Evaluation of Statin Use and Prescribing in Patients with Chronic Kidney Disease Not Receiving Treatment with Kidney Transplant or Dialysis

Background: Chronic kidney disease (CKD) is a risk factor for cardiovascular disease. The Kidney Disease Improving Global Outcomes 2013 guidelines and the Canadian Cardiovascular Society 2016 guidelines recommend statins for primary prevention of cardiovascular disease in CKD patients aged 50 years or older who are not receiving treatment with kidney transplant or dialysis. Objectives: To evaluate statin use for patients in the Vancouver General Hospital Kidney Care Clinic (VGH KCC) and to gain insight into the KCC nephrologists’ practices and perspectives regarding the prescribing of statins for patients with CKD. Methods: The study comprised 2 parts. Part 1 consisted of a cross-sectional study of all statin-eligible patients in the VGH KCC followed by a retrospective chart review. In the chart review, data were collected for 250 statin users and 250 non-users. Logistic regression analyses were performed to determine associations between demographic variables and statin use or non-use. Part 2 was an electronic survey of VGH KCC nephrologists. Results: Of the 813 statin-eligible patients, 512 (63%) were taking a statin. Patients were approximately 5 times more likely to be receiving statin therapy when it was indicated for secondary versus primary prevention (adjusted odds ratio 4.64, 95% confidence interval 2.95–7.47). Eight of the 9 KCC nephrologists completed the survey, and 7 (87.5%) of these respondents indicated that they never or rarely prescribed statins themselves to KCC patients for primary prevention. However, the same number reported that they sometimes or often suggested statin initiation to family physicians. Three of the respondents indicated agreement with guideline recommendations, but many stated that the decision for statin initiation should be individualized to the patient. Strategies to improve statin prescribing rates that were endorsed by respondents included educating family physicians, creating preprinted orders and laboratory requisitions for statin initiation, providing educational materials about statins to patients, and implementing a protocol for KCC pharmacists to counsel patients about statins. Conclusions: Many statin-eligible VGH KCC patients were not receiving statin therapy, and most of the KCC nephrologists considered statin prescribing as a role for family physicians. Within the KCC, future directions will be to develop a standardized approach to identify patients who would benefit from statin therapy, and to implement strategies to improve statin prescribing rates in appropriate patients. RÉSUMÉ Contexte : L’insuffisance rénale chronique (IRC) est un facteur de risque de maladie cardiovasculaire. Les directives du Kidney Disease Improving Global Outcomes de 2013 et celles de la Société canadienne de cardiologie de 2016 recommandent l’utilisation de statines comme mode de prévention principal des maladies cardiovasculaires par les patients âgés d’au moins 50 ans et souffrant d’IRC, qui ne reçoivent pas de traitement par greffe rénale ou dialyse. Objectifs : Évaluer l’utilisation des statines pour les patients résidant au Vancouver General Hospital Kidney Care Clinic (VGH KCC) et améliorer la compréhension des pratiques et points de vue des néphrologues de la KCC concernant la prescription de statines aux patients souffrant d’une IRC. Méthodes : L’étude comportait deux parties. La première consistait en une étude transversale de tous les patients admis à recevoir des statines au VGH KCC, suivie d’un examen rétrospectif des dossiers. Les données destinées à cet examen ont été recueillies auprès de 250 utilisateurs de statines et de 250 non-utilisateurs. Les analyses de régression logistique ont permis de déterminer les associations entre les variables démographiques et l’utilisation (ou non) de statines. La deuxième partie consistait en une enquête menée électroniquement auprès des néphrologues du VGH KCC. Résultats : Des 813 patients admissibles à l’utilisation de statines, 512 (63 %) en prenaient déjà. Les patients avaient environ cinq fois plus de chances de recevoir un traitement par statines, lorsque celles-ci étaient indiquées pour la prévention secondaire ou primaire (rapport de cote révisé 4,64, 95 % intervalle de confiance 2,95 - 7,47). Huit des neuf néphrologues de la KCC ont participé à l’enquête et sept (87,5 %) d’entre eux ont indiqué qu’ils n’avaient jamais, ou rarement, prescrit de statines aux patients du KCC dans le cadre d’une intervention primaire. Cependant, le même nombre de répondants a indiqué avoir parfois ou souvent proposé aux médecins de famille de commencer un traitement aux statines. Trois répondants ont indiqué être d’accord avec les recommandations préconisées dans les directives, mais bon nombre des néphrologues interrogés ont signalé que la décision d’entreprendre un tel traitement devait être individualisée. Les stratégies visant à améliorer les taux de prescription de statines approuvées par les répondants comprenaient la sensibilisation des médecins de famille, la création d’ordonnances et de demandes d’analyse en laboratoire préimprimées pour entreprendre un traitement aux statines, l’offre aux patients de matériel de formation sur le sujet et la mise en place d’un protocole pour les pharmaciens de la KCC leur permettant de conseiller les patients. Conclusions : Beaucoup de patients admissibles à un traitement aux statines du VGH KCC ne le recevaient pas, et la plupart des néphrologues de la KCC considéraient que la prescription de ce type de traitement relevait des médecins de famille. Au sein de la KCC, les orientations futures consisteront à élaborer une approche standardisée pour identifier les patients qui tireraient profit d’une thérapie aux statines et à mettre en place des stratégies visant à améliorer les taux de prescription de statines aux patients concernés.

Recognition of acute myocardial infarction caused by spontaneous coronary artery dissection of first septal perforator

Aims Spontaneous coronary artery dissection (SCAD) diagnosis is challenging as angiographic findings are often subtle and differ from coronary atherosclerosis. Herein, we describe characteristics of patients with acute myocardial infarction (MI) caused by first septal perforator (S1) SCAD. Methods and results Patients were gathered from SCAD registries at Minneapolis Heart Institute and Vancouver General Hospital. First septal perforator SCAD prevalence was 11 of 1490 (0.7%). Among 11 patients, age range was 38–64 years, 9 (82%) were female. Each presented with acute chest pain, troponin elevation, and non-ST-elevation MI diagnosis. Initial electrocardiogram demonstrated ischaemia in 5 (45%); septal wall motion abnormality was present in 4 (36%). Angiographic type 2 SCAD was present in 7 (64%) patients with S1 TIMI 3 flow in 7 (64%) and TIMI 0 flow in 2 (18%). Initial angiographic interpretation failed to recognize S1-SCAD in 6 (55%) patients (no culprit, n = 5, septal embolism, n = 1). First septal perforator SCAD diagnosis was established by review of initial coronary angiogram consequent to cardiovascular magnetic resonance (CMR) demonstrating focal septal late gadolinium enhancement with corresponding oedema (n = 3), occurrence of subsequent SCAD event (n = 2), or second angiogram showing healed S1-SCAD (n = 1). Patients were treated conservatively, each with ejection fraction >50%. Conclusion First septal perforator SCAD events may be overlooked at initial angiography and mis-diagnosed as ‘no culprit’ MI. First septal perforator SCAD prevalence is likely greater than reported herein and dependent on local expertise and availability of CMR imaging. Spontaneous coronary artery dissection events may occur in intra-myocardial coronary arteries, approaching the resolution limits of invasive coronary angiography.

Compatible Donor and Recipient Pairs’ Perspectives on Participation in Kidney Paired Donation Programs: A Mixed-Methods Study

Background: Compatible pair participation in kidney paired donation (KPD) may increase the likelihood of finding suitable matches for all registered pairs. Retrospective studies have shown variable enthusiasm for participating in KPD in compatible pairs. Objective: The study objective was to gather potential living donor (PLD) and transplant candidate (TC) perspectives on compatible pair participation in KPD. Design: Surveys and qualitative interviews. Setting: Three transplant programs in Canada: Centre hospitalier de l’Université de Montréal in Montreal (Québec), Vancouver General Hospital, and St. Paul’s Hospital in Vancouver (British Columbia). Patients: Both PLDs and TCs undergoing evaluation for donation/transplantation between 2016 and 2018 at 3 transplant programs in Canada. Methods: Descriptive statistical analysis was performed for the results of the survey and thematic and content analysis method was used for the content of the qualitative interviews. Results: A total of 116 PLDs and 111 TCs completed surveys and an additional 18 PLDs and 17 TCs underwent semi-directed interviews. Of those surveyed, 61.2% of PLDs and 76.6% of TCs reported a willingness to participate in KPD as a compatible pair. The possibility of a more optimally matched kidney for the TC and policies ensuring prioritization of the TC for repeat transplantation in the event of early graft failure increased willingness to participate in KPD. Major concerns expressed during the interviews included the desire to retain the emotional bond of directed donation, the fear of chain breaks or donor reneging, delays in transplantation, and additional travel associated with participation in KPD. Limitation: The limitations of this study are that it was conducted in only 3 Canadian transplant programs and that the interviews and surveys were in French and in English. As a consequence, the results may not be reflective of the views of individuals not living in these 2 provinces and from ethnic minority populations. Conclusion: Most of the compatible PLDs and TCs surveyed were willing to participate in KPD. Ensuring timely transplantation and a more optimal match for TCs and offering a policy of reciprocity to ensure timely repeat transplantation for compatible recipients if their allograft fails post KPD transplant may further increase compatible pair participation in KPD.

Bedside Ultrasound Measures of Muscle Mass and Frailty Measures in Community-Dwelling Older Adults

The age-associated loss of muscle mass and strength in older adults is called sarcopenia, and it is associated with increased rates of falls, fractures, hospitalizations and death. Sarcopenia is one of the most common physical etiologies for increased frailty in older adults, and some recent work has suggested the use of Point-of care ultrasound (PoCUS) measures as a potential measure of muscle mass. The objective of this study was to examine the association of PoCUS measures of muscle thickness (MT) with measures of frailty in community-dwelling older adults. We recruited 150 older adults (age >= 65; mean age 80.0±0.5 years, 66 women, 84 men) sequentially from 5 geriatric medicine clinics (Vancouver General Hospital). We measured lean muscle mass (LMM, by bioimpedance assay) and an ultrasonic measure of muscle quantity (MT, vastus medialis muscle thickness) in all subjects, as well as two outcome measures of frailty (FFI, Fried Frailty Index; RCFS, Rockwood Clinical Frailty Scale). In our models, MT showed an inverse correlation with the FFI (Standardized β=-0.2320±0.107, p=0.032) but no significant correlation with the RCFS (Standardized β = -0.025±0.086, p=0.776). LMM showed no significant association with either FFI (Standardized β=-0.232±0.120, p=0.055) or RCFS (Standardized β = -0.043±0.119, p=0.719). Our findings indicate that PoCUS measures show potential as a way to screen for physical manifestations of frailty and might be superior to other bedside methods such as bioimpedance assay. However, PoCUS measures of muscle thickness will likely miss patients showing frailty in the much broader context captured by the RCFS.

Abstract 14982: Paravertebral Block With a Paravertebral Catheter May Improve Outcomes After Minimally-invasive Cardiac Surgery

Background: Postoperative (post-op) pain following minimally-invasive cardiac surgery (MICS) may complicate outcomes in patients having surgery performed through a right mini-thoracotomy. Regional anaesthesia, by delivery of local anaesthetic agents to the paravertebral space using a paravertebral catheter (paravertebral block, PVB) may be useful to reduce post-op pain, however, few studies have reported outcomes on patients undergoing MICS with the use of a PVB. Methods: Ninety consecutive patients who underwent MICS at Vancouver General Hospital between January 2016 and May 2019 were included in this retrospective study. Data were collected for 53 patients who only had routine pain control (control) and 37 patients who had a PVB (PVB). Primary outcomes were post-op opioid use and hospital length of stay (LOS). Peri-operative (peri-op) death and stroke were secondary outcomes. Statistical analyses were performed using ANOVA single factor and t-tests. Results: Patient demographics and operative times were comparable between the two groups. The average total amount of opioid consumed in the PVB group was lower at 155.3 mg morphine equivalents, compared to 193.9 mg in the control group, however, the difference was not statistically significant (p=0.39) (Figure 1). However, the percentage of patients who did NOT receive any oxycodone was almost double in the PVB group (43.2% vs 24.5%, PVB vs control, respectively. p=0.06). The average LOS for the PVB group was significantly lower than the control group (5.4 vs 8.3 days, PVB vs control, respectively. p=0.006) (Figure 1). There were no peri-op deaths or strokes. Conclusion: In our experience, addition of a regional anesthetic was associated with ~20% reduction in the amount of opioid narcotic required. Although not statistically significant, this may be a clinically important difference, as the LOS was significantly lower in the PVB group. Outcomes in patients undergoing MICS may be improved with the addition of a PVB.

Rapid Turnaround ADAMTS13 Testing Is Likely to Improve Diagnosis of Thrombotic Thrombocytopenic Purpura and Avoid Unnecessary Plasma Exchange

Introduction: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy (TMA) resulting from severe ADAMTS13 deficiency, which is generally treated with therapeutic plasma exchange (PLEX). Although ADAMTS13 activity is often assayed to differentiate TTP from TMAs not requiring PLEX, technical and logistical constraints often limit rapid turnaround of results, with PLEX initiated based on clinical suspicion of TTP while awaiting ADAMTS13 activity results. We estimated the potential reduction in plasma product use if rapid turnaround ADAMTS13 activity testing were available in our centre. Methods: We reviewed medical records for all Vancouver General Hospital patients with ADAMTS13 activity testing since assay implementation. Patients receiving PLEX but ultimately diagnosed with a disease not requiring PLEX were identified as "potentially avoidable PLEX" (paPLEX), and their plasma product exposures and related blood product costs were estimated. Laboratory results, ADAMTS13 activity, and PLASMIC scores (a validated clinical tool for TTP diagnosis) of this group were compared to those of newly diagnosed TTP patients (N=35). Results: We identified 16 paPLEX patients, including TMAs secondary to malignant hypertension, infection, hemolytic uremic syndrome, illicit drug use, autoimmune renal disease, and malignancy (Table 1). These patients underwent 104 total PLEX cycles (3-12 per patient, median 6), involving 1,428 plasma units (28-199 per patient, median 71.5) and estimated product-associated costs of $187,759 CAD ($140,889 USD). Median platelet counts were significantly lower in TTP than the paPLEX group (7x109/L versus 38x109/L), as was serum creatinine (98µmol/L versus 224µmol/L). PLASMIC scores indicating low or intermediate likelihood of TTP were observed in 63% of patients receiving paPLEX and 17% of patients with TTP. All patients with TTP had ADAMTS13 activity < 10%, while all patients receiving paPLEX had ADAMTS13 activity ≥ 30%. Conclusions: Unnecessary PLEX carries significant patient blood product exposure risks and system costs that may be circumvented if TTP can be reliably distinguished from other TMAs at the time of initial presentation. In our cohort, ADAMTS13 activity results provided clear separation of these groups and improved upon TTP diagnosis by clinical judgement and PLASMIC scores. Rapid turnaround of ADAMTS13 activity testing results has the potential to reduce the unnecessary costs and blood product exposures resulting from PLEX administration to patients with non-TTP TMAs. Figure 1 Disclosures Smith: Alexion: Other: Participated in an advisory board without receiving financial compensation.

How Hospital Pharmacists Spend Their Time: A Work-Sampling Study

Background: The expanded scope of pharmacist practice allows for increased comprehensive care and improved patient outcomes at the cost of increased workload and time demands on pharmacists. There are limited descriptive metrics for the time that pharmacists spend on various activities during the workday. An evaluation of the time spent on different activities would allow for potential optimization of workflow, with a focus primarily on devoting more time to direct patient care activities.Objective: To quantify the amount of time that hospital and clinic-based pharmacists spend on clinical activities, including direct and indirect patient care, and nonclinical activities. Methods: An observational fixed-interval, work-sampling study was conducted at 2 hospitals, Vancouver General Hospital and Richmond Hospital, both in British Columbia. Trained observers followed individual pharmacists for a set period. The pharmacists’ activities were recorded in 1-min increments and classified into various categories. Results: In total, 2044 min of activity, involving 11 individual pharmacists, were observed. Clinical activities accounted for 82% of total time, 12% (251 min) on direct patient care activities and 70% (1434 min) on indirect patient care activities. The most common direct clinical activity was conducting patient medication history interviews (73 min; 4% of total time), and the most common indirect clinical activity was assessment and evaluation (585 min; 29%). The most common nonclinical activities were walking (91 min; 4% of total time), looking for something (57 min; 3%), and teaching pharmacy students on practicum (60 min; 3%). Conclusions: Although the pharmacists spent most of their time on clinical activities, face-to-face time with patients (direct clinical activities) seemed low, which highlights an area for potential improvement. The pharmacists spent much more time documenting information in pharmacy-specific monitoring forms (i.e., assessment and evaluation) than they spent writing notes or recommendations in the chart, for sharing with other health care professionals. Keywords: time, work sampling, pharmacist, activitiesRÉSUMÉContexte : L’élargissement du champ d’activité du pharmacien permet d’améliorer la qualité des soins et les résultats pour le patient au prix d’une augmentation de la charge et du temps de travail des pharmaciens. Il existe peu de mesures descriptives temps que les pharmaciens consacrent à leurs diverses activités de la journée. Une évaluation de ce temps permettrait d’optimiser le flux de travail afin que l’accent puisse être mis principalement sur l’augmentation du temps réservé aux activités de soins directs des patients.Objectif : Quantifier le temps que passent les pharmaciens des hôpitaux et des cliniques à effectuer des activités cliniques, y compris des activités de soins directs et indirects, ainsi que des activités non cliniques.Méthodes : Une étude observationnelle par échantillonnage à intervalles fixes a été menée dans deux hôpitaux : le Vancouver General Hospital et le Richmond Hospital, tous deux en Colombie-Britannique. Des observateurs formés ont suivi chaque pharmacien en particulier pendant une période déterminée. Leurs activités étaient consignées par tranches d’une minute et classées en diverses catégories.Résultats : L’observation a porté sur des activités totalisant 2044 minutes réparties entre 11 pharmaciens. Les activités cliniques représentaient 82 % du temps total, 12 % (251 min) des activités étaient consacrées aux soins directs et 70 % (1434 min), aux soins indirects. L’activité clinique directe la plus courante consistait à mener des entrevues portant sur les antécédents pharmacothérapeutiques des patients (73 min, 4 % du temps total) et l’activité clinique indirecte la plus courante était l’évaluation (585 min, 29 %). Les activités non cliniques les plus courantes étaient la marche (91 min, 4 % du temps total), la recherche de quelque chose (57 min, 3 %) et la formation des étudiants stagiaires en pharmacie (60 min, 3 %).Conclusions : Bien que les pharmaciens consacrent la plus grande partie de leur temps à des activités cliniques, le temps passé auprès des patients (activités cliniques directes) semblait faible, ce qui indique une possibilité d’amélioration. Les pharmaciens passent beaucoup plus de temps à consigner de l’information dans des formulaires de contrôle spécifiques à la pharmacie (c.-à-d. évaluation) qu’à rédiger des notes ou des recommandations dans les tableaux pour les partager avec les autres professionnels de la santé.Mots-clés : temps, échantillon de travail, pharmacien, activités

Dr Patricia Clugston—A Spirit of Determination

Dr Patricia Clugston was a British Columbia native who completed her plastic surgery residency training in Vancouver in 1993 before pursuing a fellowship in Nashville with Dr Patrick Maxwell in 1994. When Dr Clugston returned to Vancouver, she helped to establish a comprehensive and renowned breast reconstruction program. She spent her career advocating for and working towards better treatment options for women seeking breast reconstruction. As a determined surgeon and accomplished athlete, Dr Clugston was truly a tour de force in all aspects of her life. Patty, as she was affectionately known by her colleagues, loved her job. Dr Clugston was an avid advocate for medical education and an outstanding clinical researcher and speaker that established her as a shining star in Canadian plastic surgery. Patty had always lived life to the fullest and was determined that scleroderma would not change this. Her sharp wit, intellectual curiosity, and pragmatism masked an incredible courage as she fought bravely against a cruel disease. Dr Clugston died on March 1, 2005, at the age of 46 surrounded by the loving company of her husband, friends, and family at the Vancouver General Hospital. The Dr Patricia Clugston Chair in Breast Reconstruction was established in her name to honour her legacy and continue to improve the care of patients with breast cancer.