Importance The American College of Cardiology/American Heart Association Pooled Cohort risk equations were developed to estimate atherosclerotic cardiovascular disease (ASCVD) risk and guide statin initiation. Objective Assess calibration and discrimination of the Pooled Cohort risk equations in a contemporary US population. Design, Setting, and Participants Adults 45-79 years enrolled in the REasons for Geographic And Racial Differences in Stroke study between January 2003 and October 2007 and followed through December 2010. We studied participants for whom ASCVD risk may trigger a discussion of statin initiation (those without clinical ASCVD or diabetes, LDL-C between 70-189 mg/dL, not taking statins; n=10,997). Main Outcomes and Measures Predicted risk and observed adjudicated ASCVD incidence (non-fatal myocardial infarction, coronary heart disease [CHD] death, non-fatal or fatal stroke) at 5 years as REGARDS participants have not been followed 10 years. Additional analyses, limited to Medicare beneficiaries (n=3,333), added ASCVD events identified in claims data. Results There were 338 adjudicated events (192 CHD events, 146 strokes). The observed and predicted 5-year ASCVD incidence per 1,000 person-years for participants with 10-year predicted ASCVD risk <5% was 1.9 (95%CI: 1.3 – 2.7) and 1.9, risk 5% to <7.5% was 4.8 (95%CI: 3.4 – 6.7) and 4.8, risk 7.5% to <10% was 6.1 (95%CI: 4.4 – 8.6) and 6.9, and risk ≥10% was 12.0 (95%CI: 10.6 – 13.6) and 15.1 (Hosmer-Lemeshow χ2 19.9 p-value=0.01). The c-index was 0.72 (95%CI: 0.70–0.75). There were 234 ASCVD events (120 CHD events, 114 strokes) among Medicare-linked participants and the observed and predicted 5-year ASCVD incidence per 1,000 person-years for participants with predicted risk <7.5% was 5.3 (95% CI: 2.8 – 10.1) and 4.0, risk 7.5% to <10% was 7.9 (95% CI: 4.6 – 13.5) and 6.4, and risk ≥10% was 17.4 (95% CI: 15.3–19.8) and 16.4 (Hosmer-Lemeshow χ2 5.4 p-value=0.71). The c-index was 0.67 (95%CI: 0.64 – 0.71) Conclusions and Relevance In this cohort of US adults for whom statin initiation is considered based on the ACC/AHA Pooled Cohort risk equations, observed and predicted 5-year ASCVD risks were similar, indicating that these risk equations were well calibrated in the population for which they were designed to be used.

Background Variability of blood pressure (BP) across outpatient visits is frequently dismissed as random fluctuation around a patient’s underlying BP. Objective: Examine the association between visit-to-visit variability (VVV) of systolic and diastolic BP (SBP and DBP) on cardiovascular disease and mortality outcomes. Design Prospective cohort study Setting Post-hoc analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Participants 25,814 ALLHAT participants. Measurements VVV of SBP was defined as the standard deviation (SD) across BP measurements obtained at 7 visits conducted from 6 to 28 months following ALLHAT enrollment. Participants free of cardiovascular disease events during the first 28 months of follow-up were followed from the month 28 study visit through the end of active ALLHAT follow-up. Outcomes included fatal coronary heart disease or non-fatal myocardial infarction, all-cause mortality, stroke and heart failure. Results There were 1194 cases of fatal CHD or non-fatal MI, 1948 deaths, 606 cases of stroke and 921 cases of heart failure during follow-up. After multivariable adjustment including mean SBP, the hazard ratio comparing participants in the highest versus lowest quintile of SD of SBP (≥14.4 mmHg versus <6.5 mmHg) was 1.30 (1.06–1.59) for fatal coronary heart disease or non-fatal myocardial infarction, 1.58 (1.32–1.90) for all-cause mortality, 1.46 (1.06–2.01) for stroke, and 1.25 (0.97–1.61) for heart failure. Higher VVV of DBP was also associated with cardiovascular disease events and mortality. Limitations Long-term outcomes were not available. Conclusions Higher VVV of SBP is associated with increased cardiovascular disease and mortality risk. Future studies should examine whether reducing VVV of BP lowers this risk. Primary funding source National Institutes of Health

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Strategies for improving the quality of health care in maternal and child health in low-and middle-income countries: an overview of systematic reviews. There are many systematic reviews of continuing education programmes and educational strategies for quality improvement in health care. Most of the reviewed studies are one-off evaluations rather than impact evaluations with long-term follow-up. There are few systematic reviews of organisational, financial and regulatory interventions, and few high-quality studies. These interventions are probably as or more important than educational strategies, although they are less well evaluated. Few studies have been undertaken in low-and middle-income countries (LMIC) or that address maternal and child health (MCH). Thus, the results of the available studies and reviews need to be interpreted cautiously when applied to LMIC. Paediatric and Perinatal EpidemiologyInteractive workshops, reminders and multifaceted interventions can improve professional practice, and they generally have moderate effects. Educational outreach visits consistently improve prescribing but have variable effects on other behaviours. Audit and feedback interventions have variable effects on professional practice, but most often these are small to moderate effects. Mass-media and patient-mediated interventions may change professional practice. Multifaceted interventions that combine several quality-improvement strategies are also effective but may not be more so than single interventions. While all of these strategies are applicable to MCH in LMIC, the applicability of the results to rural settings, in particular, may be limited. Use of these strategies could exacerbate inequalities, and this should be taken into consideration when planning implementation. Scaling up and sustainability may be difficult to achieve in LMIC contexts and need careful consideration.The use of financial interventions has not been well studied; financial incentives and disincentives may be difficult to use effectively and efficiently, although their impact on practice needs to be considered. Organisational interventions are likely to be important, given that there are often underlying organisational or system problems. Regulatory interventions have not been well evaluated, but may sometimes be both inexpensive and effective. There are no 'magic bullets' or simple solutions for ensuring the quality of health care services. Interventions should be selected or tailored to address the underlying reasons for a failure to deliver effective services. Decision-makers should select the most appropriate interventions for specific problems. This requires a governance structure that clearly assigns responsibility for quality-improvement activities, priority setting, selection and design of interventions, and evaluation.