This research letter describes how the opt-in requirement federal regulations for text messaging influenced the study population of those who opted-in or opted-out of a clinical trial using text messages to improve cardiovascular (CV) health.

Importance:The Department of Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded opportunities for veterans to obtain care outside the VA. However, the impact on health care outcomes is uncertain. Objective:To measure the MISSION Act's impact on travel times and outcomes of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and aortic valve replacement (AVR). Design, Setting, and Participants:This retrospective difference-in-differences cohort study included veterans receiving nonemergent/nonurgent PCI, CABG, or AVR between October 2016 and September 2022 in non-VA hospitals under MISSION Act coverage or in VA hospitals in the 48 contiguous US states or the District of Columbia. Analyses were conducted in 2023-2024. Exposures:Veterans eligible for non-VA care under the MISSION Act by living far from ( >60 minutes) the nearest VA medical center vs veterans living near (≤60 minutes) a VA medical center. Main Outcomes and Measures:Major adverse cardiovascular events (MACE), defined as rehospitalization for cardiovascular cause or mortality within 30 days of the procedure, and travel times for care were the primary outcomes. Results:The cohort comprised veterans receiving PCI (n = 43 000; 42 066 [98%] male; mean [SD] age, 69 [8.8] years), CABG (n = 23 301; 22 197 [98%] male; mean [SD] age, 69 [7.7] years), or AVR (n = 14 682; 14 336 [98%] male; mean [SD] age, 74 [9.6] years). After MISSION implementation, mean PCI travel times increased by 1.3 minutes for near patients and decreased by 29.2 minutes for far patients (difference in differences, -30.5 minutes; P < .001). Mean CABG travel times increased by 9.4 minutes for near patients and decreased by 18.1 minutes for far patients (difference in differences, -27.4 minutes; P < .001). Mean travel times for AVR increased by 10.0 minutes for near patients and decreased by 23.0 minutes for far patients (difference in differences, -33.1 minutes; P < .001). After MISSION implementation, mean PCI MACE rates decreased by 0.5 percentage points for near patients and increased by 2.3 percentage points for far patients (difference in differences, 2.8 percentage points; P <.001). Mean CABG MACE rates decreased by 6.5 percentage points for near patients and increased by 1.6 percentage points for far patients (difference in differences, 8.1 percentage points; P < .001). AVR MACE rates were not statistically different between the groups (P = .45). Conclusions and Relevance:MISSION Act implementation was associated with substantial decreases in travel times among veterans who became geographically eligible for non-VA care. For these patients undergoing PCI or CABG, MISSION Act implementation was also associated with worsened 30-day MACE rates.

BACKGROUND:Ineligibility for surgical revascularization is increasingly prevalent and associated with increased mortality after percutaneous coronary intervention (PCI). High-quality, contemporary, multicenter data regarding clinical outcomes after PCI is scarce and poses a barrier to clinical decision-making for surgically ineligible patients. The aim of this study was to describe and compare the clinical characteristics, institutional variation, and longitudinal outcomes of PCI among surgically eligible and ineligible patients in the Veterans Affairs Healthcare System. METHODS:Patients with left main and/or multivessel coronary artery disease undergoing index PCI between October 1, 2017 and September 30, 2022 were identified and the prevalence of surgical ineligibility determined by review of the electronic medical record. The association between surgical ineligibility and mortality and major adverse cardiovascular events (MACE; death, myocardial infarction, repeat revascularization, and stroke) was assessed. RESULTS:A total of 6192 patients with left main and/or multivessel coronary artery disease (842 surgically ineligible and 5350 surgically eligible) underwent PCI during the study period. After adjustment, surgical ineligibility was associated with a significantly decreased time to mortality (time ratio, 0.801 [95% CI, 0.662-0.970]) over a median 1045-day (interquartile range, 583-1600) follow-up period, though not associated with composite MACE (time ratio, 0.859 [95% CI, 0.685-1.078]). After adjustment for target lesion characteristics and procedural complexity, the association between surgical ineligibility and mortality was attenuated (time ratio, 0.842 [95% CI, 0.688-1.030]). CONCLUSIONS:Ineligibility for surgical revascularization was associated with increased risk of long-term mortality after PCI. The risk of adverse outcomes after PCI, however, was similar among surgically eligible and ineligible patients after adjusting for measured comorbidities, coronary anatomic features, and procedural complexity.

BACKGROUND:The Veterans Affairs (VA) Healthcare System maintains the largest integrated health system in the United States but also supports fee-for-service insurance for veterans receiving care in community facilities outside the VA. We sought to evaluate the management and outcomes of patients referred for consultation in either venue, using cardiovascular evaluation as a model. METHODS:We conducted a retrospective cohort study identifying patients enrolled in the VA Healthcare System referred for cardiovascular evaluation from October 2020 through September 2024 and stratified the population based on the venue in which evaluation was completed. The primary outcome was major adverse cardiovascular events (acute coronary syndromes/stroke/mortality) in a matched population. RESULTS:Among 235 197 consultations for cardiovascular evaluation, 201 453 were completed in the chosen venue within 6 months. The time between consultation and evaluation was similar across venues (community, 35 days [95% CI, 17-65] versus VA, 33 days [95% CI, 19-53]), with comparable delays to diagnostic testing or therapeutic interventions. Patients receiving care in the community were more likely to undergo stress testing (43.2% versus 36.4%, P=1.5×10-46) and coronary angiography (23.1% versus 17.4%, P=2.1×10-51) within 2 years compared with those treated in the VA Healthcare System. Despite this, patients treated in the community had a significantly higher rate of major adverse events at 2 years (17.6% versus 15.3%, P=5.9×10-10) compared with those treated in the VA Healthcare System. CONCLUSIONS:Patients undergoing cardiovascular evaluation in community practices were not evaluated more rapidly than those seen in the VA, though they were more likely to receive initial and repeat diagnostic testing. Adverse events were more common among community-treated patients than those in the VA, suggesting an opportunity to optimize access to care while improving clinical outcomes.

ImportancePoor medication adherence is common. Text messaging is increasingly used to change patient behavior but often not rigorously tested. ObjectiveTo compare different types of text messaging strategies with usual care to improve medication refill adherence among patients nonadherent to cardiovascular medications. Design, Setting, and ParticipantsPatient-level randomized pragmatic trial between October 2019 to April 2022 at 3 US health care systems, with last follow-up date of April 11, 2023. Adult (18 to <90 years) patients were eligible based on diagnosis of 1 or more cardiovascular condition(s) and prescribed medication to treat the condition. Patients who did not opt out and had a 7-day refill gap were randomized to 1 of 4 study groups. Intervention(s)Generic text message refill reminders (generic reminder); behavioral nudge text refill reminders (behavioral nudge); behavioral nudge text refill reminders plus a fixed-message chatbot (behavioral nudge + chatbot); usual care. Main Outcomes and MeasuresPrimary outcome was refill adherence based on pharmacy data using proportion of days covered at 12 months. Secondary outcomes were clinical events of emergency department visits, hospitalizations, and mortality. ResultsAmong 9501 enrolled patients, baseline characteristics across the 4 groups were comparable (mean age, 60 years; 47% female [n = 4351]; 16% Black [n = 1517]; 49% Hispanic [n = 4564]). At 12 months, the mean proportion of days covered was 62.0% for generic reminder, 62.3% for behavioral nudge, 63.0% for behavioral nudge + chatbot, and 60.6% for usual care (P = .06). In adjusted analysis, when compared with usual care, mean proportion of days covered was 2.2 percentage points (95% CI, 0.3-4.2; P = .02) higher for generic reminder, 2.0 percentage points (95% CI, 0.1-3.9; P = .04) higher for behavioral nudge, and 2.3 percentage points (95%, 0.4-4.2; P = .02) higher for behavioral nudge + chatbot, none of which were statistically significant after multiple comparisons correction. There were no differences in clinical events between study groups. Conclusions and RelevanceText message reminders targeting patients who delay refilling their cardiovascular medications did not improve medication adherence based on pharmacy refill data or reduce clinical events at 12 months. Poor medication adherence may be due to multiple factors. Future interventions may need to be designed to address the multiple factors influencing adherence. Trial RegistrationClinicalTrials.gov Identifier: NCT03973931

We conducted this secondary analysis to assess whether greater engagement with a text messaging intervention was associated with improved cardiovascular medication adherence at 12 months.

Background Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System. Methods and Results We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow‐up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794–0.928]) or 1 year (HR, 0.891 [95% CI, 0.842–0.943]), or receive prescriptions for guideline‐indicated cardiovascular medications. Despite this, 1‐year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747–0.948]). Conclusions Women are less likely to receive appropriate cardiovascular follow‐up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

Background Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking. Methods and Results As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m 2 , the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy. Conclusions These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.

We conducted a multi-center pragmatic trial of a low-risk intervention focused on medication adherence using an opt-out consent approach, where patients could opt out by letter and then electronically. We focus on the cohort after opt-out by mail. Here, we describe that 8% of patients opted out electronically, resulting in a 92% participation rate. Patients who self-identify as Black or Hispanic were less likely to opt out in the study, and half the study cohort was female. This demographic data is useful for planning future trials employing this approach.

Abstract Background Many patients with coronary artery disease (CAD) do not achieve guideline-directed low-density lipoprotein cholesterol (LDL-C) goals (1,2). Purpose To quantify unrealized opportunities to improve clinical outcomes of Veterans with CAD through optimized oral lipid-lowering therapy (LLT) with statins and ezetimibe within the United States Veterans Affairs healthcare system. Methods Veterans with CAD by coronary angiography between 2015 and 2020 were identified, the observed LLT and LDL-C were described, and the observed rates of death, myocardial infarction, stroke, and coronary revascularization were determined. Potential reductions in these events with optimized statin alone or with ezetimibe were modelled based on expected further LDL-C reductions (3). Results The analysis cohort comprised 111,954 Veterans (59.7% statin-treated at baseline angiography) observed for median 3.4 (IQR 2.1-4.0) years. At 6 months, statin prescription increased to 68.7%, but high-intensity statin regimens were prescribed in only 52.9%, ezetimibe use was low (1.1%), and LDL-C remained ≥70 mg/dL in 52.1% of patients. At 4 years, observed incidences (95% CI) of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (21.3-21.8), 5.0% (4.9-5.2), 2.2% (2.1-2.3), and 15.4% (15.2-15.7), respectively (Figure 1). With optimized statin, projected absolute reductions in these incidences were 1.3% (0.9-1.7), 0.8% (0.7-1.0), 0.2% (0.1-0.3), and 2.3% (2.0-2.7). With optimized statin and ezetimibe, projected absolute reductions were 1.8% (1.2-2.4), 1.1% (0.9-1.3), 0.3% (0.2-0.4) and 3.1% (2.6-3.6). Conclusions Suboptimal LLT was prevalent among Veterans with CAD. Meaningful improvements in their cardiovascular outcomes could be achieved with optimized statin alone. Despite lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level could contribute substantially to cardiovascular risk reduction from intensified oral LLT.Figure 1Figure 2

To the Editor, Previous research has demonstrated improved outcomes among patients receiving prasugrel and ticagrelor after percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). Consequently, current European (2014) and United States (2016) guidelines recommend the preferred use of these agents over clopidogrel with a Class Ib and IIa recommendation respectively. Despite this, the preferential use of prasugrel and ticagrelor has been inconsistent with significant site variation. Further, the contemporary use of these antiplatelet agents have not been extensively evaluated since societal guideline updates reinforced their favored use or after availability of trial data comparing ticagrelor with prasugrel. The degree of site level variation in a noncommercially insured patient population is also unknown. We thus evaluated the temporal trends and hospital variation in utilization of P2Y12 inhibitors in patients undergoing PCI in the largest integrated healthcare system in the United States, the veterans affairs (VA) healthcare system. A total of 44,525 patients underwent coronary revascularization for ST‐elevation myocardial infarction (STEMI) or non‐STEMI across 69 VA hospitals that performed ≥50 such procedures between 2008 and 2022. P2Y12 inhibitor information was collected from outpatient fills 30‐days prior or 100‐days post‐PCI, and within a 7‐day window around the procedure for inpatient fills including peri‐procedural medications. To account for potential transitions during the hospitalization, priority was given to ticagrelor, followed by prasugrel and then clopidogrel. Hospital variation in the use of these agents was evaluated. Clopidogrel utilization decreased from 97.0% in 2008 to 55.9% in 2022 with a concurrent increase in the use of ticagrelor (1.0%–38.0%) and a modest increase in prasugrel (0%–5.4%, Figure 1A). Increased ticagrelor utilization was observed starting in 2014 with a steady increase to 2022. An increase in the use of prasugrel was seen in 2011 until 2014, with a subsequent steady decline. Significant institutional variation was observed in the use of all P2Y12 inhibitors (Figure 1B). The median institutional rate of ticagrelor in patients with STEMI or non‐STEMI was 12.6% (interquartile range [IQR]: 6.1%−24.5%), which increased to 20.9% (IQR: 10.4%−41.2%) since 2015, although utilization ranged from a low of 1.7%−77.9% in these patients. This study shows the contemporary use of currently available oral antiplatelet agents in patients undergoing PCI. Previous research evaluated the utilization of antiplatelet agents in STEMI, though it may not have captured the trends following the 2016 guidelines update, head‐to‐head comparison of ticagrelor and prasugrel, and generic availability of prasugrel. The present data address these limitations with a more contemporary cohort encapsulating additional forms of ACS, though still demonstrates that ticagrelor is only being prescribed in 38.0% of patients undergoing coronary revascularization for STEMI or non‐STEMI. The use of prasugrel has also remained low, which may in part be related to its contraindication in patients with prior stroke and uncertain benefit in patients over 75 years of age. This is particularly surprising given recent data suggesting that prasugrel results in a lower incidence of cardiovascular events compared to ticagrelor. Despite including more recent data and a broader population, we demonstrate that clopidogrel remains the most widely prescribed antiplatelet agent for patients undergoing coronary revascularization for myocardial infarction in a large integrated healthcare system, in contrast to current guideline recommendations. The reasons for low utilization of evidence‐based antiplatelet therapy may stem from patient, physician, or hospital‐related factors. While insurance and prescription costs affecting patient adherence are reported to be reasons to select clopidogrel, this does not apply in the VA Healthcare System. Patient tolerance may result in preferential use of a particular agent. Additionally, physician behavior and clinical practice change frequently lag behind guidelines by several years due to lack of knowledge and familiarity with newer treatments, inertia to change practice, or disagreement with guidelines. Hospital site is reported to be the strongest predictor of the type of antiplatelet used, which is consistent with the significant site variation observed in our study. This variation persists despite all sites being part of the same Healthcare System with relatively uniform administrations and formulary agreements. Because of this, cultural shifts among geographically dispersed physicians may play a prominent role in preventing complete guideline concordance. These

PURPOSE:The Nudge Study is a patient level-randomized trial testing different text message medication refill reminders sent to patients assigned to 4 arms: (1) usual care, (2) generic text, (3) optimized text, and (4) optimized text plus chatbot. This report describes the frequency and types of patient questions sent to clinical pharmacists (CPs) following text reminders.METHODS:Patients were enrolled from Denver Health and Hospital Authority (DHHA) and Veterans Affairs Eastern Colorado Health Care System (VA ECHCS) from October 1, 2019, through May 30, 2021. Included patients responded to at least 1 text or interactive voice response (IVR) message. Patients were dichotomized as those who posed at least 1 question to a CP and those who posed no questions.RESULTS:Of the 6,325 patients enrolled in an intervention arm, 3,323 (52.5%) responded to at least 1 text or IVR message, and among those responding, 305 (9.2%) responded with a pharmacist question. Patient factors associated with submitting a CP question included age (45-74 years), enrollment from DHHA, and receipt of the optimized text or optimized text plus chatbot message versus the generic text. Questions to CP were in the following categories: medication related (48.2%), refill logistics (38.4%), cost (9.2%), and other (17.7%).CONCLUSION:In a text messaging intervention focused on medication refills, there were few questions directed to the CP. Patients assigned to receive optimized texts were more likely to have questions. We hypothesize that this may suggest greater patient engagement regarding their condition, resulting in more questions.

ImportanceMany patients with coronary artery disease (CAD) do not achieve the guideline-directed goals for low-density lipoprotein cholesterol (LDL-C) levels.ObjectiveTo estimate reductions in the rates of adverse events associated with CAD in a large US military veteran population that may be achieved through use of optimized statin therapy alone or with ezetimibe compared with the prevailing lipid-lowering therapy (LLT).Design, Setting, and ParticipantsIn this observational cohort study, US military veterans with CAD were identified by coronary angiography between June 2015 and September 2020 across 82 US Department of Veterans Affairs health care facilities.ExposuresThe exposures were observed LLT, LLT with an optimized statin regimen, and LLT with optimized statin and ezetimibe.Main Outcomes and MeasuresObserved rates of death, myocardial infarction, stroke, and coronary revascularization, and potential reductions in those outcomes with optimized LLT based on expected further reductions in LDL-C levels and application of formulas from The Cholesterol Treatment Trialists’ Collaboration.ResultsThe analysis cohort comprised 111 954 veterans (mean [SD] age, 68.4 [8.8] years; 109 390 men [97.7%]; 91 589 White patients [81.8%]; 17 592 Black patients [15.7%]). The median (IQR) observation period for this study was 3.4 (2.1-4.0) years. At the time of index angiography, 66 877 patients (59.7%) were treated with statin therapy, and 623 patients (0.6%) were treated with ezetimibe. At 6 months, the number of patients with statin prescriptions increased to 74 400 (68.7%), but the number of patients with high-intensity statin prescriptions was only 57 297 (52.9%). At 6 months, ezetimibe use remained low (n = 1168 [1.1%]), and LDL-C levels were 70 mg/dL or more in 56 405 patients (52.1%). At 4 years, observed incidences of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (95% CI, 21.3%-21.8%), 5.0% (95% CI, 4.9%-5.2%), 2.2% (95% CI, 2.1%-2.3%), and 15.4% (95% CI, 15.2%-15.7%), respectively. With optimized statin treatment, projected absolute reductions in these incidences were 1.3% (95% CI, 0.9%-1.7%), 0.8% (95% CI, 0.7%-1.0%), 0.2% (95% CI, 0.1%-0.3%), and 2.3% (95% CI, 2.0%-2.7%), respectively. With optimized statin and ezetimibe treatment, projected absolute reductions were 1.8% (95% CI, 1.2%-2.4%), 1.1% (95% CI, 0.9%-1.3%), 0.3% (95% CI, 0.2%-0.4%), and 3.1% (95% CI, 2.6%-3.6%), respectively.Conclusions and RelevanceIn this cohort study of veterans with CAD, suboptimal LLT was prevalent in the clinical setting. Optimization of statin therapy was projected to produce clinically relevant reductions in the risks of death and cardiovascular events. Despite a lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level in conjunction with optimized statin therapy may be associated with further meaningful reductions in cardiovascular risk.

The role for direct current cardioversion (DCCV) in the management of atrial fibrillation (AF) in the emergency department (ED) is unclear. Factors associated with DCCV in current practice are not well described, nor is the variation across patients and institutions. All ED encounters with a primary diagnosis of AF were identified from the Nationwide Emergency Department Sample from 2006 to 2017. The independent association of patient and hospital factors with use of DCCV was assessed using multivariable hierarchical logistic regression. The relative contributions of patient, hospital, and unmeasured hospital factors were assessed using reference effect measures methods. Among 1,280,914 visits to 3,264 EDs with primary diagnosis of AF, 31,422 patients (2.4%) underwent DCCV in the ED. History of stroke (odds ratio [OR] 0.14, 95% confidence interval [CI] 0.09 to 0.22, p <0.001) and dementia (OR 0.14, 95% CI 0.10 to 0.19, p <0.001) was associated with lowest odds of DCCV. Comparing patients more likely to receive DCCV (ninety-fifth percentile) with patients with median risk, the influence of unmeasured hospital factors (OR 14.13, 95% CI 12.55 to 16.09) exceeded the contributions of patient (OR 5.66, 95% CI 5.28 to 6.15) and measured hospital factors (OR 3.89, 95% CI 2.87 to 5.60). In conclusion, DCCV use in the ED varied widely across institutions. Disproportionately large unmeasured hospital variation suggests that presenting hospital is the most determinative factor in the use of DCCV for ED management of AF. Clarification is needed on best practices for management of AF in the ED, including the use of DCCV.

INTRODUCTION: The Veterans Health Administration introduced a clinical reminder system in 2018 to help address process gaps in colorectal cancer screening, including the diagnostic evaluation of positive fecal immunochemical test (FIT) results. We conducted a qualitative study to explore the differences between facilities who performed in the top vs bottom decile for follow-up colonoscopy. METHODS: Seventeen semistructured interviews with gastroenterology (GI) providers and staff were conducted at 9 high-performing and 8 low-performing sites. RESULTS: We identified 2 domains, current practices and perceived barriers, and most findings were described by both high- and low-performing sites. Findings exclusive to 1 group mainly pertained to current practices, especially arranging colonoscopy for FIT-positive patients. We observed only 1 difference in the perceived barriers domain, which pertained to primary care providers. DISCUSSION: These results suggest that what primarily distinguishes high- and low-performing sites is not a difference in barriers but rather in the GI clinical care process. Developing and disseminating patient education materials about the importance of diagnostic colonoscopy, eliminating in-person precolonoscopy visits when clinically appropriate, and involving GI in missed colonoscopy appointments and outside referrals should all be considered to increase follow-up colonoscopy rates. Our study illustrates the challenges of performing a timely colonoscopy after a positive FIT result and provides insights on improving the clinical care process for patients who are at substantially increased risk for colorectal cancer.

BackgroundAnatomical scoring systems have been used to assess completeness of revascularization but are challenging to apply to large real-world datasets.ObjectivesThe aim of this study was to assess the prevalence of complete revascularization and its association with longitudinal clinical outcomes in the U.S. Department of Veterans Affairs (VA) health care system using an automatically computed anatomic complexity score.MethodsPatients undergoing percutaneous coronary intervention (PCI) between October 1, 2007, and September 30, 2020, were identified, and the burden of prerevascularization and postrevascularization ischemic disease was quantified using the VA SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score. The association between residual VA SYNTAX score and long-term major adverse cardiovascular events (MACE; death, myocardial infarction, repeat revascularization, and stroke) was assessed.ResultsA total of 57,476 veterans underwent PCI during the study period. After adjustment, the highest tertile of residual VA SYNTAX score was associated with increased hazard of MACE (HR: 2.06; 95% CI: 1.98-2.15) and death (HR: 1.50; 95% CI: 1.41-1.59) at 3 years compared to complete revascularization (residual VA SYNTAX score = 0). Hazard of 1- and 3-year MACE increased as a function of residual disease, regardless of baseline disease severity or initial presentation with acute or chronic coronary syndrome.ConclusionsResidual ischemic disease was strongly associated with long-term clinical outcomes in a contemporary national cohort of PCI patients. Automatically computed anatomic complexity scores can be used to assess the longitudinal risk for residual ischemic disease after PCI and may be implemented to improve interventional quality.

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.