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Janet WH Sit,1 Sek Ying Chair,1 Kai Chow Choi,1 Carmen WH Chan,1 Diana TF Lee,1 Aileen WK Chan,1 Jo LK Cheung,1 Siu Wai Tang,2 Po Shan Chan,2 Ruth E Taylor-Piliae3 1The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, New Territories, 2Department of Medicine and Rehabilitation, Tung Wah Eastern Hospital, Hong Kong Hospital Authority, Causeway Bay, Hong Kong, People’s Republic of China; 3College of Nursing, The University of Arizona, Tucson, AZ, USA Background: Self-management after a stroke is a challenge because of multifaceted care needs and complex disabling consequences that cause further hindrance to patient participation. A 13-week stroke patient empowerment intervention (Health Empowerment Intervention for Stroke Self-management [HEISS]) was developed to enhance patients’ ability to participate in self-management.Purpose: To examine the effects of the empowerment intervention on stroke patients’ self-efficacy, self-management behavior, and functional recovery.Methods: This is a single-blind randomized controlled trial with stroke survivors assigned to either a control group (CG) receiving usual ambulatory rehabilitation care or the HEISS in addition to usual care (intervention group [IG]). Outcome data were collected at baseline (T0), 1 week (T1), 3 months (T2), and 6 months (T3) postintervention. Data were analyzed on the intention-to-treat principle. The generalized estimating equation model was used to assess the differential change of self-efficacy in illness management, self-management behaviors (cognitive symptom management, communication with physician, medication adherence, and self-blood pressure monitoring), and functional recovery (Barthel and Lawton indices) across time points (baseline = T0, 1 week = T1, 3 months = T2, and 6 months = T3 postintervention) between the two groups.Results: A total of 210 (CG =105, IG =105) Hong Kong Chinese stroke survivors (mean age =69 years, 49% women, 72% ischemic stroke, 89% hemiparesis, and 63% tactile sensory deficit) were enrolled in the study. Those in IG reported better self-efficacy in illness management 3-month (P=0.011) and 6-month (P=0.012) postintervention, along with better self-management behaviors at all follow-up time points (all P0.05). Those in IG had significantly better functional recovery (Barthel, all P

Background: Despite ongoing efforts to improve the quality of pediatric resuscitation, it remains unknown whether survival in children with in-hospital cardiac arrest has improved.Methods and Results: Between 2000 and 2009, we identified children (<18 years of age) with an in-hospital cardiac arrest at hospitals with >3 years of participation and >5 cases annually within the national Get With The Guidelines-Resuscitation registry. Multivariable logistic regression was used to examine temporal trends in survival to discharge. We also explored whether trends in survival were attributable to improvement in acute resuscitation or postresuscitation care and examined trends in neurological disability among survivors. Among 1031 children at 12 hospitals, the initial cardiac arrest rhythm was asystole and pulseless electrical activity in 874 children (84.8%) and ventricular fibrillation and pulseless ventricular tachycardia in 157 children (15.2%), with an increase in cardiac arrests due to pulseless electrical activity over time (P for trend <0.001). Risk-adjusted rates of survival to discharge increased from 14.3% in 2000 to 43.4% in 2009 (adjusted rate ratio per year, 1.08; 95% confidence interval, 1.01-1.16; P for trend=0.02). Improvement in survival was driven largely by an improvement in acute resuscitation survival (risk-adjusted rates: 42.9% in 2000, 81.2% in 2009; adjusted rate ratio per year: 1.04; 95% confidence interval, 1.01-1.08; P for trend=0.006). Moreover, survival trends were not accompanied by higher rates of neurological disability among survivors over time (unadjusted P for trend=0.32), suggesting an overall increase in the number of survivors without neurological disability over time.Conclusions: Rates of survival to hospital discharge in children with in-hospital cardiac arrests have improved over the past decade without higher rates of neurological disability among survivors. [ABSTRACT FROM AUTHOR]

Background: 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.Methods and Results: 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).Conclusions: 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. [ABSTRACT FROM AUTHOR]

Background: Black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life. The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study was designed to examine whether racial differences in socioeconomic, clinical, genetic, metabolic, biomarker, or treatment characteristics mediate observed disparities in outcomes.Methods and Results: Between April 11, 2005, and December 31, 2008, 31 567 patients with MI were prospectively screened; 6152 had an eligible MI, and 4340 (71%) were enrolled from 24 US centers. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed baseline interview. Detailed genetic and metabolic data were obtained at hospital discharge in 2979 (69%) and 3013 patients (69%), respectively. In a subset of patients, blood and urine samples were obtained at 1 month (obtained in 27% of survivors) and blood samples at 6 months (obtained in 19% of survivors). Centralized follow-up interviews sought to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). At 1, 6, and 12 months, 23%, 27%, and 24%, respectively, were lost to follow-up. Vital status was available for 99% of patients at 12 months.Conclusions: TRIUMPH is a novel MI registry with detailed information on patients' sociodemographic, clinical, treatment, health status, metabolic, and genetic characteristics. The wealth of patient data collected in TRIUMPH will provide unique opportunities to examine factors that may mediate racial differences in mortality and health status after MI and the complex interactions between genetic and environmental determinants of post-MI outcomes. [ABSTRACT FROM AUTHOR]

Background: Remote coverage of ICUs is increasing, but staff acceptance of this new technology is incompletely characterized. We conducted a systematic review to summarize existing research on acceptance of tele-ICU coverage among ICU staff.Methods: We searched for published articles pertaining to critical care telemedicine systems (aka, tele-ICU) between January 1950 and March 2010 using PubMed, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Library and abstracts and presentations delivered at national conferences. Studies were included if they provided original qualitative or quantitative data on staff perceptions of tele-ICU coverage. Studies were imported into content analysis software and coded by tele-ICU configuration, methodology, participants, and findings (eg, positive and negative staff evaluations).Results: Review of 3,086 citations yielded 23 eligible studies. Findings were grouped into four categories of staff evaluation: overall acceptance level of tele-ICU coverage (measured in 70% of studies), impact on patient care (measured in 96%), impact on staff (measured in 100%), and organizational impact (measured in 48%). Overall acceptance was high, despite initial ambivalence. Favorable impact on patient care was perceived by > 82% of participants. Staff impact referenced enhanced collaboration, autonomy, and training, although scrutiny, malfunctions, and contradictory advice were cited as potential barriers. Staff perceived the organizational impact to vary. An important limitation of available studies was a lack of rigorous methodology and validated survey instruments in many studies.Conclusions: Initial reports suggest high levels of staff acceptance of tele-ICU coverage, but more rigorous methodologic study is required. [ABSTRACT FROM AUTHOR]

RATIONALE: Studies examining survival outcomes after in-hospital cardiopulmonary arrest (CPA) among intensive care unit (ICU) patients requiring medications for hemodynamic support are limited. OBJECTIVES: To examine outcomes of ICU patients who received cardiopulmonary resusitation. METHODS: We identified 49,656 adult patients with a first CPA occurring in an ICU between January 1, 2000 and August 26, 2008 within the National Registry of Cardiopulmonary Resuscitation. Survival outcomes of patients requiring hemodynamic support immediately before CPA were compared with those of patients who did not receive hemodynamic support (pressors), using multivariable logistic regression analyses to adjust for differences in demographics and clinical characteristics. Pressor medications included epinephrine, norepinephrine, phenylephrine, dopamine, dobutamine, and vasopressin. MEASUREMENTS AND MAIN RESULTS: The overall rate of survival to hospital discharge was 15.9%. Patients taking pressors before CPA were less likely to survive to discharge (9.3 vs. 21.2%; P < 0.0001). After multivariable adjustment, patients taking pressors before pulseless CPA were 55% less likely to survive to discharge (adjusted odds ratio [OR], 0.45; 95% confidence interval [CI], 0.42-0.48). Age equal to or greater than 65 years (adjusted OR, 0.77; 95% CI, 0.73-0.82), nonwhite race (adjusted OR, 0.58; 95% CI, 0.54-0.62), and mechanical ventilation (adjusted OR, 0.60; 95% CI, 0.56-0.63) were also variables that could be identified before CPA that were independently associated with lower survival. More than half of survivors were discharged to rehabilitation or extended care facilities. Only 3.9% of patients who had CPA despite pressors were discharged home from the hospital, as compared with 8.5% of patients with a CPA and not taking pressors (adjusted OR, 0.53; 95% CI, 0.49-0.59). CONCLUSIONS: Although overall survival of ICU patients was 15.9%, patients requiring pressors and who experienced a CPA in an ICU were half as likely to survive to discharge and to be discharged home than patients not taking pressors. This study provides robust estimates of CPR outcomes of critically ill patients, and may assist clinicians to inform consent for this procedure. [ABSTRACT FROM AUTHOR]

Background: Previous studies have demonstrated that microvolt T-wave alternans (MTWA) testing is a robust predictor of ventricular tachyarrhythmias and sudden cardiac death (SCD) in at-risk patients. However, recent studies have suggested that MTWA testing is not as good a predictor of "appropriate" implantable cardioverter-defibrillator (ICD) therapy as it is a predictor of SCD in patients without ICDs.Objective: To evaluate the utility of MTWA testing for SCD risk stratification in patients without ICDs.Methods: Patient-level data were obtained from 5 prospective studies of MTWA testing in patients with no history of ventricular arrhythmia or SCD. In these studies, ICDs were implanted in only a minority of patients and patients with ICDs were excluded from the analysis. We conducted a pooled analysis and examined the 2-year risk for SCD based on the MTWA test result.Results: The pooled cohort included 2883 patients. MTWA testing was positive in 856 (30%), negative in 1627 (56%), and indeterminate in 400 (14%) patients. Among patients with a left ventricular ejection fraction (LVEF) of ≤35%, annual SCD event rates were 4.0%, 0.9%, and 4.6% among groups with MTWA positive, negative, and indeterminate test results. The SCD rate was significantly lower among patients with a negative MTWA test result than in patients with either positive or indeterminate MTWA test results (P <.001 for both comparisons). In patients with an LVEF of >35%, annual SCD event rates were 3.0%, 0.3%, and 0.3% among the groups with MTWA positive, negative, and indeterminate test results. The SCD rate associated with a positive MTWA test result was significantly higher than that associated with either negative (P <.001) or indeterminate MTWA test results (P = .003).Conclusions: In patients without ICDs, MTWA testing is a powerful predictor of SCD. Among patients with an LVEF of ≤35%, a negative MTWA test result is associated with a low risk for SCD. Conversely, among patients with an LVEF of >35%, a positive MTWA test result identifies patients at significantly heightened SCD risk. These findings may have important implications for refining primary prevention ICD treatment algorithms. [ABSTRACT FROM AUTHOR]

Background: Although current guidelines recommend implantable cardioverter-defibrillator (ICD) placement in survivors of out-of-hospital cardiac arrest, contemporary data on secondary-prevention ICDs in survivors of out-of-hospital cardiac arrest remain limited., Methods and Results: Using 2013 to 2019 CARES (Cardiac Arrest Registry to Enhance Survival) linked to Medicare, we identified 3226 patients aged ≥65 years with an initial shockable rhythm who survived to discharge without severe neurological disability. Multivariable hierarchical regression models were used to examine the association between patient variables and ICD placement and quantify hospital variation in ICD implantation. The mean age was 72.2 years, 23.5% were women, 10% were Black individuals, and 4% were Hispanic individuals. Overall, 997 (30.9%) patients received an ICD before discharge, 1266 (39.2%) at 90 days, and 1287 (39.9%) within 6 months. Older age (≥85 years), female sex, history of diabetes, calendar year, and presentation with acute myocardial infarction were associated with lower odds of ICD implantation, but race or ethnicity was not associated with ICD implantation. Among 297 hospitals, the median proportion of survivors receiving ICD at discharge was 28.6% (interquartile range, 20%-50%). The relative odds of ICD implantation varied by 62% across hospitals (median odds ratio, 1.62 [95% CI, 1.38-1.82]) after adjusting for case mix., Conclusions: Fewer than 1 in 3 survivors of out-of-hospital cardiac arrest due to a shockable rhythm received a secondary-prevention ICD before discharge. Although patient variables were associated with ICD implantation, there was no difference by race or ethnicity. Even after adjusting for patient case mix, ICD implantation varied markedly across hospitals.

This study investigated the risk to social behavior and cognitive flexibility induced by chronic social defeat stress (CSDS) during early and late adolescence (EA and LA). Utilizing the "resident-intruder" stress paradigm, adolescent male Sprague-Dawley rats were exposed to CSDS during either EA (postnatal days 29-38) or LA (postnatal days 39-48) to explore how social defeat at different stages of adolescence affects behavioral and cognitive symptoms commonly associated with psychiatric disorders. After stress exposure, the rats were assessed for anxiety-like behavior in the elevated plus maze, social interaction, and cognitive flexibility through set-shifting and reversal-learning tasks under immediate and delayed reward conditions. The results showed that CSDS during EA, but not LA, led to impaired cognitive flexibility in adulthood, as evidenced by increased perseverative and regressive errors in the set-shifting and reversal-learning tasks, particularly under the delayed reward condition. This suggests that the timing of stress exposure during development has a significant impact on the long-term consequences for behavioral and cognitive function. The findings highlight the vulnerability of the prefrontal cortex, which undergoes critical maturation during early adolescence, to the effects of social stress. Overall, this study demonstrates that the timing of social stressors during adolescence can differentially shape the developmental trajectory of cognitive flexibility, with important implications for understanding the link between childhood/adolescent adversity and the emergence of psychiatric disorders., Competing Interests: Conflict of Interest The authors declare that this research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aim: Given challenges in collecting long-term outcomes for survivors of in-hospital cardiac arrest (IHCA), most studies have focused on in-hospital survival. We evaluated the correlation between a hospital's risk-standardized survival rate (RSSR) at hospital discharge for IHCA with its RSSR for long-term survival., Methods: We identified patients ≥65 years of age with IHCA at 472 hospitals in Get With The Guidelines®-Resuscitation registry during 2000-2012, who could be linked to Medicare files to obtain post-discharge survival data. We constructed hierarchical logistic regression models to compute RSSR at discharge, and 30-day, 1-year, and 3-year RSSRs for each hospital. The association between in-hospital and long-term RSSR was evaluated with weighted Kappa coefficients., Results: Among 56,231 Medicare beneficiaries (age 77.2 ± 7.5 years and 25,206 [44.8%] women), 10,536 (18.7%) survived to discharge and 8,485 (15.1%) survived to 30 days after discharge. Median in-hospital, 30-day, 1-year, and 3-year RSSRs were 18.6% (IQR, 16.7-20.4%), 14.9% (13.2-16.7%), 10.3% (9.1-12.1%), and 7.6% (6.8-8.8%), respectively. The weighted Kappa coefficient for the association between a hospital's RSSR at discharge with its 30-day, 1-year, and 3-year RSSRs were 0.72 (95% CI, 0.68-0.76), 0.56 (0.50-0.61), and 0.47 (0.41-0.53), respectively., Conclusions: There was a strong correlation between a hospital's RSSR at discharge and its 30-day RSSR for IHCA, although this correlation weakens over time. Our findings suggest that a hospital's RSSR at discharge for IHCA may be a reasonable surrogate of its 30-day post-discharge survival and could be used by Medicare to benchmark hospital performance for this condition without collecting 30-day survival data., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: ‘Dr. Khera receives support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under awards R01HL167858 and K23HL153775) and the Doris Duke Charitable Foundation (under award 2022060). He is an Associate Editor at JAMA and receives research grant support, through Yale, from Bristol‐Myers Squibb, Novo Nordisk, and BridgeBio. He is a coinventor of U.S. Pending Patent Applications WO2023230345A1, US20220336048A1, 63/346,610, 63/484,426, 63/508,315, 63/580,137, 63/606,203, 63/619,241, and 63/562,335, unrelated to the current work. He receives support from the Blavatnik Foundation through the Blavatnik Fund for Innovation at Yale. He is a cofounder of Ensight-AI, and Evidence2Health, both representing precision health platforms to improve evidence-based cardiovascular care. Dr. Chan receives support from the National Heart, Lung, and Blood Institute of the National Institutes of Health (under award R01HL160734). The remaining authors have no disclosures to report.’., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Bystander cardiopulmonary resuscitation (CPR) is associated with higher survival for out-of-hospital cardiac arrest, but whether its association with survival differs by patients' sex and race and ethnicity is less clear., Methods: Within a large US registry, we identified 623 342 nontraumatic out-of-hospital cardiac arrests during 2013 to 2022 for this observational cohort study. Using hierarchical logistic regression, we examined whether there was a differential association between bystander CPR and survival outcomes by patients' sex and race and ethnicity, overall and by neighborhood strata., Results: Mean age was 62.1±17.1 years, and 35.9% were women. Nearly half of patients (49.8%) were non-Hispanic White; 20.6% were non-Hispanic Black; 7.3% were Hispanic; 2.9% were Asian; and 0.4% were Native American. Overall, 58 098 (9.3%) survived to hospital discharge. Although bystander CPR was associated with higher survival in each race and ethnicity group, the association of bystander CPR compared with patients without bystander CPR in each racial and ethnic group was highest in individuals who were White (adjusted odds ratio [OR], 1.33 [95% CI, 1.30-1.37]) and Native American (adjusted OR, 1.40 [95% CI, 1.02-1.90]) and lowest in individuals who were Black (adjusted OR, 1.09 [95% CI, 1.04-1.14]; P interaction <0.001). The adjusted OR for bystander CPR compared with those without bystander CPR for Hispanic patients was 1.29 (95% CI, 1.20-1.139), for Asian patients, it was 1.27 (95% CI, 1.12-1.42), and for those of unknown race, it was 1.31 (95% CI, 1.25-1.36). Similarly, bystander CPR was associated with higher survival in both sexes, but its association with survival was higher in men (adjusted OR, 1.35 [95% CI, 1.31-1.38]) than women (adjusted OR, 1.15 [95% CI, 1.12-1.19]; P interaction <0.001). The weaker association of bystander CPR in Black individuals and women was consistent across neighborhood race and ethnicity and income strata. Similar results were observed for the outcome of survival without severe neurological deficits., Conclusions: Although bystander CPR was associated with higher survival in all patients, its association with survival was weakest for Black individuals and women with out-of-hospital cardiac arrest., Competing Interests: None.

Background: Contemporary research in peripheral artery disease (PAD) remains limited due to lack of a national registry and low accuracy of diagnosis codes to identify PAD patients in electronic health records., Methods & Results: Leveraging a novel natural language processing (NLP) system that identifies PAD with high accuracy using ankle brachial index (ABI) and toe-brachial index (TBI) values, we created a registry of 103,748 patients with new onset PAD patients in the Veterans Health Administration (VHA). Study endpoints include mortality, cardiovascular (hospitalization for acute myocardial infarction or stroke) and limb events (hospitalization for critical limb ischemia or major amputation) and were identified using VA and non-VA encounters. The mean age was 70.6 years; 97.3% were males, and 18.5% self-identified as Black race. The mean ABI value was 0.78 (SD: 0.26) and the mean TBI value was 0.51 (SD: 0.19). Nearly one-third (32.4%) patients were currently smoking and 35.4% formerly smoked. Prevalence of hypertension (86.6%), heart failure (22.7%), diabetes (54.8%), renal failure (23.6%), and chronic obstructive pulmonary disease (35.4%) was high. At 1-year, 9.4% of patients had died. The 1-year incidence of cardiovascular events was 5.6 per 100 patient-years and limb events was 4.5 per 100 patient-years., Conclusions: We have successfully launched a registry of >100,000 patients with a new diagnosis of PAD in the VHA, the largest integrated health system in the U.S. The ncidence of death and clinical events in our cohort is high. Ongoing studies will yield important insights regarding improving care and outcomes in this high-risk group.

Background: Survival for in-hospital cardiac arrest (IHCA) has declined since the COVID-19 pandemic. Because the burden of COVID-19 was uneven throughout the U.S., it remains unknown if top-performer hospitals in IHCA survival have remained top-performers since the pandemic., Methods: Within Get With The Guidelines®-Resuscitation, we identified hospitals with at least 2 years of registry participation pre-pandemic (2017-2019) and post-pandemic (July 2020-2022) and with at least 20 IHCA cases in both periods. Using multivariable hierarchical models with hospital as a random effect and adjusting for patient and arrest characteristics, we calculated risk-standardized survival rates to discharge (RSSR) for IHCA at each hospital during the pre- and post-pandemic periods. We then assessed the correlation between a hospital's pre-pandemic and post-pandemic RSSR for IHCA, and whether the correlation differed by the proportion of Black or Hispanic IHCA patients at each hospital., Results: A total of 243 hospitals were included, comprising 122,561 IHCAs (pre-pandemic: 57,601; post-pandemic: 64,960). Pre-pandemic, the mean RSSR was 26.8% (SD, 5.2%) whereas the mean RSSR post-pandemic was 21.7% (SD, 5.5%). There was good correlation between a hospital's pre- and post-pandemic RSSR: correlation of 0.55. When hospitals were categorized into tertiles based on the proportion of their IHCA patients who were Black or Hispanic, this correlation remained similar: 0.48, 0.68, and 0.45 (interaction P-value: 0.69) for hospitals in the upper, middle and lower tertiles, respectively., Conclusion: Although the COVID-19 pandemic affected the U.S. unevenly, there was good correlation in a hospital's performance for IHCA survival before and after the pandemic, even at hospitals caring for a larger proportion of Black and Hispanic patients. Future studies are needed to understand what characteristics of high-performing hospitals pre-pandemic allowed many to continue to excel in the post-pandemic period., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Anne Grossestreuer, PhD is a member of the American Heart Association's Get With The Guidelines®-Resuscitation Adult Research Task Force and the Resuscitation editorial board., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Pneumococcal vaccination (PV) is effective in preventing vaccine-type pneumococcal diseases. This study investigated the changes in PV uptake and its determinants before, during, and after the Coronavirus Disease 2019 (COVID-19) pandemic among community-living older adults aged ≥65 years in Hong Kong, China. Three rounds of random telephone surveys were conducted every two years from May 2019 to October 2023. Multivariate logistic regression models were fitted to examine the between-round differences in PV uptake rate and factors associated with PV uptake in each round. This study included 1563 participants. The standardized PV uptake rate in Round 1, 2, and 3 was 17.3%, 28.3%, and 35.5%, respectively. A significant difference in the PV uptake rate was found between Rounds 2 and 1 ( p = 0.02), but not between Rounds 3 and 2 ( p = 0.98). Perceived barriers, cue to action and self-efficacy, were significant determinants of PV uptake in all rounds. Perceived benefits were significant determinants of PV uptake in the first and second rounds, but not in the third round. Continuous monitoring of PV uptake and its determinants, and evaluating and adjusting the PV program, might contribute to the success of such a vaccination program in the post-pandemic era.

Importance: Survival for out-of-hospital cardiac arrest (OHCA) varies widely across emergency medical service (EMS) agencies in the US. However, little is known about which EMS practices are associated with higher agency-level survival., Objective: To identify resuscitation practices associated with favorable neurological survival for OHCA at EMS agencies., Design, Setting, and Participants: This cohort study surveyed EMS agencies participating in the Cardiac Arrest Registry to Enhance Survival (CARES) with 10 or more OHCAs annually during January 2015 to December 2019; data analyses were performed from April to October 2023., Exposure: Survey of resuscitation practices at EMS agencies., Main Outcomes and Measures: Risk-standardized rates of favorable neurological survival for OHCA at each EMS agency were estimated using hierarchical logistic regression. Multivariable linear regression then examined the association of EMS practices with rates of risk-standardized favorable neurological survival., Results: Of 577 eligible EMS agencies, 470 agencies (81.5%) completed the survey. The mean (SD) rate of risk-standardized favorable neurological survival was 8.1% (1.8%). A total of 7 EMS practices across 3 domains (training, cardiopulmonary resuscitation [CPR], and transport) were associated with higher rates of risk-standardized favorable neurological survival. EMS agencies with higher favorable neurological survival rates were more likely to use simulation to assess CPR competency (β = 0.54; P = .05), perform frequent reassessment (at least once every 6 months) of CPR competency in new staff (β = 0.51; P = .04), use full multiperson scenario simulation for ongoing skills training (β = 0.48; P = .01), perform simulation training at least every 6 months (β = 0.63; P < .001), and conduct training in the use of mechanical CPR devices at least once annually (β = 0.43; P = .04). EMS agencies with higher risk-standardized favorable neurological survival were also more likely to use CPR feedback devices (β = 0.58; P = .007) and to transport patients to a designated cardiac arrest or ST-segment elevation myocardial infarction receiving center (β = 0.57; P = .003). Adoption of more than half (≥4) of the 7 practices was more common at EMS agencies in the highest quartile of favorable neurological survival rates (70 of 118 agencies [59.3%]) vs the lowest quartile (42 of 118 agencies [35.6%]) (P < .001)., Conclusions and Relevance: In a national registry for OHCA, 7 practices associated with higher rates of favorable neurological survival were identified at EMS agencies. Given wide variability in neurological survival across EMS agencies, these findings provide initial insights into EMS practices associated with top-performing EMS agencies in OHCA survival. Future studies are needed to validate these findings and identify best practices for EMS agencies.

Importance: Cardiopulmonary resuscitation (CPR) duration is associated with cardiac arrest survival., Objectives: To describe characteristics associated with CPR duration among hospitalized children without return of circulation (ROC) (patient-level analysis) and determine whether hospital median CPR duration in patients without ROC is associated with survival (hospital-level analysis)., Design, Setting, and Participants: This retrospective cohort study of patients undergoing pediatric in-hospital CPR between January 1, 2000, and December 31, 2021, used data from the Get With the Guidelines-Resuscitation registry. Children receiving chest compressions for at least 2 minutes and/or defibrillation were included in the patient-level analysis. For the hospital-level analysis, sites with at least 20 total events and at least 5 events without ROC were included. Data were analyzed from December 1, 2022, to November 15, 2023., Exposures: For the patient-level analysis, the exposure was CPR duration in patients without ROC. For the hospital-level analysis, the exposure was quartile of median CPR duration in events without ROC at each hospital., Main Outcomes and Measures: For the patient-level analysis, outcomes were patient and event factors, including race and ethnicity and event location; we used a multivariable hierarchical linear regression model to assess factors associated with CPR duration in patients without ROC. For the hospital-level analysis, the main outcome was survival to discharge among all site events; we used a random intercept multivariable hierarchical logistic regression model to examine the association between hospital quartile of CPR duration and survival to discharge., Results: Of 13 899 events, 3859 patients did not have ROC (median age, 7 months [IQR, 0 months to 7 years]; 2175 boys [56%]). Among event nonsurvivors, median CPR duration was longer in those with initial rhythms of bradycardia with poor perfusion (8.37 [95% CI, 5.70-11.03] minutes; P < .001), pulseless electrical activity (8.22 [95% CI, 5.44-11.00] minutes; P < .001), and pulseless ventricular tachycardia (6.17 [95% CI, 0.09-12.26] minutes; P = .047) (vs asystole). Shorter median CPR duration was associated with neonates compared with older children (-4.86 [95% CI, -8.88 to -0.84] minutes; P = .02), emergency department compared with pediatric intensive car7 e unit location (-4.02 [95% CI, -7.48 to -0.57] minutes; P = .02), and members of racial or ethnic minority groups compared with White patients (-3.67 [95% CI, -6.18 to -1.17]; P = .004). Among all CPR events, the adjusted odds of survival to discharge differed based on hospital quartile of median CPR duration among events without ROC; compared with quartile 1 (15.0-25.9 minutes), the adjusted odds ratio for quartile 2 (26.0-29.4 minutes) was 1.22 (95% CI, 1.09-1.36; P < .001); for quartile 3 (29.5-32.9 minutes), 1.23 (95% CI, 1.08-1.39; P = .002); and for quartile 4 (33.0-53.0 minutes), 1.04 (95% CI, 0.91-1.19; P = .58)., Conclusions and Relevance: In this retrospective cohort study of pediatric in-hospital CPR, several factors, including age and event location, were associated with CPR duration in event nonsurvivors. The odds of survival to discharge were lower for patients at hospitals with the shortest and longest median CPR durations among events without ROC. Further studies are needed to determine the optimal duration of CPR during pediatric in-hospital cardiac arrest and to provide training guidelines for resuscitation teams to eliminate disparities in resuscitation care.

Objective: To assess the utility of tumor-intrinsic and cancer-associated fibroblast (CAF) subtypes of pancreatic ductal adenocarcinoma (PDAC) in predicting response to neoadjuvant therapy (NAT) and overall survival (OS)., Background: PDAC remains a deadly disease with limited treatment options, and both the tumor as well as the microenvironment play an important role in pathogenesis. Gene expression-based tumor-intrinsic subtypes (classical and basal-like) have been shown to predict outcomes, but tumor microenvironment subtypes are still evolving., Methods: RNA-sequencing was performed on 114 deidentified resected PDAC tumors. Clinical data were collected by retrospective chart review. Single sample classifiers were used to determine classical and basal-like subtypes as well as tumor-permissive permCAF and tumor-restraining restCAF subtypes. Survival was analyzed using the log-rank test., Results: Patients who received NAT had an increase in OS, with a median survival of 27.9 months compared with 20.1 months for those who did not receive NAT, but the difference did not reach statistical significance (hazard ratio: 0.64, P =0.076). Either tumor-intrinsic or CAF subtypes alone were associated with OS regardless of NAT or no NAT, and patients with classical or restCAF subtypes had the best outcomes. When evaluated together, patients with the classical-restCAF subtype had the best OS and basal-permCAF the worst OS ( P <0.0001). Patients undergoing NAT with the classical-restCAF subtype demonstrated the longest OS compared with the other groups ( P =0.00041)., Conclusions: CAF subtypes have an additive effect over tumor-intrinsic subtypes in predicting survival with or without neoadjuvant FOLFIRINOX in PDAC. Molecular subtyping of both tumor and CAF compartments of PDAC may be important steps in selecting first-line systemic therapy., Competing Interests: J.J.Y., X.,L.,P., and N.U.R. are inventors of PurIST Subtype Classifier, which was licensed to GeneCentric Therapeutics, Inc. The remaining authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: How frequently out-of-hospital cardiac arrest (OHCA) occurs within a reasonable walking distance to the nearest public automated external defibrillator (AED) has not been well studied., Methods: As Kansas City, Missouri has a comprehensive city-wide public AED registry, we identified adults with an OHCA in Kansas City during 2019-2022 in the Cardiac Arrest Registry to Enhance Survival. Using AED location data from the registry, we computed walking times between OHCAs and the nearest registered AED using the Haversine formula, a mapping algorithm to calculate walking distance in miles from one location to another. Results were stratified by OHCA location (home vs. public) and by whether the patient received bystander cardiopulmonary resuscitation (CPR)., Results: Of 1,522 OHCAs, 1,291 (84.8%) occurred at home and 231 (15.2%) in public. Among at-home OHCAs, 634 (49.1%) received bystander CPR and no patients had an AED applied even as 297 (23.0%) were within a 4-minute walk to the closest public AED. Among OHCAs in public, 108 (46.8%) were within a 4-minute walk to the closest public AED. For public OHCAs within a 4-minute walk, bystanders applied an AED in 13 (12.0%) of these cases and in 24.5% (13/53) of those who received bystander CPR., Conclusion: In one U.S. city with a publicly available AED registry, there were no instances in which a bystander accessed a public AED for an OHCA at home. For OHCAs in public, nearly half occurred within a 4-minute walk to the closest AED but bystander use of an AED was low., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

This systematic review and meta-analysis analyzed and summarized the growing literature on the effectiveness of chatbot-delivered interventions in increasing uptake, intention, and attitudes related to any type of vaccination. We identified randomized controlled studies (RCTs), quasi-experimental studies, and non-experimental studies from the following platforms: PubMed, Web of Science, MEDLINE, Global Health, APA PsycInfo, and EMBASE databases. A total of 12 eligible studies published from 2019 to 2023 were analyzed and summarized. In particular, one RCT showed that a chatbot-delivered tailored intervention was more effective than a chatbot-delivered non-tailored intervention in promoting seasonal influenza vaccine uptake among older adults (50.5% versus 35.3%, p = 0.002). Six RCTs were included in the meta-analysis to evaluate the effectiveness of chatbot interventions to improve vaccination attitudes and intentions. The pooled standard mean difference (SMD) of overall attitude change was 0.34 (95% confidence intervals [CI]: 0.13, 0.55, p = 0.001). We found a non-significant trivial effect of chatbot interventions on improving intentions of vaccination (SMD: 0.11, 95% CI: -0.13, 0.34, p = 0.38). However, further evidence is needed to draw a more precise conclusion. Additionally, study participants reported high satisfaction levels of using the chatbot and were likely to recommend it to others. The development of chatbots is still nascent and rooms for improvement exist., (© 2024 International Association of Applied Psychology.)

Lung nodule localization using conventional image-guided video-assisted thoracoscopic surgery involves lung puncture, which increases the risk of needle-related complications. We aimed to evaluate the feasibility and safety of a single-stage non-invasive laser-guided stamping localization technique followed by resection under general anesthesia in a hybrid operating room. We retrospectively reviewed consecutive patients who underwent thoracoscopic surgery for small pulmonary nodules using laser-guided dye-stamping localization methods in a hybrid operating room between June 2023 and October 2023. During the study period, 18 patients with 20 lesions underwent single-stage intraoperative image-guided stamping video-assisted thoracoscopic surgery in the hybrid operating room. The median size of the nodules was 7.4 mm (interquartile range [IQR] 5.7-9.8 mm), and median distance from the pleural surface was 9.8 mm (IQR 7.7-14.6 mm). The median localization time was 26 min (IQR 23-34 min), whereas median operation time was 69 min (IQR 62-87 min). The total median operating room time was 146 min (IQR 136-157 min). Twelve patients underwent less than two cone-beam computed tomography scans, while 6 underwent more than two scans. The total median dose area product, including cone-beam computed tomography scans, was 5731.4 uGym 2 . No localization-related complications were observed, and the postoperative length of stay was 1 day (IQR 1-2 days). The single-stage image-guided pleural stamping technique for localizing small pulmonary nodules in a hybrid operating room is feasible and safe. Future research with larger cohorts is required to further explore the benefits of this workflow., (© 2024. Italian Society of Surgery (SIC).)

Rationale and Objectives: Percutaneous lung tumor ablations are mostly performed in computed tomography (CT) rooms under local anesthesia with conscious sedation. However, maintaining the breath-hold phase during this can be challenging, affecting image quality and increasing complications. With the advent of hybrid operating rooms (HORs), this procedure can be performed with endotracheal tube (ETGA) intubation under general anesthesia with lung separation, ensuring precise imaging in a single-stage setting. Lung separation provides surgical exposure of one lung while ensuring ample gas exchange with the other. This study evaluated tumor ablations performed in an HOR equipped with cone beam CT and laser guidance., Materials and Methods: This retrospective study included patients who underwent lung tumor ablation under general anesthesia with an ETGA in an HOR between July 2020 and May 2023. Anesthesia considerations, perioperative management, and postoperative follow-ups were evaluated., Results: 65 patients (78 tumors) underwent ablation using two types of lung ventilation methods including a single-lumen tube with a blocker (SLT/BL) (n = 15) and double-lumen tube (DLT) (n = 50). Most patients experienced desaturation during the apnea phase of dynamic CT and needling. The average SpO 2 value was significantly lower in the DLT group than in the SLT/BL group during the procedure (81.1% versus 88.7%, P = 0.033). Five, three, and two patients developed pneumothorax, subcutaneous emphysema, and pleural effusion, respectively., Conclusion: Percutaneous ablation under general anesthesia with endotracheal intubation and lung separation performed in HORs was feasible and safe. The setup minimized complication risks and maintained a balance between patient safety and successful procedures., Competing Interests: Declaration of Competing Interests Shwetambara Malwade works for Siemens Company as a research scientist. All other authors have no conflicts of interest or financial ties to disclose., (Copyright © 2024 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objectives: Contrary to advanced cardiac life support guidelines that recommend immediate defibrillation for shockable in-hospital cardiac arrest (IHCA), epinephrine administration before first defibrillation is common and associated with lower survival at a "patient-level." Whether this practice varies across hospitals and its association with "hospital-level" IHCA survival remains unknown. The purpose of this study was to determine hospital variation in rates of epinephrine administration before defibrillation for shockable IHCA and its association with IHCA survival., Design: Observational cohort study., Setting: Five hundred thirteen hospitals participating in the Get With The Guidelines Resuscitation Registry., Patients: A total of 37,668 adult patients with IHCA due to an initial shockable rhythm from 2000 to 2019., Interventions: Epinephrine before first defibrillation., Measurements and Main Results: Using multivariable hierarchical regression, we examined hospital variation in epinephrine administration before first defibrillation and its association with hospital-level rates of risk-adjusted survival. The median hospital rate of epinephrine administration before defibrillation was 18.8%, with large variation across sites (range, 0-68.8%; median odds ratio: 1.54; 95% CI, 1.47-1.61). Major teaching status and annual IHCA volume were associated with hospital rate of epinephrine administration before defibrillation. Compared with hospitals with the lowest rate of epinephrine administration before defibrillation (Q1), there was a stepwise decline in risk-adjusted survival at hospitals with higher rates of epinephrine administration before defibrillation (Q1: 44.3%, Q2: 43.4%; Q3: 41.9%; Q4: 40.3%; p for trend < 0.001)., Conclusions: Administration of epinephrine before defibrillation in shockable IHCA is common and varies markedly across U.S. hospitals. Hospital rates of epinephrine administration before defibrillation were associated with a significant stepwise decrease in hospital rates of risk-adjusted survival. Efforts to prioritize immediate defibrillation for patients with shockable IHCA and avoid early epinephrine administration are urgently needed., Competing Interests: Dr. Stewart received funding from the American Heart Association (AHA). Dr. Chan received funding from the National Heart Lung and Blood Institute and the AHA. Drs. Chan and Girotra received support for article research from the National Institutes of Health (R01HL160734) and the AHA. Ms. Swanson is additionally supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (F30HD100074). Dr. Girotra has received funding from the National Institutes of Health (R56HL158803 and R01HL160734) and the AHA for editorial work. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Respiratory interoception is one of the internal bodily systems that is comprised of different types of somatic and visceral sensations elicited by different patterns of afferent input and respiratory motor drive mediating multiple respiratory modalities. Respiratory interoception is a complex system, having multiple afferents grouped into afferent clusters and projecting into both discriminative and affective centers that are directly related to the behavioral assessment of breathing. The multi-afferent system provides a spectrum of input that result in the ability to interpret the different types of respiratory interceptive sensations. This can result in a response, commonly reported as breathlessness or dyspnea. Dyspnea can be differentiated into specific modalities. These respiratory sensory modalities lead to a general sensation of an Urge-to-Breathe, driven by a need to compensate for the modulation of ventilation that has occurred due to factors that have affected breathing. The multiafferent system for respiratory interoception can also lead to interpretation of the sensory signals resulting in respiratory related sensory experiences, including the Urge-to-Cough and Urge-to-Swallow. These behaviors are modalities that can be driven through the differentiation and integration of multiple afferent input into the respiratory neural comparator. Respiratory sensations require neural somatic and visceral interoceptive elements that include gated attention and detection leading to respiratory modality discrimination with subsequent cognitive decision and behavioral compensation. Studies of brain areas mediating cortical and subcortical respiratory sensory pathways are summarized and used to develop a model of an integrated respiratory neural network mediating respiratory interoception., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Cancer-associated fibroblast (CAF) subpopulations in pancreatic ductal adenocarcinoma (PDAC) have been identified using single-cell RNA sequencing (scRNAseq) with divergent characteristics, but their clinical relevance remains unclear. We translate scRNAseq-derived CAF cell-subpopulation-specific marker genes to bulk RNAseq data, and develop a single- sample classifier, DeCAF, for the classification of clinically rest raining and perm issive CAF subtypes. We validate DeCAF in 19 independent bulk transcriptomic datasets across four tumor types (PDAC, mesothelioma, bladder and renal cell carcinoma). DeCAF subtypes have distinct histology features, immune landscapes, and are prognostic and predict response to therapy across cancer types. We demonstrate that DeCAF is clinically replicable and robust for the classification of CAF subtypes in patients for multiple tumor types, providing a better framework for the future development and translation of therapies against permissive CAF subtypes and preservation of restraining CAF subtypes., Significance: We introduce a replicable and robust classifier, DeCAF, that delineates the significance of the role of permissive and restraining CAF subtypes in cancer patients. DeCAF is clinically tractable, prognostic and predictive of treatment response in multiple cancer types and lays the translational groundwork for the preclinical and clinical development of CAF subtype specific therapies.

Background: Cardiac arrest is 1 of the leading causes of morbidity and mortality, with an estimated 340 000 out-of-hospital and 292 000 in-hospital cardiac arrest events per year in the United States. Survival rates are lower in certain racial and socioeconomic groups., Methods and Results: We performed a county-level cross-sectional longitudinal study using the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research multiple causes of death data set between 2016 and 2020 among individuals of all ages whose death was attributed to cardiac arrest. The Social Vulnerability Index is a composite measure that includes socioeconomic vulnerability, household composition, disability, individuals from racial and ethnic minority groups status and language, and housing and transportation domains. We examined the impact of social determinants on cardiac arrest mortality stratified by age, race, ethnicity, and sex in the United States. All age-adjusted mortality rate (cardiac arrest AAMRs) are reported as per 100 000. Overall cardiac arrest AAMR during the study period was 95.6. The cardiac arrest AAMR was higher for men compared with women (119.6 versus 89.9) and for the Black population compared with the White population (150.4 versus 92.3). The cardiac arrest AAMR increased from 64.8 in counties in quintile 1 of Social Vulnerability Index to 141 in quintile 5, with an average increase of 13% (95% CI, 9.8%-16.9%) in AAMR per quintile increase., Conclusions: Mortality from cardiac arrest varies widely, with a >2-fold difference between the counties with the highest and lowest social vulnerability, highlighting the differential burden of cardiac arrest deaths throughout the United States based on social determinants of health.

Background: Alcohol screening and brief intervention (SBI) is an evidence-based intervention recommended by the World Health Organization. This study applied the Consolidated Framework for Implementation Research (CFIR) to understand facilitators and barriers of SBI implementation in primary care settings in Hong Kong, China., Methods: This was a sequential mixed-method study. In-depth interviews of 21 physicians and 20 nurses working in the primary care settings from the public and private sectors were first conducted to identify CFIR constructs that were relevant to SBI implementation in the Chinese context and potential factors not covered by the CFIR. A questionnaire was then developed based on the qualitative findings to investigate factors associated with SBI implementation among 282 physicians and 295 nurses., Results: The in-depth interviews identified 22 CFIR constructs that were facilitators or barriers of SBI implementation in Hong Kong. In addition, the stigmatization of alcohol dependence was a barrier and the belief that it was important for people to control the amount of alcohol intake in any situation was mentioned as a facilitator to implement SBI. In the survey, 22% of the participants implemented SBI in the past year. Factors associated with the SBI implementation echoed most of the qualitative findings. Among physicians and nurses in both sectors, they were more likely to implement SBI when perceiving stronger evidence supporting SBI, better knowledge and self-efficacy to implement SBI, more available resources, and clearer planning for SBI implementation in the clinics but less likely to do so when perceiving SBI implementation to be complicated and of higher cost, and drinking approved by the Chinese culture. Participants were more likely to implement SBI when perceiving SBI fit better with the existing practice and better leadership engagement in the public sector, but not in the private sector. Perceiving a stronger need and greater importance to implement SBI were associated with higher likelihood of SBI implementation among physicians, but not among nurses. Perceiving better organizational culture supporting SBI was positively associated with SBI implementation among nurses, but not among physicians., Conclusions: There was a significant gap between SBI evidence and its implementation. Some strategies to improve SBI implementation may be different between physicians and nurses and between those in the public and private sectors. The CFIR is a useful framework for understanding facilitators and barriers of SBI implementation in primary care settings., (© 2024. The Author(s).)

Purpose: We developed a novel augmented fluoroscopy-guided intrathoracic stamping technique for localizing small pulmonary nodules in the hybrid operating room. We conducted an observational study to investigate the feasibility of this technique and retrospectively compared two augmented fluoroscopy-guided approaches: intrathoracic and transbronchial., Methods: From August 2020 to March 2023, consecutive patients underwent single-stage augmented fluoroscopy-guided localization under general anaesthesia. This included intrathoracic stamping and bronchoscopic lung marking, followed by thoracoscopic resection in a hybrid operating room. Comparative analyses were performed between the two groups., Results: The data of 50 patients in the intrathoracic stamping and 67 patients in the bronchoscopic lung marking groups were analysed. No significant difference was noted in demographic data between the groups, except a larger lesion depth in the bronchoscopic lung marking group (14.7 ± 11.7 vs 11.0 ± 5.8 mm, p = 0.029). Dye localization was successfully performed in 49 intrathoracic stamping group patients (98.0%) and 67 bronchoscopic lung marking group patients (100%). No major procedure-related complications occurred in either group; however, the time flow (total anaesthesia time/global operating room time) was longer, and the radiation exposure (fluoroscopy duration/total dose area product) was larger in the bronchoscopic lung marking group., Conclusions: Augmented fluoroscopic stamping localization under intubated general anaesthesia is feasible and safe, providing an alternative with less global operating room time and lower radiation exposure for image-guided thoracoscopic surgery in the hybrid operating room., (© 2024. CARS.)

Background: Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting., Methods: The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores., Results: Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients., Conclusions: KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed., Competing Interests: Disclosures Drs Khan and Sherrod are supported by the National Heart, Lung, and Blood Institute under award T32H110837. Dr Ikemura received an unrestricted research grant for the Department of Cardiology, Keio University School of Medicine from Bristol Myer Squibb. Dr Sauer reports industry relationships with Abbott, Boston Scientific, Biotronik, Bayer, Amgen, CSL Vifor, Acorai, Story Health, General Prognostics, Impulse Dynamics, and Edwards Lifesciences. He also serves as advisory board member and owns stock in ISHI digital health company. Dr Fonarow reports consulting for Abbott, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Cytokinetics, Eli Lilly Johnson & Johnson, Medtronic, Merck, Novartis, and Pfizer. Dr Butler reports consulting for Abbott, American Regent, Amgen, Applied Therapeutic, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardiac Dimension, Cardior, CVRx, Cytokinetics, Edwards, Element Science, Innolife, Impulse Dynamics, Imbria, Inventiva, Lexicon, Lilly, LivaNova, Janssen, Medtronics, Merck, Occlutech, Novartis, Novo Nordisk, Pfizer, Pharmacosmos, Pharmain, Roche, Sequana, SQ Innovation, and Vifor. Dr DeVore reports research funding through his institution from Biofourmis, Bodyport, Cytokinetics, American Regent Inc, the National Institutes of Health and the National Heart, Lung, and Blood Institute, Novartis, and Story Health. He also provides consulting services for and/or receives honoraria from Abiomed, Cardionomic, LivaNova, Natera, NovoNordisk, Story Health, and Zoll. Dr Lund is supported by Karolinska Institutet, the Swedish Research Council (grant 523-2014-2336), the Swedish Heart Lung Foundation (grants 20150557 and 20190310), and the Stockholm County Council (grants 20170112 and 20190525). Dr Lund reports the following relationships with industry: grants, consulting, honoraria: Abbot, Alleviant, AstraZeneca, Bayer, Biopeutics, Boehringer Ingelheim, Edwards, Merck/MSD, Novartis, Novo Nordisk, OrionPharma, Owkin, Pharmacosmos, Vifor Pharma; stock ownership: AnaCardio. Dr Chan is supported by the National Heart, Lung, and Blood Institute under award R01HL160734 and is a consultant for Optum Rx. Dr Spertus has provided consultative services on patient-reported outcomes and evidence evaluation to Alnylam, AstraZeneca, Bayer, Merck, Janssen, Bristol Myers Squibb, Edwards, Kineksia, 4DT Medical, Terumo, Cytokinetics, Imbria, and United Healthcare; holds research grants from Bristol Myers Squibb, Abbott Vascular, and Janssen; owns the copyright to the Seattle Angina Questionnaire, Kansas City Cardiomyopathy Questionnaire, and Peripheral Artery Questionnaire; and serves on the Board of Directors for Blue Cross Blue Shield of Kansas City. The other authors report no conflicts.