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Vivian L Qin,1,* Amy Yimin Chen,2,* Hasan Bashir,3 David Hsu,4 Lily Wushanley,3 Vivian Lee1 1University of Pennsylvania, Scheie Eye Institute, Philadelphia, PA, USA; 2University of Pennsylvania, Vagelos Program in Life Sciences & Management, Philadelphia, PA, USA; 3Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA; 4University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA*These authors contributed equally to this workCorrespondence: Vivian Lee, University of Pennsylvania, 51N 39th Street, Philadelphia, PA, 19104, USA, Tel +1 215-662-8125, Email Vivian.lee@pennmedicine.upenn.eduPurpose: The aim of this research is to describe the use of the social media platform, Instagram, by academic ophthalmology residency programs in the United States over time and consider the impact of the COVID-19 pandemic on ophthalmology’s social media presence.Methods and Subjects: This cross-sectional study was conducted online by reviewing the publicly accessible Instagram accounts of all accredited US academic ophthalmology residency programs.Main Outcomes and Measures: Number of US ophthalmology residency programs with an affiliated Instagram account were analyzed by year of creation. The content of the top six accounts with the most followers was analyzed by evaluating amount of engagement within defined post categories.Results: Of the 124 ophthalmology residency programs, 78 (62.9%) were identified as having an affiliated Instagram account, 60 accounts (48.4%) were created during the years 2020 or 2021, and 62 (50.0%) accounts focused specifically on promoting the residency training program. Of the top six accounts with the most followers, post categories that received the most engagement were “Medical” and “Group Photo”, while those that received the least engagement were “Department Bulletin” and “Miscellaneous.” User engagement on posts as measured by likes and comments increased across multiple post categories after January 2020.Conclusion: Social media presence of ophthalmology residency programs on Instagram increased substantially in 2020 and 2021. As a result of the COVID-19 pandemic restricting in-person interactions, residency programs have used alternative platforms to reach applicants. Given the increasing use of such applications, social media will likely continue to become an important aspect of professional engagement in ophthalmology.Keywords: social media, medical education, ophthalmology, ophthalmology residency

Denise D Quigley,1 Peter J Mendel,1 Zachary S Predmore,2 Alex Y Chen,3 Ron D Hays41RAND Corporation, Santa Monica, CA, 2RAND Corporation, Boston, MA, 3AltaMed Health Services Corporation, 4Division of General Internal Medicine and Health Services Research, UCLA, Los Angeles, CA, USAObjective: To describe how practice leaders used Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Clinician and Group (CG-CAHPS) data in transitioning toward a patient-centered medical home (PCMH).Study design: Interviews conducted at 14 primary care practices within a large urban Federally Qualified Health Center in California.Participants: Thirty-eight interviews were conducted with lead physicians (n=13), site clinic administrators (n=13), nurse supervisors (n=10), and executive leadership (n=2).Results: Seven themes were identified on how practice leaders used CG-CAHPS data for PCMH transformation. CAHPS® was used: 1) for quality improvement (QI) and focusing changes for PCMH transformation; 2) to maintain focus on patient experience; 3) alongside other data; 4) for monitoring site-level trends and changes; 5) to identify, analyze, and monitor areas for improvement; 6) for provider-level performance monitoring and individual coaching within a transparent environment of accountability; and 7) for PCMH transformation, but changes to instrument length, reading level, and the wording of specific items were suggested.Conclusion: Practice leaders used CG-CAHPS data to implement QI, develop a shared vision, and coach providers and staff on performance. They described how CAHPS® helped to improve the patient experience in the PCMH model, including access to routine and urgent care, wait times, provider spending enough time and listening carefully, and courteousness of staff. Regular reporting, reviewing, and discussing of patient-experience data alongside other clinical quality and productivity measures at multilevels of the organization was critical in maximizing the use of CAHPS® data as PCMH changes were made. In sum, this study found that a system-wide accountability and data-monitoring structure relying on a standardized and actionable patient-experience survey, such as CG-CAHPS, is key to supporting the continuous QI needed for moving beyond formal PCMH recognition to maximizing primary care medical home transformation.Keywords: PCMH, performance improvement, accountability, CAHPS®

Background: Glycoprotein (GP) IIb/IIIa inhibitors can improve outcomes in patients with non-ST-segment elevation acute coronary syndromes but raise the risk of bleeding, particularly if dosed in excess. The impact of GP IIb/IIIa dosing feedback on safety and major bleeding is unknown.Methods: Glycoprotein IIb/IIIa dosing feedback was added to the CRUSADE quarterly site reports in the first quarter of 2006. We describe GP IIb/IIIa use and dosing among 25,641 patients with non-ST-segment elevation acute coronary syndromes from the fourth quarter of 2005 to the fourth quarter of 2006.Results: Eleven thousand eight hundred forty-six patients received GP IIb/IIIa inhibitors, including 4,031 women and 2,609 elderly patients (age, ≥75 years). Among GP IIb/IIIa-treated patients, unadjusted rates of excess GP IIb/IIIa dosing declined overall (26.4%-22.4%, Ptrend=.01) and among the elderly (65.6%-52.1%, Ptrend<.001). After adjustment, declines in excess dosing remained significant only for the elderly, although more than half of GP IIb/IIIa-treated elderly patients continued to receive excess dosing at the end of the study period (64.1%-51.3%, Ptrend<.001). There were concurrent declines in unadjusted major bleeding rates overall (9.6%-8.0%, Ptrend=.02), but declines among women (14.4%-11.5%, Ptrend=.08) and the elderly (17.1%-11.0%, Ptrend=.05) did not reach statistical significance. After adjustment for baseline characteristics and excess dosing, declines in major bleeding rates were no longer significant overall or for any subgroup.Conclusion: Within 9 months of initiating a safety feedback program, we observed early decreases in excess GP IIb/IIIa dosing among the elderly but minimal changes in excess dosing overall. Further work is needed to promote safe and effective medication use in vulnerable patients who are most at risk of harm. [ABSTRACT FROM AUTHOR]

Aims The NCDR ACTION Registry-GWTG collects detailed in-hospital clinical, process-of-care and outcomes data for patients admitted with acute myocardial infarction (AMI) in the USA. The registry is a national AMI surveillance system that contributes to the scientific enquiry process of AMI care through the facilitation of local and national quality improvement efforts. Interventions No treatments are mandated, participating centres receive routine quality-of-care and outcomes performance feedback reports and access to quality of care tools, such as dosing algorithms and standing orders. Population AMI patients are retrospectively identified. No informed consent is required, as data are anonymised. From January 2007 to date, 147 165 records have been submitted from 383 participating US hospitals. Patients with a primary diagnosis of ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction are eligible for enrolment in the registry. These patients must have ischemic symptoms and electrocardiogram changes, and/or positive cardiac markers within 24 hours of initial presentation. Baseline data Approximately 350 fields encompassing patient demographics, medical history and risk factors, hospital presentation, initial cardiac status, medications and associated doses, reperfusion strategy, procedures, laboratory values, and outcomes. Data are manually entered by study personnel; there are non-financial incentives at the hospital level. Completeness within the registry is noteworthy with most fields at less than 5% missing. Endpoints Main outcome measures include American College of Cardiology/American Heart Association myocardial infarction performance indicators, as well as in-hospital patient outcomes. Data are available for research by application to: http://www.ncdr.com. [ABSTRACT FROM AUTHOR]

We evaluated the reported contraindications to early beta-blocker use and associated mortality within and across patient age groups. Contraindications to early beta-blocker use were evaluated in patients with non-ST-elevation acute coronary syndrome in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative from February 2003 to December 2006. The prevalence, reasons, and trends in the contraindications were evaluated by age (or=75 years). The associations between the reported contraindications and in-hospital mortality were determined within and compared across age groups using the logistic generalized estimating equations method, adjusting for baseline patient characteristics. Of 112,448 patients, 11,711 (10.4%) had a reported contraindication to early beta-blocker use. The prevalence varied by age (or=75, 13.4%; p <0.0001). No significant changes were seen over time, except for a small increase in patients 40 patients in the registry, the median hospital level rate of reported contraindications was 9.9% (interquartile range 6.7% to 14.3%). The distribution of rates was more widespread among the hospitals' older versus younger patients. In all age groups, a statistically significant greater association was found with in-hospital mortality in those with reported contraindications versus those without contraindications who received a beta blocker (adjusted odds ratio 2.81, 95% confidence interval 2.28 to 3.46; adjusted odds ratio 2.50, 95% confidence interval 2.07 to 3.03; adjusted odds ratio 2.11, 95% confidence interval 1.88 to 2.37, for ages or=75 years, respectively). The strength of the association was similar across all age groups (interaction p = 0.19). The reported contraindications to early beta-blocker use were common and increased with age. The contraindications were independently associated with greater in-hospital mortality, underscoring the importance of accurately identifying contraindications. In conclusion, the results did not indicate any disparity in reporting the contraindications according to patient age. [ABSTRACT FROM AUTHOR]

STUDY OBJECTIVE: We evaluate the association of emergency department (ED) length of stay with use of guideline-recommended therapies for acute treatments and clinical outcomes. Prolonged ED stays often reflect ED crowding or limited hospital capacity. We hypothesized that patients with non-ST-segment-elevation myocardial infarction who have ED stays of greater than 8 hours may have lower quality of care and worse outcomes. METHODS: Using a secondary analysis of data from an observational registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC/AHA Guidelines, CRUSADE), we compared rates of use of 5 individual acute (<24 hours) guideline-recommended therapies in patients with non-ST-segment-elevation myocardial infarction according to ED length of stay. Patients were grouped by length of stay (short [<4 hours], average [4 to 8 hours], or long [>8 hours]). Multivariable analyses were used to determine independent association of ED length of stay with acute medications and inhospital outcomes (death and myocardial infarction). RESULTS: This analysis included 42,780 patients with non-ST-segment-elevation myocardial infarction. The median ED length of stay was 4.3 hours (25th to 75th percentile 2.9, 6.3); 15% of patients stayed longer than 8 hours. Patients who had long ED stays were more likely to be women and nonwhite and less likely to have health maintenance organization or private insurance. After adjustment, patients with long ED stays less often received guideline-recommended acute myocardial infarction therapies. Although risk-adjusted inhospital mortality rates were similar among groups, the rate of recurrent myocardial infarction increased among patients with long ED stays (odds ratio 1.23; 95% confidence interval 1.01 to 1.48) compared with those with average ED length of stay. CONCLUSION: For patients with non-ST-segment-elevation myocardial infarction, long ED stays were associated with decreased use of guideline-recommended therapies and a higher risk of recurrent myocardial infarction. However, there was no observed difference in mortality. Factors associated with prolonged ED length of stay should be evaluated to optimize treatments and outcomes of patients with non-ST-segment-elevation myocardial infarction. [ABSTRACT FROM AUTHOR]

Background: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.Objective: To compare NSTE ACS care patterns by insurance type.Design: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.Setting: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.Patients: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.Measurements: Guideline-recommended treatments, and in-hospital outcomes.Results: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).Limitations: Self-pay patients and patients without insurance were not assessed.Conclusions: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation. [ABSTRACT FROM AUTHOR]

Context: Effective medical care assumes delivery of evidence-based medicines to appropriate patients with doses comparable to those studied.Objective: To investigate dosing of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and glycoprotein IIb/IIIa inhibitors, and the association between dosing and major outcomes.Design, Setting, and Participants: A prospective observational analysis in 387 US academic and nonacademic hospitals of 30,136 patients from the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) National Quality Improvement Initiative Registry who had non-ST-segment elevation acute coronary syndromes (NSTE ACS) with chest pain and either positive electrocardiograms or cardiac biomarkers between January 1 and September 30, 2004.Main Outcome Measures: Excessive dosing of UFH, LMWH, and glycoprotein IIb/IIIa inhibitors and major clinical outcomes, including bleeding, in-hospital mortality, and length of stay.Results: A total of 3354 patients (42%) with NSTE ACS who were administered antithrombotic agents received at least 1 initial dose outside the recommended range. An excess dose was administered to 2934 patients (32.8%) treated with UFH, 1378 (13.8%) treated with LMWH, and 2784 (26.8%) treated with glycoprotein IIb/IIIa inhibitors. Factors associated with excess dosing included older age, as well as female sex, renal insufficiency, low body weight, diabetes mellitus, and congestive heart failure. Relative to those patients not administered excess dosages, patients with excess dosages of UFH, LMWH, and glycoprotein IIb/IIIa inhibitors either tended toward or had higher risks for major bleeding (adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 0.94-1.26; OR, 1.39; 95% CI, 1.11-1.74; and OR, 1.36; 95% CI, 1.10-1.68; respectively). Bleeding increased relative to the degree of excess dose and to the number of agents administered in excess (6.6% [237/3590] if neither heparin nor glycoprotein IIb/IIIa excess vs 22.2% [93/419] if both excess). Mortality and length of stay were also higher among those patients administered excess dosing. We estimated that 15% (400/2766) of major bleeding in this population may be attributable to excess dosing.Conclusions: Patients with NSTE ACS treated in the community often receive excess doses of antithrombotic therapy. Dosing errors occur more often in vulnerable populations and predict an increased risk of major bleeding. [ABSTRACT FROM AUTHOR]