bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 324: Real World Use of Bivalirudin in ST-Elevation Myocardial Infarction is Associated with Lower In-Hospital Complications, 1-Year Major Adverse Cardiac Events and Mortality
Authors: Ortega Luis M , Strauss Craig E , Garberich Ross F , Porten Brandon R , Chavez Ivan J , Mooney Michael R , Burke Nicholas M , Henry Timothy D
Published: July 2021

Background:
Bivalirudin decreased bleeding and improved mortality in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) in the HORIZON trial. Currently there is limited data regarding the benefits of bivalirudin in unselected STEMI patients in real-world clinical practice.

Methods:
We reviewed consecutive STEMI patients at a large regional STEMI referral center from June 2009 to December 2011. All patients received aspirin and P2Y12 inhibitors. In-hospital complications, length of stay (LOS), total variable costs, 1-year cardiovascular readmissions, major adverse cardiac events (MACE) and mortality were compared for: bivalirudin alone, heparin alone and either medication with IIb/IIIa inhibitors.

Results:
Among 759 STEMI PCI cases, 208 (27.4%) received bivalirudin, 216 (28.5%) heparin and 335 (44.1%) IIb/IIIa, including only 48 cases with bivalirudin. Bivalirudin alone had significantly lower in-hospital complications, bleeding events, mortality and 1-year MACE and mortality (p<0.05 for all) (Figure). There were no significant differences in LOS (median 2.6 vs. 2.8 vs. 2.9 days; p=0.065), total variable costs (median $9,303 vs. $9,242 vs. $9,860; p=0.15) or readmissions within 1 year.

Conclusions:
In an unselected population of STEMI patients, those treated with bivalirudin had lower in-hospital complications and lower 1-year MACE and mortality rates compared to patients receiving heparin or IIb/IIIa inhibitors. These results provide further support for bivalirudin use in STEMI patients.
Abstract 330: Thirty-day Incidence of Cardiac Tamponade and Mortality Following Catheter or Surgical Ablation of Atrial Fibrillation
Authors: Scoggins John F , Teigland Christie , Meisnere Laura B
Published: July 2021

Background:
The risks of cardiac tamponade and mortality during the first 30 days following catheter or surgical atrial fibrillation (AF) ablation are not well known. Previous large population studies have been limited to in-hospital complication rates and might significantly underestimate the risks of these procedures.

Methods:
This population based retrospective cohort study was conducted using a large national representative administrative claims database, the Medical Outcomes Research for Effectiveness and Economics Registry (MORE2 Registry®). Thirty-day incidence rates of cardiac tamponade and mortality were calculated and compared by type of procedure (i.e. catheter or surgical), patient gender and age. We analyzed 38,974 AF ablation procedures (catheter: 30,758, 78.9%; surgical: 8,216, 21.1%; age 80 or older: 6,077, 15.6%; 65 to 79: 19,572, 50.2%; 50 to 64: 10,243, 26.3%; 18 to 49: 3,082, 7.9%) performed on 35,754 patients (men: 21,879, 61.2%; women: 13,875, 38.8%) from 2007 to 2012.

Results:
Thirty-day incidence of cardiac tamponade was 1.74% and differed significantly by type of procedure (catheter: 1.51% vs. surgical: 2.62%, p<0.001) and gender (men: 1.60% vs. women: 1.96%, p=0.010), but not by age group (18-49: 1.49%; 50-64: 1.77%; 65-79: 1.91%; 80 or older: 1.28%, p=0.425). The thirty-day mortality rate was 1.15% and differed significantly by type of procedure (catheter: 0.70% vs. surgical: 2.76%, p<0.001), but not by gender (men: 1.06% vs. women: 1.29%, p=0.058). The mortality rate did not differ significantly from the youngest age group to the next oldest (18 to 49: 0.33% vs. 50 to 64: 0.21%, p=0.315), but increased significantly for the oldest age groups (65 to 79: 1.28%; 80 or older: 2.75%, p<0.001).

Conclusion:
The 30-day risks of both cardiac tamponade and mortality following catheter AF ablation are greater than the in-hospital rates reported in a previous study. Surgical AF ablation has significantly higher 30-day rates of both cardiac tamponade and mortality, compared to catheter AF ablation. The risk of cardiac tamponade is greater for women than men, but does not vary significantly by age group. Conversely, the risk of mortality is greater for patients age 65 and older, but is not significantly different for women compared to men. These findings provide new comparative safety information that can help inform optimal treatment practices and could serve as the basis of a physician or facility quality measure designed to evaluate relative performance and provide benchmarks to support both consumer choice and quality improvement efforts.
Abstract 335: Population Well-being and Cardiovascular Disease
Authors: Spatz Erica S , Herrin Jeph , Riley Carley L , Roy Brita , Witters Dan , Coberley Carter , Krumholz Harlan M
Published: July 2021

Background:
Increasingly, policies and payment structures are holding health care systems accountable for the health of their population, refocusing attention on community attributes that influence health. However, the complex and contextual aspects of a community make it challenging to know which community attributes may affect the health risk of individuals.

Methods:
We investigated the relationship of CVD prevalence and risk factors with a novel index of well-being, the Gallup-Healthways Well-being Index (GHWBI, 2010), consisting of 55 survey responses organized into 6 domains:
life evaluation
(
LE
);
emotional health (EH)
;
work environment (WE)
;
physical health (PH)
;
healthy behaviors (HB)
; and
basic access [to food, shelter, and health care] (BA)
. Individuals >18y were randomly selected for telephone survey (n=348,846). Overall index and domain scores were made available to us aggregated to the Congressional District (CD) level. Prevalence of heart disease, stroke, hypertension, and diabetes, as well as CV health (absence of these factors), were determined using the 2011 Behavioral Risk Factor Surveillance System (BRFSS) sub-group study (224 counties). We linked datasets by assigning average BRFSS item responses at the county level to county zip codes; we then re-aggregated to CD and weighted by zip code. We used weighted linear regression to assess: (1) rates of CVD/CV health across GHWBI quintiles, and (2) independent effects of the 6 GHWBI domains on CVD/CV health, reported as t-scores. Because the
PH
domain included survey items related to CVD, we repeated this analysis excluding
PH
as an independent variable.

Results:
Higher CD well-being scores (n=316 CDs) were associated with lower prevalence of CVD and higher rates of CV health (Table). Independent effects of the GHWBI domains revealed inverse associations between CVD and
HB
, and heart disease and
LE
. CV health was positively associated with
EH
and
BA,
but negatively associated with
HB
. Excluding
PH
from this analysis did not meaningfully affect the results.

Discussion:
Population well-being is associated with reduced CVD and improved CV health, even at the CD level. Future research should investigate these relationships within smaller more homogeneous community populations, in order to identify targets for intervention.
Abstract 385: The Impact of Aspirin Primary Prevention Treatment Guidelines: Temporal Trends in Aspirin Use for Primary vs Secondary Prevention, 2005-2013
Authors: Van't Hof Jeremy R , Oldenburg Niki , Duval Sue , Dronca Serban , Olson Andrew , Peterson Kevin , Leupker Russell V , Miller Karen , Hirsch Alan T
Published: July 2021

Background:
Current national prevention guidelines recommend use of low dose aspirin (ASA) for both the primary prevention (PP) and secondary prevention (SP) of heart attack and stroke. ASA use for SP has been documented to have increased over the past decade. Since the publication of the 2009 United States Preventative Services Task Force (USPSTF) recommendations for PP ASA use, data describing the trends in PP ASA use in primary care are sparse. This study evaluates trends in PP and SP ASA use in primary care clinics from a large, regional health system over an 8 year period (2005-2013).

Methods:
A bi-annual cross-sectional electronic medical record (EMR) chart extraction was performed from 2005 to 2013 to evaluate documented ASA use for all patient encounters within primary care clinics in the Fairview Health System (Minnesota). Primary prevention candidates were defined as individuals within the USPSTF guideline age and sex target populations (men aged 45-79, and women aged 55-79 years) with no documented history of an atherosclerotic syndrome or contraindication to ASA use (aspirin allergy, peptic ulcer disease, or concurrent antithrombotic therapy). Secondary prevention candidates were defined as adults within the same age and gender range with a history of coronary artery disease, peripheral artery disease or ischemic stroke. The ASA treatment to candidacy ratio was calculated for the PP and SP populations.

Results:
Over 225,000 unique encounters at 66 primary care clinics were analyzed over the 8 year study period. The PP population was younger (60.4±8.7 vs. 66.2±8.3 years), with lower prevalence of hypertension (49 vs. 79%), hyperlipidemia (54 vs. 84%), and diabetes (17 vs. 35%) compared to the SP cohort. The mean SP ASA use of 86% was high, concordant with national trends, and did not change over this period. In contrast, PP ASA average use was 44% with no increase after publication of the 2009 USPSTF guideline. Documented contraindications to ASA use were uncommon (ASA allergy, 2.1 and 2.8%; peptic ulcer disease, 3.2 and 7.2%; and use of other antithrombotic medications, 4.6 and 32.6% in PP and SP populations respectively).

Conclusion:
Secondary prevention ASA use in primary care settings remains high, but ASA use for primary prevention of cardiovascular events is low. Despite creation of national guidelines, aspirin use in the PP population is half the rate of ASA use for secondary prevention. Additional methods to safely and effectively disseminate this primary prevention aspirin use recommendation, targeting both the public and health care providers, are warranted.
Abstract 386: 30-day Readmission Rates For Patients Discharged After Insertion, Revision, Replacement And Removal Of Cardiac Pacemaker Or Cardioverter/defibrillator: Analysis Of Nationwide Inpatient Sample Data
Authors: Aggarwal Sourabh , Gupta Vishal
Published: July 2021

Introduction:
Hospital readmission after pacemaker or cardioverter/defibrillator procedure (insertion, revision, replacement or removal) has a major impact on quality of patient’s life and cost-effectiveness of care. However, the data for 30-day readmission for patients undergoing these procedures is very limited.

Methods:
We queried Agency of Healthcare Research and Quality sponsored Healthcare Cost and Utilization Project’s Nationwide Inpatient Sample (NIS) data using Clinical Classification Software procedure Code 48 for insertion, revision, replacement and removal of cardiac pacemaker or cardioverter/defibrillator, which included ICD 9 codes of 00.50, 00.51, 00.52, 00.53, 00.54, 00.56, 00.57, 17.51, 17.52, 37.70, 37.71, 37.72, 37.73, 37.74, 37.75, 37.76, 37.77, 37.78, 37.79, 37.80, 37.81, 37.82, 37.83, 37.85, 37.86, 37.87, 37.89, 37.94, 37.95, 37.96, 37.97 and 37.98 to extract data for admissions secondary to pacemaker or cardioverter/defibrillator procedure. NIS represents 20% of all hospital data in US. Data was extracted for years 2009-2011 and 30-day readmissions secondary to these procedures identified. Statistical analysis was done using chi-square to determine parameters associated with increased 30-day readmissions.

Results:
We identified 443,719 admission for pacemaker or cardioverter/defibrillator procedure during the study period with total 30-day readmission rate of 15.38%. Females (15.91%), patients aged more than 65 years (15.78%), patients under Medicaid (17.65%), having low median income for zip code (16.44%) and staying in metropolitan areas (15.71%) were more likely to have total 30-day readmissions than other groups (P<0.01). Most common cause for readmission was congestive heart failure in 14,042 patients (20.57%), followed by complication of device in 8,244 patients (12.08%), arrhythmia in 5,750 patients (8.43%). Septicemia was responsible for readmission in 2,346 patients (3.44%)

Conclusions:
Strategies to reduce 30-day readmissions secondary to pacemaker or cardioverter/defibrillator procedure should be focused on more susceptible population including females, aged more than 65 years, covered under Medicaid, having low median income for zip code and staying in metropolitan areas and stringent control of risk factors for congestive heart failure and arrhythmia.
Abstract 174: Clinical Prediction Models for Cardiovascular Disease: The Tufts PACE CPM Database
Authors: Wessler Benjamin S , Lai YH Lana , Kramer Whitney , Cangelosi Michael , Raman Gowri , Lutz Jennifer , Kent David M
Published: July 2021

Background:
Clinical prediction models (CPMs) estimate the probability of clinical outcomes and hold the potential to improve decision making and individualize care. For patients with cardiovascular disease (CVD) there are numerous CPMs available though the extent of this literature is not well described.

Methods and Results:
We conducted a systematic review for articles containing CPMs for CVD published between January 1990 through May 2012. CVD includes coronary artery disease (CAD), congestive heart failure (CHF), arrhythmias, stroke, venous thromboembolism (VTE) and peripheral vascular disease (PVD). We created a novel database and characterized CPMs based on the stage of development, population under study, performance, covariates, and predicted outcomes. We included articles that describe newly developed CPMs that predict the risk of developing an outcome (prognostic models) or the probability of a specific diagnosis (diagnostic models). There are 796 models included in this database representing 31 distinct index conditions. 717 (90%) are de novo CPMs, 21 (3%) are CPM recalibrations, and 58 (7%) are CPM adaptations. There are 215 CPMs for patients with CAD, 168 CPMs for population samples at risk for incident CVD, and 79 models for patients with CHF (Figure). De novo CPMs predicting mortality were most commonly published for patients with known CAD (98 models) followed by HF (63 models) and stroke (24 models). There are 77 distinct index/ outcome (I/O) pairings and models are roughly evenly split between those predicting short term outcomes (< 3 months) and those predicting long term outcomes (< 6 months). There are 41 diagnostic CPMs included in this database, most commonly predicting diagnoses of CAD (11 models), VTE (10 models), and acute coronary syndrome (5 models). Of the de novo models in this database 450 (63%) report a c-statistic and 259 (36%) report either the Hosmer-Lemeshow statistic or show a calibration plot.

Conclusions:
There is an abundance of CPMs available for many CVD conditions, with substantial redundancy in the literature. The comparative performance of these models, the consistency of effects and risk estimates across models and the actual and potential clinical impact of this body of literature is poorly understood.
Abstract 18: Determinants of Adequate Blood Pressure Control in Stroke Patients Post-Discharge
Authors: Bishop Laura , Arnan Martinson , Petryna Ellen , Bushnell Cheryl
Published: July 2021

Objective:
Hypertension (HTN) is a major risk factor for stroke and transient ischemic attack (TIA). After a stroke or TIA, blood pressure control becomes even more essential for secondary prevention of stroke. Prior literature has shown that once-daily dosing of blood pressure (BP) medications improved adherence. We hypothesized that once daily BP medications may also improve BP control at follow up and aimed to determine factors that predict adequate BP control after stroke.

Methods:
We analyzed blood pressures at discharge and at follow-up in 172 adult stroke and TIA patients admitted to a single tertiary care center. Only those with known HTN at time of discharge and seen in follow-up were included in the analysis. Medication dosing was categorized as once-daily dosing vs. more than once daily dosing. Univariate and multivariate logistic regression analyses (adjusted for sex, age, and race) were performed to compare patients with adequate blood pressure control at follow up to those with poorly controlled blood pressure at follow up. Poor BP control was defined as systolic blood pressure (SBP) greater than 140mmHg.

Results:
The average age of this cohort was 65 yrs (+/- 14) and 51% (88 of 172) of patients were female. Sixty nine percent (118 of 172) of patients were white, 29% (50 of 172) of patients were black, and the remaining 2% (4 of 172) of patients were of other race-ethnicities. One hundred of the 172 patients (58%) were discharged on once daily blood pressure medications and at follow up, 59% (59 of 100) of them had adequate blood pressure control compared to 78% (54 of 69) of the patients on BP meds dosed more frequently. Once daily blood pressure medication frequency was associated with inadequate blood pressure control at follow up (p=0.0089, OR 3.00 CI 1.34-6.71). Fifty eight percent (50 of 87) of patients who did not receive home health, nursing, or therapy visits had adequate BP control at follow up compared to 76% (59 of 77) of patients who did. Patients with home health nurse or therapy visits were more likely to have adequate BP control at follow up (p=0.0095, OR 0.44; CI 0.21-0.96). Mean discharge SBP of those patients with adequate BP at follow-up was 135mmHg, whereas those with poor control at follow-up had a mean discharge SBP of 145mmHg. Adequate SBP at the time of discharge also predicted adequate blood pressure at follow up (p=0.0006, OR 1.42; CI 1.15-1.77).

Conclusions:
Contrary to our hypothesis, once daily dosed BP medications did not improve the effectiveness of BP control at follow-up. Elevated SBP at the time of hospital discharge was associated with poor blood pressure control. Those patients receiving outpatient home health and therapy visits after hospital discharge had better blood pressure control. Further studies need to be done to assess medication adherence to determine whether the poor control was related to choice of medication or patient medication-taking behavior.
Abstract 204: Cross-sectional Survey of Quality of Life and Workload Among Japanese Physicians Working in Stroke Care: The Nationwide Survey of Acute Stroke Care Capacity for Proper Designation of Comprehensive Stroke Center in Japan (J-ASPECT) Study
Authors: Nakamura Fumiaki , Nishimura Kunihiro , Takegami Misa , Miyamoto Yoshihiro , Iihara Koji
Published: July 2021

Objective:
Approximately 40% of stroke physicians in Japan are in a state of burnout. The quality of life (QOL) of physicians working in stroke care is unclear. We aimed to compare health-related QOL (HRQOL) between physicians working in stroke care and the general population, and to evaluate personal and professional characteristics associated with HRQOL of physicians working in stroke care.

Design:
Cross-sectional survey.

Setting and Participants:
All board-certified members of the Japanese Neurosurgical Society and the Societas Neurologica Japonica working in Japan.

Main outcome measure:
Scores of HRQOL (physical and mental) as assessed by the Short-Form 8 (SF-8).

Statistical analysis:
We compared scores of physician’s HRQOL with standard values of the general population. Factors associated with HRQOL were identified by multivariable regression analysis with stepwise variable selection.

Results:
Of 11,211 stroke physicians who received the survey, 2279 (20.3%) completed the surveys. The mean physical QOL score was 49.4 points (95% CI: 49.1 to 49.7), which was similar to the population norm. However, the mean mental QOL score was below the population norm (46.1 points [95% CI: 45.7 to 46.4]), and 20.8% (475/2279) of stroke physicians had a score lower than one standard deviation below the population norm. The physical QOL score was lower in women than in men (coefficient = –1.66 [95% CI: –2.82 to –0.50]). An increase in nights on call per week was associated with a lower physical QOL (each additional 1 time per week = –0.39 [–0.53 to –0.25]), and an increase in mean sleep time was associated with a higher physical QOL score (each additional 1 hour = 0.87 [0.55 to 1.20]). Physicians who worked more than 40 hours per week had a lower mean mental QOL score than those who worked less than 40 hours per week (each additional 10 hour = –0.40 [–0.57 to –0.24]). A higher salary was associated with a higher mental QOL score (lower than $100 000 = reference; $100 000-149 000 = 0.08 [–1.10 to 1.27]; $150 000-199 000 = 0.68 [–0.61 to 1.97]; $200 000 or more = 1.90 [0.46 to 3.34]), and an increase of 1 day off per week was associated with an increase in mental QOL score (each additional 1 day = 0.88 [0.24 to 1.52]).

Limitation:
This study was based on a cross-sectional design and was thus unable to determine the causal effects of factors.

Conclusion:
Mental QOL scores of stroke physicians are significantly lower than those of the population norm. Work hours, salary, and numbers of days off are associated with the mental QOL score.
Abstract 209: Driving Time to Percutaneous Coronary Intervention Capable Hospital and Acute Myocardial Infarction Mortality
Authors: Delongchamp Robert , Balamurugan Appathurai , Im Lucy , Bates Joseph , Mehta Jawahar L
Published: July 2021

Objectives:
To determine if driving time to the percutaneous coronary intervention (PCI) capable hospital is an important factor in deaths of patients with acute myocardial infarction (AMI).

Methods:
We studied the relationship between driving time to the nearest PCI-capable hospital and AMI mortality (2008-2012) in census block groups (BG), N=2147, in the state of Arkansas. Population center of a BG was used as a proxy for an individual’s place of residence. The driving time to the nearest PCI-capable hospital was calculated from the population center of a BG. The risk of AMI death was then calculated using five census measures: poverty (% of population below federal poverty level); population density (population per square mile); education (% of population over 25 years of age that did not graduate from high school); mobility (% of population who resided at the same address 1 year ago) and the percent of non-Hispanic blacks (% of population that is Black); and the calculated driving time to the nearest PCI-capable hospital. Arc GIS was used to calculate the driving time to the nearest PCI-capable hospital. Generalized additive models were used to estimate the variation in AMI mortality among BGs.

Findings:
During 2008-2012, there were 14,027 AMI deaths in Arkansas. There was considerable variation in the relative risk between BGs and AMI mortality based on the distance to the PCI hospital. The median distance to the nearest PCI-capable hospital was 12.7 miles (Interquartile range 3.5 - 30.1); and the median driving time to the nearest PCI-capable hospital was 28.3 minutes (Interquartile range 9.6-58.7). However, driving time (Range- 58.7 to 149.3 minutes) among residents in BGs (n=536) that are in the fourth quartile was much higher than the optimal timeframe to receive PCI for AMI. The regression analyses indicated that the driving time to the nearest PCI-capable hospital is a significant predictor of AMI mortality (p < 0.0001) in all BGs, after adjusting for education, poverty, race, and population density.

Conclusions:
Our study shows that the driving time to the nearest PCI-capable hospital is an independent predictor of AMI mortality. Improving health care system by reducing time to arrive at a PCI-capable hospital could reduce AMI deaths in underserved communities.
Abstract 233: Diagnostic and Treatment Capacity for Heart Failure in Sub-Saharan Africa: an Analysis of Uganda and Kenya
Authors: Durakovic Selma , Duber Herbert , Roth Gregory
Published: July 2021

Background:
There is increasing recognition that heart failure is a significant component of disease burden in Sub-Saharan Africa (SSA) and that better strategies for heart failure management are needed. However, relatively little is known about the capacity to diagnose and treat heart failure in this region.

Objectives:
In this study, we seek to better understand the health system’s capacity to diagnose and treat heart failure in Uganda and Kenya, in order to inform policy planning and interventions.

Methods:
We analyzed data from a nationally-representative survey of health facilities in Uganda and Kenya, conducted by the Institute for Health Metrics and Evaluation (IHME) as part of the Access, Bottlenecks, Costs, and Equity (ABCE) project. A structured survey instrument was administered at each facility between 2011 and 2012. In this study we examine the availability of cardiac diagnostic technologies, medications for heart failure, and emergency transportation to an inpatient facility. A package of medications for heart failure with reduced ejection fraction (HFrEF) was defined from local formulary guidelines as including beta-blocker (propranolol or atenolol), ACE inhibitor (captopril or lisinopril), and furosemide. Facility-level data was analyzed by platform type (hospital vs health center), ownership (public vs private), inpatient care availability, and location (urban, semi-urban, or rural).

Results:
We analyzed 197 health facilities in Uganda and 143 in Kenya after excluding dispensaries, pharmacies, and HIV counseling centers. Among facilities responding to this survey question, functional and staffed ECG was available in 24% of facilitiesin Uganda and 36% of facilities in Kenya. However, this survey question was left unanswered by approximately 70% of the facilities in each country. In regards to treatment capabilities, 37% of Ugandan and 24% of Kenyan facilities reported availability of a basic package of heart failure medications on the day the survey was administered. This was driven predominantly by the low availability of ACE inhibitors, which were available in only 41% of Ugandan and 29% of Kenyan facilities. Of the facilities with medication availability, 26% of Ugandan and 32% of Kenyan facilities had a significant stock out (8+ days) of at least one of the medications in the prior quarter. Of the facilities that did not offer inpatient care, 41% of Ugandan and 66% of Kenyan facilities were prepared for emergency transportation.

Conclusion:
Few facilities in Uganda and Kenya were prepared to perform necessary tests to diagnose and manage heart failure. Less than half of the facilities in both countries had the medications needed to treat HFrEF. Further investment in cardiac care will be required by these developing health systems if they are to address the growing burden of heart failure.
Abstract 260: Congruence of Speckle Tracking Echocardiography and Magnetic Resonance Imaging Assessment of Left Ventricular Ejection Fraction
Authors: Reeder K M , Ramoutar Darren , Pazdernik Vanessa K , Beasley Byron T
Published: July 2021

Background:
Assessment of left ventricular ejection fraction (LVEF) is an important aspect of diagnosing and treating patients with cardiovascular disease. While cardiac MRI is considered the gold standard for assessing LVEF, high cost and patient risk has precluded routine use of MRI in clinical practice. Echocardiography is a common non-invasive, safe, and economic method for assessing LVEF. Traditionally, these measures required making visual determinations, resulting in wide variations in LVEF estimates. Using calculations from global longitudinal peak strain (GLPS) in speckle tracking echocardiography (STE) might reduce variability in estimations of LVEF and enhance treatment decision-making. To examine whether STE GLPS compared to cardiac MRI provides clinically acceptable variation in LVEF estimations, the congruence between GLPS in STE and cardiac MRI was examined.

Methods:
At a single Midwestern regional referral center, medical records were abstracted for inpatients and outpatients with a first-listed cardiovascular disease diagnosis who were ≥18 years of age and who were evaluated using speckle tracking echocardiogram and magnetic resonance imaging procedures within a 30-day period between January, 2011 and May, 2014. Demographic and relevant clinical variables that might affect echocardiographic and MRI quality and interpretation were extracted from medical records. Overall agreement between LVEF estimates from cardiac MRI and from STE GLPS was assessed using the concordance correlation coefficient, Bland-Altman analysis, and weighted Kappa. The influence of demographic and co-morbidity factors on the agreement was also assessed using multivariable regression analysis.

Results:
A total of 93 patient medical records (48 males; age 59±18 years) underwent both STE and MRI within a maximum 30-day period. For quantification of LVEF, STE correlated well with MRI (r=0.73; CCC=0.67), but LVEF was significantly underestimated (bias=6.8%), with wide limits of agreement (-17% to 31%). Categorization of LVEF into four classes, ranging from severely impaired to normal, resulted in a weighted kappa of 0.65 (95% CI: 0.53, 0.77). The difference between MRI and STE increased with increasing BMI (b=0.48, P=.01), and this difference was greater for those with hypertension (mean=9.5) than those without hypertension (mean=3.8, P=.02).

Discussion and Conclusions:
While these two measures indicate moderate to substantial agreement, STE-derived LVEF was underestimated in most patients compared with MRI. The magnitude of STE underestimation was positively associated with both BMI and hypertension. Further research is needed on technological developments in echocardiography, as well as interventions focused on addressing inter-observer agreement variability and treatment decision-making to effectively achieve desired clinical outcomes.
Abstract 3: Impact of Financial Incentives on Variation in Use of Cardiac Imaging Tests
Authors: Kini Vinay , McCarthy Fenton , Rajaei Sheeva , Heidenreich Paul , Groeneveld Peter
Published: July 2021

Background:
Rapid growth and geographic variation in the provision of cardiac imaging tests have led to concerns about overuse due to fee-for-service (FFS) incentives. The degree to which FFS incentives may influence rates of cardiac imaging over and above patient characteristics and local practice styles is unknown.

Objectives:
To examine overall rates, degree of geographic variation, and correlation in use of echocardiography (ECHO) among veterans who primarily use services provided by the Veterans Health Administration (VA - a fixed budget health system without significant FFS incentives), versus veterans who use FFS Medicare.

Design:
We analyzed administrative claims from VA and Medicare of veterans with heart failure over the age of 65 from 2007-2010. Veterans were assigned to the VA or Medicare cohort according to the volume of services (procedures, hospitalizations, and visits) received within each system. The analysis was restricted to 34 major metropolitan service areas (MSAs). Rates of ECHO in the overall cohort and in a propensity-matched cohort were compared using multilevel mixed effects regression models adjusted for patient-level characteristics. Mean adjusted rates for each MSA according to cohort were tested for correlation and difference in variance.

Results:
The Medicare cohort included 364,413 veterans (mean age 77 years) and the VA cohort included 15,330 veterans (mean age 76 years). The Medicare cohort had a significantly higher adjusted rate of ECHO use compared to the VA cohort (1.09 versus 0.28 ECHOs per person-year, incidence rate ratio 4.23 [95% CI 4.12 to 4.34], p<.001). The higher rate persisted in the propensity-matched cohort of 14,889 pairs (Medicare incidence rate ratio 1.98 [95% CI 1.92 to 2.04], p<.001). Variance of the mean adjusted use of imaging across MSAs was greater in the Medicare cohort than the VA cohort (0.14 versus 0.02, p<.001). There was modest correlation in geographic variation between cohorts (r = 0.56, p<.001, Figure 1).

Conclusions:
ECHO rates and degree of variation were significantly higher in the Medicare cohort than the VA cohort in both overall and propensity-matched analyses, with modest regional correlation. ECHO utilization rates may be strongly influenced by payment system despite differences in patient characteristics and local practice styles.
Abstract 310: Neighborhood Socioeconomic Context Predicts Cardiac Rehabilitation Participation Above and Beyond Individual Socioeconomic Status
Authors: Bachmann Justin M , Lipworth Loren , Wang Thomas J , Mumma Michael T , Whooley Mary A , Freiberg Matthew S
Published: July 2021

Background:
Cardiac rehabilitation (CR) is underutilized in the United States, with less than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but the effect of neighborhood socioeconomic context on CR use has not been described. We investigated the association of CR participation with neighborhood socioeconomic context in the Southern Community Cohort Study (SCCS).

Methods:
The SCCS is a prospective cohort study of 84,569 largely poor adults in the southeastern United States, of which 52,117 participants have Medicare or Medicaid claims. Using these claims data, we identified SCCS participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, coronary artery bypass surgery or cardiac valve surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a previously validated neighborhood deprivation index. This index was derived using 11 census-tract level variables including median household value and percentage of households with public assistance income. We used multivariable-adjusted logistic and Cox regression to evaluate the association of CR participation with neighborhood socioeconomic context and mortality.

Results:
A total of 4456 SCCS participants (56% female, 59% Black) were eligible for CR at a mean age of 60.5
+
9.1 years and an average of 4.0
+
2.5 years after study enrollment. CR utilization was low as expected, with 308 subjects (6.9%) participating in CR programs. CR participation is inversely associated with all-cause mortality (hazard ratio [HR] 0.52, 95% confidence interval [CI] 0.39-0.70, p=<0.0001) and cardiovascular disease (CVD) mortality (HR 0.38, 95% CI 0.22-0.65, p=<0.001) after multivariable adjustment. Neighborhood socioeconomic context is strongly associated with CR participation after adjustment for individual socioeconomic status (educational level and household income) as well as rural status (Table).

Conclusions:
Neighborhood socioeconomic context predicts CR participation in addition to individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.
Abstract 368: Association of Atrial Fibrillation with In-hospital Outcomes in ST-Elevation Myocardial Infarction - A Propensity Matched Study
Authors: Harikrishnan Prakash , Mujib Marjan , Gupta Tanush , Kolte Dhaval , Palaniswamy Chandrasekar , Khera Sahil , Balasubramaniyam Nivas , Aronow Wilbert S , Jain Diwakar , Sule Sachin , Fonarow Gregg C , Ahmed Ali , Frishman William H , Cooper Howard A , Jacobson Jason , Iwai Sei , Panza Julio A
Published: July 2021

Background:
Atrial fibrillation is a relatively common comorbid condition in patients with coronary artery disease. However, there are limited data on the association of atrial fibrillation (AF) with outcomes in ST-elevation myocardial infarction (STEMI).

Methods:
We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnosis codes, to identify all patients > 18 years admitted with a primary diagnosis of STEMI. We studied the association of AF with in-hospital outcomes in these patients both by regression analysis and propensity match to adjust for demographics, hospital characteristics and co-morbidities.

Results:
Of the total 452,772 (64.5% men) STEMI hospitalizations, AF was documented in 58,273 (12.9%) cases. Patients with AF were older (mean age 75±12 vs 64±14 years; p<0.001) and had a higher proportion of women (42.5% vs 34.5%; p<0.001) than patients without AF. STEMI patients with AF had a higher risk-adjusted in-hospital mortality (OR 1.15, 95% CI 1.12-1.19, p<0.001), longer average length of stay (7 days vs 4 days, P<0.001) and higher average total hospital charges ($74,082 vs $57,331, P<0.001) than those without AF. Using propensity matching, 57,388 STEMI patients with AF were compared with the same number of patients without AF. Within these matched cohorts, STEMI patients with AF had higher in-hospital mortality (16.7% vs 15.1%, OR 1.13, 95% CI 1.09-1.16; p<0.001), longer average length of stay (7 days vs 6 days, P<0.001), and higher average total hospital charges ($73,832 vs $65,201, P<0.001) than patients without AF.

Conclusions:
In patients hospitalized with STEMI, AF was independently associated with modestly higher in-hospital mortality, higher hospital charges, and longer length of stay.
Abstract 371: Proportion of Readmissions to Non-Index Hospitals is Associated with All-Cause Risk-Adjusted Readmission Rate for Medicare Patients with AMI and CHF
Authors: Wasfy Jason H , Dominici Francesca , Wang Yun , Yeh Robert W
Published: July 2021

Background:
The Affordable Care Act introduced the Hospital Readmissions Reduction Program (HRRP), implementing financial penalties for hospitals with excess risk-standardized readmission rates (RSRRs) for specific diagnoses including congestive heart failure (CHF) and acute myocardial infarction (AMI). Hospitals may have more ability to reduce readmission rates for readmissions at their own hospitals as opposed to other hospitals. We hypothesize that hospitals with higher proportions of patients re-admitted to a different (“non index”) hospital also have higher all-cause 30-day RSRRs.

Methods:
We used a national sample of Medicare data to identify hospitalizations for CHF and AMI and subsequent all-cause 30-day readmissions using data from 5,291 hospitals for the period 1999 to 2010. For each hospital we calculated the proportion of readmissions at a different (“non-index”) hospital and the all-cause 30-day risk-adjusted readmission rate (RSRR). We then fitted a regression model to estimate the relationship between the proportion of admissions to the non-index hospital and all-cause RSRRs across hospitals.

Results:
We identified 2,863,696 discharges for AMI and 6,981,895 discharged for CHF for the period 1999 to 2010. On average across hospitals, the percentage of readmissions to non-index hospitals was 28.0% (SD 25.4%) for AMI and 22.7% (SD 17.8%) for CHF. Hospitals with higher RSRRs had higher percentages of their readmissions occurring at a different hospital for both AMI and CHF (p < 0.001 for both conditions). Due to this association, hospitals in the highest decile for 30-day RSRR had 29.1% and 20.7% of readmissions occur at non-index hospitals for AMI and CHF, respectively, while the corresponding proportions for hospitals in the lowest decile were 19.1% and 18.4%.

Conclusions:
Compared to high performing hospitals, hospitals with the worst 30-day readmission rates for AMI and CHF also have the highest percentage of those readmissions occurring at hospitals other than their own. The relationship was particularly strong for AMI. These results suggest that the proportion of readmissions to other hospitals might be a structural disadvantage associated with higher readmission rates.
Abstract 378: Using Lean Methodology to Reduce Variation in Care of Acute Coronary Syndrome Patients
Authors: Fradet Guy , Laberge Carol , Kmetic Andrew , Hamman Ronnalea
Published: July 2021

Background:
Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. To get a better understanding of the different processes of care/utilization, one of the approaches used is the application of Lean methodology to the care of acute coronary syndrome (ACS) patients.

Methods:
Lean methodology is being applied to the patient journey of ACS patients. At each revascularization center Value Steam Maps process maps (VSM) are being prepared through a series of meetings with support, frontline, administrative and clinical staff (see attached example). For each VSM the goal is to identify key decision points in the process of care for ACS patients and to drill down on (Root Cause Analysis) on the decision making environment and criteria used to determine the utilization of coronary revascularization services. Once VSM have been completed they will be compared across sites for similarities and differences. The differences in decision making will then be assessed to determine their effect on variation in utilization across the centers.

Discussion:
BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. The next step will be to determine to what extent it is possible to standardize decision making at the key decision points across the HAs. Standardization will be achieved through a mix of best practices, evidence and application of guidelines. While the undertaking is still in the early stages it is expected that it will lead to, at the very least, ACS patients receiving the same care regardless of where they receive their care in BC.
Abstract 106: A Dedicated Atrial Fibrillation Program Improves Catheter Ablation Outcomes and Electrophysiology Lab Resource Utilization
Authors: Suter Donna M , Greenwood Lisa J , Floyd Kevin C , Rosenthal Lawrence S , Ennis Cynthia A , Browning Clifford A , Donahue John K , Keaney John F , Meyer Theo E , McManus David D
Published: July 2021

Introduction:
Atrial fibrillation (AF) is a common condition that adversely impacts quality of life, reduces survival and requires significant healthcare resource utilization. Catheter-based ablation is an effective tool commonly used in the management of symptomatic AF patients, but it remains technically and logistically complex. Data describing the impact of team-based process improvement initiatives on laboratory resource utilization and outcomes of AF ablation are limited. To address this knowledge gap, we examined the impact of a real-time review of quality indicators and systems-based process improvement (PI) initiative on outcomes and resource utilization over 5 years.

Methods:
We developed an AF Treatment Program to conduct real-time review of ablation outcomes and lab resource utilization to facilitate PI and promote accountability. Key stakeholders and operational deficiencies were identified, and process changes, when needed, were implemented. Real-time feedback on performance was given and monthly results posted. In this analysis we examine the impact of our AF PI initiative on case start times, case duration, procedural adverse outcomes and ablation success rates.

Results:
Over the study period, concurrent with PI efforts, the rate of adverse outcomes decreased from 16.7% to 1.9% (p=0.03), average case start time improved by 85% (p=0.04), and the mean case duration decreased by 70 minutes (p=0.11). Maintenance of sinus rhythm at 1 year for the pre-intervention group was 78% versus 83% during the most recent study year (p=0.04).

Conclusions:
A continuous quality improvement AF program was associated with significant declines in adverse event rates and increased laboratory efficiencies, without adversely affecting long-term ablation outcomes. Although the non-randomized nature of our study precludes assumptions of causality, we hypothesize that real-time review and feedback was a major driver of performance improvement.
Abstract 116: Antinuclear Antibody levels Study in Postural Orthostatic Tachycardia Syndrome
Authors: Ashangari Chandralekha , Asghar Samreen F , Syed Sadaf , Suleman Amer
Published: July 2021

Background:
Postural orthostatic tachycardia syndrome (POTS) is an autonomic disturbance characterized by the clinical symptoms of orthostatic intolerance, mainly light headedness, fatigue, sweating, tremor, anxiety, palpitation, exercise intolerance and near syncope on upright posture. These are relieved on lying down. Patients also have a heart rate >120 beats/min (bpm) on standing or increase their heart rate by 30 bpm from a resting heart rate after standing for 10 min. An antinuclear antibody (ANA) test measures the amount and pattern of antibodies in blood that work against own body (autoimmune reaction). If there are more antibodies in the blood than normal, the test is positive. The aim of this study is to demonstrate ANA levels in POTS.

Methods:
151 patients were selected randomly from our clinic with POTS. Patients ANA levels were reviewed from electronic medical records and performed data analysis.

Results:
Out of 151 patients, 129 patients are females (85%, n=129, age 32±10.98), 22 patients are males (15%, n=22, age 27.90±12.11). 110/151(73%) patients had negative ANA, 41(27%) patients had positive ANA.

Conclusion:
Our research results demonstrated that ANA levels are positive in one fourth of Postural Orthostatic Tachycardia Syndrome (POTS) patients.
Abstract 119: Assessing Modifications to Increase Power in a Stepped Wedge Designed Trial Targeting Improved Medication Adherence for Ischemic Heart Disease Patients
Authors: Glorioso Thomas J , Grunwald Gary K , Caplan Liron , Baron Anna E
Published: July 2021

Background:
Stepped wedge trial designs are often used to avoid simultaneous roll out of an intervention to all sites, yet time and monetary constrains may prevent all sites from receiving the intervention. In a multi-faceted trial using proactive real-time monitoring of patients to improve medication adherence for ischemic heart disease (IHD) patients, control data are passively collected through the standard electronic health record. Thus, study power may be augmented in a cost-efficient manner by modifying the traditional stepped wedge design to include sites acting strictly as controls, rather than by including more intervention sites.

Methods:
Based on previously collected data, we simulated models using a continuous adherence outcome and a traditional stepped wedge design rolling out an intervention to 4 sites over 4 waves (plus 1 baseline period). We varied the proportion of total variation attributed to site level variation in baseline outcomes (intraclass correlation or ICC). Power was estimated using theory and simulation with linear mixed models accounting for site level variation and time trend. Control sites were then added and the additional power generated was compared to a strategy in which the number of intervention sites was increased.

Results:
The addition of 3 or fewer control sites provides more power compared to the addition of a similar number of intervention sites. The effect of additional control sites plateaus and eventually is surpassed by additional intervention sites (see figure). Increasing the ICC decreases both power and the asymptote for the additional control sites; however, power with additional intervention sites continues to increase towards 100%.

Conclusions:
The use of sites acting strictly as controls in a trial targeting medication adherence for IHD patients provides more power at lower cost, especially with initial additional sites. Simulation provides results needed to achieve a balance between required power for the study, hypothesized site level variation, and resources required for additional control versus intervention sites to determine the number and type of sites to include.