bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 240: Differences in Test-related Clinical and Economic Outcomes between Patients who underwent Single-photon Emission Computed Tomography using Regadenoson versus Patients who underwent Echocardiograms using Dobutamine
Authors: Xie Lin , Spalding James , Baser Onur
Published: July 2021

Adult patients who underwent single-photon emission computed tomography (SPECT) myocardial perfusion imaging testing with regadenoson and echocardiogram (ECHO) testing with dobutamine on the same day or within 1 day of testing (07/01/2006-05/31/2011) were selected from the MarketScan Commercial and Medicare Supplemental Database (01/01/2006-06/30/2011). The latest test date was designated as the index date. Continuous health plan benefits 6-month pre- and 30-day post-index date, and no stress, planar, SPECT or ECHO test, or regadenoson, dipyridamole, adenosine or dobutamine prescriptions during the 6-month baseline period were required. Test-related complications, symptoms, adverse events, healthcare costs and utilizations were defined as being measured on the index and next day. One-month follow-up healthcare costs and utilizations were estimated and compared. Propensity score matching controlled for baseline age, gender, region, comorbidities, medications and healthcare cost and utilization differences.

A total of 161,834 regadenoson and 12,842 dobutamine patients were included. Regadenoson patients were older (66.60 vs. 63.40, p<0.0001), more likely male (49.68% vs. 41.60%, p<0.0001) and with cardiovascular disease (27.16% vs. 19.96%, p<0.0001), and less likely with COPD or asthma (13.51% vs. 15.87%, p<0.0001) and renal failure (7.58% vs. 8.34%, p<0.0001) than dobutamine patients at baseline. At follow-up, regadenoson patients had fewer test-related ER and inpatient visits, lower dyspnea and renal failure rates, and lower inpatient and outpatient costs. After matching, 7,786 patients were included per cohort. Risk-adjusted results showed that regadenoson patients had fewer test-related ER (2.41% vs. 4.16%) and inpatient visits (0.60% vs.1.35%), and other arrhythmias (2.03% vs. 3.63%) (all p<0.0001). Test-related dyspnea (3.19% vs. 6.04%, p<0.0001), chronic airway obstruction (0.62% vs. 1.07%, p=0.0021) and renal failure (0.66% vs. 1.37%, p<0.0001) were also lower for regadenoson patients. Regadenoson patients incurred lower test-related inpatient ($122 vs. $360, p=0.0005), but higher total outpatient ($1,882 vs. $1,412, p<0.0001) and total costs ($2,032 vs. $1799, p=0.0021). In the 1-month follow-up, regadenoson patients had fewer inpatient (10.65% vs.14.5%, p<0.0001) and ER visits ($7.58% vs. 9.17%, p=0.0003) and lower inpatient ($3,057 vs. $4,137, p<0.0001) and higher outpatient costs ($3,887 vs. $3,112, p<0.0001). There was no significant difference in total costs ($7,333 vs. $7,641, p=0.2739).

Regadenoson patients had fewer test-related inpatient and ER visits and adverse events, and lower inpatient costs, compared to dobutamine patients. Although total test-related costs were higher for regadenoson, inpatient costs remained significantly lower in the 1 month after testing. The total cost burden was similar for both cohorts.
Abstract 245: Indirect Comparison of Efficacy and Safety data in Atrial Fibrillation patients treated with Apixaban (Aristotle study) versus Dabigatran (Rely study) based on Chads2 Score Stratification
Authors: Rasty Sam , Taheri Reza
Published: July 2021

OBJECTIVES:
In this analysis we performed indirect comparison of efficacy and safety of published data in atrial fibrillation (AF) patients stratified based on Chads2 score treated in RE-LY trial with Dabigatran (DAB) 150mg versus AF patients treated with Apixaban (APX) in ARISTOTLE study.

METHODS:
Primary efficacy and safety outcomes data for both cohorts were compared. WINPEPI (2011, version 11.15) epidemiological tool was used to compare the event rates ( safety and efficacy) per 100 patient year (100PY).

RESULTS:
For the primary end point of stroke or systemic embolism 0.7, 1.2 and 1.9 events in APX vs 0.65, 0.84 and 1.88 events in DAB occurred per 100PY (OR=1.07, 1.42, 1.01 respectively, all P statistically NS) in patients with Chads 2 score of 0-1, 2 and >=3; for safety end point of major bleed (any) 1.4, 2.3 and 2.9 events in APX vs 2.11, 3.04 and 4.85 events in DAB occurred per 100PY (OR=0.66 (P=0.055), 0.75 (P=0.093) and 0.59 (P =0.0005) in patients with Chads 2 score of 0-1, 2 and >=3. For both efficacy and safety parameters indirect comparison of the active comparator (warfarin) arms in both studies across the similar Chads 2 score categories did not exhibit statistically significant difference .

CONCLUSIONS:
This analysis of the published data suggests similar efficacy for both agents when used in AF patients across the Chad2 score categories, however there was a trend for a higher major bleeding risks ( Chads 2 score 0-1 and 2 ) and a statistically significantly higher bleeding event rate (Chads2 score >=3) with DAB.
Abstract 247: Pilot Study Examining Heart Failure Patient Internet Use and Adherence to a Web Based Portal Designed to Support Self-Care.
Authors: Mahmood Redah Z , Grossi Judith , Koelling Todd M
Published: July 2021

Background:
Experts agree that HF patients should practice appropriate self-care behaviors to minimize the risk of adverse clinical events, including early unplanned readmissions. We sought to understand patient perceptions and adherence to a web-based system designed to support self-care of HF patients.

Methods:
100 HF patients were surveyed regarding their computer use and attitudes toward using an internet based web-portal (WP) to support self-care, provide patient education, and communicate with healthcare providers (HCP’s). We then consented 42 patients to participate in a 12 week trial of using the WP to track clinical parameters (daily weights, blood pressure, sodium/fluid intake, exercise), provide links for HF self-education, and update HCP’s on their progress. Patients received a face to face teaching session on accessing and using the WP.

Results:
The computer use survey (N=100) demonstrated that 72% of patients reported having a computer at home, 67% used email and 71% used the internet. In the WP intervention group (N=41) only 24 (58.5%) were able to successfully access the WP and enter data during the pilot (see table 1).

Conclusions:
Pilot data showed a significant positive correlation (see table 1) between patients indicating use of internet to access heaIth care information (HCI) and adherence with the WP. Despite strong interest to use a home based WP for self-care and communication with providers, we found that many hurdles prevented patients from using the WP. Internet based educational tools for HF patients may be desirable, but limitations in patients’ ability to access internet based programs may ultimately render the tools ineffective.
Abstract 253: Blood Pressure Control at 6 Months After Percutaneous Coronary Intervention at a Veterans Hospital
Authors: Siddiqui Saifullah M , Blumenkrants Dmitry , Challa Karthik , Ladani Amit , Shroff Adhir
Published: July 2021

Background:
Blood pressure (BP) control in patients with coronary artery disease (CAD) decreases morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends patients with underlying CAD have a goal systolic blood pressure (SBP) < 130 and a diastolic blood pressure (DBP) < 80. These goals can be achieved by using multiple classes of drugs, including beta-blockers (BB), angiotensin antagonists (ACE-I/ARB), calcium channel blockers (CCB), nitrates and diuretics.

Methods:
We conducted a retrospective cohort study focusing on the achievement of JNC-7 recommended BP goals in a diverse population of 1052 veterans undergoing Percutaneous Coronary Intervention (PCI) between September 2004 and December 2011 at the Jesse Brown Veterans Hospital in Chicago, IL. Data was collected comparing both BP measurements and anti-hypertensive regimens pre- and post- PCI.

Results:
In the 1052 patients studied, the mean SBP decreased from 134 mm Hg to 128 mm Hg, and the mean DBP decreased from 73 mm Hg to 70 mm Hg. In regards to the JNC-7 guidelines, the percent of patients who achieved SBP goals increased from 44% (462 of 1052) to 54% (567 of 1050), and the percent of patients who achieved DBP goals increased from 71% (747 of 1052) to 78% (819 of 1050). There was a statistically significant increase in the use of ACE-I/ARB from 61% (645 of 1050) to 74% (776 of 1046), BB from 69% (723 of 1050) to 87% (912 of 1047), and nitrates from 23% (244 of 1050) to 28% (289 of 1046). The use of diuretics increased from 40% 422 of 1050) to 41% (426 of 1047), which was not statistically significant. There was a decrease in the use of CCB from 32% (332 of 1050) to 28% (293 of 1044), which was also not statistically significant.

Conclusion:
There was improvement in both mean BP and percentage of patients achieving JNC-7 recommended goals for SBP and DBP at six months post PCI, although overall percentages still remain suboptimal. Additionally, medication use improved in most drug classes. Beta-blocker, angiotensin antagonist as well as nitrate use increased significantly. Use of calcium channels blockers, which have no proven mortality benefit in this cohort, decreased, however this was not statistically significantly. Data was collected comparing both BP measurements and anti-hypertensive regimens pre- and post- PCI.
Abstract 259: The Role of Gender in Cardiac Resynchronization Therapy Response in Patients with Optimal Anatomical and Electrical Left Ventricular Lead Location.
Authors: Bose Abhishek , Kandala Jagdesh , Singh Jagmeet P
Published: July 2021

Background:
While optimal left ventricular (LV) lead location and the female sex are known to predict a favorable response to cardiac resynchronization therapy (CRT), the role of gender differences affecting CRT outcomes in patients with optimal LV lead location remains uncertain.

Methods:
We analyzed a prospective cohort of 180 CRT patients. Anatomical lead location was confirmed by coronary venograms and chest radiographs. LV lead electrical delay (LVLED) was measured from QRS onset on surface ECG to the first sensed signal of the LV lead, and standardized based on native QRS width. Echocardiographic response was evaluated at baseline and 6 months. Time to first heart failure hospitalization or death was assessed over 3 years.

Results:
100 patients (Age 68.2 ± 12.3 years; Baseline LVEF 23.2 ± 6.8 %, NYHA 3.0 ± 0.3) with optimal LV lead location defined as ‘long’ LVLED (LVLED>50%) with non-apical and anterolateral, lateral or posterolateral lead position were selected from the original cohort. They were further divided into the female (n=26) and male (n=74) groups. Baseline clinical characteristics were similar between groups except for a higher incidence of ischemic cardiomyopathy in males (72.4% vs. 47.1%, p=0.01) and longer QRS duration in females (171.3 ± 29.9 vs. 153.6 ± 26.9, p=0.008). Baseline echocardiographic characteristics revealed a smaller LV internal dimension in systole (LVIDs) and diastole (LVIDd) in females (51.7 ± 10.2 vs. 57.1 ± 8.9, p=0.02; 58.5% ± 10.1 vs. 64.5 ± 8.3, p=0.007 respectively). Survival with respect to first heart failure hospitalization (Figure 1A) and a composite of mortality and heart failure (Figure 1B) were comparable. Echocardiographic response, defined as an increase in mean LVEF by 10% was significant in females (+11.6 ± 11.0 % vs. +5.3 ± 9.0 %, p=0.01).

Conclusion:
In CRT patients with optimal lead location, females have superior outcomes with respect to reverse remodeling but gender differences donot appear to predict clinical outcomes.
Abstract 267: Prevalence of High Health-Habit Achievers Among Middle School Children and Associated Measures of Cardiovascular Health: A Report from Project Healthy Schools
Authors: Stasiak Ashley , March Michelle , Gurm Roopa , Jones Anne , Sylvester Rachel , Corriveau Nicole , DuRussel-Weston Jean , Kline-Rogers Eva , Goldberg Caren , Eagle Kim A , Jackson Elizabeth A
Published: July 2021

Background:
Studies show that maintaining a low-risk cardiovascular profile throughout life leads to significantly lower levels of cardiovascular disease (CVD), an improved quality of life, and markedly longer survival. Early education is therefore imperative to teach children about healthy lifestyle choices and reducing potential cardiovascular risk. This study reports the prevalence of “high health-habit achievers” (HHHA) among our baseline population and examines cardiovascular health parameters as a function of behavior between HHHA and their peers.

Methods:
Data was collected from 3,999 sixth grade students including: 24-hour food and 7-day physical activity recalls, typical screen time behavior, and cardiovascular parameters. Students were separated into two cohorts based on their reported number of high health-habits. HHHA were defined as those students who met 4/5 health-habits promoted by Project Healthy Schools (PHS) including: < 2 hours of screen time/day, < 1 unhealthy beverages/day, < 1 fried, fatty or sweet foods/day, > 5 sessions of moderate (30 min) or vigorous (20 min) activity/week, > 5 servings of fruits and vegetables/day. Those not considered HHHA were labeled “Other.” Health parameters were then compared between cohorts using chi-square analysis.

Results:
The percentage of HHHA at baseline was 10.4 % (415/3999). The HHHA differed significantly from their peers and expressed more favorable health parameters: HDL (p = 0.006), random glucose (p = 0.040), weight (p = 0.008), and recovery heart rate (p ≤0.001) (Figure).

Conclusions:
The prevalence of students achieving four out of five of the high heath-habits, at baseline, was extremely low. The cardiovascular profiles of the HHHA proved to be more favorable than Other in four parameters known to reflect overall cardiovascular health. This suggests that even at a young age, an increasing number of high health habits may be associated with a better cardiovascular profile and provides support, furthermore, for the goals promoted by PHS.
Abstract 270: Emergency Service Use in Heart Failure Patients on Hospice
Authors: MacKenzie Meredith A
Published: July 2021

Introduction:
Emergency service use should be almost non-existent among hospice patients, as hospice is intended to provide for all care needs at the end of life. Cancer patients comprise almost 50% of hospice patients nation-wide and have relatively low rates of emergency service use while on hospice care. Hospice enrollment has been steadily increasing among patients with heart failure, but concerns have been raised about how well hospice care meets these patients’ needs. Emergency service use is one indicator of how well heart failure patients’ needs are met on hospice.

Objective:
To explore whether emergency service use is higher among heart failure patients on hospice as compared to cancer patients on hospice and reasons for this potential disparity.

Methods:
This is a secondary analysis of the 2007 National Home and Hospice Care Survey (NHHCS). Only hospice patients with heart failure (n=311) and hospice patients with breast, prostate, colon or lung cancer (n=946) were included in the analysis. Emergency service use was measured by response to NHHCS question 73 (“did the patient use one or more types of emergent care?”) and includes the use of both emergency room and outpatient (urgicenter) services. Multiple logistic regression was used to examine the relationship between emergency service use and diagnosis. All analyses were adjusted for hospice length of stay, patient age, race/ethnicity, caregiver relationship, number of comorbidities, functional status, cognitive function and place of care.

Results:
Subjects (M age 75.3, SD 12.68) were 51% female and 89% white. The rate of emergency service use was 9.6% among the cancer patients and 17.36% among heart failure patients. Heart failure patients were almost two times more likely to utilize emergency services (OR 1.96, p<.002). Among the covariates examined, only hospice length of stay was significantly associated with emergency service use (p<.000), but did not appear to make a clinically significant difference (OR 1.003).

Conclusions:
While this study lends support to the hypothesis that heart failure patients suffer unmet care needs while on hospice, the nature of these unmet needs should be further explored. Outcome disparities have previously been suggested to be due to differences in age, comorbidities and functional status between the heart failure and cancer populations, but this study does not support that hypothesis. Hospice care plans unique to the heart failure patient should be considered.
Abstract 280: Cocaine-Related Aortic Dissection: Lessons from the International Registry of Acute Aortic Dissection
Authors: Dean Joshua H , O’Gara Patrick , Montgomery Daniel G , Trimarchi Santi , Myrmel Truls , Pyeritz Reed E , Harris Kevin M , Suzuki Toru , Braverman Alan C , Hughes G C , Kline-Rogers Eva , Nienaber Christoph A , Isselbacher Eric M , Eagle Kim A , Bossone Eduardo
Published: July 2021

Background:
Acute Aortic Dissection (AAD) associated with cocaine use is a rare event for which only limited case reports and small cohort studies are available. This study compares demographics, history, presenting symptoms and in-hospital outcomes among AAD patients with a history of cocaine use (C+) to those of patients without a history of cocaine use (C-) in a large international registry.

Methods:
Our study analyzed 3584 patients enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2012. We divided the population based on documented cocaine use and further stratified patients into Type A (33 C+/2332, 1.4%) and Type B (30 C+/1252, 2.4%) dissection cohorts.

Results:
C+ patients presented at a younger age and were more likely to be male and black for both Type A and B dissections. Type B dissection was more common among C+ patients than in C- patients. Cocaine-related AAD was reported more often at US sites compared to European sites (86.4% 51/63 v. 13.6% 8/63, p<0.001). Tobacco use was more prevalent in the C+ cohort. No differences were seen in history of hypertension, known atherosclerosis or time from symptom onset to presentation between cohorts. Type B C+ patients were more likely to be hypertensive at presentation. Both Type A and Type B C+ cohorts had significantly smaller ascending aortic diameters than C- patients. Acute renal failure was more common in Type A C+ patients but mortality was significantly lower in Type A C+ patients vs type C- patients for reasons than could not be identified from the data base.

Conclusions:
Cocaine abuse is implicated in approximately 2% of patients with acute aortic dissection. The typical patient is a relatively young male cigarette smoker, who like the majority of patients with AAD, has a history of hypertension. In hospital mortality for cocaine-related Type A dissection is lower than that seen with non-cocaine related type A dissection. The combination of tobacco use, cocaine use, and hypertension may predispose patients to AAD who may otherwise have little risk for the condition.
Abstract 293: Predictors Of Repeat Cardiovascular Testing In Patients Who Receive An Index Negative Stress Echocardiography
Authors: Zavodnik Theresa , Marwick Thomas H. , Hachamovitch Rory , Griffin Brian P.
Published: July 2021

Background:
Repeat cardiovascular imaging in most situations is of indeterminate appropriateness. We sought to identify baseline characteristics associated with repeat testing in patients who had an initial negative test result.

Methods:
Medicare beneficiaries who had a negative index stress echo (SE) between 2002-2008 were linked to corresponding Medicare claim data. We identified the nature and date of claims for repeat cardiac testing (exercise stress test, SE, cardiac PET, cardiac SPECT, or angiography). Kaplan-Meier analysis and Cox proportional hazards (CPH) analysis were used to determine the association of baseline covariates on the risk of a repeat test. The pre-defined outcome endpoint included time to first repeat test.

Results:
Of 3,113 Medicare beneficiaries with a negative SE (mean follow-up, 2.6 ± 1.9 years), 1553 (50%) received subsequent imaging [1411 (91%) white, 85 (5.5%) African-American, 55 (3.5%) Hispanic, Asian, or other origin]. Kaplan-Meier analysis stratified by race was associated with repeat cardiovascular imaging (p <0.0001). CPH analysis revealed that race, hyperlipidemia, CAD, T-wave changes after stress, resting diastolic blood pressure, maximum rate pressure product, percent peak maximum heart rate, and patients using aspirin and beta blockers were independently associated with repeat testing (χ
2
=242.3, P<0.0001). After risk-adjustment, African-American patients were half as likely to have a repeat test compared to white patients (HR 0.52 [0.40-0.70], p<.001) independent of other variables.

Conclusions:
Although some repeat testing in patients with negative studies reflects risk level, the presence of racial differences suggests that nonmedical factors may have an important role.
Abstract 298: Fibrate use in patients with type 2 diabetes
Authors: McCoy Rozalina G , Van Houten Holly K , Shah Nilay D
Published: July 2021

Diabetes mellitus is considered to be a coronary heart disease (CHD) equivalent, with heart disease and stroke accounting for the majority of diabetes-related deaths. As a result, patients with diabetes require aggressive treatment of CHD risk factors, including dyslipidemia. In addition to targeted reduction of LDL cholesterol, current guidelines recommend addition of a fibrate (gemfibrozil, fenofibrate, or clofibrate) in patients with established CHD and atherogenic dyslipidemia: triglycerides (TG) 200-499 mg/dL and HDL cholesterol (HDL-C) ≤40 mg/dL. Fibrates have also been recommended for patients with TG ≥500 mg/dL to reduce risk of acute pancreatitis. Yet, data supporting the use of fibrates in these settings remains variable and inconclusive. We therefore sought to provide an in-depth analysis of patterns of fibrate use among patients with type 2 diabetes between 2001 and 2010. Using Ingenix administrative claims, we identified 71,161 patients age ≥18 years old with an established diagnosis of type 2 diabetes (ICD-9 250.XX) and ≥3 years of continuous enrollment who were newly initiated on a fibrate between 2001 and 2010. Lab results were available for a subset of 18,863 (26.5%) patients, who were included in final analysis. During each 2-year period, between 77.6% - 84.1% of patients had a lipid test performed within the preceding 12 months (p=0.59 for change in testing over time). The prevalence of atherogenic dyslipidemia increased over time, from 20.8% (2001-2002) to 41.2% (2009-2010); 4.84% rise per 2-year period (p=0.002). The prevalence of severe atherogenic dyslipidemia (HDL-C ≤40 mg/dL and TG ≥500 mg/dL), also increased over time, from 9.3% in 2001-2002 to 13.6% in 2009-2010; 1.17% rise per 2-year period (p=0.002). In contrast, percent of patients with TG ≥500 mg/dL decreased over time, from 20.5% in 2001-2002 to 16.7% in 2009-2010; 1.19% decline per 2-year period (p=0.03). Initiation of new fibrate therapy in treatment naïve patients with diabetes remained constant; 2.0% in 2001-2002 and 1.6% in 2009-2010 (p=0.93). Subgroup analysis of patients with atherogenic dyslipidemia also showed no significant change in fibrate initiation over time; 11.4% in 2001-2002 and 15.7% in 2009-2010 (p=0.3). Similarly, while there was a trend toward increased initiation of fibrates among patients with TG ≥500 mg/dL, this trend was not statistically significant (27.4% in 2001-2002 and 41.6% in 2009-2010; 3.34% change per 2-year period (p=0.09)). In conclusion, the prevalence of atherogenic dyslipidemia among patients with type 2 diabetes has increased significantly over the past decade. However, fibrate use in all patients with type 2 diabetes, including those specifically with atherogenic dyslipidemia, has remained constant throughout the observation period, despite lack of conclusive evidence supporting its use.
Abstract 309: Prioritizing Blood Pressure Measurements Results In Improved Hypertension Control
Authors: Odunukan Olufunso W , Cha Stephen , Rahman Ahmed S , Roellinger Daniel , Naessens James M , Nyman Mark A
Published: July 2021

Background:
Blood pressure (BP) measurement is a national core quality measure for hypertension care and hypertension control rates remain a major performance measure. It remains unclear whether improving measurement directly results in better control rates in hypertension management.

Purpose:
To utilize electronic medical records to explore the relationship between measurement of blood pressure and hypertension control rates among 4 eligible primary care providers groups - Primary Care Internal Medicine (PCIM), Family medicine (FM), General Internal Medicine (GIM), Preventive Medicine (PREV) - and 2 eligible specialist groups - Cardiology (CARD), Nephrology (NEPH) at an academic group medical practice.

Methods:
A two year cross sectional study involving adults seen by eligible primary or specialist providers at 2 or more office visits with a hypertension ICD-9 code in two years with at least one office visit in the measurement year. We measured the proportion of patients who had their BP measured at their last hypertension visit (LHV) in 2009 and 2010. We compared measurement rates with control rates as defined by the proportion of hypertension patients with BP < 140/90 mmHg at their LHV.

Results:
In 2009, 84.2% of 17989 patients (95% CI 83.6 - 84.7%) had their BP measured at their LHV compared to 85.3% (95% CI 84.8 - 85.8%) of 17992 patients in 2010, an increase of 1.2% (p=0.0026).

Measurement rates varied widely across the different provider groups. PCIM, a high performing group, had significant improvement in measurement rates from 2009 to 2010 and demonstrated improvement in control rates. Lower performing groups, Nephrology and GIM, had significant improvement in measurement but did not see a direct translation to improved control rates. There was an associated worsening of the control rates for Preventive medicine along with a decrease in the measurement rates from 2009 to 2010.

Conclusion:
High BP measurement rates are associated with high hypertension control rates. Prioritizing BP measurement may result in improved intermediate outcomes in hypertension management.
Abstract 316: Costs Of Contrast Induced Acute Kidney Injury
Authors: Amin Amit P , Shapiro Robert , Novak Eric , Olsen Margaret , Singh Jasvindar , Bach Richard G , Cohen David J
Published: July 2021

Introduction:
Contrast induced Acute Kidney Injury (CI-AKI) is a common and morbid complication of cardiac catheterization (cath) and percutaneous coronary intervention (PCI), and increases patients’ mortality risk. However, little is known about the costs of CI-AKI or its impact on length of stay (LOS). Our objective was to examine independent costs and LOS associated with CI-AKI after adjusting for patient characteristics and comorbidities.

Methods:
We identified 495,655 patients with ischemic heart disease (diagnosis codes 411.x- 414.x) undergoing cath or PCI (procedure codes 88.55-88.57) from the Healthcare Cost and Utilization Project (HCUP) state inpatient database (SID) from California, Florida, and New York from 2007-2010. The SID includes 97% of all discharges from these states, regardless of payers. Costs of hospitalization were determined by applying hospital- and year-specific Cost-to-Charge Ratios to the data on total charges. CI-AKI was identified by diagnosis codes 584.5-584.9 during the index hospitalization. Independent costs of CI-AKI were identified by a linear regression model adjusting for patient characteristics and comorbidities.

Results:
Among 495,655 patients undergoing cath or PCI, CI-AKI occurred in 24,414 (4.9%). Patients developing CI-AKI were more likely to be elderly males with diabetes and chronic kidney disease. The median cost of hospitalization for cath or PCI was $13,539. CI-AKI was associated with an increased length of stay by 7 days and with a doubling of the unadjusted cost of hospitalization, by $14,668. After adjusting for patient characteristics and comorbidities, the independent, incremental cost of CI-AKI was $10,667 (95% CI 10,488 to 10,847, P<0.0001).

Conclusions:
CI-AKI occurs commonly and is a very costly complication among patients undergoing cath or PCI. In this study it increased LOS by 7 days and added an incremental cost exceeding $10,000. Our study underscores the importance of preventing CI-AKI to reduce morbidity and save costs.
Abstract 317: The Role of Age in Adult Patients with End-Stage Renal Disease Referred for Coronary Revascularization: Insights from Methodological Differences when Modeling a Continuous Variable
Authors: Krishnaswami Ashok , McCulloch Charles E , Hlatky Mark A , Leong Thomas K , Go Alan
Published: July 2021

Background:
Prior cardiovascular studies have often dichotomized the continuous variable age at a certain pre-specified cutoff which is thought to lead to a loss of information.

Methods:
To further understand this loss of information we conducted a retrospective cohort study within Kaiser Permanente Northern California and identified 1015 adults with end-stage renal disease who underwent an index coronary revascularization procedure between 1996 and 2008. We used logistic regression analysis and obtained odds ratios for the primary predictor age when age was a. dichotomized at at a cutoff of ≥ 65 years b. categorized as ≤ 55 (reference), 55-64, 65-74, & ≥ 75 years c. modeled as a continuous predictor with a clinically relevant scale (every 5 years ) and d. when age was transformed to a restricted cubic spline (RCS) with four knots. We chose to report in this abstract only the primary outcome repeat revascularization due to the ease in graphically appreciating the various modeling strategies noted above.

Results:
For the primary outcome repeat revascularization, the unadjusted odds ratio for age ≥ 65 years was 0.64 (95% CI: 0.49-0.82). Categorized age 55-64 years was 0.73 (95% CI: 0.55-0.99), 65-74 years was 0.46 (95% CI: 0.33-0.64), and ≥ 75 years was 0.75 (95% CI: 0.50-1.14), p<0.0002 (departure of trend). The odds ratio for age as a continuous variable every 5 years was 0.87 (95% CI: 0.82-0.92).
Figure 1
is a graphical representation of the four different modeling methods of age as noted above.

Conclusions:
Qualitatively, these four modeling strategies led to different conclusions. When age was dichotomized, there was a significant loss of information. Linearized age did not sufficiently address either the increase in repeat revascularization at both ends of age nor the nadir but appeared to have an adequate fit. Categorized age was able to note the nadir in repeat revascularization around the age of 65 years with a subsequent increase at both ends but the current age categories underrepresented the increased revascularization in the early years. Age transformed to a RCS was visually appealing but lacked adequate quantitative assessment.

Therefore, when modeling a continuous variable such as age, there is an imperative to balance the issues of overfitting, residual confounding, flexibility and appropriate interpretation.
Abstract 318: Takotsubos Cardiomyopathy-EKG presentations
Authors: Rajamanickam Anitha , Kansara Pranav , Fanari Zaher , Rao Abhishek D , Hopkins James , Rahman Ehsanur , Goldenbeg Edward , Kostal Michael , Stillabower Michael , Weintraub William
Published: July 2021

Background:
In patients presenting with a clinical picture of acute myocardial infarction (MI), Stress induced or Takotsubos cardiomyopathy (TCM), once considered rare is now an increasingly considered differential diagnosis. Literature regarding this disease is relatively scarce. We aimed to review the electrocardiogram (EKG ) presentation of these patients.

Methods:
Medical records were reviewed for patients, from 2006 onwards, with either a discharge diagnosis of TCM or with a clinical presentation of acute MI and with ventriculogram on cardiac catheterizations (CC) but without any coronary interventions. We retrieved 972 patients and of those 99 met the criteria for TCM after a detailed review of their records

Results:
ST elevations were seen on EKG in 20% of patients-15 patients were initially considered a STEMI and another 5 were considered a possible STEMI .80% presented as unstable angina or a NTEMI with elevated troponins and of these 50% showed t wave changes suggestive of ischemia on EKG. Of the STEMI, 6 showed ST elevations in the anterior or anteroseptal leads, 7 showed ST elevations in the lateral or anterolateral leads, 4 showed ST elevations in the inferior leads and 3 showed diffuse ST segment elevations. Only one patient showed the classic reciprocal ST segment depression on EKG. However, the type of EKG presentations did not affect in hospital mortality or recovery of LV function

Conclusions:
Most TCM patients who present like a STEMI have ST segment elevations without the classical ST reciprocal depressions. They also present with higher Troponin and CKMB values, similar to STEMI due to obstructive CAD, than patients who present like a NSTEMI. However this did not appear to influence in hospital mortality or recovery of LV function.
Abstract 320: 30-Day Outcome and Processes of Care for Patients Hospitalized for Heart Failure at Veteran and Non-Veteran US Hospitals
Authors: Heidenreich Paul , Sahay Anju , Massie Barry
Published: July 2021

Background:
Mortality and readmission at 30 days following admission for heart failure (HF) and acute myocardial infarction (AMI) are now publically reported for US hospitals. It is unclear if outcome is similar for veteran (VA) and non-VA facilities.

Methods:
We used data from Hospital Compare of the Center for Medicare and Medicaid Services (CMS) that includes hospital specific processes of care and 30-day mortality and 30-day all-cause readmission rates adjusted for patient characteristics for US hospitals from 2010-2011. VA hospitals were compared to other adult hospitals on 30-day mortality, 30-day all-cause readmission, documentation of left ventricular ejection fraction (EF), discharge instructions, smoking cession counseling and use of angiotensin converting enzyme (ACE) inhibitors if the LVEF was < 40%. Hospitals with fewer than 25 cases were excluded. Multivariate analyses of 30-day mortality and 30-day readmission were conducted to determine the impact of controlling for rates of process of HF care on the association with admission to a VA hospital. All analyses were weighted for the number of discharges per facility.

Results:
30-day mortality was lower and 30-day readmission was higher for those hospitalized at VA facilities (Table). Process of care was high for most hospitals with the VA hospitals having slightly higher rates for all process measures which were significant for documentation of EF and discharge instructions. Hospitalization at a VA was associated with a 0.47% lower 30-day mortality rate which was reduced to a 0.43% lower rate (p=0.006) after adjustment for processes of care. In contrast, hospitalization at a VA was associated with a 0.88% higher 30-day readmission rate which was reduced to a 0.81% greater rate (p<0.0001) after adjustment for processes of care.

Conclusion:
Patients hospitalized at VA hospitals had a lower 30-day mortality rate but a higher 30-day readmission rate following an admission for heart failure. Differences in process of care were small and explained only a small part of the difference in outcome between VA and non-VA hospitals.
Abstract 332: Persistent Use Of Evidence-Based Medications After Discharge Among Patients With Non-ST Elevation Myocardial Infarction Treated At Academic Versus Non-Academic Hospitals
Authors: Rymer Jennifer , McCoy Lisa , Thomas Laine , Peterson Eric , Wang Tracy
Published: July 2021

Background:
While academic hospitals are more likely to apply evidence-based therapies in-hospital for patients with non-ST elevation myocardial infarction (NSTEMI) than non-academic hospitals, differences in post-discharge persistence of evidence-based medications have never been evaluated.

Methods:
We examined 3,184 NSTEMI patients over age 65 treated at 250 hospitals in 2006 in the CRUSADE registry linked to Medicare part D pharmacy data. Using multivariable Poisson regression adjusting for case mix, we compared continued filling of prescriptions for beta-blockers, ACEI/ARB, clopidogrel, and statins at 90 days and 1 year post-discharge between patients treated at academic and non-academic hospitals.

Results:
Patients treated at academic hospitals were more frequently non-white (19% vs. 8%, p<0.001), but age (median 76 years) and gender (53% female) were not significantly different from patients treated at non-academic hospitals. Patients at academic hospitals were more likely to have a Charlson score >4 (36% vs. 30%, p=0.001), yet the rates of in-hospital PCI (48%) and CABG (8%) were similar between groups.

Rates of persistence to evidence-based medications did not differ substantially between patients treated at academic vs. non-academic hospitals at 90 days or 1 year (Table). Persistence to all drug classes prescribed at discharge was low and not significantly different between academic and non-academic hospitals at 90 days (46% vs. 45%, p=0.44 with adjusted incidence rate ratio (IRR)=0.99 (0.95,1.04) and at 1-year (39% vs. 39%, p=0.93, adjusted IRR=1.02 (0.98,1.07)). There were no significant differences in index hospitalization duration (median 4 days, interquartile range (IQR) 3-6 for both, p=0.51) and time to first post-discharge cardiac follow-up visit (median 28 days [IQR 15-54] vs. 28 days [IQR 16-56], p=0.25) between patients treated at academic vs. non-academic hospitals.

Conclusion:
Rates of persistence to evidence-based medications were similar between older NSTEMI patients treated at academic vs. non-academic hospitals, and may reflect similar in-hospital treatment and post-discharge cardiac follow-up. However, persistence rates are low both early and late post-discharge, highlighting a continued need for quality improvement efforts to optimize post-MI management.
Abstract 333: Design and Implementation of a Pediatric Outpatient Cardiology Clinic Renovation Utilizing Quality Improvement Methodology
Authors: Mays Wayne A , McDonald Mark B , Brown James , Kimball Thomas R
Published: July 2021

Background:
With increasing pressure to manage medical resources prudently, quality improvement methodology can be utilized to increase efficiency and decrease cost in current outpatient cardiology clinic operations. However, there are few examples of quality improvement methodology applied to the design, implementation and management of a renovation project aimed at meeting a five year projected volume increase of 155% and multidisciplinary clinic expansion. We hypothesized that by using quality improvement methodology, the increasing volume demands could be met by improving clinic flow and thus maintain patient access while reducing medical resource expansion.

Methods:
Outpatient cardiology clinics and testing functions were assessed for clinic visit volumes and duration, testing volumes and durations, patient no show rates, the number of provider clinic hours, room utilization, scheduling template design and accuracy, and the scheduling process. Baseline assessments were made prior to process improvement efforts. A series of interventions were made as follows: modification of the patient follow up scheduling process, reduction in the number of scheduling templates, modification of templates to include pre visit nursing and electrocardiographic acquisition time, change from half day to all day clinic templates, pre visit registration, limiting of exam room assignment to a maximum of 3 per provider and spread of the clinic across 5 days per week.

Results:
Baseline data revealed a 43% no show rate, room utilization was 34%, patient access defined by lag days between first contact and appointment was 22 days. These metrics indicated that the number of exam rooms needed to meet our projected volume increase would result in an increase from 10 to 30 rooms. Two years into our interventions and our no show rate is 6%, room utilization is 68%, patient access has improved with lag days at 10. These improvements have occurred in the presence of an 18% annual volume increase, an increase of 5% in patient provider hours and an exam room increase from 10 to 23.

Conclusions:
Process improvement methodology applied to room utilization, patient scheduling, provider staffing patterns and clinic visit templates can be successfully utilized to design and implement an outpatient cardiology clinic renovation. If properly applied, process improvement can be a method to maximize the use of current and future medical resources while insuring patient access to services.
Abstract 336: Relationship of Provider and Practice Volume to Performance Measure Adherence: Results from the NCDR®
Authors: Fleming Lisa M , Jones Philip , Tang Fengming , Chan Paul , Andrei Adin-Cristian , Maddox Thomas , Farmer Steven
Published: July 2021

Background:
Previous research demonstrates an association between higher surgical volume and improved outcomes; however, there has been limited literature evaluating the association between volume and quality of care in cardiovascular patients. We examined the relationship between volume and compliance with selected outpatient quality measures for coronary artery disease (CAD).

Methods:
Using a contemporary cohort from the PINNACLE Registry

®

(2009-2012), average monthly provider and practice volumes were calculated for CAD encounters. Performance for four American Heart Association (AHA) CAD measures (antiplatelets, beta blockers, ACE inhibitor/ARBs, lipid therapy) was assessed at the most recent encounter for each patient. The percentage of patients meeting 100% of quality measures was calculated for both providers and practices. We fit 3-level hierarchical logistic regression models to assess the relationship between provider and practice volume and performance on quality measures.

Results:
Data were available for 577,645 patients, representing 1,134 providers from 78 practices nationwide. Monthly practice volumes (median (IQR)) were 683 (251-1466) for CAD encounters and monthly provider volumes were 67 (33-119). Overall, 48% of patients met all CAD measures. The relationship between provider and practice volumes and adherence to performance measures varied significantly. Practice volume was not associated with adherence to performance measures (p = .49), however higher provider volume was positively associated with adherence to performance measures (p < 01) (See
Figure 1
).

Conclusions:
In the PINNACLE Registry

®

performance on published quality measures for CAD was modest and variable. Higher provider volume was positively associated with adherence to performance measures, but there was no association between practice volume and performance.
Abstract 350: Hospital Variation in Survival for Pediatric In-Hospital Cardiac Arrest: A Report From Get With the Guidelines -Resuscitation
Authors: Jayaram Natalie , Spertus John A , Tang Fengming , Chan Paul S
Published: July 2021

Background:
Although survival after in-hospital cardiac arrest is likely to vary among hospitals caring for children, validated methods to risk-standardize pediatric survival rates across sites do not currently exist.

Methods:
Within the American Heart Association’s Get With the Guidelines-Resuscitation registry for in-hospital cardiac arrest, we identified 1,640 cardiac arrests in children from 168 hospitals from 2006 to 2010. Using multivariable hierarchical logistic regression, we developed and validated a model to predict survival to hospital discharge. We then applied the coefficients and random hospital intercepts from the model to examine risk-standardized rates of cardiac arrest survival for those hospitals with a minimum of 10 pediatric cardiac arrest cases.

Results:
A total of 15 patient-level predictors were identified: age, sex, race, cardiac arrest rhythm, location and day of arrest, mechanical ventilation, baseline depression in neurological function, major trauma, hypotension, metabolic or electrolyte abnormalities, renal insufficiency, sepsis, and use of intravenous antiarrhythmics or vasopressors at the time of arrest. The model had good discrimination (C-statistic of 0.71), confirmed by bootstrap validation (validation C-statistic of 0.69). Among 31 hospitals with at least 10 cardiac arrests, unadjusted hospital survival rates varied considerably (median, 37%; inter-quartile range [IQR]: 21% to 44%; range: 0% to 59%). After risk-standardization, variation in hospital survival rates persisted (median, 37%; IQR: 33% to 41%; range: 31% to 49%), although the range of outcomes narrowed considerably.

Conclusion:
In a large national registry, we developed and validated a model to predict survival after in-hospital cardiac arrest in children. Even with risk-standardization, there is significant variation in survival rates across hospitals. Leveraging these models, best practices can be assessed at high-performing hospitals and shared with others to improve care in the setting of pediatric cardiac arrest.
Abstract 356: Comparison Of Inappropriate Myocardial Perfusion Imaging By Specialty Training And Encounter Location
Authors: Winchester David E , Meral Ryan , Nguyen Daniel , Ryals Scott , Dusaj Raman , Shaw Leslee , Beyth Rebecca
Published: July 2021

Objective:
To investigate the association between inappropriate use of myocardial perfusion imaging (MPI), specialty training of the ordering provider, and location of the clinical encounter.

Methods:
We conducted a retrospective analysis of MPI performed in a single Veterans Affairs (VA) medical center from August 2010 through November 2011. We classified the indication for each MPI test using the 2009 Appropriate Use Criteria (AUC). We investigated for associations between MPI ordered for inappropriate indications, the subspecialty training of the ordering provider (cardiology vs. other), and the location of the clinical encounter (emergency department [ED], inpatient, or outpatient).

Results:
We analyzed 598 subjects, 95% of whom were male. Diabetes (41.2%), hypertension (82.3%), and hyperlipidemia (76.0%) were common, as were prior myocardial infarction (40.5%) and prior revascularization (34.6%). Overall, 78.4% of MPI were appropriate, 9.5% uncertain, and 10.5% were inappropriate. An indication could not be determined for 3.2% of patients. Distribution of appropriateness by provider type and location of encounter are demonstrated in the Figure. The most common inappropriate indication did differ between groups. For Cardiology providers the most common inappropriate MPI was for asymptomatic patients within 2 years of percutaneous coronary intervention (AUC indication #59) while for noncardiology providers, the most common was asymptomatic patients with intermediate coronary heart disease (CHD) risk and a normal electrocardiogram (AUC indication #13). For inpatient MPI, definite acute coronary syndrome (AUC indication #10) was the most common inappropriate test, while for outpatient MPI, asymptomatic patients with low CHD risk was the most common (AUC indication #12), and for ED MPI syncope with low CHD risk was the most common (AUC indication #20).

Conclusions:
The proportion of MPI ordering for inappropriate indications was similar when comparing the specialty training of the ordering provider and the location of the ordering encounter. The most common inappropriate indications ordered by each group, however, were different. Our findings suggest that initiatives to reduce inappropriate use should be aimed at all providers, but targeted to specific inappropriate indications.