bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 164: Adherence to Oral Antiplatelet (OAP) Therapy among ACS Patients Undergoing Percutaneous Coronary Intervention (PCI)
Authors: Kern David M , Bhandary Durgesh , Tunceli Ozgur , Wu Bingcao
Published: July 2021

Background:
The benefit of oral antiplatelet therapy following PCI is well established. Dual antiplatelet therapy is guideline recommended treatment for one year following a PCI.

Objective:
To examine discontinuation and adherence rates of oral anti-platelet therapy of patients with acute coronary syndrome (ACS) in the year following a PCI.

Methods:
From the HealthCore Integrated Research Environment, patients ≥18 years old and hospitalized for ACS (inpatient hospitalization with a primary diagnosis for acute myocardial infarction or unstable angina) during 8/1/09-6/30/13 (index hospitalization) were identified and followed up to 12 months. Patients with an OAP prescription fill within 6 months prior to the index hospitalization, those with a fill for ticagrelor at any time during the study period, those simultaneously starting clopidogrel and prasugrel following the index hospitalization, and those who had a coronary artery bypass graft during index hospitalization were excluded. OAP prescription utilization patterns were examined drug class (clopidogrel or prasugrel) as a whole and by branded versus generic clopidogrel. Medication adherence to OAP therapy was assessed as discontinuation (a period of >45 days not covered by supply of OAP therapy) and the proportion of days covered (PDC; calculated as total day supply during the follow-up divided by days from first fill to end of follow-up).

Results:
Of 38,626 ACS patients identified, 20,753 were revascularized with PCI during the index hospitalization, and 17,237 (83.1%) went on to fill an OAP prescription (12,714 with clopidogrel as first OAP treatment; 4,523 with prasugrel). On average, patients filled OAP medication 6.7 days following index hospitalization discharge (71% filled on discharge date).

The study also found that 20% of patients discontinued OAP therapy during follow-up and 86% of follow-up days were covered by an OAP therapy supply on average. Other medication classes within the same patients had higher discontinuation rates and lower PDC: anti-hypertensive (27% discontinuation; 82% PDC), anti-diabetics (27%; 83%) statins (27%; 82%), and beta-blockers (37%; 72%).

Discontinuation rates were considerably lower in patients taking generic clopidogrel versus those filling branded drug (11% for generic vs. 37% for branded) and PDC was higher for generic clopidogrel (90% PDC vs. 75% for branded).

Conclusions:
Adherence to OAP therapy compares favorably to adherence rates of other cardiovascular/metabolic medications taken by the same patients. Lower out of pocket costs were also associated with better refill compliance. The above findings present healthcare providers with an opportunity to further improve on medication adherence post-PCI in ACS patients by reducing the economic burden on patients.
Abstract 167: The Use of a Personalized Medicine, Blood-based Gene Expression Score in a Community-Based Cardiovascular Registry Enrolling Patients Presenting with Symptoms Suggestive of Obstructive Coronary Artery Disease: Interim Results from the PRESET (A Registry to Evaluate Patterns of Care Associated with the Use of Corus® CAD in Real World Clinical Care Settings) Registry.
Authors: Ladapo Joseph , Sharp David , Maniet Bruce , Ross Linda , Blanchard John , Monane Mark , McPherson John
Published: July 2021

Background:
Patients with symptoms suggestive of obstructive coronary artery disease (CAD) frequently undergo unnecessary testing and procedures. Approximately $5.9 billion/year is spent on non-invasive and invasive testing in the US in the non-diabetic population without a prior revascularization or myocardial infarction, yet some patients continue to be misdiagnosed. A previously validated blood-based, gene expression diagnostic test with a 96% NPV can facilitate determination of the current likelihood of CAD in a symptomatic patient.

Objective:
The objective of the study is to evaluate the use of the gene expression score (GES) and its effect on clinician risk stratification of patients considered for referral to cardiology in a community-based cardiovascular registry.

Methods:
The prospective PRESET Registry (NCT01677156) will enroll 1,000 stable, non-acute adult patients without a history of CAD from 21 US primary care practices. Primary care clinicians provide the pre- and post-GES diagnosis and evaluation plan for each patient. Demographics, clinical factors, and GES results (predefined as low [GES ≤15] or elevated [GES >15]) are collected, as well as treatment plans, diagnostic tests performed and results, and referrals to cardiology and advanced cardiac testing. Clinician and patient quality of care measures, such as satisfaction with care, are being assessed.

Results:
In an interim cohort of 393 patients, 199 (50.6%) were women, the median age was 55 years with 116 (29.5%) age ≥65, and the median BMI is 29.8. The median GES was 17 (range, 1-40) and 177 patients (45.0%) had low scores. In this analysis, 19 of 177 (10.7%) patients with low scores were referred to cardiology, while 105 of 216 (48.6%) patients with elevated scores were referred (OR 7.87, p<0.0001). At 30 day follow-up, no MACE were reported in patients with low scores. Longer-term follow-up is underway.

Conclusion:
In this interim analysis of a community-based cardiovascular registry evaluating patterns of care among patients presenting with symptoms suggestive of obstructive CAD, a personalized medicine, gene-expression based test was adopted in clinical practice and was associated with a statistically significant and clinically relevant effect on medical decision making. In conclusion, use of the GES test showed clinical utility in efficiently and safely ruling out obstructive CAD, minimizing referral of low risk patients to cardiology.
Abstract 174: Organization of Cardiologists in the United States - An Early View in the Era of Accountable Care Organizations
Authors: Meier Sarah K , Shah Nilay D , Nallamothu Brahmajee K
Published: July 2021

Objective:
To understand the organization of cardiologists in the United States and territories with an emphasis on identifying the characteristics of practices where cardiologists practice.

Data:
The Healthcare Organization Services database, which provides information on the designation, specialties and business associations, or affiliations, of healthcare professionals across the US and territories. These data were updated as of September 2013.

Methods:
Cardiologists were defined as providers with an MD or DO, who have an active clinical practice, and either: (1) have Cardiology as primary specialty, or (2) who have Internal Medicine, Pediatrics or Family Medicine indicated as primary specialty, with Cardiology as secondary specialty. Cardiologists were linked to businesses and descriptive analyses were conducted to characterize the organization of cardiologists.

Findings:
We identified 33,745 cardiologists; 22,461 of these cardiologists had at least one affiliation with an ambulatory practice or independent physician association (AP/IPA), while 30,567 had at least one hospital affiliation. Approximately 57.6% (19,453 of 33,745) of cardiologists were affiliated with both the AP/IPA and hospital settings.

The overwhelming majority of ambulatory practices linked to hospital-AP/IPA affiliated cardiologists are medical groups (7,839 of 9,838), while independent physician practices comprise the next largest category (1,498 of 9,838). Of the 7,839 medical groups, 3,809 are cardiology specialty, 1,316 are multispecialty group practices, and 2,060 are family practice, general practice, geriatric medicine, internal medicine, pediatric medicine or primary care. Among all non-multispecialty medical groups (n=6,523), 59.2% (3,862 of 6,523) have 1-2 affiliated cardiologists, 21.7% (1,413 of 6,523) have 3-5, 12.6% (821 of 6,523) have 6-10 and 6.5% (427 of 6,523) have more than 10 affiliated cardiologists.

Focusing at the provider level, 17,639 hospital-AP/IPA cardiologists had any affiliation with a medical group (MG), with 12,840 cardiologists with any cardiology specialty MG affiliation, 3,215 with any multispecialty group practice MG affiliation, and 3,051 with any family practice, general practice, geriatric medicine, internal medicine, pediatric medicine or primary care MG affiliation. Overall, 15,476 hospital-AP/IPA cardiologists had any affiliation with at least one non-multi-specialty group practice (non-MSGP), with 4,279 affiliated with one or more non-MSGP(s) with 1-2 cardiologists, 4,378 with one or more non-MSGP(s) with 3-5 cardiologists, and 4,861 and 5,099 affiliated with one or more non-MSGP(s) with 6-10 and >10 cardiologists, respectively.

Conclusion:
The majority of cardiologists were affiliated with both a hospital and ambulatory practice or IPA. Of this subset, most cardiologists were affiliated with at least one group practice.
Abstract 185: The Sex Gap among Cardiovascular Disease Encounters in India
Authors: Vicera Veronique D , Glusenkamp Nathan T , Risch Samantha A , Kerkar Prafulla , Kumar Ganesh , Oetgen William J
Published: July 2021

Background:
Women have long been underrepresented in CV care studies. Studies examining this gap mainly focus on the U.S. and Europe. Investigating sex disparities in India could inform efforts to reduce gaps in access to treatment in a population phenotypically predisposed to cardiovascular conditions and metabolic syndrome.

Methods:
PINNACLE India is a cardiovascular data collection and reporting program. Data are collected for CV patients at hospital outpatient departments (OPDs) via scanning of paper records or electronic integration with hospital systems when available. Longitudinal and retrospective encounter data are collected if available.

Results:
From Jan 1, 2012 through Oct 29, 2013, 146,522 CV patient encounters were recorded, including retrospective encounters dating to Feb 1, 2007. Of these patient encounters, 71.6% (104,874) were males and 28.2% (41,285) were females (Table 1). A portion of this difference likely reflects a higher CV disease burden among Indian males, but the gap is wider than expected. The PINNACLE Registry in the U.S. collects data on a similar population of CV outpatients. Published PINNACLE U.S. data show 53.4% of encounters were male patients and 46.6% were female patients.

The gender split appears least prevalent in Indian atrial fibrillation (AF) patients, where women represent 46.6% and males account for 52.6% of patient encounters. In contrast and across a much larger patient population, 86.9% of coronary artery disease (CAD) patients were male and 13.1% were female.

Conclusion:
Untreated or poorly managed AF and CAD can lead to myocardial infarction, stroke and death. A greater awareness of gender differences in AF and CAD, and the impact of factors that are unique to each gender, would contribute to more effective management and better long-term outcomes.

Though genetic differences may contribute to greater cardiovascular disease prevalence in men, PINNACLE India’s sizable difference in male and female representation could be indicative of cultural or economic issues limiting access to specialty care for females. Implementing dedicated efforts to understand and reduce gaps in access could have far-reaching impacts on improving India’s overall population health. Factors limiting access for females should be investigated further.
Abstract 190: Predictors and Outcome of Anthracycline-induced Cardiomyopathy among Lymphoma Patients
Authors: Brown Jennifer R , Flowers Christopher R , Dai Tian , Parashar Susmita
Published: July 2021

Background:
Anthracyclines (AC) are one of the most potent anti-neoplastic agents in the treatment of lymphoid malignancies. However their therapeutic benefit is limited by cardiotoxicity. Among patients receiving AC, it is unclear whether traditional cardiovascular markers predict cardiomyopathy (CMP) and whether patients with AC-CMP have higher mortality compared with non-CMP patients.

Methods:
We performed a retrospective analysis of a cohort of Non-Hodgkin lymphoma (NHL) patients evaluated by the Emory Lymphoma program who received AC between 1992 and 2013. We assessed cardiac function by echocardiogram or equilibrium radionuclide imaging. We examined the prevalence of AC-CMP (defined as an absolute decrease in LVEF > 10% with a decline <50%, or an LVEF reduction of at least 15% with absolute LVEF > 50%). Analyses only included patients who received assessment of LVEF both pre and post-AC. Statistical analysis was performed by univariable and multivariable logistic regression models of clinical characteristics potentially associated with a decrease in LVEF.

Results:
Of 218 patients who received AC (median dose 300 mg/m2), 41% (89 of 218) had imaging surveillance before and after AC. Twenty seven percent of patients had AC-CMP. In the multivariate analyses after adjusting for demographics and traditional cardiac comorbidites, among patients receiving AC, patients with tobacco abuse [OR, 2.4; 95% CI, 0.8 to 7.0; P = 0.12], coronary artery disease [OR, 2.6; 95% CI, 0.8 to 7.9; P = 0.10] and diabetes [OR, 2.9; 95% CI, 0.9 to 9.9; P = 0.08] were more likely to have CMP although the association did not reach statistical significance. Mortality among CMP patients was numerically higher compared with non-CMP patients (50% vs. 35%; P = 0.28).

Conclusions:
Among patients receiving AC for lymphoma, there is a trend towards increased risk of CMP in patients with history of tobacco abuse, CAD and diabetes. Additionally, AC-CMP patients had numerically higher mortality compared with non-CMP patients. Future studies are needed to confirm these important findings in larger samples to ascertain predictors and outcome of AC induced CMP in cancer patients.
Abstract 211: A Patient-Centered Approach to Improve Outcomes after Cardiac Electrophysiological Device Implantation
Authors: Hernandez Natalia , Aiken Andrew P , Mitchell Joan M
Published: July 2021

Objective:
Infection associated with cardiac implantable electrophysiological device (CIED) implantation or revision occurred in our facility in 17.8% of CIED recipients, leading to hospitalization and device explantation in 5.2% of patients. Our objective was to reduce the incidence of CIED-associated infections, number of hospitalizations and device explantations by 25%.

Methods:
At baseline, a peri-procedural follow-up occurred on as needed basis. A new patient-centered program was initiated and lead by a nurse-practitioner (NP) (refer to flow map). Patients were seen 1 week prior to CIED implantation, provided with general information, familiarized with the procedure and self-care techniques. On the day of CIED implantation, NP visited patients at bedside and provided a self-care checklist. A follow up visit was scheduled 1 week after the procedure to provide local wound care, discuss symptom monitoring, activity limitations and review self-management techniques supported by a checklist. If any evidence of CIED site infection was discovered, antibiotics were initiated with a weekly follow-up until infection was resolved. If no evidence of infection was noted, further plan of care consisted of a consultation for the patients hospitalized with CIED-related infections by NP, and a chart review at 6 months after implantation in cases when no hospitalizations occurred. Data on incidence of post-CIED implantation infections, hospitalizations and explantations was collected by chart review of 152 patients prior and 66 patients after establishment of the patient-centered program.

Results:
With initiation of our patient-centered program, incidence of CIED site infections was reduced by 23.5%, and both, the number of hospitalizations and CIED explantations, decreased by 42.4%.

Conclusions:
Patient education and engagement in post-CIED implantation care combined with a close surveillance by NP can be an effective tool to improve patient outcomes by reducing frequency of CIED site infections, need for hospitalization and device explantation.
Abstract 230: Improved Prediction of 30-day Mortality after Heart Failure Hospitalization by Utilization of Admission Vital Signs and Laboratory Findings.
Authors: Zoble Robert G , Torres Benji , Zoble Adam , Gelzer Bell Ramona , Foulis Philip , Neugaard Britta
Published: July 2021

Background:
Heart failure (HF) is associated with high mortality so early identification of those at high risk may be useful in reducing mortality rates. We sought to develop a simple risk score from data readily available at the time of HF admission.

Methods:
We studied Veterans hospitalized from January 2004 to December 2009, who were discharged alive with a primary diagnosis of HF (based on ICD-9 coding). For the purposes of these analyses, only the 869 who had complete data for admission vital signs, laboratory parameters, ECG, co-morbidities and ejection fraction were included. Univariate analyses were employed to identify variables associated with mortality at a p-value < 0.10. These variables were then analyzed by MVA to determine independent predictors of mortality. The c-statistic was utilized to determine cutpoints for continuous variables. A risk score was developed by assigning risk points based on the odds ratio for each variable. Model calibration was assessed by the Hosmer-Lemeshow (H-L) statistic and by plotting observed vs. expected mortality (Figure below).

Results:
Of the 869, 35 (4.0%) died within 30-days of discharge. Twelve independent predictors of 30-day mortality were identified: admission pulse, systolic and diastolic BP, BNP, troponin-I, sodium, glucose, ALT, atrial fibrillation and absence of dyslipdemia diagnosis, and not admitted on an oral anticoagulant or a calcium channel blocker. All vartiables were assigned 1 risk point, except for not on an oral anticoagualnt, which was asigned two points. Patients with a risk score < 6 (57% of the group) had a mortality rate of only 0.4%, while a risk score > 6 (20% of the group) was associated with a 15.3% mortality, corresponding to a 49-fold range.

Conclusion:
30-day mortality can be predicted by the developed risk score which has excellent discrimination (c-statistic = 0.87), adequate calibration (H-L = 0.11) and covers a mortality range from 0% to nearly 50%. This risk score also has the advantage of being easily calculated within 24 hours of admission. Validation of the model will be an important next step.
Abstract 231: Predicting Readmission Risk Following Coronary Revascularization at the Time of Admission
Authors: Elliott Daniel J , Kolm Paul , Weintraub William
Published: July 2021

Objective:
Reducing readmissions following hospitalization for coronary revascularization is a national priority. Identifying patients at high risk for readmission early in a hospitalization would enable hospitals to target these individuals for enhanced discharge planning. Traditional risk models identify patients based on characteristics that may not be available until after discharge. We sought to compare the model performance for models based on data that is available earlier in the hospitalization.

Methods:
We developed models to predict 30-day inpatient readmission to our instititution for a cohort of patients who were revascularized at our institution between January 2010 and December 2013. We developed separate models for patients with percutaneous coronary revascularization (PCI) and coronary artery bypass graft surgery (CABG). We developed three models using data available at three different time points in the hospitalization: 1) at admission, 2) early in the hospitalization and 3) at discharge. Candidate variables for the admission model included demographics, comorbidities, and previous utilization within our system. The second model added initial vital signs and laboratory values. The discharge model added discharge vital signs and laboratory values, discharge medications, new comorbidities, and length of stay. We assessed each model using the c-index.

Results:
Our cohort included 4,941 PCI patients and 1,633 CABG patients. The readmission rate was 8.4% in the PCI group and 14.2% in the CABG group. For both populations, the discriminative ability of the admission model was high (0.805 for PCI, 0.824 for CABG). The addition of laboratory values and vital signs was associated with slight improvement in discrimination (0.812 for PCI, 0.829 for CABG). The addition of data available at the time of discharge further increased model discrimination (0.833 for PCI, 0.848 for CABG). Except for one model, the strongest predictor of readmission was carrying a diagnosis of hypertension at baseline (OR > 2 for all)). Previous hospitalization within six months was a strong predictor among PCI patients (OR 1.18, p<0.001), and having a previous acute myocardial infarction was the strongest predictor among CABG patients (OR 2.46, p = 0.002).

Discussion:
Risk prediction models based on data available only at discharge minimally improved the performance of models based solely on demographic and utilization data available at the time of admission. These simplified models may be sufficient to identify patients at highest risk of readmission following coronary revascularization early in the hospitlization. This would allow providers and health systems to target high-risk patients with enhanced discharge planning during the course of the hospitalization, and this may improve the ability to avoid readmissions.
Abstract 247: The Use of a World Health Organisation Derived Safe Surgery Checklist to Improve Patient Experience in the Cardiac Catheterisation Laboratory
Authors: Lindsay Alistair C , Bishop Jeremy , Davies Simon W , Haxby Elizabeth J
Published: July 2021

Background:
The WHO safe surgery checklist has reduced morbidity and mortality during surgery. Whether or not a modified WHO checklist could improve patient and staff experience in the cardiac catheterisation laboratory (CCL), where the majority of procedures are carried out under local anaesthetic, has not previously been investigated.

Methods:
Starting in March 2013, a WHO-derived checklist, specifically modified for the CCL, was introduced at the Royal Brompton Hospital. For three months, weekly PDSA cycles and staff feedback were used to optimise checklist design, followed by a full rollout. Patient experience (n=76, taken throughout the six-month period) and staff safety climate (taken 2 and 7 months after checklist introduction) surveys were undertaken to measure subjective impact. Clinical outcomes and efficiency data were obtained from in-house databases.

Results:
• By six months, a full checklist (Figure 1) was completed in 367/417 (88%) of procedures (Figure 2). Patient surveys revealed that the majority of patients (57%) noticed the staff ‘Time Out’ and when questioned, strongly associated the checklist with safety (mean score 9.3/10 using Likert scale) and found it highly reassuring (mean 8.9/10).

• The majority of procedures that used the checklist (56%) were shorter than average, whereas the majority of procedures that did not use a checklist took longer than average (P<0.0001)

• When the full checklist was used, screening time was correspondingly reduced in 25% more procedures

Conclusions:
The introduction of a WHO-derived checklist was associated with high levels of patient satisfaction, improved efficiency, and enhance team cohesion during procedures in the cardiac catheterisation laboratory.
Abstract 251: The Economic Implications Of Avoidable Therapeutic Obstacles In The Treatment Of Venous Thromboembolism
Authors: Patel Aarti A , Ogden Kristine , Mody Samir H , Bookhart Brahim
Published: July 2021

Objective:
Venous thromboembolism - deep vein thrombosis (DVT) and pulmonary embolism (PE) - affects an estimated 900,000 individuals, and is responsible for as many as 100,000 deaths each year in the US. Patients with a history of DVT/PE have heightened risk of recurrence. Initial parenteral anticoagulation (low molecular weight heparin [LMWH]) is standard treatment for acute DVT/PE followed by ≥3 months of warfarin, which itself introduces the risk of major bleeding. Balancing the increased risks of major bleeding and recurrent DVT/PE remains a challenge. Recent clinical trials show that rivaroxaban, an oral direct inhibitor of factor Xa, is as effective as standard therapy for acute DVT/PE and, when continued into the outpatient setting, may provide an effective, safe, single-drug, and simplified approach to treatment. We consider the economic implications of these data in the context of a commercial health plan.

Methods:
We used a decision-analytic model to estimate the annual economic burden of DVT/PE to a hypothetical commercial plan. Hospital days, acute and 1 year cost were assessed. The baseline scenario assumes that all patients with DVT/PE receive standard treatment (LMWH/warfarin). A projected scenario assumes that 75% of patients receive standard treatment, and 25% are treated with rivaroxaban. Rates of major bleed, non-major bleed, and recurrent DVT/PE events in the year following the acute DVT/PE are drawn from clinical trials. DVT/PE prevalence and healthcare costs are estimated based on published literature.

Results:
In a hypothetical plan of 1 million, our baseline model projects that management of acute DVT/PE (standard treatment) would consume 12,786 inpatient days (69% associated with DVT; 31% with PE) and $59.6 million (2013 USD). Treatment for 74 recurrent DVT/PE events (84% DVT) would cost $1.4 million; major bleed events (39; 64% DVT) and non-major bleed events (207; 70% DVT) would require an additional $1 million to treat.

In the projected scenario, a 25% shift to oral anticoagulation with rivaroxaban reduced the number of inpatient days for acute management of DVT/PE to 11,753 (67% DVT), a reduction of 1,033 days (8%). Associated acute care costs totaled $57.7 million (73% DVT), a reduction of $1.9 million (3%). Overall, recurrent DVT/PE events and costs decreased by 6% (4 events; $82,000). In the projected scenario, 4 (10%) major bleeding events were prevented, at the cost of 1 (0.5%) additional non-major bleeding event which, taken together, reduced net healthcare utilization to manage bleeding events by about $91,000.

Conclusion:
Our model suggests that the reduction in inpatient utilization, recurrent DVT/PE events, and major bleed events resulting from a shift of 25% from standard therapy to oral anticoagulation with rivaroxaban following an acute DVT/PE event would generate about $2 million in savings for every 1 million patients enrolled in a commercial health plan.
Abstract 266: No Impact of Electronic Health Records on Quality of Care and Outcomes for Ischemic Stroke
Authors: Joynt Karen E , Bhatt Deepak L , Schwamm Lee H , Xian Ying , Heidenreich Paul A , Fonarow Gregg C , Smith Eric E , Grau-Sepulveda Maria V , Hernandez Adrian F
Published: July 2021

Background:
Electronic Health Records (EHRs) may be a key tool for improving the quality of healthcare. They may be particularly important for conditions such as ischemic stroke, in which guidelines are rapidly evolving and timely care of the patient is critical.

Methods:
We used data from 1,236 hospitals participating in Get With The Guidelines-Stroke, representing 626,473 ischemic strokes between 2007 and 2010, and linked this with the American Hospital Association annual survey to characterize which study hospitals had an EHR. We conducted regression analyses to determine whether hospitals with an EHR demonstrated better performance on quality metrics, length of stay, discharge to home, and mortality.

Results:
511 hospitals had an EHR by the end of the study period. Stroke patients at hospitals with EHRs were younger, more often male and non-white, and had a lower burden of medical comorbidities. Hospitals with EHRs were larger, and more often teaching hospitals and stroke centers than hospitals without EHRs. In unadjusted analyses, patients at hospitals with EHRs were more likely to receive “all-or-none” care (87.9% versus 82.6%, p<0.001), and less likely to have a length of stay over 4 days (42.4% versus 43.9%, p<0.001). However, there were no differences in discharge to a site other than home (50.9% versus 51.1%, p=0.12) or in-hospital mortality (5.3% versus 5.2%, p=0.40). In multivariate analyses, after controlling for patient and hospital characteristics, the presence of an EHR was no longer associated with better quality care, and continued to have no association with clinical outcomes (Table).

Conclusions:
In our sample of GWTG-Stroke hospitals, EHRs were not associated with higher-quality care or better clinical outcomes. Given that these systems often create significant added burden for clinicians, further work to ensure that they are better integrated with care and fully evidence-driven is critical.
Abstract 273: Diagnostic Accuracy at a Distance: a Quality of Care Assessment of Telestroke in the Intermountain West
Authors: Tkach Aleksander , Shepard L. Wylie , Fox Lauri , Austin Jill A , Majersik Jennifer J
Published: July 2021

Objective:
Little is known about the quality of care telestroke services provide beyond the accuracy of tPA decision-making in stroke patients. The effect of telestroke on stroke mimics in particular remains relatively unexplored, though telestroke systems have up to a 50% mimic rate.

Methods:
This was a retrospective review of telestroke consults provided by 8 providers at University of Utah Hospital (the “hub”) to 15 telestroke sites in Utah, Idaho, Wyoming, and Nevada (the “spokes”) from Jan-Oct 2013. We obtained records from the spokes and compared them to those from the hub, including: telestroke and final discharge diagnoses, if IV-tPA was given, and if a patient was transferred. Final diagnosis was based on the hub or spoke site discharge summary, depending on transfer. We calculated a kappa to determine agreement between telestroke and final discharge diagnoses.

Results:
73 telestroke cases were reviewed: 9 had a telestroke diagnosis but no final diagnosis; 5 had a final diagnosis but no telestroke diagnosis; 5 had a final diagnosis that differed from the initial telestroke diagnosis (Table). Two received IV-tPA for stroke mimics; no IV-tPA candidates were denied treatment due to inaccurate diagnosis via telestroke. There were no differences in the telestroke vs the final diagnosis in cases not transferred. Kappa was good (0.69) when including the unknown diagnoses and excellent (0.91) when excluding those with poor documentation. Transfer rates were highest in patients initially diagnosed with stroke and lowest for migraine and unmasking of previous stroke.

Conclusion:
This study is one of the few to examine the accuracy of neurological diagnosis and the effects on transfer in a telestroke system. Telestroke consultants had a high degree of accuracy, particularly for stroke - the purpose of the telestroke network. Accurate diagnoses of non-critical disorders such as migraine allowed such patients to stay at the spoke hospital, reducing unnecessary transfers. These diagnoses were not later found to be inaccurate by the spoke hospital, suggesting such transfer reductions are appropriate. Though improved documentation would help improve our understanding of our system, overall our telestroke service provides accurate neurological diagnoses in the Intermountain West.
Abstract 28: Readmissions after Carotid Artery Revascularization in the Medicare Population
Authors: Al-Damluji Mohammed Salim , Zhang Weiwei , Stilp Erik , Geary Lori , Mena-Hurtado Carlos , Curtis Jeptha P
Published: July 2021

Introduction:
In appropriately selected patients with severe carotid stenosis, carotid revascularization reduces risk of ischemic stroke. Prior clinical research has focused on the efficacy and safety of carotid revascularization, but few investigators have considered readmission as a clinically important outcome. We examined frequency and timing of 30-day readmission following carotid revascularization and assessed differences in 30-day readmission rates between patients undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS). We also examined whether hospital variation in procedural choice (CEA vs CAS) was associated with differences in hospitals’ risk standardized readmission rates (RSRR).

Methods:
Medicare administrative claims data were used to identify acute care hospitalizations of CEA and CAS from 2009 to 2011. The outcome of interest was time to first hospital readmission within 30-days of carotid revascularization. Hospitals performing more than 25 carotid interventions were stratified into tertiles by the proportion of CAS cases. RSRRs were derived from hierarchical generalized linear models adjusting for hospital clustering and standardized by unadjusted national readmission rate.

Results:
Of 180,059 revascularizations from 2,287 hospitals, CEA and CAS were performed in 81.5% and 18.5% of cases, respectively. The unadjusted 30-day readmission rate following carotid revascularization was 9.7% with half of these readmissions occurring by day 9. Crude 30-day readmission rates following CEA and CAS were 9.5% and 10.6%, respectively. In multivariable analysis, risk of readmission after CAS was higher than after CEA (Adjusted OR: 1.13, 95% CI: 1.08 - 1.18, P <0.01). When stratified by tertiles of proportional use of CAS, median 30-day RSRR for hospitals using CAS more frequently were comparable to those of hospitals that used CAS less frequently (Figure 1).

Conclusions:
Almost 10% of Medicare patients undergoing carotid revascularization were readmitted within 30 days of discharge. Compared with CEA, CAS was associated with higher 30-day readmission rates. However, hospitals’ RSRR did not differ by their proportional use of CAS volume. Efforts to identify readmission risk factors are needed to reduce rates of readmissions following carotid revascularization.
Abstract 284: Association of Pre-Operative INR Evaluation with Risk of Major Adverse Cardiac Events and Bleeding Complications in Cardiac Patients Undergoing Non-Cardiac Surgery
Authors: Valle Javier A , Graham Laura , Derussy Aerin , Itani Kamal , Hawn Mary T , Maddox Thomas M
Published: July 2021

Background:
Routine laboratory testing is common in pre-operative patients, independent of specific clinical indication. One example is routine INR checks in patients without prior anticoagulant use. However, its efficacy in detecting significant coagulopathy and reducing adverse outcomes is unknown. We describe the frequency of pre-operative INR testing in a cohort of post-PCI patients not on anticoagulation undergoing non-cardiac surgery (NCS) within the VA system, and associated adverse events.

Methods:
We identified all post-PCI VA patients not prescribed warfarin undergoing NCS from 2004-2011 and determined the rates of INR assessment within 120 hours (5d) of surgery. We then measured the association of INR status (>1.5, ≤ 1.5, and unknown) with MACE within 30d and in-hospital bleeding events. We also conducted a secondary analysis excluding patients undergoing “low risk” operations, defined as eye, ear, or integumentary surgeries.

Results:
Among 20,118 post-PCI patients undergoing NCS who were not on warfarin, 3,678 (18.3%) had a pre-operative INR check. Of those, 108 (0.5%) had INR > 1.5. Patients with INR > 1.5 were more likely to suffer MACE events than those with INR assessed but ≤ 1.5, or unknowns (16.7% vs. 5.5% vs. 3.4%, p<0.001). They were also more likely to have bleeding events (18.5% vs. 9.8% vs. 4.9%, p<0.0001). After excluding patients undergoing low-risk surgeries (n=5,739), these trends remained significant.

Conclusions:
Among post-PCI patients not on warfarin undergoing NCS, nearly one-fifth had an INR checked pre-operatively. Both the presence of an INR test and an INR value >1.5 were associated with higher risks for both MACE and bleeding events, as compared to those patients without INR assessment. Our study shows that pre-operative INR testing in patients not on anticoagulants is relatively uncommon, and that testing, when it does occur, appears to be associated with higher rates of MACE and bleeding. Further research is needed to understand which patients without prior anticoagulation would benefit from pre-operative INR checks.
Abstract 3: Defining the Association of Do-Not-Attempt-Resuscitate Orders with Patients’ Likelihood of Survival after In-Hospital Cardiac Arrest
Authors: Fendler Timothy , Li Yan , Spertus John A , Chan Paul S
Published: July 2021

Background:
The long-term prognosis after In-Hospital Cardiac Arrest (IHCA) is variable, but often triggers discussions about further resuscitative efforts. Whether Do-Not-Attempt-Resuscitation (DNAR) orders after IHCA are aligned with patients’ likelihood of meaningful neurological survival is unknown.

Methods:
Using the Get With the Guidelines-Resuscitation registry, we identified 42,537 patients between 1/2000 and 9/2012 who achieved return of spontaneous circulation (ROSC) after IHCA. Each patient’s likelihood of meaningful survival without severe neurological disability (Cerebral Performance Category score ≤2) was calculated using the previously validated CASPRI prediction model. We examined the proportion of patients made DNAR within each CASPRI score decile to determine whether end-of-life decision-making was correlated with predicted likelihood of favorable neurological survival.

Results:
Overall, 26,198 patients (61.6%) were made DNAR after ROSC. These patients were older (68.7 ± 15.9 vs. 63.1 ± 17.1) and had higher rates of multiple comorbidities (all P <0.05). Among those with the best prognostic CASPRI scores (Decile 1), 34.6% were made DNAR after ROSC, as compared with 74.2% among those with the worst prognosis (Decile 10; P for trend <0.001). (Figure 1) Only 567 (2.2%) patients made DNAR survived to discharge without severe neurological disability. This rate was consistently low even in the CASPRI deciles with a high predicted likelihood of a good survival outcome (e.g., 6.4% in Decile 1). In contrast, 40.4% of patients not made DNAR survived without severe neurological disability, with a substantially higher rate in the lower CASPRI deciles (e.g., 74.7% in Decile 1).

Conclusion:
Among patients successfully resuscitated from IHCA, we found reassuring evidence that the decision to adopt DNAR status was generally aligned with a patient’s predicted likelihood of meaningful neurological survival. However, discordance between predicted and actual rates of this outcome among DNAR patients with the highest likelihood of survival suggest either competing, unmeasured interests or the need to inform physicians and patients about prognosis when discussing goals of care. Whether the use of the CASPRI score can further assist in these discussions requires prospective testing.
Abstract 327: Six months follow-up of “My Unlimited Potential”, A 12-week Worksite, Multi-Component, Lifestyle Intervention for Improving Cardiometabolic Health in High Risk Persons
Authors: Rouseff Maribeth , Aneni Ehimen , Tran Thinh H , Bou-Khalil Josette , Mora Joseph J , Guzman Henry , Das Sankalp , Brown Doris , Santiago-Charles Joann , Ochoa Teresa C , Gilliam Cynthia , Lehn Virginia , Castillo Beatriz , Roberson Lara , Veledar Emir , Post Janisse , Nasir Khurram , Ruiz Angelica
Published: July 2021

Background:
With about 59% of the entire US population currently in the work force, the American Heart Association has emphasized worksite-based interventions to improve cardiovascular health among the working population. The primary aim of this study was to assess effectiveness of an ongoing multi-component, lifestyle improvement program (My Unlimited Potential [MyUP]) extending into 6 months, among employees of Baptist Health South Florida (BHSF), a large not-for-profit health care system.

Methods:
BHSF employees with 2 or more Cardiometabolic risk factors, such as total cholesterol ≥ 200 mg/dl, systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg, hemoglobin A1C ≥ 6.5%, and body mass index (BMI) ≥ 30 were considered for the study. Behavioral interventions were focused on dietary and physical activity modifications.

Results:
Overall 202 (48±10 years, 78% females) employees who enrolled in the MyUP wellness program. The retention of subjects was high with 89% (n=181) at 12 weeks and 80% (n=162) at 6 months. The table and figure below demonstrate the baseline, 12 week and 6 months averages in anthropometric and laboratory profile in participants. Comparing follow-up from 3 months to that at 6 months, clinically meaningful improvement in endpoints were especially noted for BMI, BP, HDL targets, and reducing burden of systemic inflammation (figure).

Conclusion:
These findings suggest that an intensive behavioral modification intervention program, delivered to employees in a health care setting, results in both significant short and intermediate term benefit in weight reduction, improved blood pressure control and hbA1c, and concomitantly improves cardio-metabolic risk profile. Further follow-up is in progress to ascertain whether these benefits are sustainable over longer periods.
Abstract 333: Hypothyroidism As a Predictor of Worse Clinical Outcomes After Percutaneous Coronary Interventions: 1 Year Follow Up Study
Authors: Singh Maninder , Mishra Abhishek , Kamboj Mayanka , Chaudhary Sweta , Kaluski Edo , Stapleton Dwight
Published: July 2021

Background:
Although hypothyroidism (HT) is known to be associated with worse cardiovascular outcomes, little data exists on its influence on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI).

Methods:
In this prospective observational registry at a single center, we studied 1317 patients who underwent successful PCI (without complications) from ‘01-'12 and had thyroid function tests performed within 1 year prior to PCI. We excluded patients with cardiogenic shock at index PCI. We compared 1-year mortality and major adverse cardioascular events (MACE) between HT (both subclinical and overt hypothyroid patients, defined as TSH ≥5.5, n=78) and Euthyroid (ET) (TSH <5.5, n=1239) groups.

Results:
Both the groups were similar in baseline clinical and angiographic characteristics except for higher prevalence of prior myocardial infarction (MI) and thyroid supplement use in HT group (table 1). At 1-year, HT was associated with higher all cause mortality as compared to ET group (14%[11/78] Vs 6.7%[83/1239], p=0.014) and remained an independent predictor of mortality in the multivariate analysis (adjusted odds ratio=2.6, 95% CI: 1.2-5.3, p=0.011). There was a trend towards higher MACE in the HT vs ET group, although this was not statistically significant. (21% [16/78] Vs 16% [203/1239]respectively, p=0.342, adjusted odds ratio=1.3, 95%CI: 0.7-2.3, p=0.455) Individual 1-yr outcomes are shown in Figure 1.

Conclusion:
Although there was no difference in MACE, HT was associated with higher all cause mortality after PCI. We suggest monitoring of thyroid function for patients who undergo PCI. Treatment may improve survival in hypothyroid patients post PCI, however further outcome studies are needed.
Abstract 338: BRIDGE: A Post-Discharge Transitional Care Model in over 1600 Cardiac Patients
Authors: Sylvester Rachel , Bluhm Minnie , Froehlich William , Subramanian Meghana , Wiles Alison , Souphis Maria , Kline-Rogers Eva , Vaishnava Prashant , Eagle Kim , Rubenfire Melvyn , Bumpus Sherry
Published: July 2021

Background:
Current legislation imposes financial penalties for high 30-day readmissions for AMI. BRIDGE is a NP-led, post-discharge transitional care program for cardiac patients, aimed at ensuring prompt follow up (f/u; in 14 days) and care coordination. Herein we report the effect of BRIDGE on readmissions in over 1600 cases.

Methods:
Retrospective data was abstracted for patients referred to BRIDGE including demographics, comorbidities, medications, days to f/u, and 6-month outcomes by diagnosis.

Results:
Of 1955 patients referred to the BRIDGE clinic, 271 (13.9%) were excluded for adverse events prior to their visit (ED visit n=60, readmission n=193, or death n=14) or missing data (n=4). 1210 (71.9%) of patients from the remaining sample (n=1684) attended BRIDGE. Diagnoses included: ACS (n=462, 27.6%); angina (n=207, 12.4%); CAD (n=196, 11.7%); AFib (n=247, 14.7%); CHF (n=316, 18.9%); or other (n=256, 15.2%). With the exception of mental health disorders (35.4% v. 29.1%, p=.012) there were no baseline differences (including the Charlson Comorbidity Score) between non-attendees and attendees (Table 1). ACS attendees, compared to non-attendees, had a trend toward lower 30, 60, and 90 day readmission rates (Table 2). This was not observed for other diagnoses.

Conclusions:
A NP based transitional care clinic visit early post-discharge appears to reduce early readmissions for patients with an ACS, but in this study did not impact other cardiac conditions. Also, patients with a history of substance abuse or depression are significantly less likely to attend BRIDGE appointments. To avoid a lapse in care, these patients may need prompt f/u with their PCP or cardiologist to help reduce early readmissions.
Abstract 370: Temporal Variation in Clopidogrel Filling Delays after Percutaneous Coronary Intervention Hospital Discharge: Insights from the VA CART
Authors: McCreight Marina S , O'Donnell Colin I , Plomondon Mary E , Bradley Steven M , Bosworth Hayden B , Halligan Robert E , Tumbiolo Dorina E , Lu David Y , Jneid Hani , Rumsfeld John S , Ho P. Michael
Published: July 2021

Background:
A prior study demonstrated significant variation between hospitals in the proportion of patients who delay filling a clopidogrel prescription after percutaneous coronary intervention (PCI). We assessed whether this variation changes over time.

Methods:
Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we determined the hospital proportion of patients with a clopidogrel filling delay at the 62 VA cath labs performing at least 20 PCI annually between October 1, 2009 and September 30, 2012. Delay was defined as filling a clopidogrel prescription any time after the day of PCI hospital discharge. We categorized hospitals into quintiles based on the proportion of patients with delay in 6-month time intervals for each hospital and assessed whether hospitals changed quintiles over time.

Results:
There were 31,002 PCIs performed from 2009-2012 at 62 PCI sites with an average number of 170.3 (sd. 99.3, median149.5) PCIs performed annually. Patient characteristics included: average age 65.2 ±9.0, 1.7% were women, 48.0% were diabetic, and 33.6% had prior history of MI. 26.7% (n=8,272) of PCIs were performed for acute coronary syndrome (ACS). The mean and median proportion of patients who delayed was 9.2% (7.5%) and by quintiles was: Q5 - 16.6% (15.3%), Q4 - 11.3% (10.2%), Q3 - 8.3% (7.8%), Q2 - 6.4% (6.2%), Q1 - 3.5% (3.6%). Over the 3 years of follow-up, 14 sites remained in the same quintile (9 in the highest, 1 in the third, 1 in the second, and 3 in the lowest quintile) and 48 sites moved between quintiles. In addition, 18 hospitals had increasing proportion of patients with delay, 14 hospitals had decreasing, while the rest of the hospitals (n=30) had fluctuating proportions of patients with delay over time.

Conclusion:
There is significant temporal variation in clopidogrel delays across PCI hospitals. Future studies should assess what types of processes of care are being implemented at hospitals with low or decreasing rates of clopidogrel delay over time. In addition, these finding highlight an opportunity to implement quality improvement efforts at hospitals with persistently high or increasing rates of clopidogrel delay over time.

Figure 1. Hospital Level Proportion of Delay in 14 Sites That Stayed Within Quintile