Staff Experiences With Implementation of the Referral Coordination Initiative.

Objective: To understand VHA staff experiences with the referral coordination initiative (RCI) following nationwide dissemination.

Study Setting And Design: RCI uses a team-based approach to improve the timeliness, efficiency, and patient-centeredness of specialty care referrals, while redistributing the time-intensive triage tasks from specialist providers to nurses. To assess frontline experiences with RCI, we purposively sampled four VHA sites for qualitative interviews, ensuring variability around the use of nurses in triage and the organization of scheduling staff within three high-volume specialties: cardiology, gastroenterology, and pulmonary.

Multifaceted Intervention to Improve P2Y12 Inhibitor Adherence After Percutaneous Coronary Intervention: A Stepped Wedge Trial.

Background P2Y12 inhibitor medications are critical following percutaneous coronary intervention (PCI); however, adherence remains suboptimal. Our objective was to assess the effectiveness of a multifaceted intervention to improve P2Y12 inhibitor adherence following PCI. Methods and Results This was a modified stepped wedge trial of 52 eligible hospitals, of which 15 were randomly selected and agreed to participate (29 hospitals declined, and 8 eligible hospitals were not contacted).

Contemporary Clinical and Coronary Anatomic Risk Model for 30-Day Mortality After Percutaneous Coronary Intervention.

Background: Percutaneous coronary intervention (PCI) procedures are increasing in clinical and anatomic complexity, likely increasing the calculated risk of mortality. There is need for a real-time risk prediction tool that includes clinical and coronary anatomic information that is integrated into the electronic medical record system.

Methods: We assessed 70 503 PCIs performed in 73 Veterans Affairs hospitals from 2008 to 2019.

Impact of Operator Volumes and Experience on Outcomes After Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting and Tracking (CART) Program.

Background: Recent analyses of the volume-outcome relationship for percutaneous coronary intervention (PCI) have suggested a less robust association than previously reported. It is unknown if novel factors such as lifetime operator experience influence this relationship.

Objectives: To assess the relationship between annual volumes and outcomes for PCI and determine whether lifetime operator experience modulates the association.

Comparison of Patients With Nonobstructive Coronary Artery Disease With Versus Without Myocardial Infarction (from the VA Clinical Assessment Reporting and Tracking [CART] Program).

Comparisons of the outcomes of patients with myocardial infarction with nonobstructive coronary artery disease (MINOCA) and patients with nonobstructive coronary artery disease (CAD) without myocardial infarction (MI) are limited. Here we compare the outcomes of patients with MINOCA and patients with nonobstructive CAD without MI and assess the influence of medical therapy on outcomes in these patients. Veterans who underwent coronary angiography between 2008 to 2017 with nonobstructive CAD were divided into those with or without pre-procedural troponin elevation.

Development and Implementation of an In-Hospital Bleeding Risk Model for Percutaneous Coronary Intervention.

Background: Bleeding is a common complication of percutaneous coronary intervention (PCI) that is associated with worse clinical outcomes and increased costs. Improved pre-procedural bleeding risk prediction could promote strategies that have been shown to reduce post-PCI bleeding, including increased adoption of radial access.

Methods: We studied patients in the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program receiving PCI in VA hospitals.

The Impact of Performing a 3D Mapping Biopsy Prior to Primary Cryotherapy for the Treatment of Prostate Cancer.

Objective: To study the implications of adding a 3D mapping biopsy (3DMB) prior to prostate cryotherapy (PCT) for the treatment of prostate cancer on the following outcomes: recurrence and biochemical failure (BCF), quality of life outcomes, and complication rates.

Methods: A retrospective analysis of patients treated with either targeted focal therapy, or subtotal CT for localized prostate cancer was performed. The cohort was stratified by patients who had only had a transrectal ultrasound-guided biopsy (TRUS) and those who had undergone 1 additional 3DMB before definitive treatment.

Perceptions of Public and Nonpublic Reporting of Interventional Cardiology Outcomes and Its Impact on Practice: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Background Physicians have expressed significant mistrust with public reporting of interventional cardiology outcomes. Similar data are not available on alternative reporting structures, including nonpublic quality improvement programs with internally distributed measures of interventional quality. We thus sought to evaluate the perceptions of public and nonpublic reporting of interventional cardiology outcomes and its impact on clinical practice.

Same-day discharge among patients undergoing elective PCI: Insights from the VA CART Program.

Background: Available data suggest that same-day discharge (SDD) after elective percutaneous coronary intervention (PCI) is safe in select patients. Yet, little is known about contemporary adoption rates, safety, and costs in a universal health care system like the Veterans Affairs Health System.

Methods: Using data from the Veterans Affairs Clinical Assessment Reporting and Tracking Program linked with Health Economics Resource Center data, patients undergoing elective PCI for stable angina between October 1, 2007 and Sepetember 30, 2016, were stratified by SDD versus overnight stay.

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

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.

Improving anti-platelet therapy adherence in the Veterans Health Administration: A randomized multi-site hybrid effectiveness-implementation study protocol.

Background: P2Y12 inhibitors are critical following percutaneous coronary intervention (PCI) with stent placement; they reduce the risk of stent thrombosis and myocardial infarction. Despite the importance of the therapy, non-adherence is common among Veterans.

Methods And Results: Our main objective is to conduct a multi-site randomized stepped wedge trial to test the effectiveness of a multi-faceted intervention to improve adherence to P2Y12 inhibitors and PCI outcomes as well as formatively evaluate and refine the intervention implementation process.

Temporal Trends in Coronary Angiography and Percutaneous Coronary Intervention: Insights From the VA Clinical Assessment, Reporting, and Tracking Program.

Objectives: The aim of this study was to evaluate temporal trends in characteristics and outcomes among patients referred for invasive coronary procedures within a national health care system for veterans.

Background: Coronary angiography and percutaneous coronary intervention remain instrumental diagnostic and therapeutic interventions for coronary artery disease.

Methods: All coronary angiographic studies and interventions performed in U.

Prospective Outcome Analysis of the Safety and Efficacy of Partial and Complete Cryoablation in Organ-confined Prostate Cancer.

Objective: To determine the rate of complications and change in International Prostate Symptom Score and Sexual Health Inventory for Men scores following cryotherapy treatment of low- and intermediate-risk prostate cancer. The secondary end points were the change in prostate-specific antigen post cryotherapy and biopsy-proven recurrence.

Materials And Methods: Enrollment occurred from 2007 to 2015 to assess long-term complications of cryotherapy.

Incidence, procedural management, and clinical outcomes of coronary in-stent restenosis: Insights from the National VA CART Program.

Backround: In-stent restenosis (ISR) remains a common clinical problem associated with significant morbidity. We sought to evaluate the temporal trends in incidence and procedural management of coronary restenosis as well as evaluate the association between different treatment modalities and clinical outcomes.

Methods: We identified all patients treated for coronary ISR within the Veterans Affairs Healthcare System from October 1, 2006 to September 30, 2014.

Primary non-transecting bulbar urethroplasty long-term success rates are similar to transecting urethroplasty.

Objectives: To review the long-term outcomes of transecting versus non-transecting urethroplasty to repair bulbar urethral strictures.

Methods: A retrospective review was conducted of 342 patients who underwent anterior urethroplasty performed by a single surgeon from 2003 to 2014. Patients were excluded from further analysis if there had been prior urethroplasty, stricture location outside the bulbous urethra, or age <18 years.

Guideline Recommended Medical Therapy for Cardiovascular Diseases in the Obese: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program.

Background: Stigma against the obese is well described in health care and may contribute to disparities in medical decision-making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline-recommended medications in patients undergoing elective percutaneous coronary intervention.

Hospital Variation in Premature Clopidogrel Discontinuation After Drug-Eluting Stent Placement in the Veterans Affairs (VA) Healthcare System.

Background: Premature clopidogrel discontinuation after drug-eluting stent placement is associated with adverse outcomes. Little is known about patient and hospital factors associated with premature discontinuation or whether less variation in premature discontinuation exists in integrated health care systems such as the Veterans Affairs (VA).

Methods And Results: We evaluated the frequency of premature clopidogrel discontinuation, defined as a gap between clopidogrel refills of ≥90 days during the first 6 months of treatment, among 12 707 patients who received drug-eluting stents in VA hospitals between 2008 and 2010.

Percutaneous Coronary Intervention in Native Coronary Arteries Versus Bypass Grafts in Patients With Prior Coronary Artery Bypass Graft Surgery: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

Objectives: The aim of this study was to examine the frequency, associations, and outcomes of native coronary artery versus bypass graft percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (CABG) in the Veterans Affairs (VA) integrated health care system.

Background: Patients with prior CABG surgery often undergo PCI, but the association between PCI target vessel and short- and long-term outcomes has received limited study.

Methods: A national cohort of 11,118 veterans with prior CABG who underwent PCI between October 2005 and September 2013 at 67 VA hospitals was examined, and the outcomes of patients who underwent native coronary versus bypass graft PCI were compared.

Facility-Level Variation in Hospitalization, Mortality, and Costs in the 30 Days After Percutaneous Coronary Intervention: Insights on Short-Term Healthcare Value From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System (VA CART) Program.

Background: Policies to reduce unnecessary hospitalizations after percutaneous coronary intervention (PCI) are intended to improve healthcare value by reducing costs while maintaining patient outcomes. Whether facility-level hospitalization rates after PCI are associated with cost of care is unknown.

Methods And Results: We studied 32,080 patients who received PCI at any 1 of 62 Veterans Affairs hospitals from 2008 to 2011.

1-year risk-adjusted mortality and costs of percutaneous coronary intervention in the Veterans Health Administration: insights from the VA CART Program.

Background: There is significant interest in measuring health care value, but this concept has not been operationalized in specific patient cohorts. The longitudinal outcomes and costs for patients after percutaneous coronary intervention (PCI) provide an opportunity to measure an aspect of health care value.

Objectives: This study evaluated variations in 1-year outcomes (risk-adjusted mortality) and risk-standardized costs of care for all patients undergoing PCI in the Veterans Affairs (VA) system from 2007 to 2010.

Clopidogrel prescription filling delays and cardiovascular outcomes in a pharmacy system integrating inpatient and outpatient care: insights from the Veterans Affairs CART Program.

Background: Delays in filling clopidogrel prescriptions after percutaneous coronary intervention (PCI) have been demonstrated previously and associated with adverse outcomes.

Methods: This was a retrospective cohort study of 11,418 patients undergoing PCI with stent placement in Veterans Affairs (VA) hospitals between January 1, 2005, and September 30, 2010. Data were obtained from the national VA Clinical Assessment, Reporting, and Tracking Program, including post-PCI clopidogrel prescription fill date and outcomes of myocardial infarction and death within 90 days of discharge.

Normal anatomic relationships in prepubescent female external genitalia.

Objective: Female congenital abnormalities and concomitant ambiguous genitalia constitute the primary reason for female genital reconstruction, however, objective data describing normal female anatomy is lacking. The aim of this study is to describe the normal anatomical relationships and size of the external genital structures in prepubescent females.

Materials And Methods: Data were collected prospectively from consecutive Tanner stage 1 females undergoing surgery unrelated to the genitalia.

Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels.

Importance: Rates of testosterone therapy are increasing and the effects of testosterone therapy on cardiovascular outcomes and mortality are unknown. A recent randomized clinical trial of testosterone therapy in men with a high prevalence of cardiovascular diseases was stopped prematurely due to adverse cardiovascular events raising concerns about testosterone therapy safety.

Objectives: To assess the association between testosterone therapy and all-cause mortality, myocardial infarction (MI), or stroke among male veterans and to determine whether this association is modified by underlying coronary artery disease.