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Background Black people are disproportionally impacted by hypertension. New approaches for encouraging healthy lifestyles are needed to reduce hypertension and promote health equity in Black communities. Objective In this report, we describe the early-stage, virtual design of a just-in-time adaptive intervention (JITAI) to increase physical activity in partnership with members of a low-income, predominantly Black community. Methods The hallmark of JITAIs is highly contextualized mobile app push notifications. Thus, understanding participants' context and determinants of physical activity are critical. During the height of the COVID-19 pandemic, we conducted virtual discovery interviews and analysis guided by the Behavior Change Wheel (which focuses on participants' capacity, opportunity, and motivation to engage in physical activity), as well as empathy mapping. We then formed a community-academic participatory design team that partnered in the design sprint, storyboarding, and paper prototyping. Results For this study, 5 community members participated in the discovery interviews, 12 stakeholders participated in the empathy mapping, 3 community members represented the community on the design team, and 10 community members provided storyboard or paper prototyping feedback. Only one community member had used videoconferencing prior to partnering with the academic team, and none had design experience. A set of 5 community-academic partner design principles were created: (1) keep users front and center, (2) tailor to the individual, (3) draw on existing motivation, (4) make physical activity feel approachable, and (5) make data collection transparent yet unobtrusive. To address community-specific barriers, the community-academic design team decided that mobile app push notifications will be tailored to participants’ baseline mobility level and community resources (eg, local parks and events). Push notifications will also be tailored based on the day (weekday versus weekend), time of day, and weather. Motivation will be enhanced via adaptive goal setting with supportive feedback and social support via community-generated notifications. Conclusions We completed early-stage virtual design of a JITAI in partnership with community participants and a community design team with limited design and videoconferencing experience. We found that designing JITAIs with the community enables these interventions to address community-specific needs, which may lead to a more meaningful impact on users' health.

BACKGROUND Black people are disproportionally impacted by hypertension. New approaches for encouraging healthy lifestyles are needed to reduce hypertension and promote health equity in Black communities. OBJECTIVE In this report, we describe the early-stage, virtual design of a just-in-time adaptive intervention (JITAI) to increase physical activity in partnership with members of a low-income, predominantly Black community. METHODS The hallmark of JITAIs is highly contextualized mobile app push notifications. Thus, understanding participants' context and determinants of physical activity are critical. During the height of the COVID-19 pandemic, we conducted virtual discovery interviews and analysis guided by the Behavior Change Wheel (which focuses on participants' capacity, opportunity, and motivation to engage in physical activity), as well as empathy mapping. We then formed a community-academic participatory design team that partnered in the design sprint, storyboarding, and paper prototyping. RESULTS For this study, 5 community members participated in the discovery interviews, 12 stakeholders participated in the empathy mapping, 3 community members represented the community on the design team, and 10 community members provided storyboard or paper prototyping feedback. Only one community member had used videoconferencing prior to partnering with the academic team, and none had design experience. A set of 5 community-academic partner design principles were created: (1) keep users front and center, (2) tailor to the individual, (3) draw on existing motivation, (4) make physical activity feel approachable, and (5) make data collection transparent yet unobtrusive. To address community-specific barriers, the community-academic design team decided that mobile app push notifications will be tailored to participants’ baseline mobility level and community resources (eg, local parks and events). Push notifications will also be tailored based on the day (weekday versus weekend), time of day, and weather. Motivation will be enhanced via adaptive goal setting with supportive feedback and social support via community-generated notifications. CONCLUSIONS We completed early-stage virtual design of a JITAI in partnership with community participants and a community design team with limited design and videoconferencing experience. We found that designing JITAIs with the community enables these interventions to address community-specific needs, which may lead to a more meaningful impact on users' health.

Background: Out-of-hospital cardiac arrest (OHCA) outcomes vary significantly across U.S. communities; however, systems of care factors that increase the likelihood of survival have not been well elucidated. The Enhancing Pre-Hospital Outcomes for Cardiac Arrest (EPOC) study is quantifying variation in the rate of sustained return of spontaneous circulation (ROSC) upon ED arrival across Michigan EMS agencies as a first step to identifying ‘best practices’ in prehospital OHCA care. Methods: Michigan Cardiac Arrest Registry to Enhance Survival (CARES) data for the years 2014-2016 was used. EMS agencies with 5+ arrests over the study years were included in the analysis. Using mixed-effects logistic regression, we calculated each agency’s reliability-adjusted sustained ROSC upon ED arrival; these rates were standardized across patient-, community-, and arrest-level characteristics. Results: A total of 91 agencies covering >6.8 million lives met inclusion criteria. We included 14,219 OHCA patients with a mean age of 62.6, 40.0% female, and 18.2% with a shockable rhythm in the analyses. Across all agencies, the mean patient-standardized rate of sustained ROSC with pulse upon ED arrival was 25.3% (range, 6.1%-51.9%; IQR range, 18.9%-31.2%) ( Figure 1 ). There were 14 agencies with patient-standardized rates and 95% CIs that exceeded the overall mean survival rate suggesting better-than-average outcomes while 16 agencies had rates and 95% CIs that were lower than the overall mean survival rate. Conclusion: We found more than 8-fold variation in OHCA survival rates across EMS agencies in Michigan, suggesting large differences in the effectiveness of prehospital systems of care. Future qualitative work will seek to identify ‘best practices’ by further determining the role of key factors such as tele-dispatch CPR, EMS agencies, fire, and police within high performing systems.

Summary Background Few studies have examined the efficacy of drug-eluting stents (DES) for reducing aortocoronary saphenous vein bypass graft (SVG) failure compared with bare-metal stents (BMS) in patients undergoing stenting of de-novo SVG lesions. We assessed the risks and benefits of the use of DES versus BMS in de-novo SVG lesions. Methods Patients were recruited to our double-blind, randomised controlled trial from 25 US Department of Veterans Affairs centres. Eligible participants were aged at least 18 years and had at least one significant de-novo SVG lesion (50–99% stenosis of a 2·25–4·5 mm diameter SVG) requiring percutaneous coronary intervention with intent to use embolic protection devices. Enrolled patients were randomly assigned, in a 1:1 ratio, by phone randomisation system to receive a DES or BMS. Randomisation was stratified by presence or absence of diabetes and number of target SVG lesions requiring percutaneous coronary intervention (one or two or more) within each participating site by use of an adaptive scheme intended to balance the two stent type groups on marginal totals for the stratification factors. Patients, referring physicians, study coordinators, and outcome assessors were masked to group allocation. The primary endpoint was the 12-month incidence of target vessel failure, defined as the composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. The DIVA trial is registered with ClinicalTrials.gov, number NCT01121224. Findings Between Jan 1, 2012, and Dec 31, 2015, 599 patients were randomly assigned to the stent groups, and the data for 597 patients were used. The patients' mean age was 68·6 (SD 7·6) years, and 595 (>99%) patients were men. The two stent groups were similar for most baseline characteristics. At 12 months, the incidence of target vessel failure was 17% (51 of 292) in the DES group versus 19% (58 of 305) in the BMS group (adjusted hazard ratio 0·92, 95% CI 0·63–1·34, p=0·70). Between-group differences in the components of the primary endpoint, serious adverse events, or stent thrombosis were not significant. Enrolment was stopped before the revised target sample size of 762 patients was reached. Interpretation In patients undergoing stenting of de-novo SVG lesions, no significant differences in outcomes between those receiving DES and BMS during 12 months of follow-up were found. The study results have important economic implications in countries with high DES prices such as the USA, because they suggest that the lower-cost BMS can be used in SVG lesions without compromising either safety or efficacy. Funding US Department of Veterans Affairs Cooperative Studies Program.

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.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.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. Logistic regression with generalized estimating equations was used to adjust for correlation between patients within hospitals. Cox regressions were modeled for each outcome to determine the variables with significant hazard ratios (HRs).During the study period, patients with prior CABG represented 18.5% of all patients undergoing PCI (11,118 of 60,171). The PCI target vessel was a native coronary artery in 73.4% and a bypass graft in 26.6%: 25.0% in a saphenous vein graft and 1.5% in an arterial graft. Compared with patients undergoing native coronary artery PCI, those undergoing bypass graft PCI had higher risk characteristics and more procedure-related complications. During a median follow-up period of 3.11 years, bypass graft PCI was associated with significantly higher mortality (adjusted HR: 1.30; 95% confidence interval: 1.18 to 1.42), myocardial infarction (adjusted HR: 1.61; 95% confidence interval: 1.43 to 1.82), and repeat revascularization (adjusted HR: 1.60; 95% confidence interval: 1.50 to 1.71).In a national cohort of veterans, almost three-quarters of PCIs performed in patients with prior CABG involved native coronary artery lesions. Compared with native coronary PCI, bypass graft PCI was significantly associated with higher incidence of short- and long-term major adverse events, including more than double the rate of in-hospital mortality.

Background: Improving quality of care for patients presenting with ST elevation Myocardial infarctions (STEMI) is a national priority. However, recent data demonstrate that mortality has not changed despite numerous targeted efforts. Identifying potential areas in care that can be further optimized to decrease mortality remains a priority. Methods: We performed a root cause analysis of all patients who died following primary PCI during index hospitalization from 2008 to 2013 at the University of Michigan (n=25 deaths). Using a standardized data collection form, two interventional cardiologists reviewed patient care received prior to arrival to the catheterization lab, while in the catheterization lab, and after primary PCI to determine cause of death and to rate potential preventability of death on a Likert scale. Results: Majority of deaths were deemed unpreventable. Symptom-onset-to-medical care time was rated as the most common potentially preventable factor. Conclusion: Mortality following primary PCI was deemed mostly unpreventable. However, improvement in total ischemic time, and in particular symptom-onset to-medical care, was identified as one potential target that might be of value in further reducing the mortality associated with STEMI.

Background: Despite taking initiatives to be sustainable, health care systems continue to underachieve their potential and produce exorbitant amounts of waste. We examined the personal sustainability practices of healthcare workers, contrasting their behavior at work with that at home, since the actions of people ultimately determine the effectiveness of sustainability campaigns. Methods: We gave 52 full-time employees of the University of Michigan Cardiac Catheterization Laboratories an anonymous online survey pertaining to sustainability practices at home and work. Paired t-tests were used to compare parallel questions about recycling and energy saving habits between work and home and the Wilcoxon Mann Whitney test was used to examine demographic trends. Results: Participant sustainability habits at home consistently scored lower means, indicating a higher degree of sustainability engagement, than at work_except for the recycling of bottles, containers, and paper products, which showed no significant difference, and the use of motion sensor power strips. Physicians were found to engage in energy saving habits at home significantly less than non-physician employees (mean score, 2.7 versus 2.1; p = .0014) but otherwise, no other demographic varied significantly. Conclusion: Healthcare employees have the personal mindset to be sustainable, but the workplace offers fewer opportunities to do so than their own homes. Healthcare systems may improve sustainability by better designing care processes to maximize recycling and minimize waste, and fostering the personal responsibility for sustainability that is found in the home environment by emulating the sustainability opportunities at home.

Hospitals have been under increasing scrutiny regarding potentially inappropriate PCI. However, little is known about contemporary patterns of institutional review of PCI appropriateness and the impact of these programs on procedural appropriateness. The TOP PCI study surveyed 500 hospitals

Author(s): Saran, Rajiv; Li, Yi; Robinson, Bruce; Abbott, Kevin C; Agodoa, Lawrence YC; Ayanian, John; Bragg-Gresham, Jennifer; Balkrishnan, Rajesh; Chen, Joline LT; Cope, Elizabeth; Eggers, Paul W; Gillen, Daniel; Gipson, Debbie; Hailpern, Susan M; Hall, Yoshio N; He, Kevin; Herman, William; Heung, Michael; Hirth, Richard A; Hutton, David; Jacobsen, Steven J; Kalantar-Zadeh, Kamyar; Kovesdy, Csaba P; Lu, Yee; Molnar, Miklos Z; Morgenstern, Hal; Nallamothu, Brahmajee; Nguyen, Danh V; O'Hare, Ann M; Plattner, Brett; Pisoni, Ronald; Port, Friedrich K; Rao, Panduranga; Rhee, Connie M; Sakhuja, Ankit; Schaubel, Douglas E; Selewski, David T; Shahinian, Vahakn; Sim, John J; Song, Peter; Streja, Elani; Kurella Tamura, Manjula; Tentori, Francesca; White, Sarah; Woodside, Kenneth; Hirth, Richard A

Patients with prior coronary artery bypass graft (CABG) surgery often undergo percutaneous coronary intervention (PCI), yet the association between PCI target vessel on short- and long-term outcomes has received limited study. We sought to examine the frequency, associations and outcomes of native

Introduction: Few data describe temporal trends in presentation, treatment and outcome in men and women with acute ST-segment elevation myocardial infarction (STEMI). Methods: Swiss STEMI patients enrolled in the AMIS Plus registry from1997-2010 were analyzed using multivariate logistic regression. Results: From 20,363 STEMI patients, 5458 were women and 14,905 men. Women were 8.6 years older, had more co-morbidities (Charlson Index ≥2 16.9% vs 12.8%; P Conclusion: Therapy of STEMI patients has changed greatly during the past 14 years in Switzerland, largely in accordance with guideline recommendations.

Background: Many patients undergoing elective percutaneous coronary intervention (PCI) do not have prior stress testing. It is unknown if these patients have more severe angina or obstructive coronary artery disease (CAD), whereby proceeding directly to PCI would represent sound clinical judgment and efficient use of resources. Methods: We identified elective PCIs performed between 1/1/09 - 3/31/11 in the NCDR CathPCI Registry ® and assessed for differences in angina (CCS class) and severity of CAD in those with and without pre-procedural stress testing. To further understand whether proceeding to PCI without prior stress testing could be justified because of a high pre-test probability for obstructive CAD (e.g., >70% stenosis in an epicardial coronary artery), we evaluated cardiac catheterizations performed within the registry during the same period to assess the diagnostic yield of obstructive CAD in patients with and without prior stress testing. Results: Of 246,629 elective PCIs, 89,084 (36.1%) were performed without prior stress testing. A substantial proportion of both groups undergoing PCI were asymptomatic (no stress test group: 28.9% vs. stress test group: 30.7%), with only a modest difference in the frequency of CCS class III/IV angina (16.2% vs. 11.9%; Table). No meaningful differences in the frequency of proximal LAD (29.7 % vs. 29.9%), left main (5.6% vs. 7.2%) or 3-vessel coronary artery disease (21.1% vs. 19.5%) were observed in the 2 PCI groups. Moreover, the diagnostic yield for obstructive CAD on cardiac catheterization for patients without prior stress testing (n=462,611) was 35.4%, as compared with 58.0%, 38.8%, and 24.1% for those with severe, moderate, and mild ischemia, on pre-procedural stress testing. Conclusion: For elective PCI, the current practice of proceeding to coronary angiography and PCI without prior stress testing does not identify higher risk coronary anatomy or more symptomatic patients and may not improve diagnostic yield.

The ABIM has offered a certification exam in Interventional Cardiology (IC) since 1999, but limited information is available regarding its association with outcomes of patients undergoing percutaneous coronary intervention (PCI). We examined whether PCI outcomes varied by IC certification status.

Additional file 2. Copy of survey sent to cardiac arrest first-responders.

Additional file 2. Copy of survey sent to cardiac arrest first-responders.