bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 284: Comparison Of Patterns Of ICD Deactivation In Community Hospice Center Vs Hospice In An Academic Institution.
Authors: Lakshmanadoss Umashankar , Kulkarni Abhishek , Sherazi Saadia , Shah Abrar , Aktas Mehmet , Quill Timothy , Daubert James P
Published: July 2021

Background:
There have been an increasing number of patients receiving implantable cardioverter defibrillators (ICDs) over the last decade. Although ICDs prevent arrhythmic death, patients may still develop other terminal illnesses, or progression of underlying heart failure. ICD delivered shocks are associated with significant pain, anxiety and reduced quality of life. Therefore for this population of patients, it may become undesirable to receive shock therapy nearing the end of life. The practice of ICD deactivation may differ from community hospice center and teaching institution where in-house palliative care and cardiology service is available. We reviewed the practices for ICD deactivation on a series of patients admitted to a community hospice center and compared to a hospice center in teaching institution. We hypothesized that for patients with ICDs, the frequency for ICD deactivation at end of life would be low in community hospice center.

Methods:
In this retrospective study we reviewed records of patients with ICDs who were admitted to the Hildebrandt Hospice Care Center, an inpatient hospice facility and in University of Rochester medical center, Rochester NY from January 2005 to December 2009. We have included patients with ICD for primary prevention of sudden cardiac arrest. Information regarding patient's demographics, indications for ICD implantation, deactivation of ICD (frequency, location) and history of shock in hospice care was recorded.

Results:
We identified 32 and 35 patients who were admitted to inpatient hospice units of community and academic centers respectively, with ICDs for primary prevention of sudden cardiac arrest. Ninety one percent of ICDs were deactivated in patients in academic center, when compared to 62% of deactivated ICD in community center. Twelve (38%) patients from community center (vs three patients from academic center) were transferred to the hospice center without ICD deactivation. Among these 12 patients, 3 (10%) received ICD shock while in hospice and subsequently died in the center (average 2 days after receiving the shock). Three patients refused to have their ICD deactivated in both group.

Conclusion:
Rates of deactivation of ICD is higher in academic institutions, when compared to non academic centers. The discussion about ICD deactivation should be initiated in terminally ill patients who are opting for hospice care for end of life care. Deactivating the device allows patients to die without the discomfort of electric shocks.
Abstract 287: The Utilization pattern of Stress Myocardial Perfusion Imaging in a rural health care system
Authors: Singh Maninder , Sattur Sudhakar , Dedhia Paras , Harjai Kishore , Babayan Zaruhi , Jagasia Dinesh
Published: July 2021

Background:
Appropriate use criteria (AUC) for Single-Photon Emission Computed Tomographic Myocardial Perfusion Imaging (MPI) were revised in 2009 to include 15 new clinical scenarios. Prior studies showed that ∼15 % of MPI studies were requested for inappropriate indications, mostly by non-cardiology providers. Although awareness of the AUC has improved, few studies have specifically evaluated the impact of 2009 AUC in an electronic, integrated, rural health care system.

Methods:
All MPI studies done between April - Sep 2011 were reviewed in this single centre study at a rural, electronic, integrated health care system. Using 67 scenarios in AUC guidelines, these studies were classified into four categories: Appropriate (A), Inappropriate (I), Uncertain (U) and Unclassifiable. To estimate the independent impact of ordering provider specialty on level of appropriateness, multivariable analysis was performed using backward stepwise variable selection.

Results:
During 6 month study period, 328 patients underwent MPI. Overall, 287 (87.5%) studies were classified as (A), 18 (5.5%) as (I), 23 (7%) as (U) and none were deemed as unclassifiable out of these 328 studies. Preoperative testing accounted for 8 (44%) of the total 18 (I) studies. Of the 23 studies classified as (U), 16 (70%) were performed for patients with new or worsening symptoms and prior normal coronary angiography or prior normal stress imaging study. The ordering physician specialty (cardiologists vs. non-cardiologists) did not show a multivariable correlation with appropriateness of the test (p=0.46). Results are summarized in Fig. 1

Conclusion:
In a rural, integrated, electronic, health care system; majority of providers, regardless of their specialty utilized MPI studies for (A) indications. Only 5.5% of MPI studies were ordered for (I) indications, suggesting a significant decrease in (I) tests compared to prior reports, which may reflect an increase in awareness of the revised 2009 criteria. However, certain common scenarios still account for a majority of small proportion of (I) studies. These findings may suggest a continuing need for provider education and possibly focusing the preauthorization triage process only for (I) clinical scenarios.
Abstract 299: Association of Chronic Lung Disease with Treatments and Outcomes of Acute Coronary Syndromes: Results from the NCDR®
Authors: Enriquez Jonathan R , de Lemos James A , Farzaneh-Far Ramin , Rohatgi Anand , Peng S. A , Spertus John A , Holper Elizabeth M , Roe Matthew T , Das Sandeep R
Published: July 2021

Background:

Previous reports are conflicting regarding outcomes, treatments, and processes of care after acute myocardial infarction (MI) for patients with chronic lung disease (CLD).

Methods:

Using the NCDR ACTION Registry
®
-GWTG
™
(AR-G), demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after NSTEMI and STEMI were compared between patients with (n= 22,624; 14.2%) and without (n= 136,266; 85.8%) CLD. CLD was defined by a history of COPD, chronic bronchitis, or emphysema. Multivariable adjustment using published AR-G in-hospital mortality and major bleeding risk adjustment models was performed to quantify the impact of CLD on treatments and outcomes.

Results:

CLD was present in 10.1% of STEMI patients and 17.0% of NSTEMI patients. In both STEMI and NSTEMI, CLD patients were older, more likely to be female, and had more comorbidities including diabetes, renal disease, prior MI and heart failure, compared to those without CLD. Although on admission CLD patients were more likely to be on cardiovascular medications, by discharge slightly fewer CLD patients received composite core measures (aspirin, beta-blockers, ACE-inhibitors, and statins) (table). In NSTEMI, CLD was also associated with less use of invasive procedures and with increased risk of both death and major bleeding. In STEMI, major bleeding but not mortality was increased.

Conclusions:

CLD is a common comorbidity and is independently associated with an increased risk for major bleeding after MI. In NSTEMI, CLD is also associated with receiving fewer evidence-based medications, less timely angiography and revascularization, and increased in-hospital mortality. Close attention should be given to this high-risk subgroup for the prevention and management of bleeding complications after MI, and further investigation is needed to determine the reasons for treatment and outcome disparities in NSTEMI.
Abstract 305: Trends in and Risk Factors Affecting Survival for Infants with Critical Congenital Heart Disease: Atlanta, Georgia, 1979-2005
Authors: Oster Matthew , Lee Kyung A , Honein Margaret A , Colarusso Tiffany , Shin Mikyong , Correa Adolfo
Published: July 2021

Introduction:
Pulse oximetry screening for critical congenital heart disease (CCHD: hypoplastic left heart syndrome, transposition of the great arteries, tricuspid atresia, truncus arteriosus, tetralogy of Fallot, total anomalous pulmonary venous return, and pulmonary atresia) was added to the Recommended Uniform Screening Panel for newborns in 2011. However, population-based data on trends in survival and prognostic factors for infants with CCHD are limited.

Methods:
We performed a retrospective cohort study of infants born with structural congenital heart disease (CHD) between 1979 and 2005 and identified through the Metropolitan Atlanta Congenital Defects Program. Survival was determined via linkage with state vital records and the National Death Index. We estimated Kaplan-Meier survival probabilities for CCHD by birth era and timing of diagnosis, and we used proportional hazards models to assess several prognostic factors, including birth era, timing of diagnosis, maternal age, birth weight, race/ethnicity, sex, socioeconomic status, and presence of non-cardiac defects.

Results:
Overall 1-year survival was 65.2% for those with CCHD (n=1204) vs. 89.9% for those with other forms of CHD (n=5761; p<0.0001). One-year survival for CCHD improved from 56.5% for the 1979-1986 birth era to 75.1% for the 2000-2005 era (p<0.0001). For infants with CCHD but without non-cardiac defects (n=864), overall 1-year survival was 68.4% for those diagnosed at ≤1 day of age (n=673) vs. 75.9% for those diagnosed at ≤1 day of age (n=191; p=0.04). There was a higher risk of mortality for infants with earlier birth era, earlier diagnosis, maternal age <30, low birth weight, and presence of non-cardiac defects (Table).

Conclusions:
One-year survival for infants with CCHD has been improving over time, yet mortality remains high. Identification of prognostic factors for CCHD may aid future evaluations of the impact of pulse oximetry screening on survival from CCHD.
Abstract 331: Elevated Pre-discharge B-type Natriuretic Peptide Predicts 30-day Heart Failure-specific Rehospitalization
Authors: Flint Kelsey M , Heidenreich Paul A
Published: July 2021

Background:
Studies support the use of B-type natriuretic peptide (BNP) to guide both the diagnosis and treatment of heart failure. However the variation in clinical use of BNP, and its impact on outcomes outside the clinical trial setting, has not been well characterized. Our aim was to evaluate the clinical use of BNP across the Veterans Affairs (VA) Health Care System, and to identify factors associated with 30-day rehospitalization.

Methods:
We determined both the frequency and timing of BNP and amino-terminal pro-B-type natriuretic peptide (NT-proBNP). We examined all hospital discharges with the diagnosis of heart failure in the VA Health Care System from 2006 - 2009 (n=109,875). The relationship between pre-discharge BNP and 30 day rehospitalization was evaluated using generalized estimating equations that adjusted for covariates and clustering of patients within facilities.

Results:
There were 59,720 out of 109,875 patients (54%) with a BNP (50%) or NT-ProBNP (4%) obtained during admission. Use of a BNP or NT-ProBNP test increased from 41% in 2006 to 60% in 2009. Patients evaluated with a BNP test had an older mean age (71 vs, 68 years, p<0.001). Black patients were less likely to have a BNP (50%) compared to non-black patients (58%, p<0.001). There were 125 VA hospitals with at least 80 heart failure discharges in the time period studied. Among these hospitals, the use of BNP (or NT-proBNP) during admission ranged from 0% to 83% of heart failure hospitalizations (median 57%, interquartile range 42% to 72%). BNP within 2 days of discharge (pre-discharge) was measured in 25,988 (24%) heart failure admissions. Higher pre-discharge BNP was associated with a greater risk for rehospitalization with heart failure as the principal diagnosis (Table; p<0.001 for trend). Risk for heart failure readmission tripled from a pre-discharge BNP of 200 to 1000 pg/ml. Pre-discharge BNP was not a significant predictor of other causes of readmission. There were too few NT-proBNP values for comparison. Similar findings were seen after adjustment for patient characteristics.

Conclusions:
There is significant variability in BNP usage across the VA Health Care System, although use of the test is growing. Pre-discharge BNP is a strong predictor of heart failure readmission but not of other causes of rehospitalization. These data may help clinicians identify high-risk patients prior to hospital discharge, and perhaps indicate a need for more aggressive heart failure-specific therapy and outpatient monitoring.
Abstract 44: Osteopontin, Cardiovascular Events, and Mortality: The Heart and Soul Study
Authors: Welles Christine C , Ix Joachim H , Whooley Mary A
Published: July 2021

Background:
Osteopontin is a glycoprotein found primarily in bone which is also abundant in atherosclerotic plaques and calcified valves. Prior studies demonstrate that serum osteopontin levels are associated with cardiovascular (CV) mortality in subjects with stable angina, but the underlying mechanisms are unknown. Therefore, we investigated the relationship between osteopontin and CV events in outpatients with stable coronary heart disease (CHD).

Methods:
We measured osteopontin levels in 981 outpatients with prevalent CHD who were recruited between 2000 and 2002 from 12 clinics in the San Francisco Bay Area. We used proportional hazard models to evaluate the association between osteopontin and CV events.

Results:
During a mean follow-up of 6.4 ± 3.1 years, 300 subjects experienced the combined outcome of any CV event (myocardial infarction, heart failure, stroke or CV mortality). After adjustment for traditional CV risk factors, subjects with osteopontin in the highest quartile had 1.9 times the risk of a CV event compared to those in the lowest quartile (adjusted HR 1.9, 95% CI 1.3-2.9, p=0.001), and each standard deviation increase in osteopontin was associated with a 30% increase in risk (adjusted HR 1.3, 95% CI 1.1-1.5, p<0.001). This association was only minimally attenuated after adjustment for markers of calcific valvular disease (mitral annular calcification, aortic sclerosis), and other known markers of vascular calcification (calcium, phosphorus, FGF-23, MGP1, feturin A, adiponectin, leptin, and PTH), inflammation (C-reactive protein), and prognostic markers (NT-proBNP) (adjusted HR 1.2, 95% CI 1.1-1.4, p=0.007).

Conclusions:
Higher osteopontin levels are strongly associated with cardiovascular events in subjects with prevalent CHD. This association is not explained by extensive measures of inflammation, valvular disease, or vascular calcification.
Abstract 58: Health Literacy Influences Knowledge Attainment but not Self-Care or Self-Efficacy Longitudinally in Heart Failure Patients
Authors: Chen Aleda M , Yehle Karen S , Albert Nancy M , Ferraro Kenneth F , Mason Holly L , Murawski Matthew M , Plake Kimberly S
Published: July 2021

Introduction:
Inadequate health literacy may be a barrier during traditional clinic-based heart failure (HF) education. The influence of health literacy on gains over time in knowledge, self-efficacy and self-care is unknown. The purpose of this study was to examine health literacy, knowledge, self-efficacy, and self-care longitudinally in HF.

Hypotheses:
Patient health literacy level will be associated with differential gains in knowledge, self-efficacy, and self-care after completion of traditional clinic-based education.

Methods:
First-time patients at 3 HF clinics (N=51, age: 64.7±13.04 years) completed assessments of health literacy (Short-Form Test of Functional Health Literacy in Adults), knowledge (HF Knowledge Questionnaire), and self-care/self-efficacy (Self-Care of HF Index v.6) prior to HF education (baseline), 2 months (education completion), and 4 months post-baseline. Repeated measures Analysis of Variance was used to analyze longitudinal associations, and post-hoc tests with Bonferroni-adjusted alpha-levels were used for comparison.

Results:
Higher health literacy was associated with greater HF knowledge at 2 and 4 months (p<0.001), but there were no associations between health literacy and self-care or self-efficacy. In post-hoc analyses (Figure 1), patients with inadequate health literacy had less knowledge than those with marginal (p=0.024) or adequate (p<0.001) health literacy at 2 months. At 4 months, patients with inadequate health literacy continued to have less knowledge compared to adequate (p<0.001).

Conclusions:
Health literacy level is associated with attaining and retaining HF knowledge; however, it is not associated with self-care confidence or adherence. Tailoring HF education to health literacy level may aid in grasping concepts taught. It is unknown if a better grasp of concepts would enhance self-care adherence and promote improved health. Future research is needed to more fully understand the consequences of inadequate health literacy on self-care.
Abstract 65: Use of Implantable Cardioverter-Defibrillators Among Older Patients Hospitalized with Heart Failure
Authors: Hess Paul L , Grau-Sepulveda Maria , Hernandez Adrian F , Peterson Eric D , Bhatt Deepak L , Schwamm Lee H , Yancy Clyde W , Fonarow Gregg C , Al-Khatib Sana M
Published: July 2021

Background:
Practice guidelines recommend the use of implantable cardioverter defibrillators (ICDs) in patients with heart failure (HF) and a left ventricular ejection fraction (LVEF) of ≤ 35% across all age groups in the absence of contraindications. The influence of age on ICD use among eligible patients, including sex differences, has not been fully explored.

Methods:
We performed an analysis of patients admitted with HF and a LVEF of ≤ 35% and discharged alive from 251 hospitals participating in the American Heart Association’s Get With The Guidelines-HF program between January 2005 and September 2011.

Results:
Among 35,772 eligible patients, 17,639 (49.3%) had ICDs at discharge (10,886 with ICDs present on admission, 4,876 with ICDs placed during the hospitalization, and 1,877 with referral for ICDs post discharge). Among those eligible, ICDs were used in 3,383 of 7,153 (47.3%) aged <55 years; 4,003 of 7,360 (54.4%) aged ≥ 55 to 64 years; 4,828 of 3,843 (55.7%) aged ≥ 65 to 74 years; 4,394 of 8,890 (49.4%) aged ≥ 75 to 84 years; and 1,031 of 3,698 (27.9%) aged ≥ 85 years. After adjustment for patient characteristics and hospital factors, the odds ratio (OR) of ICD use was 0.89 (95% confidence interval (CI), 0.87-0.91) for every 5-year increase in age. Compared with males in the same age group, females were statistically significantly less likely to receive an ICD; this disparity is more marked with increasing age (p-value for interaction=0.006). There was an overall temporal increase in ICD use (adjusted OR of ICD use per year=1.23, 95% CI 1.15-1.31), mainly driven by a rise in the proportion of ICDs present on admission. The temporal increase in ICD use was similar in each age group (p-value for interaction =0.67) (
Table
).

Conclusions:
After accounting for patient and hospital characteristics, eligible older patients were significantly less likely to receive an ICD. With increasing age, females were less likely to receive ICDs. Despite an overall increase in ICD use over time, age- and sex-related differences in ICD use persist.
Abstract 80: STEMI System collaboration within the Steward Health Care System substantially reduces Door-to-Door-to-Balloon times: A system of care based model
Authors: Nadolski Adam , Pearlmutter Mark
Published: July 2021

Introduction:
The 2008 release of the American College of Cardiology/American Heart Association (ACC/AHA) Clinical Performance Measures for AMI prompted more thorough investigations of STEMI systems modeled after the AHA's Mission: Lifeline. Large retrospective studies have shown that response times vary substantially based on the structure of the individual system. Quality improvement studies should focus on a clearly defined system to accurately identify and apply beneficial measures.

Hypothesis:
We hypothesize that by analyzing process intervals between arrival at a non PCI hospital and PCI at a receiving hospital a focused Project Intervention (PI) strategy can improve overall Door-to-Door-to-Balloon (D2D2B) times within the ACC/AHA goal of 90 minutes.

Methods:
A Retrospective review of 31 patients with STEMI transferred from Carney Hospital to St. Elizabeth's Medical Center for PCI between January 2010 and December 2011. Records were collected from Carney Hospital Emergency Department, EMS transport providers, and St. Elizabeth's Medical Center Cardiac Catheterization Laboratory. Data was compiled for each and broken down into the following time intervals: Door to ECG, ECG to STEMI activation, ECG to EMS call, EMS call to arrival, EMS arrival to depart, EMS depart to PCI hospital arrival, Cath lab arrival to device deployment. In addition, door-in-door-out (DIDO) time segments were also analyzed. PI initiatives included: 1) ECG upon arrival 2) Immediate read 3) Remote activation of STEMI page 4) Preferred EMS provider 5) STEMI order sets 6) Adoption of EMS load and go procedure 7) Mapping of ideal transportation routes 8) PCI hospital efficiencies.

Results:
When comparing STEMI patient transfers before and after PI in July 2010 geometric mean D2D2B time decreased from 152 to 79 minutes (
t
-Test,
P
=0.006), representing an 80% improvement in times under ACC/AHA 90 minute goal. In addition, cardiac catheterization lab arrival to device deployment times decreased from 51 to 22 minutes (
t
-Test,
P
=0.037).

Conclusions:
This study focuses on a STEMI system of care model where key intervals are identified along with focused QI efforts designed to optimize efficiencies, limit practice variation, and reduce D2D2B times. Although long-term mortality was not assessed, ACC/AHA Mission: Lifeline goals have shown that reduction in door to PCI times correlate with improved survival and overall morbidity. Urgent demand exists for expansion of STEMI systems with implementation of the identified process interventions within both the Steward Health Care System and similar systems throughout the country.
Abstract 109: Emergency Medical Services Strategies for Reducing First Medical Contact to Device Times in ST-Elevated Myocardial Infarction Patients in South Dakota
Authors: Spier Travis , Hambek Brian , Myers Gary , Moe Pam , O’Neill Kathleen , Gardner Michelle
Published: July 2021

Background and Objectives:
Mission: Lifeline STEMI is a strategic initiative to save lives and reduce disability by improving emergency personnel readiness and response to heart attack patients, specifically focusing on ST-elevation myocardial infarctions (STEMIs) - the deadliest type. South Dakota ranks among the top ten states with the highest STEMI death rates. The Emergency Medical Services (EMS) objective is to reduce the time from First Medical Contact (FMC) in the field to device placement in a Percutaneous Coronary Intervention (PCI) capable hospital. Reduction in time results in improved patient outcomes. Several factors can impede the timely delivery of optimal care to STEMI patients, particularly in rural states like South Dakota, which has 66 counties covering nearly 76,000 square miles. Unequal dispersion of PCI-capable facilities throughout the state results in transport distances that can exceed 200 miles, while response times vary greatly dependent weather. South Dakota is heavily dependent upon volunteer ambulance services, and the capabilities of non-PCI referral hospitals to receive the STEMI patient and transfer in a timely manner.

Methods:
In order to improve the state STEMI system, all 133 EMS agencies were offered funding for 12-Lead equipment in order to capture and transmit ECGs from the field. Education was provided that included the signs and symptoms of a STEMI and proper utilization of the 12-Lead. Stakeholder meetings were held to develop the infrastructure of the statewide system.

Results:
133 EMS agencies in South Dakota are now 12-Lead capture and transmit capable and education has been offered to all agencies. Additional education is planned throughout the next year. Since 2010, ECG transmissions from the field have nearly tripled. In Q1 2012 FMC to PCI less than 90 minutes occurred with 58.3% of STEMI patients in South Dakota. In Q2 2012, this increased to 78.6% of STEMI patients.

Conclusions:
EMS training programs and increased 12-Lead use has yielded marked improvement in FMC to device times. In order to maintain an effective and efficient system of care for STEMI patients in South Dakota, a sustainability plan is under development.
Abstract 111: Assessing Statin Therapy and Lipid Profile Goals 6 Months After Percutaneous Coronary Intervention at a Veterans Hospital
Authors: Blumenkrants Dmitry , Siddiqui Saifullah M , Challa Karthik , Ladani Amit , Shroff Adhir
Published: July 2021

Background:
Patients undergoing percutaneous coronary intervention (PCI) represent a high-risk cohort for cardiovascular events. Lipid lowering therapy is an established core measure of secondary prevention in coronary artery disease management. The NCEP-ATPIII advises a minimum LDL level < 100 mg/dL in patients with coronary heart disease (CHD). However, further research suggests that an LDL < 70 is more desirable in this population to further reduce adverse CHD endpoints.

Methods:
We conducted a retrospective, observational study on all patients undergoing PCI at an urban Veterans Hospital from September 2004 to December 2011. Statin use and lipid profiles at 6 months post-PCI were compared to pre-PCI values.

Results:
A total of 1052 unique patients had PCI during the study period. Approximately 70% of patients were on statins at baseline, which improved to 88% at 6 months post-PCI (p < 0.0001). LDL levels improved significantly when compared to pre-PCI levels, from a mean of 97.2 to 85.1 (p < 0.0001). With regards to NCEP-ATPIII guidelines, the proportion of the study population that met minimum LDL goals (<100) post-PCI increased from 59% to 76% (p < 0.0001). The percentage of patients meeting ideal goals for LDL (<70) increased from 23% to 33% (p < 0.0001).

Conclusion:
In patients who have undergone PCI, there was significant improvement in LDL levels. At six months, there was an increase in usage of statin therapy. Furthermore there was a statistically significant increase in adherence to NCEP-ATIII guidelines at both the minimum and ideal LDL levels on follow-up after PCI.
Abstract 133: Perceived Barriers And Facilitators Of Adoption Of Radial PCI Among Participants In A Pilot Training Program
Authors: Helfrich Christian , Tsai Thomas T , Lemon Jaclyn , Bryson Christopher L
Published: July 2021

Background:
Trial and registry studies have demonstrated the safety and efficacy of routine use of radial-access PCI (rPCI). However, while rPCI has been widely adopted in other countries, in the US it accounts for fewer than 2% of PCIs. Although a number of papers have conjectured reasons, virtually no research has been conducted to understand why adoption and implementation is so limited or what might be done to improve it.

Aims:
Our specific aim was to identify barriers and facilitators to adoption of radial PCI among catheterization (cath) lab personnel participating in a pilot training program for rPCI.

Methods:
We conducted semi-structured interviews with cardiac cath teams at 3 pilot training program sites. We analyzed interviews inductively, using the constant comparative method for the purpose of surfacing possible barriers and facilitators.

Results:
We interviewed 8 participants: 2 interventionalists, 4 cath nurses, and 2 radiology technicians. We identified 8 overall themes (Figure 1). Facilitators related to the advantages for patients, staff and the facility in terms of releasing patients sooner, and making patients more comfortable. Barriers related to concerns about safety and long term outcomes of rPCI, and the technical difficulty and lack of training support and standard policies and procedures.

Discussion:
By conducting interviews among participants in a pilot training program, we largely precluded lack of motivation and interest as barriers. However, even in this group, concerns emerged about lack of long term research on complications for patients, and radiation exposure for the cath team. These data were collected among participants in a VA rPCI pilot training program, and may not be representative of other cardiac catheterization laboratory staff. Nor do our findings speak to the prevalence or relative importance of these factors. Future research will develop and field a structured survey to assess these barriers and facilitators in the population of VA interventionalists.
Abstract 148: Association of Dosing Frequency on Medication Adherence in Patients with Non-Valvular Atrial Fibrillation
Authors: Burton Tanya , Lee Lauren J , Fan Ying , Kwong Winghan Jacqueline
Published: July 2021

Objective:
Previous studies suggest that the complexity of a dosing regimen may affect medication adherence. We examined the association between dosing frequency and adherence for 2 concomitant medications commonly prescribed to patients with non-valvular atrial fibrillation (NVAF), metoprolol (MET) and carvedilol (CAR).

Methods:
A retrospective claims study from a large US commercial and Medicare Advantage health plan analyzed data of adults (
>
18 years) with 1 inpatient or 2 outpatient claims for NVAF between 1/1/2008 - 12/31/2010. Patients with
>
2 pharmacy claims for MET or CAR were analyzed separately. Within MET and CAR samples, once-daily (QD) and twice-daily (BID) cohorts were defined by the dosing frequency on pharmacy claims. The index date was set as the date of the first MET or CAR claim. Patients were continuously enrolled in the health plan for 1 year before (pre-index) and 1 year after (post-index) the index date. MET patients were required to have
>
1 pre-index claim for acute myocardial infarction, angina, heart failure, or hypertension; CAR patients were required to have ≥1 claim for heart failure or hypertension. Patients using both QD and BID formulations of the index medication were excluded. Adherence to the index medication was assessed by the proportion of days covered (PDC) during the post-index period. PDC between QD and BID patients was compared using logistic regression to adjust for demographic and pre-index clinical characteristics. The proportion of QD and BID patients who discontinued the index medication (defined by a gap
>
30 days) during the post-index period was also compared.

Results:
The analysis included 11,621 MET patients (QD: 6,084; BID: 5,537) and 4,393 CAR patients (QD: 203; BID: 4,190). Mean (SD) age was 70 (12) years for MET and CAR patients; 59% of MET and 69% of CAR patients were male. Compared to patients with BID dosing, patients with QD dosing were on average younger, more likely to be male, and had a lower comorbidity burden. Fewer patients discontinued MET or CAR with QD than BID dosing (MET: 38% vs. 51%, p<0.001; CAR: 39% vs. 48%, p=0.009). The proportion of patients with PDC
>
80% was greater for patients with QD than BID dosing (MET: 62% vs. 50%, p< 0.001; CAR: 63% vs. 53%, p=0.004). MET patients with BID dosing were less likely to achieve PDC
>
80% than patients with QD dosing (adjusted OR: 0.66; 95% CI: 0.609-0.712). CAR patients with BID dosing were less likely to achieve PDC
>
80% than patients with QD dosing (adjusted OR: 0.69; 95% CI: 0.508-0.934). Among MET and CAR patients, age <60 years was associated with lower adherence (p<0.001) while prior use of index medication was associated with higher adherence (p≤0.001) to the index medication.

Conclusion:
Medication adherence to MET and CAR was higher with QD than BID dosing. Quality initiatives that reduce the dosing frequency of treatment regimens may improve medication adherence among NVAF patients.
Abstract 252: Cost of Hospitalization for Balloon Aortic Valvuloplasty in the US: A 10-Year Contemporary Perspective
Authors: Chothani Ankit , Shah Neeraj , Patel Nileshkumar J , Mehta Kathan , Grover Peeyush , Deshmukh Abhishek , Rathod Ankit , Singh Vikas , Badheka Apurva , O’Neill William W , De Marchena Eduardo , Cohen Mauricio G
Published: July 2021

Background:
Limited data is available on health care cost of balloon aortic valvuloplasty (BAV). We analyzed trends and predictors of cost for BAV over the last decade (2001-2010).

Methods:
The analysis is based on Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) between 2001 and 2010 using the ICD9 procedure code of 35.96 for valvuloplasty. Only patients with age > 60 years with aortic stenosis were included & those with concomitant mitral, tricuspid or pulmonic stenosis were excluded. NIS represents 20% of all hospitals in US. We examined selective contribution of patient demographics, hospital characteristics, Charlson Comorbidity Index (CCI) and peri-procedural complications to hospitalization cost by using mixed effects linear regression modeling. For each year, cost was adjusted for inflation according to 2010 cost. Operator & hospital volume were calculated based on the unique operator and hospital identification numbers. Operator volume data were available for only 50% of the population.

Results:
Total 1,525 (weighted n = 7,595) BAV were performed from 2001 to 2010 with available cost data. Weighted cost of hospitalization for BAV increased from $21,562 in 2001 to $29,559 in 2010 (p for trend < 0.001). In a multivariable model including operator volume, 748 (weighted n = 3,708) BAV were available for analysis. The independent predictors of increased cost of hospitallization were occurrence of periprocedural complications ($22,509; p < 0.001), unstable patient, defined as having ICD-9 code for shock or ventilator dependence ($24,856; p < 0.001) and weekend admission ($11,416; p=0.002). Predictors of decreased cost for BAV were increase in operator volume (-$1,929 per every unit increase, p = 0.006). Increase in hospital valvuloplasty volume (-$1,644 per every 10 units increase, p = 0.2) showed a trend of decreasing cost, but this was statistically non-significant.

Conclusion:
In our current observational study we identified peri-procedural complications, unstable patient & weekend admission to be associated with increased cost & increase in operator volume to be associated with decreased cost of hospitalization for BAV. We also found a significant trend of increase in cost of hospitalization from 2001 to 2010.
Abstract 256: The Effect Of Credentialed Cardiovascular Pharmacists On Process Measures And Outcomes In Myocardial Infarction And Heart Failure
Authors: Dorsch Michael P , Lose Jennifer , DiDomenico Robert J
Published: July 2021

Background:
Although cardiology pharmacist credentialing is strongly advocated, there is little to no evidence suggesting board certification improves patient outcomes. The purpose of this study is to determine if institutions with inpatient cardiology credentialed pharmacists exhibit improved quality measure performance for myocardial infarction and heart failure compared to institutions without inpatient cardiology credentialed pharmacists.

Methods:
This is a multicenter, retrospective, cross-sectional, matched case-control study. The cardiology credentialing studied was the Board of Pharmaceutical Specialties (BPS) Added Qualification in Cardiology (AQCV). A list of AQCV pharmacists was derived from publically available data on the BPS website in July 2011 for inclusion in the study. Each case AQCV pharmacist hospital was matched to a hospital without an AQCV pharmacist in a 1 to 3 manner. Control hospitals were matched by geographical region, number of cardiovascular discharges, and the type of hospital. The proportion of patients meeting HF and AMI process of care measures, 30-day readmission rate, and 30 day mortality for each hospital were determined from the website Hospital Compare.

Results:
The 34 AQCV hospitals were matched to 102 non-AQCV hospitals. Hospitals that employed inpatient AQCV pharmacists performed better on a composite of 5 medication-related process of care measures compared to hospitals that do not employ inpatient AQCV pharmacists (OR 1.41, 95% CI 1.25-1.58, p <0.0001, p<0.001 for heterogeneity). The individual measures that were improved were aspirin on discharge for AMI and ACEi/ARB on discharge for HF. Thirty day readmission and mortality for HF and AMI were not different in hospitals that employed inpatient AQCV pharmacists compared to those that do not.

Conclusions:
Hospitals that employ inpatient AQCV credentialed pharmacists have improved performance on process of care measures compared to those that do not employ AQCV credentialed pharmacists. This analysis did not demonstrate that inpatient AQCV credentialed pharmacists improve readmissions or mortality for AMI and HF.
Abstract 349: Variability of Anticoagulant Dosing Among Hospitals for Patients Presenting with Acute Coronary Syndrome in the VA
Authors: Plomondon Meg , Jennewein Xuefei , Lambert-Kerzner Anne , Tsai Thomas , Ho Michael
Published: July 2021

Background:
Anticoagulant therapy for ACS patients is recommended by clinical practice guidelines. Further, appropriate dosing of anticoagulant therapy is necessary to ensure effectiveness and safety and is a current ACC/AHA STEMI/NSTEMI test performance measure. This study describes the variability in excess dosing of unfractionated heparin (UFH), low-molecular weight heparin (LMWH), and glycoprotein IIb/IIIa inhibitors among all VA hospitals and the association between patient, provider and facility characteristics with excessive dosing.

Methods:
This was a national cohort of 53,489 patients admitted for ACS at 135 VA hospitals between FY09-FY11 and administered anticoagulation therapy during their hospital stay. Excess dosing was defined based on the ACC/AHA test performance measures: unfractionated heparin > 70U/kg or infusion >15U/kg per hour, low molecular weight heparin (LMWH) >1.05mg/hr and glycoprotein IIb/IIa inhibitors, epifibitide: >180ug/kg and infusion of >2.0 ug/kg per minute among patients with creatinine clearance <50ml/min; tirofiban >0.4ug/kg and infusion of >0.1ug/kg among patients with creatinine clearance <30ml/min.

Results:
Dosing information was available in 39,873 (~75%) patients. Among these patients, 62.7% (25003) were prescribed unfractionated heparin, 34.9% (13919) were prescribed LMWH, and 2.4% (951) were prescribed glycoprotein IIb/IIIa. The average (standard deviation) percentage of patients receiving excess dosing of any anticoagulant at a hospital was 10.1% (12.2%); and 10.7% (20.9%) for unfractionated heparin, 12.9% (8.4%) for LMWH and 0.54% (1.9%) for glycoprotein IIb/IIIa. In general, common factors associated with excess dose across the three types of anticoagulants included older age, lower BMI, and higher serum creatinine. Among the provider and facility characteristics, anticoagulant dose ordered by an emergency department physician versus hospitalist, and first administered anticoagulant occurring in ICU versus not ICU were also associated with reduced risk of excessive dosing.

Conclusions:
There is wide hospital variability in excess dosing of anticoagulants for patients treated for ACS. Next steps include conducting qualitative interviews at sites to further understand reasons for variation in anticoagulant dosing. It will be important to incorporate both the identified factors associated with excessive dosing and the qualitative interview findings into future interventions to ensure appropriate dosing of anticoagulants for ACS patients.
Abstract 108: Differences in Cardiologists’ Interpretation and Management of Chest Pain Symptoms and Abnormal Stress Tests in Women and Men
Authors: Daugherty Stacie L , Havranek Edward P , Blair Irene V , Dickinson Miriam , Bronsert Michael , Karimkhani Elhum , Main Debbi , Masoudi Frederick A
Published: July 2021

Background:
Gender differences in evaluation of coronary artery disease (CAD) have been suggested in observational cohorts. Whether gender differences in care exist under standardized conditions is not well known.

Methods:
We developed a web-based survey that randomly varied a case vignette by patient gender alone. The first part described a patient presenting with symptoms suggestive of CAD and the second described the results of an abnormal ETT (exercise treadmill test) in that patient. For both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD regardless of patient gender. Providers were asked to rate the likelihood of obstructive CAD and to choose the best treatment option. The survey was emailed to all physician members of a state cardiology association. A total of 3 reminder emails were sent.

Results:
Of the 317 cardiologists with valid addresses, 71 (22.4%) completed the survey. Participants were mostly men (82.4%) and non-invasive cardiologists (63%). For both parts of the vignette, cardiologists tended to estimate the likelihood of obstructive CAD as “high” more often when the patient was a man (Table). Respondents were equally likely to recommend cardiac testing based on symptoms suggestive of CAD regardless of patient gender; however, after an abnormal ETT, cardiologists were more likely to recommend angiography for male patients and more likely to recommend a second stress test with imaging for female patients (Table).

Conclusions:
Using a standardized case patient at intermediate risk for CAD, cardiologists tended to estimate the likelihood of CAD as higher and were more likely to recommend cardiac angiography after an abnormal ETT in male patients and more likely to recommend stress testing with imaging for women. Our findings suggest differences in how cardiologists evaluate symptoms and manage abnormal stress test results according to patient gender.
Abstract 147: Do Billing Data Accurately Describe Causes Of Readmission After PCI? An Analysis Of A Large PCI Readmission Database.
Authors: Wasfy Jason H , O'Brien Cashel , Strom Jordan B , Zai Adrian , Luttrell Jennifer , Spertus John A , Mauri Laura , Normand Sharon-Lise T , Yeh Robert W
Published: July 2021

Introduction:
Early readmission after PCI can be a useful performance measure, particularly if the reasons for readmission are related to patient management (e.g. angina, stent thrombosis or bleeding). Prior studies on readmission have used principal billing discharge diagnosis, but the validity of billing codes for this purpose is unclear.

Methods:
PCI patients readmitted within 30 days of discharge at the Massachusetts General Hospital (January 2007-December 2011) and Brigham and Women’s Hospital (June 2009-December 2011), were identified, and their medical records reviewed by a cardiologist. For each readmission, the principal billing discharge diagnosis of the readmission was compared to the primary diagnosis of the readmission as determined by the chart review. The accuracy of billing discharge diagnoses for readmissions due to chest pain or other symptoms concerning for angina and vascular access complications was assessed.

Results:
Of 9081 patients undergoing PCI and surviving to hospital discharge, 1011 (11.1%) were readmitted to the index hospital within 30 days. After excluding repeat readmissions, 894 readmissions were reviewed and of those, 754 (84.3%) could be matched to billing diagnoses. For each reason for readmission, corresponding billing diagnoses were diverse (Table 1).

The sensitivity and specificity of billing code 414.01 for a readmission for chest pain or other symptoms concerning for angina were 0.36 and 0.85, respectively. The sensitivity and specificity of billing code 997.2 (Peripheral vascular complications, not elsewhere classified) for a bleeding or vascular complication of PCI were 0.28 and 0.997, respectively.

Conclusions:
The diversity of ICD-9 codes does not allow straightforward categorization of principal diagnoses of readmission from billing data. More complex algorithms need to be developed and validated to reliably derive reasons for readmission after PCI from billing data.
Abstract 21: Variation in Hospital Costs of Percutaneous Coronary Intervention
Authors: Amin Amit P , Bach Richard G , Novak Eric , Lasala John M , Singh Jasvindar
Published: July 2021

Introduction:
A great emphasis exists on improving PCI outcomes and quality, but there are no data on the variation in hospitals' costs of PCI. As Payers move away from a fee-for-service model, most forms of bundled payments or gain-sharing, increasingly require hospitals to contain costs. Hospitals are at financial risk if costs exceed a specified budget. Our goal was to understand the variation in costs of PCI across hospitals, and the extent of the variation in PCI costs explained by hospitals, after controlling for patient characteristics.

Methods:
We identified 230,410 patients undergoing PCI at 258 hospitals (performing ≥100 PCIs), from 2007-2010 from the Healthcare Cost and Utilization Project state inpatient database (SID) from California, Florida and New York. The SID includes 97% of all discharges regardless of payers, from these states. Costs of PCI were determined by applying hospital- and year-specific Cost-to-Charge Ratios to the total charges. Variation in costs of PCI across hospitals were examined by a hierarchical linear regression model with PCI costs as the dependent variable and hospital site as a random effect, adjusting for differences in prevalence of patient and demographic characteristics by hospital site.

Results:
The mean cost of performing a PCI procedure was $17,543 ± $ 12767. We observed a large degree of variation in mean PCI costs across hospitals ranging from $5,823 to $38,532. Length of stay (LOS), was associated with incrementally higher PCI cost ($2,400, per day p<0.0001). After adjusting for LOS, PCI complications, and patient comorbidities, we observed a persistent 24% variation in PCI costs across hospitals. A significant interaction between hospital cost quintile and LOS (interaction P-value <0.001) was also observed, such that in the highest quintile hospital, PCI costs were higher by $1,277 per day LOS, despite adjusting for LOS and patient comorbidities and PCI complications.

Conclusions:
PCI costs vary tremendously across hospitals. Approximately one quarter of the variation in PCI costs is explained by hospitals, despite controlling for differences in LOS, PCI complications and patient characteristics. The same LOS costs differently across different hospitals. There is an urgent need for hospitals to examine and reduce the variation in PCI costs.