bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 185: Comparative Efficacy of Revascularization Procedures for severe CAD in patients with Chronic Kidney Disease.
Authors: Roberts John K , Rao Sunil V , Shaw Linda K , Marroquin Oscar C , Patel Uptal D
Published: March 2022

Introduction:
Patients with Chronic Kidney Disease (CKD) are at increased risk for cardiovascular mortality. However, there are few comparative efficacy studies of coronary revascularization procedures in this high-risk population.

Hypothesis:
There is an association between treatment strategy, estimated glomerular filtration rate (eGFR), and survival among patients with CKD and coronary artery disease (CAD).

Methods:
We examined patients in the Duke Databank for Cardiovascular Diseases (N=8604) who had significant CAD by cardiac catheterization from 2003-2009. Patients were excluded if they had prior revascularization or if pre-procedure serum creatinine was missing. Patients were stratified by estimated pre-cath estimated glomerular filtration rate (eGFR) into 5 groups: normal (eGFR ≥ 60 ml/min/1.73m
2
), mild CKD (eGFR 45-59 ml/min/1.73m
2
), moderate CKD (eGFR 30-44 ml/min/1.73m
2
), severe CKD (eGFR <30 ml/min/1.73m
2
) and ESRD (dialysis). Multi-variable Cox Proportional Hazards models were used to determine the association between CKD severity and mortality according to four possible treatment strategies: coronary artery bypass-graft surgery (CABG), PCI with drug eluting stent (DES), PCI with bare metal stent (BMS), or medical management (MED). In addition, we tested for interactions between treatment strategy and eGFR groups.

Results:
The sample was mostly male (64.9%, 5591/8604), median age was 62 y (IQR 54-71), and 28.8% (2476/8604) had diabetes. Median follow up was 4.0 y (IQR 2.0-6.1). After adjusting for 17 covariates, baseline eGFR was significantly associated with mortality. For all treatment strategies, there was an inverse association between mortality and each 10ml/min drop in baseline kidney function: MED HR = 1.185 (1.146-1.225), BMS HR = 1.246 (1.190-1.303), DES HR = 1.294 (1.244-1.347), and CABG HR = 1.262 (1.204-1.323). Multivariable models comparing treatment strategies demonstrated differential effects by kidney function (Table; interaction for treatment effect across eGFR groups, p=0.0053). In contrast to BMS, DES and CABG were associated with similar mortality reductions among groups with lower eGFR.

Conclusions:
There are strong associations between eGFR and increased mortality among patients with documented CAD, however, these vary significantly by revascularization strategy. These data suggest that a randomized trial of revascularization strategies in patients with CKD may be warranted to guide clinical practice.
Abstract 189: Capture of Comorbidities by Administrative Data is Lacking and Varies across Centers
Authors: Fosbol Emil L , Wang Tracy Y , Thomas Laine , Li Shuang , Roe Metthew T , Peterson Eric D
Published: March 2022

Background:
National hospital performance ratings use administrative claims data to adjust for patient case mix. Yet, the degree to which the capture of clinical comorbidities in administrative data varies between hospitals has never been described.

Methods:
We examined overall patient-level and hospital-level agreement between linked clinical registry data from the CRUSADE quality improvement registry and Medicare claims data for patients with Non-ST elevation acute coronary syndromes. Comorbidities examined included diabetes mellitus (DM), hypertension (HTN), prior myocardial infarction (MI), and heart failure (HF) and patient level measures of agreement were calculated using CRUSADE as the gold standard.

Results:
A total of 66,139 NSTEMI patients from 504 sites were included in our study. Patient level agreement was good for DM but only moderate for HF, HTN, and MI (Table). At the hospital level, CRUSADE generally categorized patients as having more comorbidities compared with Medicare. Agreement rates for all comorbidities varied significantly across centers: 5
th
-95
th
percentiles of agreement were DM, 84-99%; HTN, 69-90%; HF, 66-92%; and MI, 60-86%.

Conclusion:
In a contemporary cohort, administrative claims data still underestimate comorbidity burden and there is varying degrees of capture from one center to the other. This needs to be recognized when comparing center-level quality metrics assuming equal capture and risk adjustment across centers.
Abstract 196: Compounded Point-Scoring Of Dysphagia Risk Factors Predict Clinical Dysphagia In An Acute Care Hospital Setting
Authors: Jarquin-Valdivia Adrian A , Goodman Caroline C , Strong Sara J
Published: March 2022

Compounded Point-Scoring Of Dysphagia Risk Factors Predict Clinical Dysphagia In An Acute Care Hospital Setting

Introduction
Dysphagia places patients at risk for malnutrition, dehydration, and pulmonary aspiration; reduces quality of life; and lengthens hospitalization. The published literature describes individual dysphagia risks factors (DRF) . We felt that in many patients, the risk would be given by the number and types of DRF. Further, each risk factor could have its own independent contribution to the dysphagia.

Hypothesis
Can the risk of dysphagia be identified with a simple screening questionnaire where the clinical DRF are numerically weighed-scored, and later compounded?

Methods
Individual DRF (n=21) were each weighed from 1 to 5. The decision on the assigned score was given by 3 individual experts, the values averaged. • A score of 0 means that no dysphagia risk factors were present. • A score 1-4 means that some DRF are present, but the risk probably low. It prompts the bedside nurse to administer standardized swallowing trials. (video available in vimeo.com/speechpathology). • A score ≥5 signifies high risk for aspiration. The patient is placed in full-NPO status, and the Speech Language Pathology (SLP) service is consulted for a bedside swallowing evaluation (BSE). Patients admitted to floors where stroke patients would be admitted more commonly were given the Swallowing Safety Screening (SSS) by the trained bedside nurse. The SSS has 2 components the 1) scoring, and 2) the administration of swallowing trials. Here, we report on the scoring component of the SSS.

Results
SSS was reviewed for 357 patients (n=357) who were referred to the SLP. Patients on SLP’s caseload were reviewed in a blinded, time-limited, non-randomized fashion. Data was collected for patients for whom a SSS had been completed, and a BSE had been triggered (n=133). Of patients in this subset (n=114) who scored ≥5 on the SSS, 70% were judged positive for the presence of dysphagia, 30% were negative. Further analysis of the data reveals that the mean SSS score for negative dysphagia diagnoses is <6.1, and for positive dysphagia diagnoses is >7.95. The confidence intervals (95%) are 1.29 and 1.4, respectively. Using z statistics, the probability of getting this separation of the data by chance is p =0.00014.

Conclusions
It is possible to identify dysphagia patients using a questionnaire where the DRF are given a numerical weight and then summated. There is a point where the score of the DRF adds such clinical weight that dysphagia is identified or predicted.
Abstract 198: Assessing Performance Perceptions And Realities In Outpatient Atrial Fibrillation Care
Authors: Glusenkamp Nathan T , Mullen Brendan , Alexanian Claire , Fiocchi Fran , Risch Samantha
Published: March 2022

Introduction:
Clinician self-perception is the basis of assessments of care quality in the absence of frequent, quantitative reports on clinical guideline adherence. However, physicians’ self-assessments may reflect an unconscious upward bias. We suspect that gaps exist between clinician perception of care and the care that patients actually receive. We focus on outpatient treatment of atrial fibrillation (AF) patients, as performance measure (PM) rates are variable in AF, and because the introduction of novel anticoagulants has the potential to impact established stroke prevention regimes.

Hypothesis:
This study investigates the gaps between provider perceptions of AF care and documented performance on outpatient AF treatment. We hypothesize that perceptions of performance on AF outpatient PMs will exceed documented performance.

Methods:
A survey of PINNACLE Registry participants, including 37 physicians, 6 NPs, 3 PAs and 4 RNs was conducted July-August 2011 to assess clinician perception of outpatient AF treatment. Responses were compared to data collected in the ACC’s PINNACLE Registry, an outpatient registry with 222,451 AF patients from over 300 sites.

Results:
Gaps were revealed between provider perceptions of AF care and in documented care from PINNACLE. Providers overestimated the time spent in the therapeutic INR range, stating that their patients are in the optimal range 70.2% of time (average of 49 responses providing individual percentage range). Best estimates from literature indicate that patients, on average, are in the therapeutic range 55% of time
1
. Clinicians also overestimated the percent of time that they prescribe anticoagulants, estimating that they were prescribed to 93% of eligible patients (average of 49 responses providing individual percentage range). According to PINNACLE, only 60.4% (38841 of 64318) of eligible patients are receiving anticoagulants, leaving 21,225 patients at possible risk for stroke. Finally, clinicians predicted that 66.7% of their patients with AF have two or more risk factors for stroke. Yet, only 13% (11091 of 85433) of patients had their thromboembolic risk factors documented.

Conclusion:
There is a discrepancy between the care patients with AF should be receiving and the care they actually receive in practices, as documented in the PINNACLE Registry. The gap between clinician perception and reality highlights the importance of CV registries and of regular feedback reporting on clinician performance. 1. The PINNACLE Registry does not measure time spent in therapeutic INR range. This statistic from Baker, WL, Cios DA, Sander SD et al. Meta-analysis to assess the quality of warfarin control in atrial fibrillation patients in the United States.
Journal of Managed Care Pharmacy
. 2009;15:244_52.
Abstract 201: Trends In Preventive Care Among High Risk Diabetics Prior To Acute Coronary Syndromes; Is There Room For Improvement?
Authors: Darden Douglas , Krishnan Sangeetha , Rubenfire Melvyn , Jackson Elizabeth
Published: March 2022

Background:
Effective heart disease prevention for patients with diabetes (DM) includes pharmacotherapy such as aspirin, ace-inhibitors and statins. Thus use of such medications among diabetics is an important quality measure. We examined trends in such therapies over time, comparing mediations utilization at time for acute coronary syndrome (ACS) admission for DM and non-DM patients

Methods:
Data on home medications prior to index ACS event, demographics, and co-morbidities was collected as part of a registry of ACS patients from January 1999 to January 2007.

Results:
A total of 3,240 ACS patients were included, of which 951(29%) had a diagnosis of DM on admission. Compared to non-DM patients, those with a history of DM were older, and more likely to be obese and have a prior diagnosis of hypertension, hyperlipidemia, and heart disease including angina, myocardial infarction, and coronary revascularization. On admission, DM patients were significantly more likely to be on aspirin 3.51 [1.79, 6.88, p=0.0003], beta blockers 1.71 [1.46, 1.99, p <0.001]; ACE inhibitors 2.79 [2.39, 3.27, p<0.001] and Lipid Lowering Agents 1.95 [1.67, 2.28, p<0.001] compared to non-DM patients. However the overall rates of preventive medications among DM patients was low. Among DM patients with no contraindication, medication prevalence prior to admission was 58.3% for aspirin, 52.9% for ace-inhibitors, and 52.5% for lipid lowering medications including statin therapy. Rates of these medications did increase significantly from 1999 to 2007 (Figure1.) After adjusting for a DM status, age, gender, and six month GRACE 6-month mortality risk score, use of preventive medications prior to admission were associated with a reduced risk of major adverse cardiac events at six months.

Conclusions:
Despite being at high risk for cardiac events, patients with a history of DM are often not receiving preventive medications such as aspirin, ace-inhibitors and statins. Such medications are independently associated with outcomes at six-month post ACS; suggesting improvements in receipt of these medications may reduce risk pre and post ACS among patients with DM.
Abstract 202: Transitional Care of Cardiac Patients with Psychiatric Disorders: How Bridging the Discharge Gap Effectively Measures-up
Authors: Stalhbaum Danielle E , Bumpus Sherry M , Smith Cydni A , Kline-Rogers Eva , Mahmood Redah Z , Montgomery Daniel , Krishnan Sangeetha M , Froehlich James B , Eagle Kim A , Rubenfire Melvyn
Published: March 2022

Background:
BRIdging the Discharge Gap Effectively (BRIDGE), a nurse practitioner delivered cardiac transitional care program, reduces 30-day readmissions and ED visits. Since psychiatric (psych) conditions are known to complicate care, we sought to determine if BRIDGE attendance reduces events in this at-risk population.

Methods:
Retrospective data was abstracted for all patients referred to BRIDGE (June ’08- Dec ’10) including: demographics, comorbidities and events within 6 months of discharge. Of 770 patients referred, 189 (24.5%) had a referral diagnosis of acute coronary syndrome (ACS).

Results:
Of these ACS patients, 73 (38.6%) were female, 162 (87%) were white, 16 (8.6%) were black. Mean age was 63.0±13.6 years, Charlson Comorbidity Index Score was 1.7± 1.0 and median length of initial hospitalization was 3[2-4] days. Fifty-five patients(29.7%) had psych disorders including 39 (20.6%) with depression, 21 (11.1%) with anxiety, 5(2.7%) with dementia and 17 (9%) with substance abuse. There was a high degree of correlation between the presence of anxiety and depression (r^2= 0.44376, p<0.0001). Referred patients who had a psych disorders had significantly lower odds of attending BRIDGE (OR 0.39[0.19, 0.80; p=0.011]). For patients who attended BRIDGE, the odds of readmission or emergency department visit within 30,60,90 and 180 days of discharge trended higher for patients with anxiety or depression; lower for dementia or substance abuse.

Conclusion:
Data from this small sample suggests that BRIDGE does not improve outcomes for some patients with psych conditions. More research is needed to better understand the special needs of patients with anxiety or depression and the degree to which attending BRIDGE impacts outcomes in this population.
Abstract 208: Physician Adherence to the Prescription of Proven Doses of Secondary Prevention Medications After Acute Myocardial Infarction. Insights from TRIUMPH and PREMIER.
Authors: Arnold Suzanne V , Spertus John A , Li Yan , Dodson John A , Jones Philip G , Maddox Thomas M , Daugherty Stacie L , Chan Paul S
Published: March 2022

Background:
Performance measures after an acute myocardial infarction (AMI) are designed to improve quality by explicitly quantifying the use of evidence-based treatments. While current performance measures assess whether patients are prescribed certain medications, the doses used to establish their benefit in clinical trials are not part of the measures. It is unknown whether patients are being discharged on doses with proven effectiveness and whether these doses are increased over time in the outpatient setting.

Methods:
We assessed doses of beta blockers (BB), statins, and ACE/ARBs at discharge and 6-12 months post-AMI among 6699 patients eligible for these meds from 31 hospitals enrolled in 2 US registries (2003-08). Target doses were defined from clinical trials establishing benefit. Doses were categorized as none, low (<50% target), moderate (50-74% target), or goal (≥75% target). Titration was defined as an increase in dose category from discharge to follow-up. Analyses excluded patients with heart rate <50 (BB), SBP <100 (BB, ACE/ARB), GFR <30 (ACE/ARB), EF>35% (ACE/ARB), or any chart-documented contraindication (all assessed at discharge). Hierarchical logistic models explored factors, including discharge dose, associated with achieving goal dose of each med at follow-up.

Results:
At hospital discharge, most eligible patients (>87%) were prescribed some dose of each medication, although fewer than 1/5 received goal doses of BB and ∼1/3 were prescribed goal doses of statins or ACE/ARBs (Table). Of patients discharged on suboptimal doses, few were titrated up as outpatients (BB 19%, statins 25%, ACE/ARBs 27%). After adjustment for sociodemographic and clinical factors, only a goal dose of med at discharge was associated with being on goal dose at follow-up.

Conclusions:
Although ∼90% of eligible patients are discharged on appropriate secondary prevention medications after an AMI, most are prescribed doses far below those with proven efficacy in clinical trials. Importantly, doses are infrequently increased in the outpatient setting. Integration of dose intensity into performance measures may help improve the use of optimal medical therapy and outcomes.
Abstract 21: Transfer Times and Outcomes in ST-Elevations Myocardial Infarction Patients Undergoing Inter-Hospital Transfer for Primary Percutaneous Coronary Intervention: APEX-AMI Insights
Authors: van Diepen Sean F , Widimski Petr , Lopes Renato D , White Kyle R , Weaver W. D , Van de Werf Frans , Ardissino Diego , van't Hof Arnoud W , Armstrong Paul W , Granger Christopher B
Published: March 2022

Background:
Transfer delays for primary percutaneous coronary intervention (PPCI) may increase mortality in patients with ST-segment elevation myocardial infarction (STEMI). We examined the association between door 1 to door 2 (D1D2) time, a measure capturing the entire transfer process, and outcomes in patients undergoing inter-hospital transfer for primary PCI.

Methods:
We evaluated the relationship between D1D2 time and the 90 day incidence of death, shock, and heart failure in the sub-set of 2075 (36.1%) of 5745 patients who underwent inter-hospital transfer for PPCI in the APEX-AMI trial.

Results:
There was no significant difference in the 90 day incidence of death, shock, and heart failure between the transferred and the non-transferred groups (10.3% vs 10.2%, p=0.89). The median difference in symptom to balloon time between the two groups was 45 minutes (229 vs 184, p<0.001). The primary composite outcome in patients with D1D2 times <60, 60-90, 90-120, and >120 minutes were 7.3%, 9.6%, 11.9%, and 12.8% (p=0.028), respectively (see Figure). This worsening outcome with longer transfer delay was no longer statistically significant after multivariable adjustment.

Conclusion:
Longer transfer times were associated with higher rate of death, shock, and heart failure among patients undergoing inter-hospital transfer from PPCI, although this difference did not persist after adjusting for baseline characteristics. This lack of demonstrable worsening of outcome with longer transfer delays may relate to the complex relationships as well as the modest degree of delays in this clinical trial compared to the much longer delays in clinical practice.
Abstract 213: Lower Satisfaction in Atrial Fibrillation Patients Taking Warfarin-Thromboprophylaxis Versus Non-Warfarin-Thromboprophylaxis
Authors: Coleman Craig I , Coleman Stacey M , Vanderpoel Julie , Nelson Winnie , Colby Jennifer , Scholle Jennifer , Kluger Jeffrey
Published: March 2022

Introduction:
Warfarin reduces the risk of stroke in atrial fibrillation (AF) patients by up to 65%; however, there are significant disadvantages to warfarin therapy, including complex and variable dosing, inconvenient monitoring and potentially dangerous food and drug interactions. We sought to evaluate and compare patient-reported feelings of limitation, concern and burden when receiving warfarin- vs. non-warfarin-thromboprophylaxis.

Methods:
We conducted a cross-sectional survey study of AF patients receiving various agents for thromboprophylaxis for stroke prevention. Patients were recruited from arrhythmia clinics associated with a large, urban teaching hospital. Each patient completed the “Anti-Clot Treatment Scale” (ACTS) survey instrument. Mean scores of patients receiving and not receiving warfarin were compared for each of the 17 items and for the “Burdens” (questions 1-12) and “Benefits” (questions 14-16) subscales. The Burdens and Benefits subscales are scored so that a higher score suggests greater satisfaction.

Results:
A total of 80 AF patients completed the survey. Of these, 65 were receiving a regimen containing warfarin (n=39 warfarin, n=26 warfarin+antiplatelet agent(s)) and 15 were not (n=11 aspirin, n=2 aspirin+clopidogrel, n=2 dabigatran). The mean age of surveyed patients was 74.2±9.7; 60% were male, and the mean CHADS2 score was 2.1±1.2. Six of the 17 individual questions, depicting patients perceived limitations in physical activity due to bleeding, limitations on diet, feelings of inconvenience of occasional aspects of anti-clot therapy, frustration, burden and overall negative impact on life, had significantly less favorable scores in warfarin patients compared to patients not receiving warfarin (p<0.05 for all). Mean ACTS Burdens scores were higher (more favorable) in the no warfarin group (44.5±6.4) compared to the warfarin group (39.8±8.0) (p=0.003). No significant difference was seen between the 2 groups in regards to the ACTS Benefits score (11.1±3.4 vs.10.4±3.7, p=0.38).

Conclusion:
AF patients receiving warfarin had less favorable feelings about their thromboprophylaxis. Warfarin-treated patients reported more limitations and suffered greater feelings of burden.
Abstract 217: Reliable Exclusion of Acute Coronary Syndrome Among Hospitalized Patients With Elevated Troponin
Authors: Davis Melinda B , Shafton Asher , Bach David
Published: March 2022

Background:
Elevated cardiac troponin-I (cTn) occurs in acute coronary syndrome (ACS) as well as a variety of non-ACS settings with oxygen supply - demand mismatch. This study sought to test the ability to reliably exclude ACS using simple clinical data in the setting of elevated cTn.

Methods:
Records for patients hospitalized January - April 2011 with elevated cTn (>0.29ng/dl) and an echocardiogram were retrospectively reviewed. STEMI was excluded. Patients were classified as having ACS (NSTEMI) versus Non-ACS (demand). Delta cTn was defined as the absolute difference between the highest and initial cTn values.

Results:
Of 266 records meeting inclusion criteria, 82 (31%) had ACS and 184 (69%) had Non-ACS. Clinical variables that were significantly associated with ACS vs. Non-ACS are shown in the table. Echocardiographic wall motion abnormality (WMA) had a negative predictive value of 80% and positive predictive value of 63%. In multivariable analysis, odds ratios for Non-ACS were 7.6 (95% CI 3.8-15.2) for peak cTn less than 2ng/dl, 6.3 (95% CI 3.1-13.1) for absent WMA, and 4.4 (95% CI 2.2-8.7) for no prior coronary artery disease (CAD) history. The area under the receiver operating curve for a model using these 3 variables was 0.86, with a 98% negative predictive value.

Conclusion:
Among hospitalized patients with elevated cTn, no history of CAD, peak troponin less than 2ng/dl, and no new echocardiographic WMA reliably identifies patients at very low likelihood for ACS.
Abstract 218: Case-mix Analysis of AIM-HIGH Patients in the Real-world
Authors: Nair Radhika , Karas Richard H , Thakker Kamlesh M , Simko Robert , Manthena Shivaji
Published: March 2022

Background:
Subjects are enrolled in randomized clinical trials according to strict entry and exclusion criteria. The extent to which these study subjects are similar to or different from ‘real world’ patients importantly impacts the extent to which the results of clinical trials can be generalized

Objectives:
To examine the baseline characteristics of AIM-HIGH-like patients identified in real-world practice and compare them to the patients enrolled in the AIM-HIGH clinical trial.

Methods:
This was a retrospective claims database study. The earliest complete lipid panel of individuals 45-64 years of age, was identified. The date of the lipid panel was set as index date. Individuals had to be enrolled at least a year prior to the index date and fulfill the cardiovascular disease (CVD) and atherosclerotic dyslipidemia inclusion criteria in AIM-HIGH. Descriptive analyses were conducted to understand the baseline characteristics of these AIM-HIGH-like (A-H-like) patients.

Results:
A total of 52,712 patients with a complete lipid panel and previous CVD history, as specified in the inclusion criteria, were identified. Applying the atherosclerotic dyslipidemia criteria, an overall 11,906 (22.6%) patients(A-H) were identified of which 5,645 patients (44.4%) were treated with statin or statin-ezetimibe. These 5,465 statin-treated patients account for 10.4% of the patients with a CVD history. The average LDL-C (±SD), HDL-C(SD) and median TG of the treated A-H patients in the real-world were 74.5mg/dL(16.4), 37.4mg/dL(6.4) and 164.0mg/dL respectively. These values were slightly higher (p<0.0001 for LDL-C and HDL-C) than the average LDL-C (SD), HDL-C (SD) and median TG of patients in AIM-HIGH (95% statin-treated), 71.0mg/dL(18.0), 34.9mg/dL(5.6) and 161.0mg/dL, respectively. In the real-world, while only 63.0% of the A-H-like patients had LDL-C<100mg/dL, 98.2% of the treated A-H-like patients had LDL-C< 100 mg/dL. Likewise, only 21.8% of the A-H-like population in the real-word had LDL-C < 70 mg/dL and 36.3% of the treated A-H-like real-world patients had LDL-C < 70 mg/dL. There was a very small proportion of the treated real-world population (15.0%) that had all lipid values at recommended levels.

Conclusion:
In the real-world, A-H like patients with atherosclerotic dyslipidemia represent only 22.6% of the secondary prevention population. Majority of patients in AIM-HIGH trial were statin-treated (95%), and these well-controlled treated A-H-like patients account for only 10.4% of the secondary prevention population in the real-world, indicating that there remains a large secondary prevention population in the real-world that needs further evaluation regarding need for treatment.
Abstract 225B: Nursing Home Care Quality and 30-Day Readmission Rates for patients with Heart Failure
Authors: Ogunneye Owolabi , Rothberg Michael , Friderici Jennifer , Slawsky Mara , Kleppel Reva , Calcasola Stephanie , Gadiraju Taraka V , Stefan Mihaela
Published: March 2022

Background:
Acute decompensated heart failure (ADHF) is one of the most frequent cause for hospitalization in the United States but little is known about how the quality of care provided by the skilled nursing facilities (SNFs) influences readmission rates.

Objectives:
1)To determine the association between care quality reported on Medicare's Nursing Home Compare website and 30-day risk-adjusted readmission rate (RAR) for ADHF. 2) To assess the correlation of processes of care and characteristics of SNFs with 30-day RAR.

Methods:
Retrospective cohort study at Baystate Medical Center, a 659-bed tertiary care hospital. Subjects: Patients aged ≥18 years discharged to 17 local SNFs after hospitalization for ADHF from November 2008 to October 2011. SNF quality of care was assessed based on the quality rating (health inspection, quality measures and staff rating) obtained from www.medicare.gov/NHCompare (range 1 to 5 stars). Based on the distribution of quality ratings, SNFs with only 1 star were considered lower quality. A telephone survey about SNF characteristics (e.g. physician hours, number of beds, licensed nurse's minutes) and processes of care (e.g. telemonitoring capability, onsite IV lasix, Heart failure (HF) treatment protocol) was completed by each director of nursing. RAR's were calculated using a mixed-effects logistic regression model adjusting for demographics, comorbidities and clinical characteristics of the patients.

Results:
Of the 605 discharges (491 patients), 121 were readmitted within 30-days, 57 were ADHF related; 64% were female, 86% white and median age was 84 years (interquartile range 13). Nearly all (99%) patients had Medicare or Medicaid. At discharge, 37% had ejection fraction <40% and 60% had at least one high-risk comorbidity (e.g. coronary artery disease, hypertension, atrial fibrillation). Higher quality SNFs (58%) were more likely to be non-profit and had more beds. The 30-day all-cause RAR was 19% (95% CI 14 -23) and 22% (95% CI 17 - 26) and the 30-day ADHF RAR was 9% (95% CI 6 -11.6) and 10% (95% CI 7 - 12.9) for higher and lower quality SNF's respectively. Both all-cause and ADHF RARs declined significantly between 2008- 2011 (P=0.02, χ2 test of trend). Although RAR were slightly lower in higher quality SNFs, these differences were not statistically significant in either adjusted or unadjusted models. Higher SNF staff ratings was marginally correlated with lower readmission rates (Spearmean R = - 0.39, p = 0.05). Self-reported processes of care (e.g. telemonitoring capability, weight graph), as well as SNF care structure (e.g. physician hours) did not correlate with RAR.

Conclusions:
Overall Quality rating reported on www.medicare.gov/NHCompare, as well as processes of care performed by SNFs were not associated with RARs for patients with Heart failure. Higher staff ratings correlated with lower RAR.
Abstract 227: Aldosterone Antagonists in Post-Acute Myocardial Infarction Use, Predictors, and Temporal Trends of a Class I Recommendation
Authors: Rassi Andrew N , Cavender Matthew A , Fonarow Gregg C , Cannon Christopher P. Cannon P , Hernandez Adrian F , Peterson Eric D , Peacock W. F , Laskey Warren K , Zhao Xin , Schwamm Lee H , Bhatt Deepak L
Published: March 2022

Objectives:
To measure the use of guideline-recommended aldosterone antagonist therapy in eligible patients with post-MI and reduced ejection fraction (EF), temporal trends, and characteristics associated with use.

Background:
Current guidelines recommend the initiation of aldosterone antagonist therapy post-AMI for those with an EF ≤ 40% with heart failure or diabetes prior to hospital discharge, in the absence of contraindications. We explored the relationship between this Class IA recommendation issued in 2004 (STEMI)/2007 (NSTEMI) and its implementation into practice.

Methods:
Data from the AHA’s Get with the Guidelines-CAD national database were analyzed for 81,570 post-AMI patients from 219 hospitals between January 1, 2006 and December 29, 2009 of whom 11,255 (13.8%) were eligible for aldosterone antagonist therapy.

Results:
Among eligible patients, 1023 (9.1%) were prescribed an aldosterone antagonist at discharge. There was wide variation in use among hospitals (0% to 40.0) with no hospital treating even half their eligible patients. Patient and hospital characteristics independently associated with prescription of aldosterone antagonists were history of diabetes, heart failure, or coronary revascularization. Conversely, patients less likely to have an aldosterone antagonist prescribed had a history of renal insufficiency, were smokers, and had higher EF. Larger hospital size was associated with higher aldosterone antagonist use. Prescription of an aldosterone antagonist increased in the study population from 6.0% to 13.4% from January 2006 to December 2009 (p<0.001).

Conclusions:
Fewer than one in ten post-MI patients eligible for an aldosterone antagonist, were discharged with this Class IA recommended therapy. Although rates of utilization are rising modestly over time, compliance continues to be extremely low. This discrepancy between evidence based therapy and actual prescribing patterns suggests the need for specific targeted performance improvement efforts.
Abstract 232: The Society of Thoracic Surgeons Mortality Risk Score Predicts 30-Day Hospital Readmissions
Authors: Benuzillo Jose , Roberts Colleen , Dyer Robert , Jones Kent , Lappé Donald
Published: March 2022

Introduction-
Readmissions are associated with poor quality of care and unnecessary healthcare costs. Hence, minimizing unplanned hospital readmissions has become a priority among health care professionals and policymakers. Accurately predicting the risk for readmission could guide the efficient delivery of timely transitional care. Recently, the Society of Thoracic Surgeons (STS) risk score was used to predict hospital charges and resource use after aortic valve replacement. We hypothesize that the STS predicted mortality risk score could accurately discriminate which of the patients will be readmitted within 30 days.

Methods-
Clinical data from patients undergoing cardiac surgical procedures at four Intermountain hospitals over a three year period (1/2009 - 12/2011) were analyzed. The main outcome was 30-day all-cause acute care readmissions. The predicted mortality risk score was ascertained using the STS risk algorithm and categorized into tertiles based on the population distribution. Odds ratio (OR) estimates and 95% confidence intervals (CI) were obtained from logistic regression.

Results-
The overall mean STS predicted mortality risk score was 2.02 (SD = 3.12). The overall unadjusted readmission rate among the cardiac surgical cohort was 11.04%. Patients with a moderate mortality risk score (M = 1.13, SD = 0.28) were more likely (OR=1.45; 95% CI 1.00 - 2.08) to be readmitted than patients with a low mortality risk score (M = 0.46, SD = 0.14). Similarly, patients with a high mortality risk score (M = 4.48, SD = 4.47) had higher odds of readmission (OR=2.51; 95% CI 1.79 - 3.52).

Conclusions-
Our results suggest that the STS mortality risk score predicts 30-day all cause acute care readmissions. More research is warranted to investigate its clinical usefulness.
Abstract 24: Outcomes of Single and Dual Chamber ICDs for Primary Prevention of Sudden Cardiac Death
Authors: Peterson Pamela N , Varosy Paul , Heidenreich Paul , Wang Yongfei , Dewland Thomas A , Curtis Jeptha , Go Alan S , Normand Sharon-Lise T , Greenlee Robert , Magid David J , Masoudi Frederick A
Published: March 2022

Background:
Randomized trials demonstrating the efficacy of implantable cardioverter defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with systolic heart failure (HF) predominantly used single chamber devices. However, in clinical practice, patients often receive dual chamber ICDs even in the absence of indications for pacing. The long-term safety of dual chamber devices relative to single chamber devices is uncertain.

Methods:
We identified all Medicare patients in the National Cardiovascular Data Registry's (NCDR®) ICD Registry™ from 2006-2009 who received an ICD for primary prevention that could be matched to CMS claims data. Patients were excluded if they had an EF >35%, received a bi-ventricular device or had a documented indication for pacing. Adjusted risks of complications, mortality, all cause readmission and HF readmission were estimated with propensity-score matching based on demographic, clinical and diagnostic information.

Results:
Among 32,034 eligible patients, 38% (n=12,246) received single chamber device and 62% (n=19,788) received a dual chamber device. Unadjusted rates of complications and 6-month all-cause readmission were lower among patients who received a single chamber device (3.5% vs. 4.8%; p <0.001, and 31.7% vs. 33.2%; p=0.004). According to analysis of matched pairs (12,133 single and 12,133 dual), rates of complications were lower among patients who received a single chamber device (3.5% vs.4.6%; p<0.001), but rates of all other outcomes did not differ significantly between the two groups. (Table)

Conclusions:
Dual chamber ICDs are associated with higher rates of complications. No significant differences between single and dual chamber ICDs were observed for death, all-cause readmission or HF readmission. Future studies should evaluate the potential benefit of dual chamber devices in reducing inappropriate shocks. In Medicare patients undergoing primary prevention ICD placement without clear indications for pacing, the decision to implant a dual chamber device should be considered carefully given the higher risk of complications with this strategy.
Abstract 241: Are Patients With Metabolic Syndrome or Its Components at Higher Risk of Atrial Fibrillation Recurrence After Catheter Ablation? A Meta-analysis.
Authors: Lin Kueiyu Joshua , Tiwari Nidhish , Cho Soung Ick , Bergman Michael , Palma Eugen C , Taub Cynthia C
Published: March 2022

Objective:
Metabolic syndrome (MetS) has been associated with incidence of atrial fibrillation (AF), but its impact on recurrence of AF after catheter ablation is unclear. We conduct a meta-analysis to summarize the relative risks (RR) of AF recurrence after catheter ablation in patients with versus (vs.) without MetS or its components, including obesity, hypertension, diabetes, and dyslipidemia.

Methods:
Among 666 articles identified from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, we included 21 studies with a total of 10726 patients (6739 with paroxysmal AF and 3987 with non-paroxysmal AF) for analysis. Variables assessed included: study years/size/design/population characteristics, including mean left atrial diameter, left ventricular ejection fraction and AF duration, AF ablation methods, blanking period, use of anti-arrhythmic drugs, AF recurrence ascertainment methods, variables adjusted in the original analysis, and other quality indicators. RRs were synthesized by random-effects models.

Results:
Our meta-analysis found an elevated risk of AF recurrence after ablation in patients with vs. without MetS (RR: 2.27, 95 % confidence interval [CI]: 1.35–3.80). Among the components of metabolic syndrome, the risk of AF recurrence was higher in patients with hypertension (RR: 1.36, 95 %CI: 1.13–1.62) but not in those with diabetes (RR: 1.23, 95 % CI: 0.92–1.66), or dyslipidemia (RR: 1.12, 95 % CI: 0.77–1.65). There was a non-significant trend suggesting a positive association between obesity and AF recurrence (RR: 1.77, 95% CI: 0.90–3.48) when body mass index (BMI) was evaluated as a categorical variable (BMI>25) but not as a continuous variable (RR: 1.00, 95% CI: 0.94–1.07). Vast majority of the studies assessed any AF recurrence after blanking period (2-3 months). Only 2 studies specifically addressed very late recurrence (>1 year) and they found higher AF recurrence in those with hypertension and dyslipidemia.

Conclusion:
Metabolic syndrome may be associated with a 2-fold increased risk of AF recurrence after catheter ablation. Hypertension appears to play a more important role in this association. The results regarding BMI and AF recurrence were heterogeneous but the relationship is likely non-linear. Further studies are warranted to evaluate the impact of modification of these factors on the risk of AF recurrence.
Abstract 244: Patient age and Riata lead abrasions
Authors: Sullivan Roberta A
Published: March 2022

Background
St Jude Medical's Riata defibrillator lead was US-approved in 2002 and subject to a Class I Recall in December 2011 due to insulation abrasion defects. Approximately 227,000 Riata leads were sold worldwide. A patient age analysis was performed for the abrasion-related adverse event reports submitted to the Food and Drug Administration (FDA).

Methods
The FDA medical device adverse event database was queried for all reports received containing “Riata” in the device brand name. The resulting reports were narrative text-searched for “abrade” and/or “abrasion”. Patient age data was compared between the abrasion-related group and those not identified as abrasion-related. T-testing of means was performed for significance testing at a 95% confidence level.

Results
As of January 1, 2012, FDA had received a total of 6,410 reports for Riata leads. Patient age was provided in 1,492 (23%) of these reports, and ranged from 10 to 94 years. A total of 1,037 reports were identified through text-searching as abrasion-related. Of these, 247 (23%) reports provided age. Compared to the non-abrasion group (n=1,245), patient age was found to be significantly younger in the abrasion group (mean 58.49 [
s
=15.2] v. 63.7 [
s
=14.4], p<0.00001). Nearly all the reports (99.4%) were submitted to FDA by St. Jude Medical. The prevalence of missing patient age in reports was found consistent across groups, and considered as related to factors other than the adverse event of lead abrasion.

Conclusions
Among the Riata adverse events reported to FDA, patient age was found to be younger in those identified with insulation abrasions compared to non-abrasion adverse events. Reasons for this are not known but age could be related to patient activity level or other factors. Limitations include missing data and all other limitations associated with the use of a passive surveillance system. Physicians may consider multiple factors in patient management decisions when recalled implantable leads are involved.
Abstract 260: Components of Change Processes of Quality of Life among Stable Coronary Patients with or without Percutaneous Coronary Intervention
Authors: Zhang Zugui , Kolm Paul , Jurkovitz Claudine , Spertus John A , Weintraub William S
Published: March 2022

Background:
Percutaneous coronary intervention (PCI) plus intensive pharmacologic and lifestyle intervention (optimal medical therapy, OMT) to OMT alone was compared in reducing the risk of cardiovascular events in a total of 2,287 patients with stable coronary disease in the COURAGE trial, in which health related quality of life data were measured repeatedly over time for a median of 4.6 years. We examined components of changes in angina-related quality of life over time.

Methods:
Angina-specific health status was assessed with the Seattle Angina Questionnaire (SAQ). Scores range from 0 to 100; higher scores indicate better health status. Linear piece-wise latent growth curve modeling was conducted to reveal the components of process and risk factors of SAQ score changes over time.

Results:
For each domain the change process can be divided into two components: a process of improvement from baseline to 6 or 12 months during which the scores significantly increase with a steep upward trajectory till reaching the maximum score value; and followed by a process of stabilization during which the scores kept stable or in a downward slope until the end of the follow-up. Patients in both PCI and OMT alone groups experienced significant increase on SAQ scores over time in each domain. PCI had significant impact in the process of improvement: patients with PCI had about 0.603 (SE=0.193, p-value=0.002) and 0.442(SE=0.22, p-value =0.044) points increase per month in scores in the domains of physical limitation and angina frequency, respectively; the benefit of PCI decreased in the process of stabilization until it disappeared so that the scores in both groups were eventually similar (Table 1). The important risk factors of change in SAQ scores were the use of long-acting nitrates at randomization, the Charlson comorbidity index, and several additional factors that differed by domain.

Conclusions:
Mechanism and processes of change in angina-related quality of life and health status were significantly related to the impact of adding PCI to OMT. Piece-wise growth curve modeling can be used to capture advantages of PCI over OMT and identify patient characteristics associated with subsequent measures of angina.
Abstract 262: Speed and Distance Requirements for Community Ambulation: A Systematic Review
Authors: Salbach Nancy M , O'Brien Kelly , Brooks Dina , Irvin Emma , Martino Rosemary , Takhar Pam , Chan Sylvia , Howe Jo-Anne
Published: March 2022

Introduction:
People with chronic conditions, such as stroke, commonly experience walking limitations and require rehabilitation services to optimize ability. Speed and distance requirements for walking around common community sites would help patients and health care professionals gauge readiness for community ambulation and set realistic goals relevant to activities patients wish to perform.

Objective:
To synthesize the research literature on speed and distance requirements for adults walking outside the home.

Methods:
A systematic review was conducted to identify full text peer-reviewed articles written in English, French or Spanish reporting distance and/or speed requirements for walking outside the home. Eight electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, ProQuest® digital dissertations and
The Cochrane Library
) were searched until August 2011. The principal investigator’s library and reference lists of included studies were also reviewed. Two authors independently reviewed titles and abstracts. One reviewer determined inclusion and extracted data. A second reviewer independently verified data accuracy. Stakeholders and decision-makers from the physical therapy community were consulted throughout the course of the review to guide the team with respect to the review question, interpretation of results and message creation.

Results:
Six English-language studies (5 in the United States and 1 in Singapore) were included. In the American studies, community sites were measured in 26 cities/towns. Across all studies, 27 unique community sites were investigated. Sites most frequently examined include: banks, supermarkets, department stores, drugstores, post offices and physican’s offices. Superstores and club warehouses required the greatest average walking distance of 606.6 metres (m) and 676.8 m, respectively. In four studies that examined common sites using the same protocol, the average walking distance was highest for supermarkets, department stores and drugstores (Range 129-380 m) and lowest for banks, physican’s offices and post offices (Range 38-98 m). Walking distance requirements appeared to substantially increase with population size for some sites (supermarkets, department stores, drugstores and post offices) but not others (banks, physican’s offices). The median speed required to cross the street was lowest in rural areas (0.74 metres/second (m/s)) and highest in cities (1.06 m/s).

Conclusions:
In conclusion, our findings suggest that retail sites have the highest walking distance requirements and that site distances increase with population size. Walking speed requirements for crosswalks also appear to increase with population size. Clients and health professionals may use findings to help establish practical rehabilitation goals and to determine readiness for community ambulation.