 2 or more different dates in the prior 2 years.Exposures: Intensity of statin therapy was defined by the 2013 American College of Cardiology/American Heart Association guidelines, and use was defined as a filled prescription in the prior 6 months. Patients were excluded if they were taking a higher statin dose in the prior 5 years.Main outcomes and measures: The primary outcome was death from all causes adjusted for the propensity to receive high-intensity statins.Results: The study sample included 509 766 eligible adults with ASCVD at baseline (mean [SD] age, 68.5 [8.8] years; 499 598 men and 10 168 women), including 150 928 (29.6%) receiving high-intensity statin therapy, 232 293 (45.6%) receiving moderate-intensity statin therapy, 33 920 (6.7%) receiving low-intensity statin therapy, and 92 625 (18.2%) receiving no statins. During a mean follow-up of 492 days, there was a graded association between intensity of statin therapy and mortality, with 1-year mortality rates of 4.0% (5103 of 126 139) for those receiving high-intensity statin therapy, 4.8% (9703 of 200 709) for those receiving moderate-intensity statin therapy, 5.7% (1632 of 28 765) for those receiving low-intensity statin therapy, and 6.6% (4868 of 73 728) for those receiving no statin (P \u3c .001). After adjusting for the propensity to receive high-intensity statins, the hazard ratio for mortality was 0.91 (95% CI, 0.88-0.93) for those receiving high- vs moderate-intensity statins. The magnitude of benefit of high- vs moderate-intensity statins was similar, for an incident cohort hazard ratio of 0.93 (95% CI, 0.85-1.01). For patients aged 76 to 84 years, the hazard ratio was 0.91 (95% CI, 0.87-0.95). Patients treated with maximal doses of high-intensity statins had lower mortality (hazard ratio, 0.90; 95% CI, 0.87-0.94) compared with those receiving submaximal doses.Conclusions and relevance: We found a graded association between intensity of statin therapy and mortality in a national sample of patients with ASCVD. High-intensity statins were associated with a small but significant survival advantage compared with moderate-intensity statins, even among older adults. Maximal doses of high-intensity statins were associated with a further survival benefit