bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 148: Evaluation of Value, Relevance and Comprehensiveness of a Web-based Heart Failure Toolkit
Authors: Sahay Anju , Mittman Brian , Heidenreich Paul A
Published: March 2022

Objective:
Reducing readmission rates for heart failure (HF) patients is the primary goal of the Department of Veterans Affairs (VA) and its Chronic Heart Failure (CHF) QUERI. Since its establishment in 2005 the CHF QUERI has undertaken many initiatives to improve the quality of HF care by providers for Veterans. One such initiative is the development of a comprehensive evidence-based “Heart Failure Toolkit for Providers”. This is a web-based toolkit with links and downloadable PDF documents. It has been developed through collaboration with the members of the CHF QUERI’s Heart Failure (HF) Provider Network along with existing quality tools provided by non-VA organizations.

Method:
Using a mixed methods approach we gathered quantitative data using a cross-sectional web-based survey from all current members of the HF Network who have been participating in it for at least six months (n=878). The response rate was 24.9%. Qualitative data was gathered from semi-structured phone interviews of selected HF Network members who hadn’t responded to the survey (n=25).

Results:
Survey finding showed 133 member respondents (61.3%) were aware of the HF Toolkit and all of them had accessed it 1-9 times. Among them 60.9% had recommended and/or sent the link for the toolkit to other providers. These members perceived the toolkit positively in terms of its usability to manage HF patients (96.6%), comprehensiveness of topics (98.3%), layout of web-based toolkit (97.4%) and opportunity to provide feedback about the availability of tools and/or upload other tools (93.0%). These members felt the toolkit helped provide evidence-based care for HF patients (98.0%), helped improve their quality of care (98.1%), helped educate providers about current standards of HF care (99.0%), and can be used by providers in primary care and by teamlets (98.0%) at all types of small/ large and urban/rural facilities (98.0%).

Interestingly, qualitative data substantiated these findings. 75% of the members had heard about the HF Toolkit, and 57% of them specifically mentioned the following components as being extremely useful: patient education, guidelines, clinical pathways, order sets and discharge instructions. The organization of the toolkit was cited as a key contributor to its ease of use. Several of the members also appreciated the direct access to information specific to the VA context.

Conclusions:
VA providers and staff found an online toolkit valuable in the management of heart failure patients.

Implications:
Evidence-based comprehensive, well-organized and easily accessible resources are helpful for improved outcomes of heart failure patients.
Abstract 154: Trends in the Use of Lipid Lowering Therapies and LDL-C Levels in the US Adult Population with High Cardiovascular Risk Between 2003-2012
Authors: Ton Thanh G , Camphina-Bacote Avrita , Yurgin Nicole , Stevens Warren
Published: March 2022

Background:
Cardiovascular disease (CVD) remains the largest cause of mortality worldwide, and will claim an estimated 20 million lives annually by 2030. For those at highest risk from CVD, lipid lowering therapies (LLT), including statins, are the mainstay of treatment. Despite the widespread use of LLTs, it remains unclear whether greater intervention is required to reduce LDL-C among those at high risk.

Objectives:
We examined the utilization patterns of LLTs between 2003-2012, and the proportion of LLT users with LDL<70 mg/dL among those in the 4 statin benefit groups (SBGs) defined by the 2013 American College of Cardiology and the American Heart Association (ACC/AHA) guidelines.

Methods:
We used data from National Health and Nutrition Examination Survey (NHANES) between 2003-2012 to assess trends in LLTs use and percent of users with LDL-C<70 mg/dL among adults ≥18 years old in the US population who met the criteria for the 4 SBGs. We calculated frequencies, means, and percents that were weighted using NHANES-provided population weights to obtain population estimates. We conducted linear trend tests to assess whether changes in estimates were statistically significant over time.

Results:
The percent of adults in the 4 SBGs who used LLTs increased from 31% to 47% (p<0.001) between 2003-2012. In particular, the two SBGs with a statistically significant increase in LLTs between 2003-2012 were the group with atherosclerotic cardiovascular disease (ASCVD) (p<0.001) and the group with type 2 diabetes (p=0.046). Among LLT users overall, the percent with LDL-C<70 mg/dL increased from 11% in 2003-2004 to 22% in 2011-2012 (p<0.001). The type 2 diabetes SBG was the only one of the 4 SBGs to have a significant improvement from 2003-2012 in the percent of LLT users with LDL-C < 70 mg/dL (p=0.014). In 2011-2012, 46% of the LLT users in the type 2 diabetes SBG had an LDL-C <70 mg/dL. The other 3 SBGs experienced no significant change in the percent of LLT users with LDL-C < 70 mg/dL, even when there was an increase in the use of LLTs in that group. For instance, among people with ASCVD, 73% used LLTs in 2011-2012, yet only 20% of these users had LDL-C<70 mg/dL.

Conclusions:
Despite an increase in the number of people considered at high risk by the ACC/AHA guidelines and the significant rise in LLT use between 2003-2012, few LLT users have LDL-C levels less than 70 mg/dL. With recent evidence showing that lower LDL-C levels confer the greatest decreases in risk of cardiac events, a significant treatment gap and opportunity to intensify treatment remains in the US adult population at high cardiovascular risk.
Abstract 157: An Early Assessment of Hospital Readmissions Among Nonvalvular Atrial Fibrillation Treated with the New Oral Anticoagulants, Apixaban, Dabigatran, and Rivaroxaban
Authors: Deitelzweig Steve , Bruno Amanda , Trocio Jeffrey , Tate Natalie , Lin Jay , Lingohr-Smith Melissa
Published: March 2022

Background:
As the new oral anticoagulants (NOACs), dabigatran, rivaroxaban, and apixaban, have been introduced to the market for the indication of nonvalvular atrial fibrillation (NVAF) no studies have examined their impact on hospital readmissions. The objective of this study was to provide an early assessment of hospital readmissions among hospitalized NVAF patients treated with the 3 different NOACs in the US.

Methods:
Patients (≥18 years) with a hospital discharge diagnosis of AF who received apixaban, dabigatran, or rivaroxaban during hospitalization were identified from the Premier Hospital database between 1/1/2012 and 2/28/2014. Patients were grouped into 3 cohorts depending on the NOAC received. Patient characteristics, hospital resource use, and costs associated with the initial hospitalizations and readmissions within 1 month were evaluated and compared among patients treated with the 3 NOACs at the unadjusted and regression adjusted levels.

Results:
Among NVAF patients included in the study population, 4,138 were treated with apixaban, 37,754 were treated with rivaroxaban, and 32,838 were treated with dabigatran during hospitalization. Patients who received apixaban were older, had greater severity of comorbidity, and had higher stroke and bleeding risks (Table). At the unadjusted level, mean total hospital costs for readmission were $2,065, $2,345, and $2,078 for patients treated with apixaban, rivaroxaban, and dabigatran, respectively. After controlling for patient characteristics, including stroke and bleeding risks, in comparison with use of apixaban, the odds of all-cause and bleeding-related 1-month hospital readmissions for rivaroxaban were estimated at 1.2 (p<0.001) and 1.4 (p<0.01) respectively and for dabigatran at 1.1 (p=0.18) and 1.2 (p=0.13) respectively. In comparison with use of apixaban, the use of rivaroxaban and dabigatran were associated with longer average hospital length of stay (0.25 days, p<0.001; 0.11, p=0.08 respectively) and higher hospital cost per patient ($418, p<0.01; $156, p=0.27 respectively) due to the 1-month readmissions.

Conclusion:
In this early assessment, treatment with rivaroxaban vs. apixaban was associated with greater risk of all-cause or bleeding-related 1-month readmissions and higher hospital costs due to readmissions.
Abstract 166: Developing the Veterans Affairs Cardiac Risk Score
Authors: Sussman Jeremy B , Wiitala Wyndy , Hofer Timothy , Zawitowski Matthew , Vijan Sandeep , Hayward Rodney
Published: March 2022

Objective:
The risk-based approach employed in the 2013 ACC/AHA lipid guidelines is based on extensive research showing that cardiovascular (CV) risk, not individual risk factors like LDL levels, are more efficient and effective guides for CV prevention pharmacotherapy. The primary limitations of the guideline are ease of use and specific risk scores’ poor calibration between different populations. We hypothesized that we could create a risk tool that solves these problems for 6 million Americans with a relatively small investment by creating an automated risk prediction tool that only uses the VA electronic health record. We hypothesize that this tool will perform as well or better than existing risk tools.

Methods:
Our population consisted of US Veterans ages 45-80 who used VA ambulatory care services in 2001. Participants could have no history of myocardial infarction (MI), stroke, coronary artery bypass grafting, percutaneous coronary intervention, congestive heart failure, or furosemide use. We divided our population into derivation and validation cohorts. We predicted events using traditional risk factors and other established risk factors. Our outcome variable was new-onset MI, stroke, or cardiovascular mortality. We obtained outcome data from VA sources, Medicare, and the National Death Index. We predicted events with logistic regression. We compared the effect of using our risk score in our population with using the “ASCVD” score and the Framingham Score. We then assessed the implication on statin use of guiding care with the ASCVD score vs. our new VARS score.

Results:
Our population had 1.7 million patients. 96% were men. The AUROC was 0.68 for both the VARS score and the ASCVD score in our population. However, the ASCVD score substantially
underpredicted
events, by well over 20% . The VARS score was well-calibrated in the validation analysis. In our sample, almost all US Veterans age 45 and older had a cardiac risk that would recommend statin use.

Conclusion:
We demonstrated that an EHR in a specific population could risk-stratify patients as well those from as organized cohort studies and greatly improve calibration. Further, our finding that the ASCVD score greatly underpredicted in our population, while previous work have reported the ASCVD over-predictind in other cohorts, suggests that rather than arguing about which risk tool is best, our patients may be better served by us focusing on calibrating CV risk tools for our specific patient population using their EHR data.
Abstract 180: Variation in the Use of Angiography Between Procedural and Non-procedural Cardiologists
Authors: Thompson Lauren E , Furniss Anna , Masoudi Frederick A , Peterson Pamela N , Havranek Edward P , Dickinson L Miriam , Main Debbi , Karimkhani Elhum , Daugherty Stacie L
Published: March 2022

Background:
Physician specialty is associated with adherence to practice guidelines; clinical activities may influence management approaches when guidelines create equipoise. In a scenario in which either a non-invasive stress test or invasive angiography is appropriate, we hypothesized that cardiologists who perform cardiac procedures would be more likely to recommend an invasive approach compared to non-procedural cardiologists.

Methods:
We developed a web-based, email survey with a 2-part standardized patient case. The first part described a patient with symptoms suggestive of obstructive coronary artery disease (CAD) the second part described an abnormal exercise treadmill test (ETT) result in that patient. In both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD. Providers were asked to rate the likelihood of obstructive CAD and choose between angiography and stress testing for that patient; both a secondary stress and angiography would be consistent with guidelines. Cardiologists were classified based on self-report to non-procedural (general, non-invasive, heart failure/transplant, congenital) or procedural (invasive, interventional, electrophysiology and cardiothoracic surgery) practice. Multivariable models were used to determine the association between procedural practice and referral for angiography controlling for provider factors (age, gender, years in practice, practice setting) and estimated likelihood of CAD for that patient.

Results:
Of the 500 cardiologists who responded, 41.8% were procedural cardiologists. Procedural cardiologists similarly rated the patient as having a high likelihood for CAD (part 1: 38.8% vs 40.9%, p= 0.63; part 2: 81.8% vs 81.1%, p = 0.84) compared to non-procedural cardiologists. Although for a patient with intermediate risk of CAD by symptoms, more procedural cardiologists recommended direct angiography referral (12% vs 5.6%, p <0.01) than non-procedural cardiologists. In multivariable models, procedural practice remained associated with higher direct angiography referral (OR 2.67; 95% CI 1.30, 5.49, p= 0.008). After an intermediate risk ETT result, both groups recommended angiography more often (70.5% vs 68.2% p=0.58) than secondary stress testing.

Conclusions:
Procedural cardiologists more often referred a patient with symptoms concerning for CAD directly for angiography compared to non-procedural cardiologists. When presented an abnormal stress test, both groups were equally likely to recommend angiography over additional stress testing. Therefore, clinical activities may influence management approaches; procedural cardiologists pursued an invasive approach earlier in the diagnostic pathway. Efforts to understand variation in invasive procedure use should take physician clinical activities into account.
Abstract 201: Increased Frequency of Early Dispensed but Unused Tpa Shortens Door to Needle Times in Potentially Eligible Thrombolysis Patients Presenting to a Tertiary Stroke Center
Authors: Siddiqui Khawja A , Ali Syed F , Anderson Christopher D , Rost Natalia , Schwamm Lee H
Published: March 2022

Introduction:
Door to needle time (DTN) is an important factor in determining patient outcomes after tPA, and varies widely across hospitals. We sought to determine if early dispensing of tPA in likely eligible patients further would shorten DTN times below 60 min, as suggested by the AHA Target Stroke Phase 2.

Methods:
Using our hospital’s GWTG-Stroke database we selected patients over 7 yrs (2007-Q2 through 2014-Q2) who presented within 4 hours of last known well and had a vial of tPA dispensed from the pharmacy. A “tPA return rate” was calculated as the proportion of these cases with tPA dispensed in whom it was not administered, and reported per quarter. Median DTN time and tPA return rate were displayed graphically by quarter and their association compared by Pearson’s r. A partial correlation, controlling for NIHSS, was also performed.

Results:
A total of 382 patients had tPA dispensed, and 143 (37.4%) of those had tPA returned unused. The tPA return rate increased over time and DTN decreased (Figure 1). The tPA return rate was negatively correlated with the median DTN time per quarter (R2 = 0.18, p =0.01) (Figure 2). When additionally controlling for median NIHSS per quarter, the correlation became weaker but remained significant (R2 = 0.14, p=0.03).

Conclusion:
Implementing a strategy of early dispensing of tPA for potentially eligible stroke patients was correlated with significant reductions in DTN times, with median DTN times per quarter consistently below 45 min in the final year. Our data remained significant even after adjusting for stroke severity. These data support the use of the early dispensing strategy recommended by Target Stroke to further reduce DTN times. Further research is warranted to confirm these findings.
Abstract 205: Improving Door to Needle Time for IV Thrombolysis in Stroke
Authors: Johnson Brenda , Butler Jaime , Bojang Binta , Ortmann Melinda , Murtaza Umbreen , Lindauer Cathleen , Tolson Tina , Saheed Mustapha , Hill Peter , Urrutia Victor C
Published: March 2022

Background:
Door to Needle Time (DNT) for IV tPA administration in acute stroke, has become an important quality metric. The rationale for this is based on evidence that earlier administration of IV tPA, improves patient outcomes.

Methods:
In 2010 we undertook a review of our hospital’s performance and process for administration of IV tPA for acute stroke. At the time, we were already using 7 elements of the AHA’s Target Stroke 10 best practices.

We created a pocket card for our Brain Attack team to record the time at which each task in the process was completed. We found that the greatest delay was in the time between the decision to treat and administration of tPA. The factors that contributed were insertion of a Foley catheter (part of our order set at the time), blood pressure control, and mixing tPA.

We instituted the 3 remaining Target Stroke best practices: activation of the Brain Attack team upon EMS advance hospital notification, mixing tPA ahead of time (right after CT scan), and prompt data feedback (case by case and aggregate).

We also eliminated the Foley catheter insertion requirement from the order set, instituted a streamlined blood pressure control guideline, created an incentive pin awarded for treatment under 60 minutes, started timely case by case review and feedback, and included DNT on our department’s safety dashboard.

Results:
From 2007 to 2010, there were 5/43 (11.6%) patients with a DNT less than 60 minutes (DNT<60), and the average yearly median DNT was 80 min.

After implementation:
In 2011, DNT<60 was 5/14 (35.7%) and median DNT was 67 min.

In 2012, DNT<60 was 11/28 (39%), DNT<45: 1/28 (3.6%),and median DNT was 67 min.

In 2013, DNT<60 was 16/39 (41%), DNT<45: 3/39 (7.7%), and median DNT was 68 min.

In 2014, DNT<60 was 19/39 (49%), DNT<45: 7/39 (18%), and median DNT was 61 min.

Adjusted (aDNT<60) results based on the Get With The Guidelines accepted medical reasons for exclusion of the metric (released in the Fall of 2012).

In 2013, aDNT<60 was 8/13 (61.5%) and median DNT was 55 min.

In 2014, aDNT<60 was 9/10 (90%) and median DNT was 56 min.

Conclusions:
Efforts to reduce DNT are effective and create incremental improvement over time. The organization required to lower door to needle time, results in an increase of the number of patients treated. This may be a result of the greater efficiency needed to achieve fast administration of IV tPA, which in turn, improves recognition of stroke patients and efficiency of decision making.

Our experience demonstrates that these gains are sustainable.
Abstract 206: Aiming to Improve Stroke Care Continuity with Primary Care Follow-up Appointments Scheduled Prior to Hospital Discharge
Authors: Prvu Bettger Janet , Burns Brianna , Lender Stacy , Nutter Diane ,   On Behalf of the Ohio Coverdell Stroke Program Leadership, Participating Hosps and Partners
Published: March 2022

Background:
Follow-up care can facilitate patient recovery. To improve care continuity the Ohio Coverdell Stroke Program aimed to improve the proportion of hospitalized stroke patients for whom prior to discharge the hospital scheduled a follow-up appointment with primary care. This is not yet standard of care for stroke.

Methods:
Of 48 Ohio Coverdell Stroke Program participating hospitals, 37 had data entered into the registry for each quarter of the 12 month quality improvement initiative. Admitted stroke patients of any type planned for discharge home were included. Patients younger than 18 years of age, not admitted to the hospital from the emergency department, or admitted and only receiving comfort care were excluded. Patient-level and hospital-level data were examined to determine performance in a 6 month baseline period (quarters 1-2) and a 6 month active improvement phase (quarters 3 and 4). Patients discharged with and without an appointment scheduled were compared to identify targeted areas for continued improvement.

Results:
There were 4,558 stroke patients discharged home over 12 months from 37 geographically distributed hospitals (62.4% ischemic stroke, 29.0% TIA, 8.5% hemorrhagic stroke). At baseline, 13.4% of patients had an appointment scheduled with a primary care provider prior to discharge home. This increased to 18.7% in quarter 3 and 26.6% in quarter 4, representing a 98.5% improvement from baseline to quarter 4 in the proportion of patients with a primary care follow-up appointment scheduled. Median quarter 4 performance at a hospital level was 10.5% (distributed from 0-80.0% across 37 hospitals). Analysis of patient characteristics showed differences in the proportion of patients with an appointment by age (15.5% for ages>65 years vs. 18.5% of younger patients, p=0.004); race (15.1% white race vs. 22.1% of African Americans, p<0.001); history of prior stroke (19.0% with prior stroke vs. 16.3% with no prior stroke, p=0.031); comorbid diabetes (18.6% with diabetes vs. 16.1% without, p=0.021); dyslipidemia (18.2% with vs. 15.6% without, p=0.013); and obesity (14.4% were obese/overweight vs. 17.7% who were not overweight/obese, p=0.007). No significant patient level differences were found by patient sex, insurance, stroke type, stroke severity, prior myocardial infarction or coronary artery disease, prior TIA, family history of stroke, or comorbid atrial fibrillation, heart failure, or hypertension.

Conclusions:
Hospital performance with scheduling primary care follow-up appointments improved significantly; however, only 1 in 4 patients had an appointment scheduled prior to discharge. Case study analysis of missed opportunities may help identify barriers and facilitators associated with access, availability, and awareness that can be addressed in future improvement cycles.
Abstract 208: Association of Hospital Prices for Coronary Artery Bypass Graft Surgery with Hospital Quality and Reimbursement
Authors: Giacomino Bria , Cram Peter , Vaughan-Sarrazin Mary , Girotra Saket
Published: March 2022

Background:
Although prices for medical services are known to vary markedly between hospitals especially for patients without medical insurance, it remains unknown whether this large variation in price is explained by differences in hospital quality or reimbursement from major insurers.

Methods:
We obtained an “out-of-pocket” hospital and physician price estimate for a coronary artery bypass graft (CABG) surgery for a hypothetical patient without medical insurance via telephone call from a random sample of U.S. hospitals during January 2014. We examined whether the price provided by a hospital was associated with its 1) structural characteristics obtained from the American Hospital Association data, 2010 2) risk-standardized CABG mortality obtained from the Society of Thoracic Surgeons data, 2013 and 3) “fair price” estimate for CABG base don reimbursement data from major insurers in the zip code of the hospital location (Healthcare Bluebook, www.healthcarebluebook.com).

Results:
We contacted a total of 111 U.S. hospitals, of which 56 (50.5%) were able to provide a price estimate for CABG. The mean price for CABG obtained from the hospitals was $151,784.64, and ranged from $44,824 - $448,039. Except geographic location (p=0.03), which was weakly associated, hospital prices for a CABG surgery were not associated with teaching status, for-profit/not-for-profit/government classification, urban/rural location, or CABG volume (p >0.10 for all). Likewise, we found no association between a hospital’s quoted price for CABG and its risk-standardized CABG mortality (r= -0.03 p=0.89), or its average reimbursement for CABG surgery from major insurers within the same zip code (r= 0.07, p=0.6).

Conclusion:
We found a 10-fold variation in the prices obtained from U.S. hospitals for CABG surgery for an uninsured patient. Although there was slight variation in CABG surgery prices based on geographic region, we found no evidence to suggest that hospitals with higher prices have lower mortality or receive higher reimbursement from insured patients.
Abstract 210: Evaluation of US Prescription Patterns: Are Treatment Guidelines For Cancer-associated Venous Thromboembolism (VTE) Followed?
Authors: Khorana Alok , Yannicelli Daniel , McCrae Keith , Milentijevic Dejan , Crivera Concetta , Nelson Winnie W , Schein Jeff
Published: March 2022

Background:
VTE is a major contributor to morbidity and mortality in cancer patients. Although low-molecular-weight heparins (LMWHs) are recommended by most guidelines for treatment of cancer-associated VTE, compliance with this recommendation is unknown.

Aims:
To assess treatment patterns of anticoagulation for treatment of cancer-associated VTE in the United States.

Methods:
We conducted a retrospective cohort study utilizing MarketScan® Treatment Pathways dataset (80 million insured lives) between 1/2009 and 7/2014. Patients were included if they had a new diagnosis of cancer of lung, breast, prostate, stomach, colon, pancreas genitourinary, gynecologic, or brain and developed VTE. Patients with prior VTE or anticoagulation were excluded. Time to VTE diagnosis, utilization, and switching patterns of anticoagulants were evaluated.

Results:
Of 1.7 million newly diagnosed cancer patients, 105399 (6.2%) developed VTE at a median of 181 days. Rates of VTE varied by cancer site, ranging from 4% (breast) to 17% (pancreas). Median time to VTE diagnosis ranged from 74 (brain) to 365 days (prostate). Of 52911 patients who were prescribed anticoagulants as outpatients, half (N=26456) received warfarin, 40% (N=21164) received LMWH, and 10% (N= 5291) received other oral anticoagulants. Patients on injectables persisted less on treatment than those on oral anticoagulants. Amongst patients on LMWH, 44% switched to warfarin (79%) and other anticoagulants (21%), while 28% on warfarin switched to LMWH (77%) and other anticoagulants (23%). Median time to switch was 23 days for LMWH and 98 days for warfarin.

Conclusion:
Despite guidelines recommendations, warfarin was the most utilized anticoagulant for outpatient treatment of VTE in cancer. Even of those treated with LMWH, nearly half switched to other anticoagulants, often early in the course. More patients persisted on oral than injectable agents, which may be related to the burden of self-injection or costs.
Abstract 22: Cost of Transcatheter Aortic Valve Replacement in Medicare Patients
Authors: McCarthy Fenton H , McDermott Katherine M , Anwaruddin Saif , Giri Jay , Hoedt Ashley C , Kobrin Dale , Szeto Wilson Y , Groeneveld Peter W , Desai Nimesh D
Published: March 2022

Background:
The financial impact of transcatheter aortic valve replacement (TAVR) in the US remains unknown. A rigorous comparison to surgical aortic valve replacement (SAVR) costs and payments is warranted.

Methods:
Medicare claims provided hospital charges and Medicare payments for patients undergoing SAVR or TAVR between January and December 2012. Hospital-specific cost-to-charge ratios were used to estimate hospital costs. Charges, payments, and costs were examined in a group of TAVR and SAVR patients propensity-matched by age, sex, and common comorbidities (n=3281 pairs).

Results:
In the propensity-matched sample, Medicare payments were lower for TAVR hospitalizations ($52,200 ± $28,200) than for SAVR hospitalizations ($56,300 ± $32,600, p<0.001). Estimated hospital costs were not significantly different between TAVR ($55,700 ± $26,700) and SAVR ($54,700 ± $36,600) hospitalizations (p=0.185). The difference between estimated hospital costs and payer reimbursements was greater for TAVR hospitalizations ($2,800 ± $23,500, representing a net loss) than for SAVR hospitalizations (-$2,600 ± $18,500, representing a net profit, p<0.01). Post-procedure length of stay was significantly shorter for TAVR patients than for SAVR patients (6.6 ± 5.6 days vs. 10.0 ± 8.1 days, p<0.001). The same was true for total ICU stay (TAVR 3.4 ± 5.1 days vs. SAVR 6.2 ± 8.2 days, p <0.001).

Conclusions:
Among similarly high-risk patients, Medicare pays more on average for SAVR index hospitalizations than for TAVR index hospitalizations. Conversely, SAVR hospitalizations represent a net profit to providers, whereas TAVR hospitalizations represent a net loss. The magnitude of this loss may affect the future growth of TAVR programs as well as the diffusion of other, new high-cost cardiovascular interventions.
Abstract 220: Understanding Nonattendance in Cardiac Transitional Care
Authors: Steinbacher Michaela , Sylvester Rachel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: March 2022

Background:
Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner based transitional care clinic shown to reduce readmissions in acute coronary syndrome patients. Unfortunately, more than 20% of patients referred do not attend. This study aims to determine reasons for nonattendance.

Methods:
Patients who did not attend their BRIDGE appointments between February and June 2014 were contacted by phone and surveyed about their reasons for nonattendance. Patient records were abstracted for discharge (D/C) and BRIDGE appointment details.

Results:
Of 171 patients referred, 60 (35.1%) did not attend their BRIDGE appointment; 45 (75.0%) participated in the study. Reasons for nonattendance were grouped into five categories (Table 1). The majority of patients reported their health status (n=15) as a reason for nonattendance or simply made a choice to not attend (n=16). Many patients (n=30, 66.7%) did not recall receiving information about BRIDGE at D/C. However, of those who did (n=10) nearly all (90.0%) understood the rationale for the appointment (Table 2). A high percentage of these patients were readmitted within 30 days (n=11, 24.4%) and patients who reported being too ill to travel were readmitted more frequently (4 of 7, 57.1%). These rates are in stark contrast to the 8.3% 30-day readmission rate for attenders.

Conclusions:
Patients had a variety of reasons for nonattendance, illustrating multiple opportunities to impact attendance rates. Focus should be placed on identifying and addressing patients who are too ill to travel as they represent a population at high risk for complications post-discharge. Further research, in a larger sample, is warranted to better understand these patients and their transitional needs.
Abstract 221: Outcomes Associated with Warfarin Time in Therapeutic Range Among Nonvalvular Atrial Fibrillation Patients Treated in an Integrated Healthcare Delivery System in the U.S.
Authors: Deitelzweig Steve , Evans Michael , Hillson Eric , Trocio Jeffrey , Bruno Amanda , Tan Wilson , Lingohr-Smith Melissa , Lin Jay
Published: March 2022

Background:
The efficacy of warfarin therapy for stroke risk reduction among nonvalvular atrial fibrillation (NVAF) patients is reduced when its time in therapeutic range (TTR) is not optimal. This study assessed differences in healthcare resource utilization and costs among NVAF patients with different warfarin TTRs in an integrated healthcare delivery system (IHDS) setting in the U.S.

Methods:
Patients with NVAF were identified from an electronic medical record database (1/1/2004-8/31/2013). Patients were required to have ≥6 international normalized prothrombin time ratio (INR) tests to ensure chronic warfarin therapy. The first INR test was defined as the index event with the corresponding date as the index date. The warfarin TTR of NVAF patients was determined by the modified Rosendaal method. NVAF patients were grouped into two cohorts, those with warfarin TTR <60% (Low TTR) and those with warfarin TTR ≥60% (High TTR). Demographics, clinical characteristics, healthcare resource utilization and costs were evaluated during a 12-month follow-up period. Multivariable regressions were used to assess the impact of different levels of warfarin TTRs on healthcare costs.

Results:
NVAF patients in the high TTR cohort (n=1,595) had an average warfarin TTR of 73%, while patients in the low TTR cohort (n=1,356) had an average warfarin TTR of 45%. Total all-cause healthcare resource utilization was greater among patients in the low TTR cohort vs. the high TTR cohort (number of all-cause healthcare encounters: 70.2 vs. 56.1, p<0.001). The mean number of all-cause inpatient admissions (0.64 vs. 0.33, p<0.001), hospital length-of-stay (3.3 vs. 1.6 days, p<0.001), and ICU length-of-stay (0.21 vs. 0.09, p=0.02) were significantly greater for the low TTR cohort in comparison to the high TTR cohort during the follow-up period. After adjusting for patient characteristics, total healthcare costs for all-cause and stroke-related healthcare costs were $2,398 (p<0.001) and $687 (p=0.02) higher, respectively for patients in the low TTR cohort vs. the high TTR cohort (Table).

Conclusions:
NVAF patients with low warfarin TTR, in comparison to those with high warfarin TTR, used more healthcare resources resulting in higher healthcare costs.
Abstract 223: Outcomes of Older Patients Receiving Secondary Prevention Implantable Cardioverter Defibrillators: An Analysis From the NCDR ICD Registry
Authors: Betz Jarrod , Katz David , Peterson Pamela , Borne Ryan , Mathew Jehu , McManus David , Wang Yongfei , Hansen Carolina , Al-Khatib Sana , Masoudi Frederick
Published: March 2022

Background:
The clinical trials establishing the efficacy of implantable cardioverter defibrillators (ICDs) for secondary prevention of sudden cardiac death enrolled limited numbers of older patients. We sought to assess the morbidity and mortality of older patients receiving ICDs for secondary prevention in contemporary clinical practice.

Methods:
Using the NCDR ICD Registry, we identified 20,751 Medicare beneficiaries
>
65 years old who underwent secondary prevention ICD implantation between 2006 and 2010 in 1027 US hospitals. Using a probabilistic method, eligible subjects were matched to Medicare claims to assess longitudinal outcomes, including death, hospitalization, and skilled nursing facility (SNF) admission over 1 year. Outcomes were evaluated in strata according to age (<70, 70-74, 75-79, and >80 years).

Results:
The mean age of the cohort was 75 years at the time of implantation; 24.1% were<70 and 26.8%
>
80 (Table). Overall 1-year survival was 87%, with 91% and 82% in ages <70 and >=80 respectively. Regardless of age, hospitalizations at one year were frequent, ranging from 47% in <70 to 57% in
>
80. Early admission to a SNF was much higher for
>
80 (12%) than for <70 (4%) (p <0.01).

Conclusions:
In older patients receiving secondary prevention ICDs, 1-year survival was high in all age strata including age
>
80. However, rates of hospitalization and SNF admission indicate substantial care needs after device implantation.

Figure:
Abstract 226: Electrocardiographic and Echocardiographic Changes in Patients Undergoing Liver Transplant Stratified by Outcomes
Authors: Gajanana Deepakraj , Gupta Shuchita , Bhalla Vikas , Koshkelashvili Nikoloz , Rubio Manolo , Navarro Victor , Amanullah Aman
Published: March 2022

Background:
Association between electrocardiographic (EKG) and echocardiographic (Echo) parameters and outcomes in cirrhotic cardiomyopathy are not clear.

Methods:
We studied 73 adult patients with liver cirrhosis referred for liver transplantation between January 2007 and December 2013 at a tertiary liver transplant center. A complete 12-lead EKG and Echo was done prior to and after liver transplant. Patients with history of coronary artery disease, pre-existing heart failure and valvular heart disease were excluded. Standard 2D echo and diastolic function parameters were studied. We excluded 10 patients with incomplete data.

Results:
Mean age was 55± 8yrs, 65% (41 of 63) were men and the mean EF (ejection fraction) was 61±8%. Prevalence of diastolic dysfunction (DD) was 57% (36 of 63), of which 25%(9 of 36) were Stage 1, 67%(24 of 36) were Stage 2 and 8%(3 of 36) were Stage 3, respectively. There were 22(30%) deaths in the follow up period (1132 ± 795 days). Among the survivors, the PR-interval, QRS duration, QTC interval and Left atrial volume index showed statistically significant improvement compared to the deceased subjects. There was a trend towards improvement in DD post-transplant. Mortality was 15% in subjects with improved diastolic function versus 34% with worsening diastolic function (p=0.1). Death was predominantly due to non-cardiac complications (table).

Conclusions:
Prevalence of DD in cirrhotic cardiomyopathy was 57% in our study. There was a significant improvement in EKG and Echo parameters post-transplant. However, it did not significantly improve outcomes as most of the deaths were due to non-cardiac complications. Incidence of post-transplant major complications
Abstract 227: Treatment Variations in Early Dual Antiplatelet Therapy for Nstemi Patients Who Are at Risk for Undergoing Cabg
Authors: Shafiq Ali , Jang Jae-Sik , Kureshi Faraz , Valle Javier , Gosch Kensey , Jones Philip , Bach Richard , Cohen David , Spertus John
Published: March 2022

Background:
Current guidelines recommend “early” dual antiplatelet therapy (DAPT) with aspirin and an adenosine diphosphate P2Y12 inhibitor in patients with acute coronary syndromes. However, initiation of DAPT prior to defining coronary anatomy (“upstream” therapy) can increase bleeding complications_particularly among patients who ultimately require coronary artery bypass grafting (CABG). We sought to examine the use of upstream DAPT in contemporary practice and to determine whether clinicians consider the likelihood of requiring CABG in these decisions.

Methods:
The study group included patients with non-ST-elevation myocardial infarction (NSTEMI) selected from the 24-center TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) registry. Patients who were already taking a P2Y12 inhibitor were excluded. Demographics, clinical features and scores for predicting probability of CABG (GRACE CABG score) were compared between NSTEMI patients who did and did not receive early (within 24 hours of admission) P2Y12 inhibitor therapy. Multivariable analyses were used to identify factors associated with the early use of P2Y12 inhibitors.

Results:
Among 2,020 NSTEMI patients, 49% received a P2Y12 inhibitor early after admission. The patients in the early DAPT group were more likely to be white, but less likely to have a history of myocardial infarction, heart failure, lung disease or diabetes. The early DAPT group was also more likely to have a higher hemoglobin level, not be taking warfarin and have normal or mild LV systolic dysfunction on arrival to the hospital, as compared with the control group. Among the 658 patients with NSTEMI that had high GRACE CABG scores (>10), 52% received early P2Y12 inhibitor therapy. After adjustment, independent predictors of early P2Y12 therapy in NSTEMI patients are shown (Figure). High GRACE CABG score was not associated with reduced early DAPT use (OR 1.12, 95% CI 0.96 to 1.31, p = 0.157).

Conclusion:
Approximately half of NSTEMI patients were treated with early DAPT. There was no association between avoidance of early DAPT use and GRACE CABG score, suggesting that many clinicians may not be considering an important potential risk of early P2Y12 inhibitor treatment in NSTEMI patients.
Abstract 234: Comparison of Hospital Length of Stay and Costs between Non-valvular Atrial Fibrillation Patients Treated with Either Apixaban or Warfarin
Authors: Xie Lin , Vo Lien , Keshishian Allison , Price Kwanza , Singh Prianka , Mardekian Jack , Bruno Amanda , Baser Onur , Kim Jully , Tan Wilson , Trocio Jeffrey
Published: March 2022

Background:
Patients with non-valvular atrial fibrillation (NVAF) have an increased risk of stroke and are often treated with oral anticoagulants (i.e. warfarin). However, apixaban, a novel oral anticoagulant (NOAC), has been shown to significantly reduce stroke risk and result in a significantly shorter hospital length of stay (LOS) compared to those treated with warfarin.

Objectives:
To compare LOS and hospitalization costs among real-world hospitalized NVAF patients treated with apixaban or warfarin. Evaluate the difference in costs among different patient characteristics, including LOS and CHADS
2
score.

Methods:
Patients ≥18 years of age diagnosed with AF (ICD-9-CM code: 427.31) were identified from the Premier Perspective Claims Database (01JAN2009-31MAR2014). Patients were required to have 30 days of follow-up post-index hospitalization discharge. Patients with claims for mitral valvular heart disease, valve replacement procedures, pregnancy or other NOACs during the index hospitalization were excluded. Patients were classified into two cohorts (apixaban and warfarin) depending on treatment received during hospitalization. Demographic and clinical characteristics were collected 12 months prior to and during the NVAF index hospitalization. The two cohorts were 1:1 propensity score matched (PSM) on patient and hospital characteristics to compare hospital LOS (days) and index hospitalization costs. Additionally, costs were stratified by LOS and CHADS
2
score.

Results:
Before matching, patients treated with warfarin were older and sicker compared to those treated with apixaban. After 1:1 PSM, 2,571 patients were matched in each cohort, and baseline characteristics were well-balanced. The mean CHADS
2
score was 2.4 for both cohorts. The mean (standard deviation [SD], median) hospital LOS (p<0.001) was significantly shorter for patients prescribed apixaban (5.1 [5.7], 3 days) compared to warfarin (5.7 [5.3], 4 days). Patients treated with apixaban had significantly lower hospitalization costs compared to those prescribed warfarin ($11,115 vs. $13,483; p<0.001), specifically among patients with LOS ≤7 days (0-2 days: $4,909 vs. $5,780, p=0.006; 3-7 days: $9,430 vs. $10,289, p=0.007). The results were consistent when stratified by CHADS
2
score; patients with CHADS
2
0-1 ($9,761 vs. $13,418) and CHADS
2
≥2 ($11,607 vs. $13,506) treated with apixaban incurred significantly lower costs compared to those treated with warfarin (p<0.001).

Conclusions:
NVAF patients treated with apixaban had significantly shorter hospital LOS and lower index hospitalization costs compared to those treated with warfarin. Costs remained significantly lower for apixaban patients across all CHADS
2
scores.
Abstract 245: Cost Effectiveness and Safety of Abbreviated Eptifibatide Infusion in Veterans Undergoing Percutaneous Coronary Intervention
Authors: Ghadban Rugheed , Shah Ankur , Ampadu James , Linneman Travis , Thomas Jean-Alfred , Forsberg Michael , Stolker Joshua , Klein Andrew
Published: March 2022

Background:
For patients undergoing percutaneous coronary intervention (PCI), many interventional operators prescribe a bolus of intravenous glycoprotein IIb/IIIa inhibitor during PCI, followed by an infusion for several hours afterward. An abbreviated infusion of eptifibatide has been adopted by many operators based on a small randomized trial from 2009, in which early discontinuation after 2 hours was not inferior to the standard 18-24 hour infusion. However, no subsequent studies have evaluated the safety or cost-effectiveness of the abbreviated infusion among unselected PCI patients.

Methods:
Of the 1440 patients undergoing PCI at our institution between March 2009 and December 2010, we identified 108 who received the abbreviated eptifibatide infusion (33% undergoing PCI for acute coronary syndrome, 67% for stable coronary disease indications). We used 20 mg vials for bolus followed by 75 mg vials for the 2 hour infusion. All patients were treated with the standard intravenous double-bolus (180 mcg/kg) followed by a weight-based, renally adjusted infusion for 2 hours. For each patient we calculated the cost of the 2 hour infusion at our hospital using the actual amount administered, according to the number of vials required per patient. We then compared these findings to the estimated cost if a standard 18 hour infusion had been administered instead. We also collected data about pre-defined endpoints including: target vessel revascularization (TVR), clinical evidence of myocardial infarction, stroke, death, and stent thrombosis within 30 days of the procedure. In-hospital bleeding events, using the Bleeding Academic Research Consortium (BARC) definitions, were also collected.

Results:
In our patient population the mean dose required was 55.6 mg, resulting in 2.2 bolus and 1 infusion vials per patient, and an overall cost of $384 per patient receiving the 2 hour infusion. Using the same data for a standard 18 hour infusion, the mean drug dose would have been 224.2 mg, resulting in 2.2 bolus and 3 infusion vials per patient and $838 cost per patient. When comparing the 2 protocols in all 108 patients, using the abbreviated infusion saved 222 infusion vials (67%) and $4905 overall, or 161 mg (2 vials) and $454 cost per patient. Among these 108 patients, there was no TVR, myocardial infarction, stent thrombosis, or death within 30 days. One patient had transient ischemic attack (1%) and one patient had a type 1 minor bleed using the BARC definition (1%).

Conclusion:
In this real world cohort of patients undergoing PCI, an abbreviated 2 hour eptifibatide infusion after PCI was safe and had a cost savings of greater than 50% per patient, when compared with a standard 18 hour infusion. This approach is more cost-effective and should be considered in patients undergoing PCI who are not pretreated with dual antiplatelet therapy.