bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 147: The Trend of In-hospital Complications During Acute Ischemic Stroke Hospitalization Among US Elderly
Authors: Man Shumei , Schold Jesse D , Uchino Ken
Published: April 2019

Background:
Stroke is the fifth leading cause of death in the United States and the leading cause of long-term disability in adult. Many efforts have been devoted to improve the stroke quality of care. We aimed to examine the recent rate and trend of in-hospital complications among U.S. elderly who were hospitalized for acute ischemic stroke from 2009 to 2013.

Methods:
We examined the prevalence and trend of in-hospital pneumonia, urinary tract infection (UTI), deep vein thrombosis (DVT) and pulmonary embolization (PE) among Medicare beneficiaries aged 65 years and older who were hospitalized between January 2009 and December 2013 with a primary discharge diagnosis of acute ischemic stroke. The data of patient information were obtained from the Medicare Provider Analysis and Review file. The in-hospital complications were identified using the ICD-9 CM codes that have been previously validated.

Results:
A total of 1,070,574 Medicare beneficiaries were hospitalized for ischemic stroke between 2009 and 2013. The in-hospital pneumonia decreased from 17507 (7.7%) in 2009 to 14078 (6.8%) in 2013, an 11.7% decrease. The in-hospital UTI decreased from 34356 (15%) in 2009 to 29134 (14.1%) in 2013, a 6% decrease. The in-hospital DVT increased from 2263 (1.0%) in 2009 to 2605 (1.3%), a 30% increase. The in-hospital PE increased from 754 (0.3%) in 2009 to 800 (0.4%) in 2013, a 33% increase.

Conclusion:
Among Medicare beneficiaries who were hospitalized for acute ischemic stroke from 2009 to 2013, the prevalence of in-hospital pneumonia and UTI decreased while DVT and PE dramatically increased. These results call for further interventions to prevent in-hospital thrombotic complications.
Abstract 148: Differences Between Participants and Nonparticipants in a Survey of Community Patients with Heart Failure
Authors: Simsek Irmak , Manemann Sheila , Yost Kathleen , Chamberlain Alanna , Fabbri Matteo , Jiang Ruoxiang , Weston Susan , Roger Veronique L
Published: April 2019

Background:
Patient reported measures are fundamental to patient centered research and are often collected by questionnaires. Low participation can compromise the validity of the results; transparent reporting and comparing characteristics of participants to nonparticipants is important to assess the generalizability of survey results. We analyzed participation in a survey of social determinants of health among a population-based sample of patients with heart failure (HF).

Methods:
A total of 7920 residents from 11 Minnesota counties were identified with a first-ever code for HF (ICD-9 428 and ICD-10 I50) between 1/1/2013 and 12/31/2016. Participants completed a battery of 12 questionnaires by mail or telephone. Characteristics and outcomes data were extracted from medical records and compared between participants and nonparticipants. Response rate (RR) was calculated using guidelines of the American Association for Public Opinion Research (AAPOR). The association between nonparticipation and outcomes was examined by Cox proportional hazards regression for death and Andersen-Gill modeling for hospitalizations.

Results:
Among 7920 patients, 3438 responded to the survey (AAPOR RR#2= 43%). Numerous clinical and demographic differences between participants and non-participants were noted (Table), particularly for education, marital status, and neuropsychiatric conditions. After a mean (±SD) of 1.5±1 years after survey administration, 1,577 deaths and 5,873 hospitalizations had occurred. Nonparticipation was associated with a two-fold increased risk of death (HR: 2.30; 95% CI: 2.06-2.57; p<0.001) and a 10% increased risk of hospitalizations (HR: 1.10; 95% CI: 1.01-1.21; p=0.03) after adjusting for age, sex, marital status, coronary disease, arrhythmia, hyperlipidemia, cancer, chronic kidney disease, depression and anxiety.

Conclusions:
In a large survey of patients with HF, participation was associated with large differences in clinical and demographic characteristics and outcomes. Examining the impact of participation is critical to draw inference from studies of patient reported measures.
Abstract 151: Therapeutic Intensity in Medically Managed Incident Heart Failure Patients with and without Mitral Regurgitation: A Claims Based Analysis
Authors: McCullough Peter A , Cork David P , Mehta Hirsch S , Barker Colin M , Gunnarsson Candace , Ryan Michael , Mollenkopf Sarah , Van Houten Joanna , Verta Patrick
Published: April 2019

Background:
Understanding the therapeutic intensity of medically managed heart failure (HF) patients with and without secondary MR can be challenging when using claims data. This research showcases the development of a therapeutic intensity score (TIS) and reports the impact of the score on annual all-cause inpatient hospitalizations.

Methods:
This study included data from the Truven Health MarketScan Commercial Claims and Medicare Supplemental Databases from October 2011 to September 2016. Inclusion criteria were patients who had a minimum of 1 inpatient or 2 outpatient claims for HF with a 6-month pre-period (baseline). A 6-month post-period (landmark) after HF index was used to capture MR diagnosis and severity. Following the landmark period, patients were required to have 12 months of continuous medical and prescription drug plan enrollment with at least two records of HF medication refills. Additional exclusions (age under 18, chordal rupture, hospice, etc) were applied. TIS was calculated based on the patient’s pharmacologic regimen. Drug categories included but were not limited to: ACE inhibitors, angiotensin receptor blockers, beta blockers, and diuretics. Within drug categories, each prescription fill was assigned 1 point for low doses, 2 points for moderate doses, and 3 points for high doses. The highest point totals from each drug category were summated across categories with the maximum score being 24. HF patients were separated into three cohorts: without MR, not clinically significant MR (nsMR), and significant MR (sMR). Annual all-cause inpatient hospitalizations were modeled using the ordinary least squares method and MR, TIS, demographics, and comorbid conditions were included as covariates.

Results:
HF patients with sMR had the highest TIS at a mean of 6.9, followed by nsMR at 6.5 and no MR at 5.9. Based on the regression model, having clinically significant MR was associated with an increase (0.22 [0.05, 0.38]; P=0.0112) in annual all-cause inpatient hospitalizations. Additionally, every point increase of TIS was associated with an increase (0.20 [0.18, 0.21]; P<0.0001) in annual all-cause inpatient hospitalizations.

Conclusion:
While clinically significant MR is an important factor in healthcare utilization, the intensity of heart failure medication should also be considered when estimating the burden of illness. A 5 point increase in TIS is associated with an increase in one inpatient admission per year.
Abstract 155: Undergraduate Student Nurse ACLS Certification to Improve Practice Transition and Confidence
Authors: Miller Catherine
Published: April 2019

Abstract Summary:
Simulation research is well-established for existing teaching methods in academic settings. The study introduced an in-class simulation method focused on the transformation of a stagnant classroom into an engaging, simulation arena to improve student’s recognition of a deteriorating patient. In addition to the in-class simulation, a leveled code blue curriculum and code blue multi-patient simulation provided a foundation for students to complete an Advanced Cardiac Life Support (ACLS) certification prior to graduation from a traditional Baccalaureate of Science (BSN) nursing program.

Purpose:
The presentation synthesizes data on the impact of the in-class simulation experience. The specific area of interest is the ability of the nursing student to recognize and assess the deteriorating patient. It is through the swift acknowledgement of such life-threatening situations, that the development of code blue critical thinking can begin. In conjunction with simulation, a leveled code blue curriculum with the inclusion of an ACLS certification will facilitate student confidence for transition into clinical practice.

Methods:
An exploratory, single group design with a convenience sample of 92 BSN senior nursing students enrolled in the 3-credit, seventh semester medical-surgical, didactic nursing course.

Variables:
Variables included age, gender, race, exposure to code blue events in the clinical and work settings, and previous years of health care experience.

Procedures:
The modified 12-item survey, Code Blue Self-Confidence, assessed participant code blue confidence pre/post intervention. A demographic survey was utilized to measure correlative data with code blue skill confidence.

Findings:
Correlative findings revealed a significant improvement in student confidence with recognizing and intervening with the deteriorating patient to ensure swift implementation of code blue processes.

Recommendations:
Recommendations are for a multi-site study to replicate the validity of the in-class simulation, leveled code blue curriculum, and ACLS certification to facilitate the undergraduate nursing student’s transition into clinical practice.

Practice Implications:
Nurse response times greatly impact patient outcomes in critical situations. The safe zone of a simulation environment versus clinical practice creates opportunities for students to transition from novice to beginner to competent, while able to make errors and glean reflective knowledge before managing the direct care of a critically ill patient. One critical skill is the ability of a new nurse to identify and quickly respond to the needs of a deteriorating patient. Patient outcomes are improved when nurses launch proficiently from graduation into the transition of the nursing profession.
Abstract 163: Economy of Handheld Ultrasound in an Outreach Clinic Setting
Authors: Patel Nidhi , Patel Aarti
Published: April 2019

Introduction:
The usefulness of Handheld Ultrasound (HHU) is increasingly recognized in a variety of settings. This study demonstrates the ability of HHU to dramatically reduce costs in the clinic setting.

Objectives:
An HHU was implemented in 2018 to perform bedside echocardiograms at the USF outreach clinic (BRIDGE) with the expectation of cost savings.

Methods:
The implementation of the HHU at the BRIDGE clinic began in early 2018. Prior to 2018, all BRIDGE patients requiring any cardiac tests were referred to the separate USF Cardiology clinic. Following the implementation of the HHU at the BRIDGE clinic, all necessary echocardiograms were performed initially with the HHU in-clinic with additional testing referred to USF Cardiology, if needed. Data on all BRIDGE clinic patients who received cardiac care in 2017 was compiled and compared to all clinic patients who received cardiac care in 2018, after the implementation of the HHU. Primary variables compared by patient were number of follow-up visits, and number and type of tests ordered (complete and stress echocardiograms, treadmill and nuclear stress tests, and ambulatory monitors). An analysis was then conducted to determine differences in visits and overall costs by BRIDGE clinic patients before and after HHU implementation. Cost data for tests was obtained from the USF financial department.

Results:
In 2017, 17 patients were seen in BRIDGE clinic that were subsequently referred to cardiology for further care/testing. In 2018, 20 cardiac patients were evaluated in BRIDGE clinic and 25% required further testing. Across 2017 patients, there was an average of 1.53 cardiology follow-up visits and 1.47 cardiac tests conducted per patient, while overall tests costs averaged $383.77 per patient. In comparison, across 2018 patients there was an average of 0.4 cardiology follow-up visits and 0.3 cardiac tests conducted per patient, while overall test costs averaged $284.40 across patients who received further testing. This represents an 25.9% decrease in cost after implementation of HHU.

Conclusions:
These results demonstrate that BRIDGE clinic patients after HHU implementation had both less cardiology follow-up visits and tests conducted, which led to lower overall costs. This was largely due to the significant reduction in the number of complete echocardiogram tests ordered as these were performed in-clinic with the lower-cost HHU.
Abstract 167: Pragmatic Electronic Medical Records Registry Utilization to Identify Care-Gaps and Improve Cardiovascular Health of Cancer Patients and Cancer Survivors
Authors: Philips Steven , Zaha Vlad , Willett Duwayne , Basit Mujeeb
Published: April 2019

Title:
Use of an Electronic Medical Records Registry to Identify Care-Gaps in Cardiovascular Care of Cancer Patients

Background:
The cardio-toxic effects of chemotherapeutic agents have been well documented. Current cardiology and oncology guidelines recommend baseline and surveillance screening of ventricular function in patients exposed to these cardio-toxic agents. Given the multi-disciplinary nature of care of the oncology patient, it is unclear how effectively this population is screened and/or treated for cardiomyopathy. We sought to develop an electronic medical records (EMR) registry to identify gaps in care of this at-risk population.

Methods:
Patients were identified in a real-time Cancer Registry within our EMR (Epic), containing 73,067 patients with at least one active diagnosis of cancer. For cardio-oncology questions, we studied patients treated for cancer at our institution since on our EMR’s oncology module in 2011, yielding a population of 8,292 patients.

Results:
Our analysis identified 8,275 patients who underwent initial treatment for cancer within our institution. Pre-chemotherapy EF screening was documented for 20% of these patients with no significant variation across cancer types or planned chemotherapy exposures. Post-chemotherapy EF surveillance was documented for 41% of these patients with significant variability by cancer type (greater for breast cancer) and documented chemotherapy exposure (greater for anthracyclines and HER2 antibodies). Patients exposed to chemotherapies not traditionally associated with cardiotoxicity had the lowest rate of post-exposure surveillance. Post-chemotherapy LVD was detected in 10% of the population that underwent surveillance. Post-chemotherapy clinical heart failure was documented in 2.5% of all patients treated for cancer. Of the living patients with post-chemotherapy LVD or systolic HF (n=237), the proportion with active prescriptions for heart failure medications were 35% (guideline directed beta blocker), 46% (ACEi/ARB), 8% (mineralocorticoid receptor antagonist). The rate of prescription of GDMT was significantly higher in patients with LVD/HF who were referred to a cardiologist.

Conclusions:
An EMR-registry was created and used to identify patients with known exposure to cardio-toxic chemotherapeutic agents. A significant portion of these patients had not undergone surveillance of left ventricular function prior to chemotherapy. Furthermore, among patients with documented evidence of LV dysfunction or clinical heart failure, adherence to guideline directed therapies was sub-optimal. This study represents a novel method of care-gap identification for a population at risk for cardiomyopathy. Clinical Implications: This study will help enable cardiovascular physicians to identify care-gaps in monitoring and treating cardiomyopathy related to chemotherapeutic agents.
Abstract 180: Association of Risk Factor-Based Educational Programs on Stroke Hospitalization and Death Rates in West Central Florida
Authors: Sheeran Megan , Strom Joel A , LeFrancois Susan
Published: April 2019

Background:
Since 2003 six public health educational campaigns were begun in Florida to reduce stroke rate and mortality by increasing public awareness of stroke-related symptoms and its risk factors.

Hypothesis:
The public health campaigns reduced hospitalization and death rates due to stroke in West Central Florida (WCF).

Methods:
Using the Florida Department of Health databases, we tabulated the annual stroke-related rates of hospitalization and death in 10 WCF counties (Polk, Hardee, Sarasota, Hillsborough, Hernando, Pasco, Pinellas, Manatee, Desoto, and Highlands) from 1997-2016. Population (total: 4.75 million), median age, race/ethnicity distribution, and median income were recorded for each county. The pre-campaign period was defined from 1997 to 2002. Annual rates/100,000 population for stroke-related hospitalization and death were compared yearly before and after the campaigns were launched to determine their impact.

Results (graphs):
Compared to other WCF counties, Sarasota had the lowest baseline rate for stroke hospitalization, but its death rates did not significantly differ. Post-initiation, yearly declines average hospitalization (6.51%) and death rates (0.67%) were observed, but the decline in annual death rate was attenuated after 2006, suggesting the greatest impact was due to the Get With The Guidelines® campaign begun in 2003.

Conclusions:
Public health campaigns were associated with an almost linear decline in West Central Florida stroke hospitalization rates, suggesting a benefit from improved stroke recognition and risk factor reduction. The blunted effect on the death rate may reflect the limitations of therapeutic measures and implementation protocols employed during this period.
Abstract 185: The Expanded Benefit of Neprilysin Inhibitor Therapy on 30 Day Readmissions: A Useful Tool at a Safety Net Hospital
Authors: Taklalsingh Nicholas , Wengrofsky Perry , Levitt Howard
Published: April 2019

Introduction:
Heart failure (HF) related hospitalizations contribute to the ever-increasing financial burden of chronic disease. There are approximately 6.5 million individuals in the US with HF, with an estimated annual cost of $39 billion. Within the arsenal of strategies developed to curb this trend, pharmacological therapy has shown to be very effective. Whilst many drugs are favored for their ability to reduce mortality and morbidity, neprilysin-inhibitors (ARNI) have recently shown to reduce 30-day readmissions in patients with HF, presenting an expanded indication to favor its usage.

Methods:
A retrospective review of patients discharged from the Kings County Hospital Center from October 1
st
2017 to June 30
th
2018 with a diagnosis of heart failure was conducted. Inclusion required follow up in the Heart Health Clinic at Kings County Hospital and discharge therapy with a beta-blocker and either an ACE-I, ARB or ARNI. Patients were divided into 2 groups, those continued on an ACE-i/ARB versus those who were transitioned to an ARNI. The end outcome was a 30-day all-cause readmission for heart failure at any point after enrollment. Time to event was calculated using the date the drug was started. If the drug was started prior to being enrolled, we used the date that the patient was enrolled in the study. Demographic data was extracted via chart review and analyzed by descriptive statistics. A Kaplan-Meier survival analysis was done to compare the time-to-event between both study cohorts.

Results:
There were 101 patient discharges. There was no statistically significant age or gender difference between cohorts. The mean age in the ARNI group was 60.4 and in the ACE-i/ARB group was 64.7. A 30-day readmission occurred in 3 (10.7%) of the 28 patients in the intervention group, compared with 21 (28.8%) of the 73 patients with ACE-i/ARB therapy. The patients transitioned to ARNI therapy had a better event free survival with a 62.8% reduction in 30-day readmission events (log rank p=0.046).

Conclusion:
There is statistically significant reduction in 30-day all-cause readmission following the initiation of ARNI therapy in the treatment for HF. While this trend was shown in a prospective post-hoc analysis of the initial PARADIGM-HF trial, our study presents a unique patient benefit group. Kings County Hospital serves as a safety net hospital that has a large volume of uninsured, low socioeconomic status patients, with a large African American influence, and compounded social and environmental factors that make them highly prone to CHF readmissions. It underscores the need for clinically useful strategies to reduce the burden of CHF related readmissions especially for hospitals located in low socioeconomic areas at risk for penalties.
Abstract 187: Baseline 7 Day Follow Up Rates in Cardiology Patients: Impact of Electronic Medical Record-Based Appointment Order
Authors: Telukuntla Kartik , Sobol Tim , Abdallah Mouin , Hulseman Michael , Barzilai Benico , Starling Randall , Stephens John , Khot Umesh
Published: April 2019

Background:
There has been intense focus on 7 day follow up in congestive heart failure patients, but this approach has not been emphasized in all cardiology patients. We measured baseline early follow up rates and implemented an electronic medical record (EMR)-based order to secure early follow up at discharge for all cardiology patients.

Methods:
We performed an analysis of 39,211 patient discharges from the cardiovascular medicine services within an academic center between 2012 and 2017. In the pre-implementation era, scheduling of follow up appointments was at the discretion of clinical team. The EMR-based order scheduled appointments at time of discharge. The order provided an option for a 7 day visit with a physician assistant and/or 30 day follow up with the physician. Follow up rates were monitored for six years; pre (2012-2013) and post-implementation (2014-2017) era rates were compared using chi square analysis.

Results:
The average age of the patient was 69.3 ± 14.7, 60.7% were male, 75.7% were white and 20.8% were black. In the pre-implementation era between 2012 and 2013, average rate of follow up at 7 days after discharge was 13.4% (1,723 of 12,854). In the post-implementation era, the average rate of follow up at 7 days after discharge increased to 19.8% (5,225 of 26,357, p < 0.0001).

Conclusion:
An EMR-based appointment order led to improvement of 7 day follow up rates. However, absolute rates of follow up remained low indicating the need for further refinements of the process and patient engagement to increase follow up rates.
Abstract 188: Burden of Complications After Thoracic Aortic Repair Surgery Among Medicare Beneficiaries
Authors: Thompson Michael P , Kim Karen M , Cabrera Lourdes , Wu Xiaoting , Zhang Min , Brescia Alexander A , Yang Bo , Fukuhara Shinichi , Patel Himanshu J , Deeb G. M , Likosky Donald S
Published: April 2019

Objective:
Despite the growth in thoracic aortic repair surgery, there remain concerns about the clinical and financial impact of complications secondary to these procedures. Therefore, we leveraged Medicare administrative claims to estimate the incidence, outcomes, and spending associated with complications during 90-day episodes of thoracic aortic repair surgery.

Methods and Results:
Using a previously validated claims-based algorithm, we identified 11,240 Medicare fee-for-service beneficiaries hospitalized for thoracic aortic repair surgery [open type A (n=4,538), open type B (n=4,091), and thoracic endovascular aortic repair procedures (TEVAR, n=2,611)] from April 2014 to March 2015. We identified any (and total number) of the following complications within 30-day of surgery: renal failure, stroke/transient ischemic attack, respiratory failure, bleeding, pneumonia, deep vein thrombosis or pulmonary embolism, surgical site infection, paralysis, or acute myocardial infarction. Overall, 5,525 patients (49.2%) developed any complication (zero complications: 50.9%, one: 28.4%, two: 13.0%, three: 5.3%, or four or more: 2.4%). For the entire sample, 90-day episode mortality was 15.4%, which was higher in patients with any complication (23.0%) compared to patients without complications (8.1%). Adjusting for patient demographics, admission status, comorbidities, and hospital random effects, the relative odds of mortality comparing patients with and without complications was 2.41 (95% CI: 2.11-2.76) (Table). On average, 90-day episode spending was $54,668±$43,287, which was also higher among patients with any complication ($69,243 vs. $40,578, p<0.001). After similar adjustment, 90-day episode spending was 50% higher on a relative scale (95% CI: 46% to 54%), largely attributed to inpatient stays, post-acute care spending, and more frequent readmissions. Both mortality and spending increased significantly as the number of complications increased from zero to four or more.

Conclusions:
Complications after thoracic aortic repair were common and associated with worse outcomes and higher episode spending. Identifying and intervening upon patient and provider factors predictive of complications is essential to improving the value of thoracic aortic repair procedures.
Abstract 19: Cardiovascular Health Amongst Asian-Americans: National Health and Nutrition Examination Study
Authors: Kalra Rajat , Patel Nirav , Doshi Rajkumar , Arora Garima , Arora Pankaj
Published: April 2019

Background:
Variable propensity towards cardiovascular disease amongst the different ethnicities in the United States (U.S.) has been reported. We aimed to characterize the prevalence of cardiovascular risk factors, as defined by the American Heart Association’s Life’s Simple 7 metrics amongst Asian-Americans. We also hypothesized that the prevalence of cardiovascular risk factors is changing among Asian-Americans and that that the prevalence varies between American-born and foreign-born Asian-Americans.

Methods:
The National Health and Examination Nutrition Study (NHANES) 2011-2016 cross-sectional surveys were used to evaluate the prevalence trends for cardiovascular risk factors adjusted for age, sex, educational attainment, family income to poverty ratio, and insurance status amongst self-identified Asian-Americans. We further divided foreign-born Asian-Americans into strata based on residence in the U.S. for
<
10 years, 10-19 years, and
>
20 years to assess the difference in the prevalence of cardiovascular risk factors between American-born and foreign-born Asian-Americans. The difference in the prevalence of cardiovascular risk factors between American-born and foreign-born Asian-Americans were adjusted for the same covariates as above and presented as odds ratios.

Results:
Amongst cardiovascular health metrics, the prevalence of Asian-Americans reporting no physical activity increased from 21.5% in 2011-2012 to 32.4% in 2015-2016 (p for linear trend = 0.001). The prevalence of Asian-American subjects reporting a healthy diet decreased from 44.1% in 2011-2012 to 36.8% in 2015-2016 (p for quadratic trend = 0.02). There was a concomitant decline in the prevalence of subjects with healthy weight (BMI<25 kg/m
2
) from 60.5% in 2011-2012 to 55.3% (p for linear trend = 0.04). We did not observe any significant trend in smoking, total cholesterol, blood pressure and diabetes. Compared with American-born Asian-Americans, foreign-born Asian-Americans had lower odds of having a healthy diet [odds ratio (OR): 0.51; 95% confidence interval (CI): 0.35-0.74 in
<
10 years; OR: 0.48; 95% CI: 0.34-0.64 in 10-19 years, and OR: 0.56; 95% CI: 0.41-0.76 in
>
20 years]. Similarly, foreign-born Asian-Americans had lower odds of having hypertension (OR: 0.55; 95% CI: 0.36-0.82 in
<
10 years; OR: 0.56; 95% CI: 0.41-0.76 in 10-19 years, and OR: 0.71; 95% CI: 0.51-0.99 in
>
20 years) compared to the American-born Asian-Americans.

Conclusions:
In the NHANES 2011-2016 surveys, Asian-Americans exhibited a declining prevalence of healthy weight, ideal diet, and ideal physical activity levels. Compared with American-born Asian-Americans, foreign-born Asian-Americans had better diet and blood pressure. Further research should be undertaken to delineate trends amongst Asian-American sub-groups and optimal cardiovascular preventive and treatment strategies amongst Asian-Americans.
Abstract 191: BRAVE: Blood Pressure and Vascular Health Around Menopause
Authors: Wali Muhammad Ahmer , Raparelli Valeria , Pilote Louise
Published: April 2019

Background:
Post-menopausal women are more likely to have uncontrolled hypertension and are at higher risk of cardiovascular disease compared with age-matched men. Blood pressure variability (BPV) has recently emerged as a predictor of adverse cardiovascular outcomes. It is unknown if there is a relationship between BPV and menopause and whether BPV can predict vascular health in perimenopausal women.

Methods:
BRAVE (Blood pRessure And Vascular hEalth around menopause) is an observational study recruiting perimenopausal healthy women, aimed at studying the relationship between BPV, the menopause transition and vascular health. A 24-hour blood pressure (BP) measurement [including 24-hour coefficient of variation, night dipping and maximum BP] was used to define the BPV. Menopausal status and cardiovascular risk factors were collected through questionnaires. Arterial stiffness, as a marker of vascular health status, was measured using pulse wave velocity. Multivariable models were performed to identify factors associated with BPV as well as those associated with arterial stiffness in perimenopausal women.

Results:
Fifty healthy women (mean age 52.9 ± 4.0, 62% post-menopausal) were recruited. There was a low prevalence of cardiovascular risk factors, except physical inactivity (60%). In around 40% of patients, we observed an abnormal pattern of BPV. However, all measures of BPV were similar between peri and post menopausal women. In the multivariable analysis, BMI was the only factor associated independently with maximum overnight BP (ß=1.95, p<0.0001) and maximum daytime BP (ß=2.46, p=0.008). Furthermore, maximum overnight BP was found to significantly associated with the arterial stiffness measurement (ß=0.035, p=0.048) after adjusting for confounders, including mean BP and cardiovascular risk factors.

Conclusion:
An abnormal pattern of BPV is common in perimenopausal women with normal office BP measurement. Maximum overnight BP provides useful information on vascular health beyond mean blood pressure in this population. BPV measurements in normotensive perimenopausal women may therefore have additional clinical value in stratifying their cardiovascular risk.
Abstract 204: Comparison of Hemodynamic Parameters and Clinical Outcomes in Jehovah’s Witness Patients versus Non-Jehovah’s Witness Patients Undergoing Transcatheter Aortic Valve Replacement
Authors: Alvarado Francisco J , Patel Jaymin , Bhandari Ajay , Radhakrishnan Anita , Bitetzakis Christopher , Sadic Edin , Sunjic Igor , Kasprowicz Thomas , Parikh Vishal , Mehlman Andrew , Hernandez Burgos Paula , Labovitz Arthur , Chen Allan , Patel Aarti
Published: April 2019

Background:
Surgical aortic valve replacement may be complicated by significant perioperative bleeding. TAVR is a less invasive procedure, however bleeding may still occur related to periprocedural complications and anti-thrombotic therapy. We sought to compare baseline characteristics, hemodynamic parameters and clinical outcomes following TAVR between Jehovah’s witness (JW) patients who decline the use of blood products, and non-JW patients.

Methods:
Demographic, echocardiographic, and hemodynamic data of 245 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR at our institution between January 2013 and December 2015 were analyzed at baseline and at 30 day follow-up.

Results:
10 patients were identified as JW refusing blood transfusion. None of the JW patients received blood products. JW and non-JW patients did not differ in respect to hemodynamic or echocardiographic parameters at baseline or 30 days post TAVR, including: blood pressure, heart rate, valve area, gradient, valvuloarterial impedance, cardiac output, stroke volume and ejection fraction. Baseline hemoglobin was higher in the JW versus non-JW groups, respectively (12.76 vs. 11.62 mg/dL p=0.045) and this was sustained at follow-up. Clinical outcomes were similar at 30 days between JW and non-JW patients, notably major bleed (10% vs 8.97%, respectively; p=0.91, defined as a clinical bleeding event with hemoglobin decrease > 2g/dL or transfusion of > 2 units of whole blood/red cells ) and 30 day mortality (0% vs 6.41%, respectively; p=0.19).

Conclusion:
JW patients were found to have similar hemodynamic and clinical outcomes up to 30 days. TAVR may be considered a reasonable treatment option for patients with symptomatic severe aortic stenosis who refuse transfusion of blood products.
Abstract 211: Reduction in Laboratory Associated Cost Through Education Based Gatekeeping
Authors: Basit Abdul , Polimera Hyma , Bedi Simranjit , Marshall Britt , McGillen Brian , Domen Ron , Towery David , Ahmad Tariq
Published: April 2019

Background:
Laboratory testing is one the factors contributing to rising health care expenditures. Recent estimates show that laboratory and pathology testing accounts for 4% of all yearly healthcare costs. Depending on the country, clinical setting, method, and specific tests evaluated, studies have shown that a relatively large percentage (up to 42%) of laboratory testing may be wasteful. We proposed a study to evaluate the lab related costs in our institution.

Objectives:
To evaluate the effects of behavioral interventions that may result in lab-associated cost reduction.

Methods:
We identified the top 10 Diagnosis-related Groups (DRG) for our institution, along with most common requested laboratory investigations for the patients hospitalized during three fiscal years 2015-2017. Extensive review of data from fiscal year 2015 (identification period) was performed by a review committee comprising of physicians, lab leadership, billing & coding team and Internal Medicine operations director. Two interventions were selected based on the institutional work flow design, and included removal of default duration from complete blood count and basic metabolic panel orders, and behavioral modification with structured education to create awareness for the cost associated with unnecessary lab tests. Interventions were implemented by the end of fiscal year 2016 and start of 2017. Comparison of each fiscal year cost data was performed.

Results:
A total of 1612 patients with selected DRGs were identified in pre-intervention fiscal year 2016 with total lab cost of $1,603,724 and average cost of $995/patient. During post-intervention fiscal year 2017, 1530 patients were identified with total lab cost of $1,174,557 with average cost of $768/patient. Post-intervention overall cost reduction was noted to be $429,167 which is 26.7% lower than pre-intervention fiscal year. Per patient cost was lowered by an amount of $227; a 22.8% decrease.

Conclusion:
In this single center study, implementing modification of default lab orders along with structured educational program showed a significant reduction in lab related cost without interfering with the clinical decision-making process of the providers.
Abstract 212: What are the Imaging Capabilities at Referring Hospitals for Large Vessel Occlusion Triage? Results from the Massachusetts Statewide Survey
Authors: Bemben Lisa A , Leslie-Mazwi Thabele , Egan Abigail , Magdon-Ismail Zainab , Schwamm Lee H , Lev Michael H ,   Massachusetts CTA Workgroup
Published: April 2019

Introduction:
We assessed availability/ feasibility of computed tomography angiography (CTA) acquisition and its potential for screening stroke patients for large-vessel occlusion (LVO) at referring hospitals (RH) (hospitals without endovascular capabilities) in Massachusetts (MA).

Methods:
The MA CTA Stroke Workgroup (a statewide committee of stroke neurologists, neurointerventionalists, and radiologists) developed a CTA capability survey with 28 questions on logistics, protocols and CT scanner availability. The survey was sent to all 62 RH to be completed by interdisciplinary stroke teams.

Results:
Response rate was 100 % (62/62 RH); 96.8% have protocols for acute stroke care; 77.4% have protocols for transferring patients to a receiving center; only 35.5% have revised protocols reflecting the extended thrombectomy window. Regarding CTA availability, 95.2% have 24-hour CTA imaging available all year, with 64.5% having two or more scanners. CTA technologist availability is high with 95.2% having a technologist available 24/7. Just over half (53.2%) report protocols where CTA head and neck are obtained immediately after non-contrast head CT, while patient remains in scanner; 29.0 % report non- contrast head CT with patient removed from scanner for further clinical evaluation, followed by CTA head and neck as indicated. For CTA interpretation, 36.9% use emergent reads by local radiology; 31.5% use Nighthawk (remote) radiology; 14.6 % transmit scans for interpretation by the receiving hospital; the remainder use a combination of scan interpretation options. The majority (90.3%) have capability to share images through the cloud. The most challenging element of the CTA process was changing emergency department protocols (45.2%); availability of scanners and technology was identified as least challenging. The majority of RH (88. 7%) prefer to retain patients not in need of transfer to a receiving hospital if no LVO is present on CTA.

Conclusion:
There is wide spread availability of CTA across MA. Improving LVO detection and triage to thrombectomy capable centers with a focus on RH CTA acquisition is a clear opportunity for intervention. The methods and survey tool developed may prove useful for other states/regions working to enhance stroke systems.
Abstract 215: Risk Factors, Management, and Outcomes Among Pregnant Women with Atrial Fibrillation
Authors: Dassanayake Maya , Langen Elizabeth , Norris Mark , Cotts Timothy , Baughman Davis Melinda
Published: April 2019

Background:
Atrial fibrillation and atrial flutter (AF) during pregnancy may confer increased risk of perinatal complications, particularly since pregnancy is a known hypercoagulable and arrhythmogenic state. However, few studies of outcomes among this population exist, and the optimal management strategy is unclear. We sought to determine the risk of adverse outcomes among pregnant women with AF.

Methods:
In this single-center study, patients with documented AF in pregnancy (1/1998-9/2018) were retrospectively analyzed. Charts were manually reviewed for demographics, comorbidities, underlying cardiac disease, and medications. Outcomes included arrhythmias, need for cardioversion, and thromboembolic events.

Results:
Of 66 pregnant women with documented AF, 20 (30.3%) had a diagnosis of AF prior to pregnancy and 46 (69.6%) had new onset AF during pregnancy or immediately postpartum (within six weeks of delivery). Nine women (13.6%) had persistent AF. Thirty women (45.4%) had valve disease and/or congenital heart disease and/or preexisting cardiomyopathy, and eight (12.1%) had AF precipitated by active infection or severe nausea/vomiting. Comorbidities included diabetes mellitus (3%), hypertension (9%), thyroid disease (13.6%), and obesity (32.6%). Electrical cardioversion was performed in 10 women before or after pregnancy, and five women underwent electrical cardioversion during their first or second trimesters of pregnancy. Rate-controlling medications were prescribed in 75.7%, with the most common medication being metoprolol (39.3%). Anticoagulation strategies varied from no intervention (53%), low-dose aspirin monotherapy (18.2%), enoxaparin (13.6%), warfarin (13.6%), or warfarin plus aspirin (3%). AF with rapid rate occurred during labor/delivery in 6/44 (13.6%) women with available telemetry data. One woman had a stroke during pregnancy related to vertebral artery dissection; she was in sinus rhythm at presentation. No other thromboembolic complications occurred.

Conclusion:
Pregnant women with AF may require rate-controlling medication and/or cardioversion during pregnancy, but appear to be at low risk for thromboembolic complications when appropriately anticoagulated. Larger studies of pregnant women both with and without underlying structural heart disease are needed to further assess complications and thromboembolic risk to optimize management of AF in pregnancy.
Abstract 216: Evolution of Medicare Formulary Coverage Changes for Antithrombotic Therapies after Guideline Revisions
Authors: Dayoub Elias J , Dhruva Sanket S , Ross Joseph
Published: April 2019

Introduction:
The 2014 ACC/AHA/HRS atrial fibrillation (AF) guideline recommends either warfarin or direct oral anticoagulants (DOACs) as first-line antithrombotic therapies for patients with non-valvular AF. In 2016, the American College of Chest Physicians (CHEST) venous thromboembolism (VTE) guideline recommended DOACs over warfarin in non-cancer patients. Formulary coverage and utilization management can be used to promote guideline recommended medications, but the impact of these guidelines is unknown.

Methods:
We used Medicare Prescription Drug Plan Formulary Files, which include data on all Medicare Advantage and Part D plans, to compare coverage in the second quarters of 2013 (pre-guidelines), 2015 (post-ACC/AHA/HRS AF guideline), and 2017 (post-CHEST VTE guideline) for warfarin and each of the following DOACs: apixaban, dabigatran, edoxaban, and rivaroxaban. We determined formulary coverage and, among formularies that provided coverage, formulary restrictiveness based on use of utilization management strategies (i.e., cost-sharing tier level 3 or higher, prior authorization requirement, or step therapy requirement). Formularies were categorized as unrestrictive if no strategies were used, restrictive if any strategy was used, and no coverage.

Results:
In 2013, 2015, and 2017, there were 314, 389, and 378 Medicare formularies, respectively. All but one plan provided unrestrictive coverage of warfarin in all 3 time periods (Figure). Among DOACs, in 2013, 12% and 38% of formularies provided unrestrictive and restrictive coverage of apixaban, 20% and 78% of dabigatran, and 25% and 62% of rivaroxaban, whereas by 2017, 24% and 70% provided unrestrictive and restricted coverage of apixaban, 24% and 73% of dabigatran, and 30% and 69% of rivaroxaban (
p
< .001). From 2013 to 2017, formularies providing restrictive or unrestrictive coverage for at least one DOAC increased from 84% to 100% (
p
< .001). Most plans restricted DOAC coverage by increased tier-level cost-sharing, which increased over time, while prior authorization requirements decreased.

Conclusions:
After guidelines recommended DOACs as first-line or preferred therapy for AF and VTE, unrestrictive coverage increased, but the vast majority of plans restrict coverage by requiring high patient cost-sharing through tier placement.
Abstract 218: Challenges and Opportunities in Using Cardiovascular Health Metrics and Social Determinants of Health to Inform Population Health Management
Authors: Dean Caress A , Ventline Brittany , Jagirdar Rachita
Published: April 2019

Background:
The collection of cardiovascular health (CVH) metrics and social determinants of health (SODH) can inform population health management activities such as care management and the development of CVH interventions. Therefore, this study sought to examine professionals’ knowledge of the term, CVH, and to gain their perspective on the collection and operationalization of CVH and SODH metrics.

Methods and Results:
The Population Health Conceptual framework guided the design of this mixed method study and inclusion criteria of participants. Specifically, the sample consisted of professionals that directly and indirectly influence the collection and use of CVH and SODH measures, including healthcare providers/practitioners, healthcare management/administration, physician organizations, and public health, health insurance, and health informatic professionals that provide services to Michigan residents. Data collection (2018-2019), consisted of participants completing a cross-sectional survey that determined their knowledge of the term, CVH, and identified CVH and SODH measures they currently collect and/or are interested in using. Quantitative questions were also utilized to obtain demographics (e.g., credentials and years of experience) of professionals. Following survey completion, individual semi-structured interviews were performed to gain insights on measure collection tools, and how CVH and SODH factors were operationalized in healthcare delivery and interventions. Descriptive statistics were conducted using STATA/MP14. Qualitative analysis, applying grounded theory to assess the data thematically to identify patterns was performed using NVivo12. Tableau Software illustrate study results. Findings indicated that professionals were knowledgeable of the term CVH, but were not familiar with the seven CVH metrics/goals. More than half of participants expressed interest in collecting populations’ sodium intake to inform programs and referrals. Neighborhood characteristics was one of the top SODH participants expressed interest in collecting. One of the most common barriers reported to collecting CVH metrics included lack of reliable collection methods for CVH measures. Additionally, participants articulated that CVH and SODH measures do not align with current performance measures (e.g., HEDIS) collected, thus, capturing CVH and SODH metrics would increase the number of measures they would be responsible for acquiring.

Conclusions:
Additional efforts are warranted to increase knowledge and awareness of CVH metrics across all professions that aid in the prevention and management cardiovascular disease. Further research is needed to develop reliable data collection tools. Additional advocacy should be performed to encourage the consolidation and alignment of performance measures to facilitate the collection of CVH and SDOH measures.
Abstract 221: Transcatheter Aortic Valve Replacement is Associated with a Reduction in Hospitalization Rates: Insights from Nationwide Readmission Database
Authors: Elkaryoni Ahmed , Qintar Mohammed , Cohen David J , Chhatriwalla Adnan K , Arnold Suzanne V
Published: April 2019

Background:
In inoperable patients with severe aortic stenosis, transcatheter aortic valve replacement (TAVR) reduced mortality and hospitalization as compared with medical therapy. However, hospitalization rates after TAVR remain high, given the age and comorbidities of patients undergoing TAVR. Studies have thus far focused on rehospitalization after TAVR and have not examined the decline in hospitalizations achieved with TAVR. We sought to compare hospitalization rates in the 3 months before and after TAVR and further examine these changes in patients with and without LV dysfunction.

Methods:
We used the 2014 Nationwide Readmission Database (NRD) to identify patients who underwent TAVR between April and September, to allow for assessment of hospitalizations 3 months before and after TAVR. We compared hospitalization rates before and after TAVR using McNemar tests and also examined rates among patients with heart failure with reduced ejection fraction (HFrEF) and those without HFrEF.

Results:
Among 10416 who underwent TAVR between 4/1/14-9/30/14, mean age was 81.1 ± 8.4 years, 45.4% were men, mean number of chronic condition was 9.6 ± 3.1, and 40.6% had HFrEF. The rate of all-cause hospitalization in the 3 months before TAVR was 34.1%, which decreased to 25.5% in the 3 months after TAVR (p <0.001; Figure). Among patients with HFrEF, rates changed from 40.2% before TAVR to 26.8% after (p <0.001), as compared with 29.8% to 24.6% among patients without HFrEF (p<0.001). Mixed effects logistic regression to examine patient characteristics associated with change in hospitalization rates after TAVR will be performed.

Conclusion:
Although patients who are treated with TAVR have high rates of rehospitalization after the procedures, TAVR is associated with a reduction in all-cause hospitalization, which appears to be even more pronounced among patients with HFrEF. Further investigation is needed to better understand the patient factors associated with response to TAVR, in terms of hospitalization