bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 226: Association Between Sleep Duration and Mediterranean Diet Score in Costa Rica
Authors: Gupta Kashvi , Baylin Ana B , Jansen Erica
Published: May 2020

Background:
Short and long sleep are risk factors for coronary artery disease. One of the mechanistic pathways is likely through diet. While many studies have examined associations between sleep and individual dietary components, few have examined diet patterns. We hypothesized that those with short sleep (< 7 hours/night) and long sleep (>9 hours/night) would have lower adherence to the Mediterranean diet. We also examined the effect of social jetlag, that is, a difference in the sleep duration between weekdays and weekends, on the Mediterranean diet.

Methods:
Participants in this study are population based-controls that were recruited for a case-control study on myocardial infarction and matched by sex, age and area of residence. Study participants (1600 men and 569 women) were recruited randomly using data from the National Census and Statistics Bureau of Costa Rica between 1994 and 2004 and therefore are representative of the Costa Rican population within matching strata. Sleep and napping patterns were self-reported by the participants. Social jetlag was defined as a ≥ 1-hour difference in sleep duration from weekdays to weekends. Validated food frequency questionnaires, detailed socio-demographic, medical history and physical activity questionnaires were administered. Alternative Mediterranean Diet (AMED) scores were calculated based on the consumption of vegetables, fruits, whole grains, nuts, legumes, fish, red and processed meat, alcohol and monounsaturated fat-to-saturated fat ratios. We used adjusted linear regression models stratified by sex to study the association between sleep duration, social jetlag and AMED score.

Results:
Men and women with short sleep tended to be younger, more educated, non-smokers, diabetic and have lower physical activity compared to those getting optimal hours (≥ 7 and ≤ 9 hours/night) of sleep. Among women, short sleep on weekdays was significantly associated with having a lower AMED score when compared to those with optimal hours of sleep. This association remained unchanged after adjusting for confounders including age, area of residence, education, napping frequency, caffeine intake, smoking status, physical activity and diagnosis of type 2 diabetes mellitus and hypertension (ß, -0.41 and CI, -0.69 to -0.13). Women with short sleep had a lower intake of vegetables, fruits, and legumes that contributed to their lower AMED score. There were about 20% of men and women with social jetlag. Social jetlag was associated with lower AMED scores, but it was not statistically significant amongst men (p=0.08) or women (p=0.15) after adjusting for confounders.

Conclusions:
Short sleep is associated with lower adherence to a Mediterranean diet amongst women in Costa Rica. The lack of an association amongst men might imply different biological pathways and residual confounding by lifestyle factors that drive food consumption in men as compared to women.
Abstract 231: Racial and Ethnic Disparities in Anticoagulant Choice for Atrial Fibrillation in the Veterans Health Administration: Results From the REACH AF Study
Authors: Essien Utibe R , Kim Nadejda , Hausmann Leslie , Mor Maria , Good Chester , Gellad Walid , Fine Michael
Published: May 2020

Background:
Atrial fibrillation (AF) affects nearly 1 million patients in VA, with morbidity and mortality disproportionately affecting racial/ethnic minorities. Anticoagulation reduces stroke risk in AF, yet warfarin and direct oral anticoagulants (DOACs) are underused in minorities. We compared anticoagulant initiation by race/ethnicity for patients with AF in VA—which facilitates access to medications through a uniform drug formulary.

Methods:
Using the VA Corporate Data Warehouse, we identified patients from 1/1/2014 - 12/31/2018 with an AF diagnosis and a confirmatory diagnosis ≦180 days of their index AF diagnosis. We excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis, as well as those with valvular heart disease, who died within 180 days of AF diagnosis, or had missing or “other” race/ethnicity. We categorized our independent variable as non-Hispanic white (NHW), non-Hispanic black (NHB), and Hispanic. Our primary outcome was receipt of any anticoagulant ≦180 days of AF diagnosis as well as the type of anticoagulant (warfarin, DOAC) initiated. We used logistic regression to compare outcomes by race/ethnicity, adjusting for year of diagnosis, stroke risk with CHADS2VA2Sc score, renal disease, region and rurality.

Results:
We identified 148,062 patients with incident AF: 8.6% were NHB, 3.4% Hispanic. Overall, NHBs (57.7%) and Hispanics (58.4%) were less likely than NHWs (61.4%) to initiate any anticoagulant therapy (p <0.01), driven by lower DOAC initiation for minorities (36.8% NHBs, 36.5% Hispanics, 43.0% NHWs; p <0.01). Compared to NHWs, the adjusted odds ratios (AORs) for receiving any anticoagulant or DOACs were significantly lower for NHBs and Hispanics (Table); in contrast, AORs for receiving warfarin were significantly higher among minorities. As DOAC initiation increased from 16.8% (2014) to 60.3% (2018), racial disparities in initiation increased from 1.7 to 9.1% for NHBs vs. NHWs and from 0.9 to 9.4% for Hispanics vs. NHWs.

Conclusions:
In a national cohort of AF in VA, we identified significant racial/ethnic disparities in anticoagulant initiation, driven by growing disparities in DOAC initiation. Understanding these differences is essential to ensuring equitable AF care in the largest U.S. integrated health care system.
Abstract 233: Quality of Collaboration Between Cardiologists and Internists During Inpatient Consultations
Authors: Gavin Jordan L , Walters Elizabeth , O'Leary Kevin J
Published: May 2020

Background:
Collaboration between cardiologists and internists is essential to providing safe, effective, and patient-centered cardiovascular care. The objective of this study was to determine the quality of collaboration between these clinicians during inpatient consultations and identify areas for improvement.

Methods:
We surveyed hospitalists, general internal medicine faculty, and resident physicians from inpatient general medicine services and consulting cardiology attendings and fellows at a large tertiary care hospital over a two month period. Respondents were asked to rate each other’s level of collaboration on a 5-point ordinal response scale and answer multiple choice and free-response questions on consultation practices and personal preferences.

Results:
Overall, 92 of 155 (59%) eligible hospitalists, general internal medicine faculty, and resident physicians completed the primary survey. Collaboration with cardiology consultants was rated as high or very high quality by 72% of respondents. There was no significant difference between ratings of collaboration quality based on respondents’ level of training. Internists identified resistance or disagreement with indication for consultation, difficulty receiving a timely response, and poor follow-up communication as the largest barriers to high quality collaboration. Most internists preferred receiving recommendations by page, phone, or written in a consult note, rather than in person. Internists appreciated close communication throughout the consultation process. For longitudinal consultations, internists preferred when an intention to sign-off was communicated by page or wrote in that day’s consult note. In total, 9 cardiology attendings and fellows completed the specialty survey. Cardiologists reported providing recommendations the same day for routine consultations, or within 2-3 hours when urgent. Most consultants communicated their recommendations thru page, phone conversations, or written consult note. Providing recommendations in person was rare. Half of cardiology attendings and fellows rated collaboration with internists as high or very high quality. There was no significant difference between their ratings of collaboration with hospitalists and residents. Cardiologists appreciated when outside hospital records had already been obtained. They identified receiving an unclear reason for consult, consulting prior to initial work-up, late in the day, or when an outpatient appointment was more appropriate as the largest barriers to high quality collaboration.

Conclusions:
While cardiologists and internists appear to agree on modes of communication, they have different perceptions of timeliness and disagreements on appropriateness of consultations. Further research is needed to design and study interventions that address these barriers to high quality collaboration.
Abstract 236: Triaging Young Patients With Acs in the Ed - A Case Report
Authors: Schwartz Brian , Grevious Salih N
Published: May 2020

Introduction:
Cardiovascular Disease (CVD) is the leading cause of death in the United States. According to the Centers for Disease Control and Prevention (CDC), one person dies every 37 seconds from complications of CVD. One of the main complication of CVD is acute coronary syndrome (ACS) which includes unstable angina as well as an acute myocardial infarction (AMI).
1
More than 790,000 Americans have an AMI annually, of which 73% are first-time AMIs.
2
These events generally affect older people, with an average age of 65.6 years for men and 72 years for women. Furthermore, only 0.3% of men and women under the age of 39 will have an AMI.
3,4
As a result, it is often overlooked among this population in the acute care setting. We present the case of a young man with a delayed diagnosis of ACS despite typical presentation and EKG findings.

Case presentation:
A 27 year old male presented after three days of progressive substernal chest pain at rest. ECG revealed anterolateral ST elevations, but “No STEMI” was noted on the EKG and a troponin was not drawn for 4 hours. While the ED did not have a specific diagnosis in mind, they did not believe such a young person likely had ACS and originally ‘misread’ the EKG. Triage to PCI did not occur until troponin returned positive later that afternoon, more than 8 hours after initial presentation. Cardiac angiography showed a complete occlusion of the mid LAD requiring a single DES. Post-procedure ECG showed persistent anterolateral ST elevation raising concern for future complications in part due to delayed triage.

Discussion:
The delayed presentation and triage of this patient warrants discussion. While there is a lack of data on door to balloon time based on age for ACS patients, it appears extremely likely that this diagnosis was missed, despite EKG findings and typical chest pain, in part due to age related bias. This case raises concern that providers are hesitant to diagnosis ACS in young patients due to its low prevalence in this population and warrants further study on steps that can be taken to decrease missed ACS diagnoses and the resultant suboptimal medical outcomes that may follow.
Abstract 238: Heart Failure: Do We Get With the Guidelines?
Authors: Kanwal Jugeet , PURI NEHA , Finkel Jonathan , Sattar Muhammad , Ali Muhammad Usman , Parsi Meghana , rai maitreyee
Published: May 2020

Background:
Acute decompensated heart failure is a leading cause of hospitalizations in adults older than 65 years. While randomized trials have shown medical therapy to be effective in reducing heart failure hospitalisations, real-world data showing the effectiveness of their implementation and impact on readmissions is scarce. This study aimed to evaluate ACC/AHA directed discharge practices for patients with heart failure with reduced ejection fraction (HFrEF) at a community hospital and its effect on 30-day readmission rates.

Methods:
This was a retrospective analysis of 868 patients admitted to a community hospital with HFrEF. HFrEF was confirmed for patients based on their most recent Echocardiogram. Data collection points included age, comorbidities (HTN, DM, CKD) and ejection fraction on last Echo. There were 2 primary measured outcomes: medications at discharge and 30-day readmission rates for HFrEF. Discharge medications were subdivided into a combination of either {ACEI/ARB, Beta-blocker (BB) and Spironolactone} or {ACEI/ARB and BB} or {Nitrates/Hydralazine}-all combinations recognised as guideline directed medical therapy (GDMT); or BB alone or ACEI alone. Secondary outcomes included fluid and salt restriction recommendations on discharge and its effect on 30-day readmission rates.

Results:
After applying exclusion criteria, 320 patients admitted from 2016-2019 for HFrEF were assessed. Using descriptive analyses, it was found that 77% of patients (247/320) were appropriately discharged on GDMT including a combination of {ACEI/ARB, BB and Spironolactone (59/320)}, {ACEI/ARB and BB (173/320)} and {Nitrates/Hydralazine (15/320)}, respectively. The remaining 23% patients were discharged on ACEI or BB alone (73/320). Only 4.38% of patients discharged on ACEI/ARB, BB and Spironolactone were readmitted within 30 days. Similar results were seen across the ACEI/ARB and BB arm (9.38%) and the Nitrates/Hydralazine arm (1.88%). Readmission was significantly higher for patients discharged on a BB alone (27.78%) or ACEI alone (28.57%). Readmission rates for patients recommended fluid and salt restriction versus those who were not, were not statistically significant.

Conclusion:
While ACC/AHA guidelines in accordance with Target HF, recommend early initiation of GDMT in HFrEF, our study aimed to assess real world implementation of these guidelines at a community hospital. Our study found that while our readmission rates remained higher than the national average (21.9%) in patients discharged on ACEI or BB alone, in agreement with trials, readmission rates were significantly lower in patients discharged in each combination of GDMT. Our study highlights the importance of greater focus on providing high-value care with high compliance with GDMT to reduce readmissions and improve patient outcomes.
Abstract 244: Real World Evaluation of Implementing a Mock Cardiac Arrest Program
Authors: Trumpower Brad , Kamphuis Lee A , McEvoy Joseph , Weber Pamela J , Krein Sarah , Stanke Sharon L , Iwashyna Theodore J , Nallamothu Brahmajee K
Published: May 2020

Introduction:
In 2019, the Veterans Health Administration (VHA) began rolling out a national initiative to create a standardized mock code training program through the Resuscitation Education Initiative (REdI). We partnered with REdI and the local REdI Mock Code Program team at a Midwestern VA medical center to evaluate the launch of this mock cardiac arrest training program using a mixed methods approach.

Methods:
The REdI mock cardiac arrest program provided training to VA medical center clinical and non-clinical staff using didactic, small group, and hands-on simulation activities over a 2-day site visit in January 2019 where all facets of the resuscitation team were reviewed. Following this training visit at one VA medical center, 10 mock cardiac arrests were conducted between March 2019 and December 2019. One mock cardiac arrest included a hospital-wide activation and nine were conducted on individual units without activation of the cardiac arrest response team. The research team was composed of clinical and methodological experts who observed 8 of the mock cardiac arrests. We used an observation template to record structured data elements and take field notes during the mock code (e.g., how participants made decisions, assigned roles and quality of communication between the participants). At the end of the mock code, facilitators and the study team collected oral and written feedback from the participants.

Results:
In the 8 mock cardiac arrests observed, we identified 54 participants. Participants overwhelmingly rated the mock cardiac arrests as positive (83.3%, 45/54). Debriefing-feedback after the mock cardiac arrest was identified as the most helpful aspect (42.6%, 23/54). Areas for improving implementation of the mock cardiac arrest training program focused primarily on the need for a better introduction to the exercise. This included understanding the manikin’s functionality (9.3%, 5/54) and the expectation that participants should perform CPR just as they would in an actual cardiac arrest event (7.4%, 4/54). Two critical takeaways frequently cited by participants related to performance during the mock cardiac arrest were a need for better communication (20.4%, 11/54) and defined roles (18.5%, 10/54).

Conclusions:
Implementation of a mock cardiac arrest program was positively received by participants at a VA medical center. Moreover, participants identified both opportunities for improving resuscitation performance and optimizing learning experiences as part of program implementation.
Abstract 247: Process Improvement Initiatives to Reduce No Show Rates in Rural Communities
Authors: Haskell Tara , Cushman Melissa
Published: May 2020

Objective:
A large pediatric academic medical center (AMC) acquired an out-of-state private cardiology practice serving rural communities and without an EMR. No show rates at the private practice consistently ranged from 20-40%, compared to 11% at the AMC. No shows contribute to inefficient use of clinician time and access to care challenges for other patients. Upon acquisition, process improvement efforts began with the goal of decreasing the abnormally high no show rates.

Methods/Findings:
Under private practice, staff scheduled patient appointments without inquiring for their availability and then notified patients of their appointment date and time via letter 10 days prior to the scheduled appointment and then by phone 2 days prior to the appointment. Immediately following the acquisition in December 2018, staff began calling patients to inquire when they would like to be scheduled based on their availability. Patients were scheduled six months out, so the true impact of this process change would be fully realized in May 2019. Once an EMR was implemented, a dashboard was created to monitor no show rate data and identify trends. After six months, no show rates only slightly improved, so in addition to the automated emails, calls, or text reminders from the scheduling center, a dedicated staff member began making reminder calls to patients the day before their appointment. As a result of the process improvement efforts, no show rates decreased from a high of 42% to 16% in eight months. Further, to better understand why patients were not showing for their appointments, staff began calling patients after a no-show appointment to determine if there were barriers for not showing and offering to reschedule the appointment. Data collected shows that out of 470 no show appointments from May 2019 to December 2019, 117 patients had disconnected phone numbers, 230 had appointment reminder messages left on their voicemail, 68 did not answer the call and did not have voicemail to leave a message and 55 patients confirmed their appointment with staff, but did not show for the appointment. Of the 470 no shows, 394 were pediatric patients and 76 were adults. Data shows 185 out of 470, or 39% of reminders never reached the patient, and an additional 49% went to voicemail and may not have been heard.

Conclusion:
No show appointments negatively impact clinic efficiencies and the ability to provide care to the greatest number of patients. When a patient doesn’t show for their appointment, they are non-compliant with their recommended care and reserve a clinic appointment that another patient may need. Small tests of change were made in phases to ensure appointments were convenient for patients and families and metrics were set and tracked to monitor improvement. By implementing new patient-centric processes and data tracking, more patients in rural communities receive the required follow up CHD care, leading to improved outcomes.
Abstract 249: Online Health Information for Myocardial Infarction: Trusted Source or Fake News?
Authors: Kumar Vishak , Abualenain Mohammed , Choi Andrew D
Published: May 2020

Objective:
As the internet is a leading destination for health information for patients, there is a need for this information to be accurate and easy to understand. In this study, we assessed the quality and readability of online health related information for myocardial infarction (MI) directed towards patients.

Methods:
Websites were collected from 3 search engines (Google, Yahoo! and Bing) using the search term “Heart Attack” on a newly installed Mozilla Firefox browser. The first 30 websites from each engine were selected and those belonging to advertisements, new articles and physician oriented sites were excluded. The resulting sites were assessed for quality using the DISCERN instrument via 2 physician investigators knowledgeable in MI and blinded to each other’s results; following this, the results were discussed amidst the team to agree on a coalesced score for each website. Health On the Net (HONcode) was also used as an added measure to assess quality. Readability was assessed using the Flesch-Kincaid Readability Ease (FLRE) and the Flesch-Kincaid Grade level (FLGL) tool.

Results:
Overall, 24 websites were assessed. The average overall quality for DISCERN was 2.58 out of 5 with a median of 2.5 while the average total DISCERN score was 37.75 out of 80; the highest total quality among them being 61 out of 80. Only 29.17% (7 of 24) of the websites were HONcode certified. The average FLRE was 59.07 out of 100, while the average FLGL was 7.28 with the lowest grade level being 5.20.

Conclusion:
Patient health related information, on average, were of lower quality, while those higher quality websites were deemed less readable and needed a higher level of education to understand. The average reading grade level was that of the 7
th
grade which is lower than what the average American reads at (8
th
grade). The highest quality website based on total DISCERN score was from Wikipedia, however FLRE and FLGL tell us it was also harder to comprehend for the average American. Going forward there are important opportunities to improve the quality of online health related information for MI, in order to remain a trusted source of medical information for patients.
Abstract 252: Implementation and Ongoing Evaluation of a Novel Method for Stroke Severity Assessment and Routing: NYC S-LAMS
Authors: Redlener Michael , Ben-Eli David , Lai Pamela , Lancet Elizabeth , Prezant David , Carrano Vincent , Asaeda Glenn , Magdon-Ismail Zainab , Murphy Sheree , Brandler Ethan S
Published: May 2020

Introduction:
For the New York City 911 system stroke population, we sought to create and monitor a system for identifying stroke and large vessel occlusion (LVO) and to route LVO patients to thrombectomy capable centers which would reduce delays in the provision of endovascular care.

Methods:
We trained all emergency medical technicians and paramedics in the NYC 911 system to perform the Los Angeles Motor Score and to evaluate speech in cases of suspected stroke. We used a minimum score of 4/6 on a combined scale to screen positive for a possible LVO. An on-line medical control (OLMC) contact was required for every case that screened positive. Patients were eligible for transport specifically to thrombectomy capable centers if they screened positive, symptoms were present for less than 5 hours, symptoms were not due to trauma or seizure and the patient was previously ambulatory.

Results:
In the first six months of activity, there were 907 OLMC contacts, consistent with our prediction of approximately 5 patients per day that was derived from our 911 system’s historical database. After excluding ineligible patients, of these, 328 were transported to primary stroke centers and 579 were transported to thrombectomy capable centers. Of the 579 transported to thrombectomy capable centers, 447 (77.2%) had a confirmed stroke diagnosis. There were 189 (32.6%) LVO cases and 76 (13.1%) intracranial hemorrhages. Median time from EMS arrival to endovascular intervention first pass was 182.6 minutes and from hospital arrival to first pass was 141.5 minutes.

Discussion:
Overall, the process behaved as expected. We believe that our system can be further refined to reduce time to intervention. Further investigation is required to determine whether or not the system improved outcomes for patients and whether or not any cases of LVO or ICH were missed.
Abstract 253: Abstract: Self-advocacy in the Diagnostic Process Among Emergency Department Patients: A Qualitative Study
Authors: Bondal Paula Emille C , Villanueva Mariel , Gleason Kelly T
Published: May 2020

Background:
Evidence suggests that including the patient in the decision-making process leads to better health outcomes. The objective of this qualitative study is to explore barriers and facilitators to self-advocacy among patients during the diagnostic process in the emergency department (ED).

Methods:
ED patients (n=16) completed 15-30 minute semi-structured phone interviews 2 weeks to 3 months following an ED visit. Patients were eligible who had at least one chief complaint linked to common, dangerous cardiovascular conditions that are often misdiagnosed (chest pain, dizziness, headache, abdominal pain, and/or cough). Interviews were transcribed verbatim and coded by two independent reviewers using an inductive thematic analysis approach.

Findings:
The participants’ average age was 51 years-old (range 26-73 years-old). 62.5% of participants identified their race as White, 37.5% Black or African American, and 6.2% Asian. Interviews centered on the patients’ experience with the diagnostic process in the ED, including expectations, communication with clinical care team, and satisfaction and understanding of follow-up plans. The analysis revealed three common themes: (1) Doctors perceived as having total authority. Patients voiced that they must do as prescribed and not question the explanation given for their health problems by the doctors, who were the experts. (2) Satisfaction without a thorough assessment. Patients reported an acceptance of being “rushed” from the ED without thorough diagnosis or explanation because they expect doctors to be busy. Patients are satisfied with being told their diagnosis is unknown but not life-threatening. (3) Patients reported a high-level of self-awareness of their baseline health status, and used their intuition to seek medical care. Three of the sixteen patients reported developing a dangerous cardiovascular condition, including a stroke and a venous thromboembolism, after discharge that potentially could have been identified in the ED. They each reported a self-awareness that a dangerous health situation may be developing, but a trust in providers’ decision-making to discharge them.

Conclusions:
The interviews shared common themes of reduced self-advocacy in the setting of the ED and trust in providers’ opinions over patients’ own intuition. In three cases, patients reported developing a dangerous cardiovascular condition shortly after discharge that may have been identified earlier with increased self-advocacy.Implications for Practice: The fast-paced ED system may exacerbate patient vulnerability and impede their willingness to assert themselves. Empowering patients to provide input in the diagnostic process may contribute valuable information that leads to more accurate diagnoses.
Abstract 258: Mortality Comparison of Right Bundle Branch Block and Left Bundle Branch Block in US Veterans Undergoing Left Heart Catheterization - A Long Term Follow-up Study
Authors: Garg Swapnil , Soofi Muhammad , Markert Ronald , Agarwal Ajay
Published: May 2020

Background:
The prognostic importance of right bundle branch block (RBBB) has been debated. It has been described as a benign variant, especially when compared to left bundle branch block (LBBB). We studied the presence of bundle branch blocks in a high-risk U.S. Veteran cohort.

Methods:
Retrospective electrocardiogram (ECG) analysis for presence of RBBB or LBBB was conducted in 1,535 consecutive patients presenting for left heart catheterization. Evaluated risk factors were gender, age, BMI, hypertension, hyperlipidemia, diabetes, smoking history, chronic kidney disease, reduced ejection fraction and history of previous revascularization. Mean follow up time was 112 ± 66 months.

Results:
Analysis of 1,535 ECGs revealed 113 patients with RBBB and 65 patients with LBBB. Risk factor burden between the two groups appeared similar with exception of higher incidence of reduced ejection fraction and previous revascularization in the LBBB group. Mortality of RBBB group was 92.0% compared to 96.9% of LBBB group. Mean time to death for RBBB group was 74.1 months compared to 61.0 months for LBBB group. Hazard ratio (HR) for RBBB with Cox regression controlling for aforementioned risk factors was 1.41, 95% CI = 1.14-1.74; p =.002. HR for LBBB controlling for the same risk factors was 1.84, 95% CI = 1.42-2.40; p =<.001.

Conclusion:
In a high-risk cohort of US Veterans, both LBBB and RBBB are independent risk factors for mortality. While LBBB is a known adverse risk factor, presence of RBBB portends a poor prognosis and warrants further research.
Abstract 259: Association Between 90-minute Door-to-balloon Time and Selective Exclusion of Myocardial Infarction Cases: Insights From the Cardiac Care Outcomes Assessment Program From Washington State
Authors: Yang Nancy , Nathan Ashwin , Hira Ravi S , Doll Jacob A , Groeneveld Peter W , Giri Jay , Fanaroff Alexander C
Published: May 2020

Background:
For patients presenting with ST segment elevation myocardial infarction (STEMI), shorter door-to-balloon (D2B) times are associated with lower mortality, and national quality improvement initiatives encourage hospitals to reduce D2B time to ≤90 minutes. Hospitals can exclude patients from public reporting for various non-system reasons. This raises the possibility that cases with D2B time marginally over 90 minutes may be excluded inappropriately to avoid detrimental effects of not meeting the cutoff.

Methods:
All adult patients with STEMI undergoing primary PCI in 2011-2018 in Washington State were identified from the Cardiac Care Outcomes Assessment Program, a statewide public reporting program. We compared the proportion of cases excluded from public reporting above and below the 90-minute D2B cutoff using Chi-Square analysis. We then plotted histograms of frequency of cases by D2B time and used a regression discontinuity framework to test for a discontinuity in the frequency of reported cases at 90 minutes, with a sharp cutoff at 90 minutes and 5-minute bandwidth around the cutoff.

Findings:
Of 19,348 patients, 7,436 (38.4%) were excluded from the D2B metric. Among patients with D2B time 85-90 minutes, 47.9% (477/996) were excluded, versus 54.4% (345/634) of patients with D2B time 90-95 minutes (p < 0.01). Patient and procedural characteristics were similar for those with D2B time 85-90 versus 90-95 minutes. After application of exclusion criteria, there appeared to be a visible discontinuity in the distribution of cases around 90 minutes (Figure). However, local quadratic regression with bandwidths of 5 minutes above and below the 90-minute cutoff did not find a significant discontinuity (p = 0.66).

Conclusions:
Among patients undergoing primary PCI for STEMI in Washington State, a higher proportion of patients with D2B time of 90-95 minutes were excluded from public reporting compared with 85-90 minutes; however, there was no evidence of a discontinuity in the frequency of reported cases around the 90-minute cutoff. Together, these findings suggest that although more patients are excluded above the cutoff, there is no evidence of systemic manipulation or inappropriate exclusion of cases near the cutoff.

Figure:
An overlaid distribution centered at 90 minutes of included and excluded cases
Abstract 261: Improving Hypertension Control Among an Underserved Urban Patient Population
Authors: Anand Shruti , Santillan Yeriko , Isaath Ameesh , Goldberg Tamara , Patel Dipal
Published: May 2020

Needs and Objectives:
Poorly-controlled hypertension is associated with increased risk of adverse cardiovascular outcomes and thus is an important healthcare quality metric for primary care practices. Yet achieving blood pressure goals among socially-complex, economically-disadvantaged patient populations can be challenging due to cost-related non-adherence, poor health literacy and other social determinant barriers. Indeed, by early 2019, only 59% of hypertensive patients at our inner-city community health clinic had a blood pressure less than 140/90. The goal of this resident-driven quality improvement (QI) project was to increase blood pressure control among our hypertensive patients to a network target of 75% over 6 months.

Setting and Participants:
Our project was implemented at the Ryan Adair Center, a Federally Qualified Health Center located in Central Harlem that serves as a primary care practice site for Internal Medicine residents. The patient population consists predominantly of Black and Latino patients, most of whom are on Medicaid and live well below the federal poverty line. Our target population was hypertensive patients.

Intervention:
We used the Plan-Do-Study-Act method to carry out our clinic-based project. PGY1’s at the site served as the QI project leaders with faculty oversight. Cycle 1 focused on nurse education regarding proper blood pressure measurement. Cycle 2 focused on home blood pressure monitoring including patient education on proper technique and the importance of maintaining a daily log. Cycle 3 focused on assessment of health literacy via a patient questionnaire. Cycle 4 focused on provider education by ensuring that our patients were prescribed an appropriate medication regimen based on ACC/AHA Guidelines. Cycle 5 focused on referring patients with continued poor control to community health coaches to identify barriers like nutrition, medication access, and health literacy.

Evaluation:
Using our clinic’s online hypertensive registry (DRVS), we tracked on a monthly basis the percentage of hypertensive patients who had controlled blood pressure (<140/90). Percent of patients at goal went from 59% in February 2019 to 73% in July 2019.

Discussion/lessons learned:
Through this project, we demonstrated a meaningful improvement in hypertensive control among an economically-disadvantaged, racially diverse urban patient population. Accurate nurse measurements, engagement of patients in self-management, and resident education on evidence-based medication standards have all contributed to this success. Future directions will explore the impact of community health coaches in hypertension control and use of standard questionnaire to assess health literacy.
Abstract 262: The Impact of Social Determinants of Health on Heart Failure Readmission in a Veteran Population: A Single Center Study
Authors: Mahabir Sunita K , Olarte Neal , Palacio Ana M
Published: May 2020

Background:
Chronic heart failure (CHF) affects more than 5 million Americans and accounts for approximately 1 million hospitalizations annually. Readmission in CHF patients is associated with higher mortality and consumes a significant portion of hospital resources. Readmission rates may be higher when socioeconomic factors limit medication compliance and follow-up. In light of the high prevalence of CHF and the penalties associated with readmission rates, our study aims to identify factors that place our veterans with CHF at higher risk for readmission and in so doing, develop a profile for patients with a high risk of readmission that will benefit from focused intervention. Our goal is to use the information acquired in this study to reduce CHF readmission in the Miami VAMC by 10% over a 12-month period.

Methods:
This is an ongoing retrospective study conducted at the Miami VAMC. The Strategic Analysis for Improvement and Learning (SAIL) report was used to identify patients with CHF who were admitted to the Miami VAMC over fiscal year 2019 (FY19), the period from September 2018 to August 2019. Data was collected on various clinical baseline characteristics and social determinants of health from the patients' electronic health records for those admitted as well as for those with recurrent admissions within FY19. Using a previously validated questionnaire, identified patients will undergo further interview, in person or by phone, to identify social factors that may place them at higher risk for readmission.

Results/Anticipated Results:
A total of 185 patients were admitted during FY19 and of these, 38 had recurrent admissions. The mean time to readmission was 82 days. 76% of the patients readmitted had heart failure with reduced ejection fraction. Multiple co-morbidities were seen in the readmitted group, the commonest being hypertension (82%), diabetes (63%) and chronic kidney disease (39%). Thirty percent of those readmitted had a history of illicit drug use compared to 26% of those who were not readmitted. This population was also found to have multiple psychiatric co-morbidities - depression, anxiety and post-traumatic stress disorder. The odds of having one or more readmission within 12 months was 25% greater in those with psychiatric illness than in those without.

Conclusion:
Preliminary data analysis shows that psycho-social factors may play a role in recurrent admission in CHF patients. Further data will be collected to determine the impact of factors such as housing, education level and income on readmission risk so that patients at high risk can be identified and targeted with improved care co-ordination services to reduce this risk. As a unified health system, the VAMC is uniquely equipped with resources to address these disparities.
Abstract 264: Utilizing Risk Scoring for Prescribing Statins to Hospitalized Patients to Primarily Prevent Coronary Artery Disease
Authors: Atere Muhammed , Lim William , Leelaruban Vishnuveni , Narala Bhavya , Herrera Stephanie , Foo Francine , Muzangwa Lloyd , Bhavsar Urvi , Ashique Nafia , Abukar Sarah , Grodman Richard S , Saverimuttu Jessie
Published: May 2020

Background:
Cardiovascular disease is the leading cause of mortality in the United States. Approximately 25% of total deaths in the United States are attributed to cardiovascular diseases. Modification of risk factors has been shown to reduce mortality and morbidity in people with coronary artery disease. Medications such as statins are well known for reducing risks and recent data has shown that statins are beneficial in the primary prevention of coronary artery disease. The purpose of this study is to assess whether statins are being prescribed on discharge to patients who are identified as intermediate to high risk using the ACC/AHA Pooled Cohort Equations.

Methodology:
We reviewed and analyzed the charts of hospitalized patient’s ages 40 to 79 years who were discharged under the service of Internal Medicine at Richmond University Medical Center from September 2018 to August 2019. Exclusion criteria included: patients that expired before discharge or were admitted to the intensive or coronary care units, pregnancy, previous diagnosis of coronary/peripheral artery disease or stroke, already on statins or lipid-lowering medications, allergic to statins, discharged on statins for coronary/peripheral artery disease or stroke, and patients with liver disease or elevated liver enzymes. We used the ACC/AHA Pooled Cohort Equations risk to calculate the 10-year coronary artery disease risk for each patient.

Results:
The 10-year risk is grouped as low risk (<5%), borderline risk (5% to 7.4%), intermediate risk (7.5% to 19.9%) and high risk (≥20%). Among 898 patients, 10% had intermediate and high risk that were not discharged with statins. Among the 10%, about 6.6% were intermediate risk and 3.4% were high risk.

Conclusions:
A significant number of intermediate and high-risk patients were discharged without statins, although a CT coronary calcium may be helpful in further classifying the risk in some of them. We believe that a lipid profile should be checked in all hospitalized patients 40 years and older in order to calculate their atherosclerosis cardiovascular disease risk score and to possibly initiate statins after discussing the benefits and side effects, particularly in the intermediate risk group. The continuation of statins would be followed up by their primary care physicians. We plan to liaise with the information technology department in our facility to provide a link to the risk calculator in the electronic medical record so that the risk can be calculated and statins initiated as necessary. We will conduct a follow up review to assess for effectiveness.
Abstract 27: Patients' Perspectives on a Decision Aid to Facilitate Cost-sensitive Decisions for Sacubitril-Valsartan
Authors: Mitchell Andrea R , Venechuk Grace , Allen Larry A , Matlock Dan D , Moore Miranda , Morris Alanna A , Speight Candace , Dickert Neal W
Published: May 2020

Background:
Decision aids frequently focus on decisions that are preference-sensitive due to an absence of superior medical option or qualitative differences in treatments. Out of pocket cost can also make decisions preference-sensitive. However, cost is infrequently discussed with patients, and cost has not typically been considered in developing approaches to shared decision-making or decision aids. Determining a therapy’s value to a patient requires an individualized assessment of both benefits and cost. A decision aid addressing cost for sacubitril-valsartan in heart failure with reduced ejection fraction (HFrEF) was developed because this medication has clear medical benefits but can entail appreciable out-of-pocket cost.

Objective:
To explore patients’ perspectives on a decision aid for sacubitril-valsartan in HFrEF.

Methods:
Twenty adults, ages 32-73, with HFrEF who met general eligibility for sacubitril-valsartan were recruited from outpatient HF clinics and inpatient services at 2 geographically-distinct academic health systems. In-depth interviews were conducted by trained interviewers using a semi-structured guide after patients reviewed the decision aid. Interviews were audio-recorded and transcribed; qualitative descriptive analysis was conducted using a template analytic method.

Results:
Participants confirmed that cost was relevant to this decision and that cost discussions with clinicians are infrequent but welcomed. Participants cited multiple ways that this decision aid could be helpful beyond informing a choice; these included serving as a conversation starter, helping inform questions, and serving as a reference later. The decision aid seemed balanced; several participants felt that it was promotional, while others wanted a more “positive” presentation. Participants valued the display of benefits of sacubitril-valsartan but had variable views about how to apply data to themselves and heterogenous interpretations of a 3% absolute reduction in mortality over 2 years. None felt this benefit was overwhelming; about half felt it was very small. The decision aid incorporated a novel “gist statement” to contextualize benefits and counter tendencies to dismiss this mortality reduction as trivial. Several participants liked this statement; few had strong impressions.

Conclusion:
Out of pocket cost should be part of shared decision-making. These data suggest patients are receptive to inclusion of cost in decision aids and that a “middle ground” between being promotional and negative may exist. The data, however, raise concerns regarding potential dismissal of clinically meaningful benefits and illustrate challenges identifying appropriate contextualizing language. The impact of various framings warrants further study, as does integration of decision aids with patient-specific out-of-pocket cost information during clinical encounters.
Abstract 278: Phenomapping of Worsening Renal Function During Hospitalization for Acute Heart Failure
Authors: Yagi Ryuichiro , Kosaka Shun , Takei Makoto , Endo Ayaka , Hirata Naoki , Suzuki Kenji , Hasegawa Tasuku , Shoji Satoshi , Shiraishi Yasuyuki , Saji Mike , Nishihata Yosuke , Goda Ayumi , Sujino Yasumori , Nagatomo Yuji , Kohno Takashi , Takahashi Toshiyuki , Fukuda Keiichi , Yoshikawa Tsutomu
Published: May 2020

Background:
Worsening renal function (WRF) during the hospitalization has been recognized as a predictor for worse outcomes in patients with acute heart failure (AHF). However, in recent years, elevation of serum creatinine during the acute phase of the treatment is accepted as a sign of efficient decongestion. Herein, we aimed to evaluate the phenotypic difference in this heterogeneous phenomenon by using clustering analysis.

Methods:
A total of 4000 patient data from the West-Tokyo Heart Failure Registry, a multicenter, prospective registry for consecutive AHF hospitalization were analyzed. Within 632 patients identified to have WRF (17%; defined as elevation of eGFR over 20 percent during the hospitalization), we applied two-step clustering analysis of phenotypic data (37 variables) to define and characterize phenotypically distinct population. After identification of phenotypically distinct subgroups, survival analysis with Cox proportional hazard was conducted to elucidate the impact of the classification on composite outcomes of heart failure re-hospitalization and all cause death.

Results:
The analysis identified four distinct populations (group 1-4) that distinctly differed in terms of clinical characteristics: Group1 composed of patients with reduced ejection fraction (EF), while group 2 to 4 were composed of patients with mid-range and preserved EF. Group 1 patients also had lowest eGFR and blood pressure at the time of admission. Group 1 and 2 patients were younger, but had higher plasma BNP compared to 3 and 4. Among these subgroups, group 1 had the worst, and group 2 had the most favorable prognosis. The difference in prognosis between these two groups was significant after adjustments with known prognostic factors (hazard ratio, 0.58; 95 percent confidence interval, 0.35-0.97).

Conclusion:
WRF represents heterogeneous condition; our clustering analysis revealed four phenotypically distinct population with significant difference in their prognosis. Further investigation is needed to assess its therapeutic implication.
Abstract 28: Health Care Cost Burden of Infective Endocarditis in United States: A Nationwide Study
Authors: Lone Ahmad Naeem , Khan Muhammad , Khan Muhammad U , Khan Safi U , Balla Sudarshan
Published: May 2020

Introduction:
Aging population and recent opioid epidemic have contributed to increase incidence and cost of Infective endocarditis (IE). We aimed to assess health care burden of IE using nationally representative derived data that is designed for inpatient health care cost and utilization.

Methods:
Using the National inpatient sample (NIS), we examined 591,871 hospitalizations with a diagnosis of IE from 2002 to 2016. Risk Adjusted rates were calculated using univariate generalized logistic model for analysis of co variance. Trends were assessed with Linear regression and Pearson’s Chi square when appropriate.

Results:
Mean age of admission was 59.2[SD;18.8]. Females represented 40.9% (242,024 of 591871) of admissions. The proportion of patients with history of drug use increased from 11.5% (3,361 of 29,226) in 2002 to 23.1% (12,385 of 53,615) in 2016. We noticed an overall downtrend in mortality, from 16.4% (4,450 of 27,134) in 2002 to 8.8% (5,370 of 61022) in 2016. There was also a downtrend in the mean length of stay (16.2 days in 2002 to 14.2 days in 2016, p<0.01) but increase in the adjusted for inflation average cost ($100,643 in 2002 to $168,734 in 2016, p<0.01). There was also an increase in hospital-based procedures like valvular surgery.

Conclusion:
In-hospital mortality from IE has been on a decline but total hospitalization and average cost of stay in IE has increased. The reasons behind this warrant further investigation.