Steven M Bradley

VA Eastern Colorado Health Care System, Denver, Colorado, United States

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Publications (35)211.29 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: -The safety of percutaneous coronary intervention (PCI) at medical facilities without on-site cardiothoracic (CT) surgery has been established in clinical trials. However, the comparative effectiveness of this strategy in real world practice, including impact on patient access and outcomes, is uncertain. The Veterans Affairs (VA) health care system has employed this strategy, with strict quality oversight, since 2005, and can provide insight into this question.
    Circulation 09/2014; · 15.20 Impact Factor
  • Steven M Bradley
    Circulation Cardiovascular Quality and Outcomes 09/2014; · 5.66 Impact Factor
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    ABSTRACT: Posttraumatic stress disorder (PTSD) is prevalent in the general population and US veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and postprocedural outcomes of veterans with and without PTSD undergoing coronary angiography.
    American heart journal. 09/2014; 168(3):381-390.e6.
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    ABSTRACT: Diagnostic coronary angiography in asymptomatic patients may lead to inappropriate percutaneous coronary intervention (PCI) due to a diagnostic-therapeutic cascade. Understanding the association between patient selection for coronary angiography and PCI appropriateness may inform strategies to minimize inappropriate procedures.
    JAMA Internal Medicine 08/2014; · 10.58 Impact Factor
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    ABSTRACT: Whether increasing use of radial access has improved percutaneous coronary intervention outcomes remains unknown. We sought to determine the relationship between increasing facility-level use of transradial percutaneous coronary intervention (TRI) and periprocedural outcomes.
    Circulation Cardiovascular Quality and Outcomes 06/2014; · 5.66 Impact Factor
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    ABSTRACT: Dispatcher-assisted CPR (DA-CPR) canincrease rates of bystander CPR, survival,and quality of life following cardiac arrest. Dispatcher protocols designed to improve rapid recognition of arrest and coach CPR may increase survival by 1) reducing preventable time delaysto start of chest compressions and 2) improving the quality of bystander CPR. Methods:We conducted arandomized controlledtrial comparing a simplified DA CPR script to a conventional DA CPR script in a manikin cardiac arrest simulation with lay participants. The primary outcomes measured were the time interval from call receipt to the first chest compression and the core metrics of chest compression (depth, rate, release, and compression fraction). CPR was measured using a recording manikin for the first 3minutes of participant CPR. Results:Of the 75 participants, 39 were randomized to the simplified instructions and 36 were randomized to the conventional instructions. The interval from call receipt to first compression was 99seconds using the simplified script and 124seconds using the conventional script for a difference of 24seconds (p<0.01). Although hand position was judged to be correct more often in the conventional instruction group (88% versus 63%, P<0.01), compression depth was an average 7mm deeper among those receiving the simplified CPR script (32mm versus 25mm, p<0.05). No statistically significant differences were detected between the two instruction groups for compression rate,complete release, number of hands-off periods, or compression fraction.
    Resuscitation 05/2014; · 4.10 Impact Factor
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    ABSTRACT: Having 911 telecommunicators deliver CPR instructions increases cardiac arrest survival, but limited English proficiency (LEP) decreases the likelihood callers will perform CPR and increases time to first compression. The objective of our study was to assess which 9-1-1 CPR delivery modes could decrease time to first compression and improve CPR quality for LEP callers. 139 LEP Spanish and Chinese speakers were randomized into three arms: receiving CPR instructions from a 9-1-1 telecommunicator (1) with telephone interpretation, (2) using alternative, simple ways to rephrase, or (3) who strictly adhered to protocol language. Time interval from call onset to first compression, and CPR quality were the main outcomes. The CPR quality was poor across study arms. Connecting to interpreter services added almost 2 min to the time. CPR training in LEP communities, and regular CPR training for phone interpreters may be necessary to improve LEP bystander CPR quality.
    Journal of Immigrant and Minority Health 04/2014; · 1.16 Impact Factor
  • Heart (British Cardiac Society) 02/2014; 100(4):348. · 5.01 Impact Factor
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    ABSTRACT: Dabigatran is a novel oral anti-coagulant (NOAC) that reduces risk of stroke in patients with non-valvular atrial fibrillation (NVAF). It does not require routine monitoring with laboratory testing which may have an adverse impact on adherence. We aimed to describe adherence to dabigatran in the first year after initiation and assess the association between non-adherence to dabigatran and clinical outcomes in a large integrated healthcare system. Methods We studied a national cohort of 5,376 patients with NVAF, initiated on dabigatran between October-2010 and September-2012 at all Veterans Affairs hospitals. Adherence to dabigatran calculated as proportion of days covered (PDC) and association between PDC and outcomes was assessed using standard regression techniques. Results Mean age of the study cohort was 71.3+9.7 years, 98.3% were males and mean CHADS2 score was 2.4+1.2 (mean CHA2DS2VASc score 3.2+1.4). Median PDC was 94% (IQR 76%-100%; mean PDC 84%+22%) over a median follow-up of 244 days (IQR 140-351). A total of 1,494 (27.8%) patients had a PDC <80% and were classified as non-adherent. After multivariable adjustment, lower adherence was associated with increased risk for combined all-cause mortality and stroke (HR 1.13, 95% CI 1.07–1.19 per 10% decrease in PDC). Adherence to dabigatran was not associated with non-fatal bleeding or myocardial infarction. Conclusions In the year after initiation, adherence to dabigatran for a majority of patients is very good. However, 28% of patients in our cohort had poor adherence. Furthermore, lower adherence to dabigatran was associated with increased adverse outcomes. Concerted efforts are needed to optimize adherence to NOACs.
    American Heart Journal. 01/2014;
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    ABSTRACT: Objectives This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry. Background Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics. Methods Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics. Results Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients. Conclusions Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.
    Journal of the American College of Cardiology 01/2014; 63(6):539–546. · 14.09 Impact Factor
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    ABSTRACT: Objectives This study sought to determine if an integrated healthcare system is selective and consistent in the use of angiography, as reflected by normal coronary rates. Background Rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. This variation may in part reflect incentives in fee-for-service care. Methods Using national data from the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program representing all 76 VA cardiac catheterization laboratories, we evaluated all patients who underwent elective coronary angiography from October 2007 to September 2010. Normal coronary angiography was defined as <20% stenosis in all vessels. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries. Results Overall, 4,829 of 22,538 patients (21.4%) had normal coronary angiography. Hospital proportions of normal coronaries varied markedly (median hospital proportion 20.5%; interquartile range: 15.1% to 25.3%; range: 5.5% to 48.5%). Categorized as hospital quartiles, the median proportion of normal coronaries in the lowest quartile was 10.8%, as compared with a median proportion of 19.1% in the second lowest quartile, 23.1% in the second highest quartile, and 30.3% in the highest quartile. Hospitals with lower rates of normal coronaries had higher rates of obstructive coronary disease (59.2% vs. 51.3% vs. 52.6% vs. 44.3%; p < 0.001) and subsequent revascularization (38.1% vs. 33.9% vs. 31.5% vs. 29.3%; p < 0.001). Conclusions Approximately 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests opportunities to improve patient selection for diagnostic coronary angiography.
    Journal of the American College of Cardiology 01/2014; 63(5):417–426. · 14.09 Impact Factor
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    ABSTRACT: Background Post-traumatic stress disorder (PTSD) is prevalent in the general population and U.S. Veterans in particular and is associated with an increased risk of developing coronary artery disease (CAD). We compared the patient characteristics and post-procedural outcomes of Veterans with and without PTSD undergoing coronary angiography. Methods Multicenter observational study of patients who underwent coronary angiography in Veterans Affairs (VA) hospitals nationally from October 2007 to September 2011. We described patient characteristics at angiography, angiographic results, and following coronary angiography we compared risk-adjusted one-year rates of all-cause mortality, myocardial infarction (MI), and revascularization by the presence or absence of PTSD. Results Overall, 14,918 (12.8%) of 116,488 patients undergoing angiography had PTSD. Compared to those without PTSD, patients with PTSD were younger (median age 61.9 vs 63.7, P < .001), had higher rates of cardiovascular risk factors and were more likely to have had a prior MI (26.4% vs 24.7%, P < .001). Patients with PTSD were more likely to present for stable angina (22.4% vs 17.0%) or atypical chest pain (58.5% vs 48.6%) and less likely to have obstructive CAD identified at angiography (55.9% vs 62.2%, P < .001). Following coronary angiography, PTSD was associated with lower unadjusted one-year rates of MI (HR 0.86; 95% CI 0.75-1.00; P = 0.04), revascularization (HR 0.88; 95% CI 0.83-0.93; P < .001) , and all-cause mortality (HR 0.66; 0.60-0.71; P < .001). After adjustment for cardiovascular risk, PTSD was no longer associated with one-year rates of MI or revascularization, but remained associated with lower one-year all-cause mortality (HR 0.91; 95% CI 0.84-0.99; P = 0.03). Findings were similar after further adjustment for depression, anxiety, alcohol or substance use disorders, and frequency of outpatient follow-up. Conclusions Among Veterans undergoing coronary angiography in the VA, those with PTSD were more likely to present with elective indications and less likely to have obstructive CAD. Following coronary angiography, PTSD was not associated with adverse one-year outcomes of MI, revascularization, or all-cause mortality.
    American Heart Journal. 01/2014;
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    ABSTRACT: Background and aim: Expert guidelines for treatment of cardiac arrest recommend administration of adrenaline(epinephrine) every three to five minutes. However, the effects of different dosing periods of epinephrine remain unclear. We sought to evaluate the association between epinephrine average dosing period and survival to hospital discharge in adults with an in-hospital cardiac arrest (IHCA). Methods We performed a retrospective review of prospectively collected data on 20,909 IHCA events from 505 hospitals participating in the Get With The Guidelines-Resuscitation (GWTG-R) quality improvement registry. Epinephrine average dosing period was defined as the time between the first epinephrine dose and the resuscitation endpoint, divided by the total number of epinephrine doses received subsequent to the first epinephrine dose. Associations with survival to hospital discharge were assessed by using generalized estimating equations to construct multivariable logistic regression models. Results Compared to a referent epinephrine average dosing period of 4 to <5minutes per dose, survival to hospital discharge was significantly higher in patients with the following epinephrine average dosing periods: for 6 to <7min/dose, adjusted odds ratio [OR], 1.41 (95% CI: 1.12, 1.78); for 7 to <8min/dose, adjusted OR, 1.30 (95%CI: 1.02, 1.65); for 8 to <9min/dose, adjusted OR, 1.79 (95%CI: 1.38, 2.32); for 9 to <10min/dose, adjusted OR, 2.17 (95%CI: 1.62, 2.92). This pattern was consistent for both shockable and non-shockable cardiac arrest rhythms. Conclusion Less frequent average epinephrine dosing than recommended by consensus guidelines was associated with improved survival of in-hospital cardiac arrest.
    Resuscitation 11/2013; · 4.10 Impact Factor
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    ABSTRACT: 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. 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. A retrospective national cohort study of men with low testosterone levels (<300 ng/dL) who underwent coronary angiography in the Veterans Affairs (VA) system between 2005 and 2011. Primary outcome was a composite of all-cause mortality, MI, and ischemic stroke. Of the 8709 men with a total testosterone level lower than 300 ng/dL, 1223 patients started testosterone therapy after a median of 531 days following coronary angiography. Of the 1710 outcome events, 748 men died, 443 had MIs, and 519 had strokes. Of 7486 patients not receiving testosterone therapy, 681 died, 420 had MIs, and 486 had strokes. Among 1223 patients receiving testosterone therapy, 67 died, 23 had MIs, and 33 had strokes. The absolute rate of events were 19.9% in the no testosterone therapy group vs 25.7% in the testosterone therapy group, with an absolute risk difference of 5.8% (95% CI, -1.4% to 13.1%) at 3 years after coronary angiography. In Cox proportional hazards models adjusting for the presence of coronary artery disease, testosterone therapy use as a time-varying covariate was associated with increased risk of adverse outcomes (hazard ratio, 1.29; 95% CI, 1.04 to 1.58). There was no significant difference in the effect size of testosterone therapy among those with and without coronary artery disease (test for interaction, P = .41). Among a cohort of men in the VA health care system who underwent coronary angiography and had a low serum testosterone level, the use of testosterone therapy was associated with increased risk of adverse outcomes. These findings may inform the discussion about the potential risks of testosterone therapy.
    JAMA The Journal of the American Medical Association 11/2013; 310(17):1829-36. · 29.98 Impact Factor
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    ABSTRACT: This study assesses practice variation of secondary prevention medication prescription among coronary artery disease (CAD) patients treated in outpatient practices participating in the NCDR® PINNACLE Registry®. Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics. Using data from NCDR® PINNACLE Registry®, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics. Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% CI 1.2,1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients. Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.
    Journal of the American College of Cardiology 10/2013; · 14.09 Impact Factor
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    ABSTRACT: To determine if an integrated health care system is selective and consistent in the use of angiography, as reflected by normal coronary rates. Rates of normal coronary arteries with elective coronary angiography vary considerably among U.S. community hospitals. This variation may in part reflect incentives in fee-for-service care. Using national data from the VA CART Program representing all 76 VA cardiac catheterization labs, we evaluated all patients who underwent elective coronary angiography from October 2007 to September 2010. Normal coronary angiography was defined as <20% stenosis in all vessels. To assess hospital-level variation in normal coronary rates, we categorized hospitals by quartiles as defined by their proportion of normal coronaries. Overall, 4,829 of 22,538 patients (21.4%) had normal coronary angiography. Hospital proportions of normal coronaries varied markedly (median hospital proportion 20.5%, interquartile range 15.1% to 25.3%, range 5.5% to 48.5%). Categorized as hospital quartiles, the median proportion of normal coronaries in the lowest quartile was 10.8%, as compared with a median proportion of 19.1% in the second lowest quartile, 23.1% in the second highest quartile, and 30.3% in the highest quartile. Hospitals with lower rates of normal coronaries had higher rates of obstructive coronary disease (59.2% vs 51.3% vs 52.6% vs 44.3%, P<.001) and subsequent revascularization (38.1% vs 33.9% vs 31.5% vs 29.3%, P<.001). About 1 in 5 patients undergoing elective coronary angiography in the VA had normal coronaries. This rate is lower than prior published studies in other systems. However, the observed hospital-level variation in normal coronary rates suggests opportunities to improve patient selection for diagnostic coronary angiography.
    Journal of the American College of Cardiology 10/2013; · 14.09 Impact Factor
  • Charles Maynard, Steven M Bradley
    Nature Reviews Cardiology 07/2013; · 10.40 Impact Factor
  • Charles Maynard, Steven M Bradley, Chris L Bryson
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    ABSTRACT: Transradial percutaneous coronary intervention (tPCI) as opposed to the femoral approach (fPCI) is associated with lower rates of bleeding. The purposes of this study were to describe the use of tPCI in the Washington State Clinical Outcomes Assessment Program, identify the predictors of bleeding, and determine whether tPCI was associated with less bleeding in women vs men, age <75 years vs ≥75 years, and baseline creatinine <2.0 mg/dL vs ≥2.0 mg/dL. This study included 23,599 individuals who had a first tPCI or fPCI performed in 30 centers in Washington State in 2010 and 2011. Data were collected according to specifications from the American College of Cardiology National Cardiovascular Data Registry Cath-PCI version 4.3. The American College of Cardiology National Cardiovascular Data Registry bleeding model was used to calculate adjusted rates. Transradial percutaneous coronary intervention was used in only 5% of procedures, and in just 3 centers, tPCI was used in >10% of cases. Patient demographics and medical histories were similar in tPCI and fPCI, although the percent of acute cases was higher in fPCI (68% vs 45%, P < .0001). The overall bleeding rate was 2.2%, and the 3 most important predictors of bleeding were acute procedure, women, and age ≥75 years. For women, unadjusted rates of bleeding were 1.4% for tPCI and 4.0% for fPCI (P = .013). Among women, adjusted rates were almost 20% lower for tPCI (3.3% vs 4.1%). In Washington State, tPCI was used infrequently, although it was associated with lower bleeding rates in high-risk groups including women.
    American heart journal 03/2013; 165(3):332-7. · 4.65 Impact Factor
  • Charles Maynard, Steven M Bradley
    Journal of electrocardiology 01/2013; · 1.08 Impact Factor
  • Source
    Steven M Bradley, Evan P Carey, P Michael Ho
    Journal of the American Heart Association. 01/2013; 2(6):e000552.

Publication Stats

132 Citations
211.29 Total Impact Points

Institutions

  • 2012–2014
    • VA Eastern Colorado Health Care System
      Denver, Colorado, United States
    • University of Colorado
      Denver, Colorado, United States
  • 2013
    • University of Texas Southwestern Medical Center
      Dallas, Texas, United States
  • 2009–2013
    • University of Washington Seattle
      • • Division of Cardiology
      • • Department of Medicine
      Seattle, Washington, United States
    • Trinity Washington University
      Washington, Washington, D.C., United States