Steven M Bradley

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

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Publications (25)164.22 Total impact

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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
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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: 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 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 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: 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
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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
  • 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
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    Steven M Bradley, Evan P Carey, P Michael Ho
    Journal of the American Heart Association. 01/2013; 2(6):e000552.
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    ABSTRACT: Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown. We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the range of inappropriate PCI was 0.0% to 8.1% in the lowest tertile, 8.1% to 15.2% in the middle tertile, and 15.2% to 58.6% in the highest tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.73-1.19) or highest-tertile hospitals (OR, 1.12; 95% CI, 0.88-1.43; P=0.35 for differences between tertiles). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR, 1.13; 95% CI, 1.02-1.16; highest-tertile OR, 1.02; 95% CI, 0.91-1.16; P=0.07 for differences between tertiles) nor did use of optimal medical therapy at discharge (85.3% versus 85.7% versus 85.2%; P=0.58). In a national cohort of nonacute PCIs, a hospital's proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. This suggests PCI appropriateness measures aspects of hospital PCI quality that are independent of how well the procedure is performed. Therefore, PCI appropriateness and postprocedural outcomes are both important metrics to inform PCI quality.
    Circulation Cardiovascular Quality and Outcomes 05/2012; 5(3):290-7. · 5.66 Impact Factor
  • Steven M Bradley, Charles Maynard, Chris L Bryson
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    ABSTRACT: In anticipation of applying Appropriate Use Criteria for percutaneous coronary intervention (PCI) quality improvement, we determined the prevalence of appropriate, uncertain, and inappropriate PCIs stratified by indication for all PCIs performed in the state of Washington. Within the Clinical Outcomes Assessment Program, we assigned appropriateness ratings to all PCIs performed in 2010 in accordance with published Appropriate Use Criteria. Of 13 291 PCIs, we successfully mapped the clinical scenario to the Appropriate Use Criteria in 9924 (75%) cases. Of the 3367 PCIs not classified, common failures to map to the criteria included nonacute PCI without prior noninvasive stress results (n = 1906; 57%) and unstable angina without high-risk features (n = 902; 27%). Of mapped PCIs, 8010 (71%) were for acute indications, with 7887 (98%) rated as appropriate, 39 (<1%) as uncertain, and 84 (1%) as inappropriate. Of 1914 mapped nonacute indications, 847 (44%) were rated as appropriate, 748 (39%) as uncertain, and 319 (17%) as inappropriate. Assuming results for noninvasive stress tests when data were missing, in the best-case scenario, 319 (8%) of nonacute PCIs were classified as inappropriate compared with 1459 (38%) in the worst-case scenario. Variation in inappropriate PCIs by facility was greatest for mapped nonacute indications (median = 14%; 25(th) to 75(th) percentiles = 9% to 24%) and nonacute indications with missing data precluding appropriateness classification (median = 54%; 25(th) to 75(th) percentiles = 35% to 66%). In a complete cohort of PCIs performed in Washington state, 1% of PCIs for acute indications and 17% of PCIs for nonacute indications were classified as inappropriate. Missing data on noninvasive stress tests present a challenge in the application of the criteria for quality improvement.
    Circulation Cardiovascular Quality and Outcomes 05/2012; 5(4):445-53. · 5.66 Impact Factor
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    ABSTRACT: Get With the Guidelines (GWTG-R) is a data registry and quality improvement program for in-hospital cardiac arrest (IHCA). It is unknown if duration of hospital participation in GWTG-R is associated with IHCA outcomes. We analyzed adults with IHCA from 362 hospitals participating in GWTG-R between 2000 and 2009. Using logistic regression with generalized estimating equations to account for clustering on hospital, we determined the association between duration of hospital participation in GWTG-R and patient outcomes after IHCA, adjusted for patient and arrest characteristics and secular trend. Using these methods, we also evaluated the association between duration of participation and factors previously correlated with survival after IHCA, including ECG monitored status, after-hours arrest, and time to defibrillation. Of 104,732 patients with IHCA, 17,646 patients (16.9%) survived to discharge. Duration of hospital participation in GWTG-R was associated with IHCA event survival (per year of participation, odds ratio [OR] 1.02; 95% CI 1.00-1.04; p=0.046) but not survival to discharge (OR 1.02; 95% CI 0.99-1.04; p=0.18). Among factors previously correlated with IHCA survival, duration of participation was associated with time to defibrillation ≤2min (per year of participation, OR 1.06; 95% CI 1.03-1.10; p<0.001), but not ECG monitored status (OR 1.00; 95% CI 0.93-1.06; p=0.90) or survival of after-hours arrest (OR 1.01; 95% CI 0.99-1.03; p=0.41). Among ventricular tachycardia or ventricular fibrillation (VT/VF) arrests, time to defibrillation attenuated the association between duration of hospital participation and outcomes. Duration of hospital participation in GWTG-R was significantly associated with survival of the IHCA event, but not with survival to discharge. In VT/VF arrests, this association may have been mediated by improvements in time to defibrillation.
    Resuscitation 03/2012; 83(11):1349-57. · 4.10 Impact Factor
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    ABSTRACT: It is unknown how in-hospital cardiac arrest (IHCA) rates vary across hospitals and predictors of variability. Measure variability in IHCA across hospitals and determine if hospital-level factors predict differences in case-mix adjusted event rates. Get with the Guidelines Resuscitation (GWTG-R) (n=433 hospitals) was used to identify IHCA events between 2003 and 2007. The American Hospital Association survey, Medicare, and US Census were used to obtain detailed information about GWTG-R hospitals. Adult patients with IHCA. Case-mix-adjusted predicted IHCA rates were calculated for each hospital and variability across hospitals was compared. A regression model was used to predict case-mix adjusted event rates using hospital measures of volume, nurse-to-bed ratio, percent intensive care unit beds, palliative care services, urban designation, volume of black patients, income, trauma designation, academic designation, cardiac surgery capability, and a patient risk score. We evaluated 103,117 adult IHCAs at 433 US hospitals. The case-mix adjusted IHCA event rate was highly variable across hospitals, median 1/1000 bed days (interquartile range: 0.7 to 1.3 events/1000 bed days). In a multivariable regression model, case-mix adjusted IHCA event rates were highest in urban hospitals [rate ratio (RR), 1.1; 95% confidence interval (CI), 1.0-1.3; P=0.03] and hospitals with higher proportions of black patients (RR, 1.2; 95% CI, 1.0-1.3; P=0.01) and lower in larger hospitals (RR, 0.54; 95% CI, 0.45-0.66; P<0.0001). Case-mix adjusted IHCA event rates varied considerably across hospitals. Several hospital factors associated with higher IHCA event rates were consistent with factors often linked with lower hospital quality of care.
    Medical care 02/2012; 50(2):124-30. · 3.24 Impact Factor
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    ABSTRACT: The incidence and incidence over time of cardiac arrest in hospitalized patients is unknown. We sought to estimate the event rate and temporal trends of adult inhospital cardiac arrest treated with a resuscitation response. Three approaches were used to estimate the inhospital cardiac arrest event rate. First approach: calculate the inhospital cardiac arrest event rate at hospitals (n = 433) in the Get With The Guidelines-Resuscitation registry, years 2003-2007, and multiply this by U.S. annual bed days. Second approach: use the Get With The Guidelines-Resuscitation inhospital cardiac arrest event rate to develop a regression model (including hospital demographic, geographic, and organizational factors), and use the model coefficients to calculate predicted event rates for acute care hospitals (n = 5445) responding to the American Hospital Association survey. Third approach: classify acute care hospitals into groups based on academic, urban, and bed size characteristics, and determine the average event rate for Get With The Guidelines-Resuscitation hospitals in each group, and use weighted averages to calculate the national inhospital cardiac arrest rate. Annual event rates were calculated to estimate temporal trends. Get With The Guidelines-Resuscitation registry. Adult inhospital cardiac arrest with a resuscitation response. The mean adult treated inhospital cardiac arrest event rate at Get With The Guidelines-Resuscitation hospitals was 0.92/1000 bed days (interquartile range 0.58 to 1.2/1000). In hospitals (n = 150) contributing data for all years of the study period, the event rate increased from 2003 to 2007. With 2.09 million annual U.S. bed days, we estimated 192,000 inhospital cardiac arrests throughout the United States annually. Based on the regression model, extrapolating Get With The Guidelines-Resuscitation hospitals to hospitals participating in the American Hospital Association survey projected 211,000 annual inhospital cardiac arrests. Using weighted averages projected 209,000 annual U.S. inhospital cardiac arrests. There are approximately 200,000 treated cardiac arrests among U.S. hospitalized patients annually, and this rate may be increasing. This is important for understanding the burden of inhospital cardiac arrest and developing strategies to improve care for hospitalized patients.
    Critical care medicine 06/2011; 39(11):2401-6. · 6.37 Impact Factor
  • Steven M Bradley, Thomas D Rea
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    ABSTRACT: Summary estimates indicate that bystander cardiopulmonary resuscitation (CPR) can improve the chances of out-of-hospital cardiac arrest survival two-fold to three-fold. And yet, only a minority of arrest victims receive bystander CPR. This summary will review the challenges and approaches to achieve early and effective bystander CPR. Given the host of barriers, a successful strategy to improve bystander CPR must enable more timely and comprehensive arrest identification, encourage and empower bystanders to act, and help assure effective CPR. Arrest identification can be simplified so that bystanders should start CPR when a person is unconscious and not breathing normally. Evidence from observational studies and interventional trials supports the effectiveness of chest compression-only CPR for bystanders. As a consequence, the emphasis of bystander CPR training has been modified to feature and assure chest compressions. Bystanders should initiate CPR with compressions and consider the addition of rescue breathing based on their CPR training and skills as well as special circumstances of the victim. Bystander CPR training has evolved to incorporate this emphasis. Although general community-level CPR training remains a cornerstone strategy, training directed to those most likely to witness an arrest also has a useful role. In particular, 'just-in-time' dispatcher-assisted CPR instruction can increase bystander CPR and improve the likelihood of survival. Recent developments in bystander CPR have simplified arrest recognition and improved CPR training, while retaining CPR effectiveness. The goal of these developments is to increase and improve bystander CPR and in turn improve resuscitation.
    Current opinion in critical care 06/2011; 17(3):219-24. · 2.67 Impact Factor
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    ABSTRACT: The proportion of non-native English speakers is increasing in the United States. We sought to determine if limited English proficiency in callers to 9-1-1 for out-of-hospital cardiac arrest is associated with provision of bystander cardiopulmonary resuscitation (CPR) and delays in telephone-assisted CPR. We completed a secondary analysis of cohort data collected as part of a randomized trial of emergency dispatcher bystander CPR instructions. Included patients suffered confirmed cardiac arrest treated by emergency medical services. Callers were identified as limited English proficient through review of the dispatcher report. Of 971 eligible cardiac arrest cases, 5.9% (n = 57) of 9-1-1 callers were limited English proficient. Comparing arrest events of limited English proficient 9-1-1 callers with English-fluent callers, a lower proportion of limited English proficient arrest cases received bystander CPR (64.3% [36/56] vs. 77.5% [702/906]; p = 0.02) or survived to hospital discharge (8.8% [5/57] vs. 16.5% [151/914]; p = 0.12). Dispatchers took longer to recognize cardiac arrest with limited English proficient callers compared with English-fluent callers (median 84 vs. 50s; p < 0.001). Among callers attempting bystander CPR, the interval from call receipt to initiation of CPR was longer for limited English proficient compared with English-fluent callers (median 237 vs. 163s; p < 0.001). In this observational study of dispatcher-identified cardiac arrest, limited English proficiency in 9-1-1 callers was associated with less frequent provision of bystander CPR and delays in arrest recognition and implementation of telephone CPR, underscoring the health challenges and potential disparities of pre-hospital care related to limited English proficiency.
    Resuscitation 03/2011; 82(6):680-4. · 4.10 Impact Factor
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    ABSTRACT: High-quality systems have adopted a comprehensive approach to preventive care instead of diagnosis or procedure driven care. The current emphasis on prescribing medications to prevent complications of coronary artery disease (CAD) at discharge following an acute coronary syndrome (ACS) may exclude high-risk patients who are hospitalized with conditions other than ACS. Among a sample of patients with CAD treated at Veterans Affairs medical centers between January, 2005 and November, 2006, we investigated whether recent non-ACS hospitalization was associated with prescriptions of preventive medications as compared with patients recently hospitalized with ACS. Of 13,211 patients with CAD, 58% received aspirin, 70% β-blocker, 60% angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), and 65% lipid-lowering therapy. Twenty-five percent of eligible patients were receiving all four medications. Having been hospitalized for a non-ACS event in the prior 6 months did not substantially affect the adjusted proportion on preventive medications. In contrast, among patients hospitalized for ACS in the prior 6 months, the adjusted proportion prescribed aspirin was 21% higher (p < 0.001), β-blocker was 14% higher (p < 0.001), ACE-I or ARB was 9% higher (p < 0.001), lipid therapy was 12% higher (p < 0.001), and prescribed all four medications was 18% higher (p < 0.001) than among patients hospitalized for ACS more than 2 years earlier. Being hospitalized for a non-ACS condition did not appear to influence preventive medication use among patients with CAD and represents a missed opportunity to improve patient care. The same protocols employed to improve use of preventive medications in patients discharged for ACS might be extended to CAD patients discharged for other conditions as well.
    BMC Cardiovascular Disorders 01/2011; 11:42. · 1.46 Impact Factor

Publication Stats

90 Citations
25 Downloads
1k Views
164.22 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
    • University of Everett Washington
      Seattle, Washington, United States