bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 241: Evaluation of the Parameters of the Euro Qol- 5 D Questionnaire Among Patients With Ischemic Heart Disease With Normal and Elevated BMI
Authors: James Cyril , Ohri Shreya , Tisheva Snezhana , Yakova Dilyana , Hristov Martin , Stancheva Nadia , Jose Soumya
Published: July 2021

Objective:
The epidemic of obesity and obesity related morbidities is an important public health challenge, and is paralleled by growing incidence of metabolic syndrome which acts as a strong and significant risk factor for Ischemic heart disease and other atherosclerotic vascular events. The psychological impact of these chronic conditions can be very disturbing. In practical terms the functional effect of an illness and its therapy upon a patient, as perceived by the patient - could be estimated by introducing the quantitative approach of - Health Related Quality of Life (HRQoL).

Aim:
The aim of this study is to evaluate the impact of obesity on quality of life of patients with ischemic heart disease.

Design and method:
Questionnaire based cross sectional study was conducted among patients with established Coronary Artery Disease admitted in the Department of Cardiology in the University Hospital. 520 patients who were admitted in the Cardiology Department between 1st of January 2012 and 30th June 2014 with acute coronary syndrome or coronary angiographic or Electrocardiography evidence of ischemic heart disease were included in the study, stratified by age, sex and BMI ( normal weight 18.5 - 24.9, overweight 25 - 29.9, obese 30 and above). EuroQol - 5D (EQ-5D) was administered in the patients during their hospital stay. EQ-5D comprises 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. The height, weight and basic laboratory parameters were recorded.

Results:
Mean age of the participants was 65.1± 10.6 years. Male female ratio was 0.76. The distribution of patients in BMI groups was 36.8%/ 24.4%/ 38.8%. Statistically significant differences between BMI groups were seen in Usual activity (p=0.005) and self-care (p=0.044) dimensions of EQ-5D-5L with poorest outcome in the obese. We have found significantly positive correlation between BMI and usual activities (R=0.234, p=0.001) and between age and anxiety (R= 0.366 p=0.045). Mean BMI of patients with extreme problems with extreme problems with usual activities is significantly greater than those with lower intensity of problems. Patients with extreme anxiety tend to have higher mean age.

Conclusion:
Our study revealed that Ischemic heart disease patients with obesity had impaired QoL in terms of health, mobility, usual activity, discomfort and anxiety. Hence non-obese ischemic heart disease patients had a better sense of overall wellbeing.
Abstract 242: Impact of Hospitalists on Heart Failure Outcomes in Hawaii
Authors: Mannem Santhosh R , Ahn Ayeong Jun , Miyamura Jill , Juarez Deborah , Chen John , Seto Todd
Published: July 2021

Background:
Hospital Medicine is the fastest growing subspecialty in the US. However, limited data compare care provided by Hospitalists (H) with Non-Hospitalists (NH) (ie, internal medicine, family practice). Because much of heart failure (HF) care is provided by non-cardiologists, we examined HF outcomes among pts treated by H and NH.

Methods:
All pts discharged with primary dx of HF from 2009-11 were identified from a statewide all-payer database in Hawaii (n=6,581). We categorized pts by specialty of discharging physician and examined length of stay (LOS), 30-day readmission and inhospital mortality comparing H and NH. Because pts discharged by cardiologists accounted for a minority of cases (345/6,581 or 5.2%) and may substantially differ from other pts, they were excluded from our study.

Results:
There were slight differences between pts cared by H and NH, while disease severity (Charlson Index) was similar. Readmissions were similar for H and NH, although inhospital mortality was significantly lower for H. These differences persisted after adjusting for potential confounders (readmission: OR=1.08, 95% CI: 0.96-1.20; mortality: OR=0.59, 95% CI: 0.46-0.75).

Conclusions:
In a statewide, all-payer hospital discharge database H care for the majority of HF pts. Compared with NH, 30-day readmission was similar but inhospital mortality was lower. Further research is needed to study the impact of cardiologists, who often serve as consultants for this population.
Abstract 253: Variability in the Rates of Normal Diagnostic Coronary Catheterizations and Non-invasive Pre-catheterization Cardiac Diagnostic Testing in Ontario
Authors: Oakes Garth H , Kingsbury Kori J
Published: July 2021

The Cardiac Care Network of Ontario (CCN) serves as a system support to the Ministry of Health and Long Term Care as well as hospitals, and care providers in the province of Ontario, Canada. CCN is dedicated to improving the quality, efficiency, access and equity in the delivery of adult cardiovascular services in the province. CCN works to plan, coordinate, implement and evaluate adult cardiovascular care in Ontario, and is responsible for the CCN Cardiac Registry. Nineteen hospitals in Ontario perform diagnostic coronary catheterizations (CATH) and all enter data into the CCN Cardiac Registry. The objective of this analysis was to analyze temporal trends in the rates of CATH procedures across Ontario and examine in detail the rate of pre-CATH non-invasive cardiac diagnostic testing in patients who had normal or non-significant coronary artery disease (CAD) CATH results. CATH data in the CCN Cardiac Registry from patients with stable CAD in Ontario from fiscal years 2011/12 to 2014/15 were analyzed. Recognizing that non-elective CATH patients may present with acute symptoms that warrant immediate intervention and non-invasive cardiac diagnostic testing may not be appropriate, we excluded these patients from our analysis. We defined stable CAD as CATH patients assigned an urgency ranking of “Elective” or “Semi-Urgent” at the time of their procedure. From 2011/12 to 2014/15 the number of stable CAD CATH procedures performed in Ontario remained relatively unchanged, ranging between 29,000 and 30,000 procedures per year. The rate of CATH procedures in which the result was normal or non-significant CAD also remained stable, ranging from approximately 32 to 33.5% per year. Approximately 75% of all patients in this cohort received some type of pre-CATH non-invasive cardiac diagnostic test. Although these results remained relatively stable year-over-year at a provincial level, we identified considerable variation in these results between cardiac centres with centre-specific rates of normal CATHs ranging from 7% to 56% and the rate of pre-CATH diagnostic testing ranging from approximately 37% to 92%. While a proportion of CATH results are expected to be in the range of normal or non-significant CAD, the exact expected rate is undetermined. Our analysis revealed large variation in the rate of normal/non-significant CAD results between cardiac centres in Ontario, with several programs having a rate considerably higher than the provincial average. The appropriate use of non-invasive cardiac diagnostic testing in elective, stable patients prior to CATH requires additional evaluation as the quality of the diagnostic testing is uncertain. Equivocal and/or uncertain non-invasive diagnostic test results may prompt more patients with normal anatomy/non-significant disease to undergo CATH to render a definitive diagnosis. These present important opportunities for ongoing quality improvement.
Abstract 254: Absence of Evidence? A Systematic Review of Randomized Controlled Trials for In-hospital and Out-of-Hospital Cardiac Arrests
Authors: Polavarapu Vivek A , Sinha Shashank A , Chan Paul S , Nallamothu Brahmajee K
Published: July 2021

Background:
Cardiac arrests are a major public health problem worldwide. The extent and types of randomized clinical trials (RCTs) - our most reliable source of clinical evidence - that have been conducted in this patient population are unknown. We performed a systematic review of contemporary RCTs in cardiac arrest, with a focus on determining key differences between In-Hospital Cardiac Arrests (IHCA) and Out-of-Hospital Cardiac Arrests (OHCA), which have different epidemiological patterns and disease mechanisms.

Methods:
A computerized search query of Medline was performed using the terms “cardiac arrest” or “heart arrest” or “cardiopulmonary resuscitation” from 1995 to 2014, yielding a total of 1652 publications. After manual abstract review, 80 RCTs involving either IHCA or OHCA were then identified for inclusion in the final analysis. The following data were ascertained: number of patients, demographic information, blinded vs. unblinded, geography (US/non-US), single vs. multicenter, a positive or negative study outcome, and the type of intervention being studied.

Results:
There were a total of 80 RCTs with cardiac arrest performed containing 84,500 subjects between January 1, 1995 and December 31, 2014. Of these 80 RCTs, only 6 studies with 1143 total subjects involved IHCA whereas 74 studies with 83,357 total subjects pertained to OHCA (Table). All six studies with respect to IHCA were not performed in the U.S. In contrast, eight of the OHCA RCTs were performed both in the U.S. and abroad, 15 of the OHCA RCTs were performed in the U.S., and the remaining 51 studies were performed outside of the U.S. Four of the six IHCA studies were blinded, and two of the six IHCA studies were multicenter studies. In contrast, 29 of the OHCA RCTs were blinded and 39 of the OHCA RCTs were multicenter trials. Only two of the six IHCA RCTs demonstrated a positive study outcome and mortality benefit. Conversely, 39 of the 74 OHCA RCTs reported a positive study outcome but only 15 of the 74 OHCA RCTs had a survival benefit.

Conclusion:
We found limited evidence of high-quality RCTs in cardiac arrest with a striking paucity of evidence with respect to IHCA. Given key differences between IHCA and OHCA, further RCTs directly investigating IHCA are warranted to elucidate our understanding of the evaluation and management of these high-risk patients.
Abstract 269: Association of Atrial and Ventricular Arrhythmias with In-hospital Outcomes in Peripartum Cardiomyopathy
Authors: Harikrishnan Prakash , Gupta Tanush , Kolte Dhaval , Palaniswamy Chandrasekar , Khera Sahil , Mujib Marjan , Aronow Wilbert S , Jain Diwakar , Lanier Gregg , Sule Sachin , Fonarow Gregg C , Ahmed Ali , Frishman William H , Cooper Howard A , Jacobson Jason , Iwai Sei , Panza Julio A
Published: July 2021

Background:
Arrhythmias are relatively common in patients with non-ischemic cardiomyopathies. There are limited data on the association of atrial and ventricular arrhythmias with outcomes in patients with peripartum cardiomyopathy (PPCM).

Methods:
We queried the 2003-2011 Nationwide Inpatient Sample databases using the ICD-9 diagnostic codes 674.50 to 674.55, to identify all women aged between 15-55 years admitted with a diagnosis of PPCM. The various arrhythmias were identified using appropriate ICD-9 diagnostic codes - atrial fibrillation (AF) (427.31), atrial flutter (427.32), supraventricular tachycardia (SVT) (427.0), ventricular tachycardia (VT) (427.1), ventricular fibrillation (VF) (427.41 and 427.42). Multivariable adjusted logistic regression was used to study the association of arrhythmias with in-hospital mortality and multivariable adjusted linear regression was used to study the association of arrhythmias with length of stay and hospital charges.

Results:
From 2003 to 2011, 34,944 patients were hospitalized with PPCM. The mean age was 30±7 years. Among these patients with PPCM, ventricular tachycardia (VT) (4.8%) was the most common arrhythmia followed by atrial fibrillation (AF) (2.2%), ventricular fibrillation (VF) (1.3%), atrial flutter (0.8%) and supraventricular tachycardia (SVT) (0.6%). The risk adjusted in-hospital mortality was higher in PPCM patients with AF (3.6% vs 1.2%, adjusted OR 2.38, 95% CI 1.50-3.78), VT (3.7% vs 1.1%, adjusted OR 1.8, 95% CI 1.30-2.48) and VF (14.2% vs 1.1%, adjusted OR 5.39, 95% CI 3.75-7.74) compared to those without arrhythmias. Among the study population, the average length of stay was longer in patients with AF (8 vs 5 days, p<0.001), atrial flutter (10 vs 5 days, p<0.001), SVT (10 vs 5 days, p<0.001), VT (9 vs 5 days, p<0.001) and VF (10 vs 5 days, p<0.001). The average hospital charges was also higher in patients with AF ($74,799 vs $40,974; p=0.004), atrial flutter ($129,692 vs $41,042; p<0.001), SVT ($133,223 vs $41,165; p<0.001), VT ($97,525 vs $38,929; p<0.001) and VF ($158,381 vs $40,194; p<0.001).

Conclusions:
In patients hospitalized with PPCM AF, VT and VF were independently associated with significantly higher in-hospital mortality. Also in these patients AF, atrial flutter, SVT, VT and VF were independently associated with higher hospital charges and longer length of stay.
Abstract 278: The China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of Acute Myocardial Infarction: Study Design
Authors: Li Jing , Dreyer Rachel P , Li Xi , Du Xue , Downing Nicholas S , Li Li , Feng Fang , Zhang Haibo , Zhan Lijuan , Guan Wenchi , Xu Xiao , Li Shu-Xia , Lin Zhenqiu , Masoudi Frederick A , Spertus John A , Krumholz Harlan M , Jiang Lixin
Published: July 2021

Background:
The incidence of acute myocardial infarction (AMI) is growing rapidly in China, but there is limited information about the patient experience in the post-acute period. Specifically, long-term outcomes and patient-reported outcomes (PROs), including quality of life, symptoms and mood, after AMI, have not been systematically studied in China.

Objectives:
To conduct a nationwide prospective study following patients after AMI that 1) measures long-term clinical outcomes, PROs, cardiovascular risk factor control and adherence to medications for secondary prevention; and 2) identifies patient characteristics and hospital attributes that are associated with these outcomes.

Methods:
The China PEACE Prospective Study of AMI has recruited 4000 consecutive patients from 55 hospitals across China and is following them for 1-year. The first patient was enrolled in December 2012, and the last follow-up visit is scheduled for June 2015. After obtaining informed consent from patients, we abstracted details of their medical history, treatment, and in-hospital outcomes from medical charts. We conducted comprehensive baseline interviews characterizing patient demographics, risk factors, clinical presentation, and healthcare utilization. In addition, we used validated PRO instruments to measure quality of life, symptoms, mood, sleep, cognition and sexual activity. Follow-up interviews, measuring PROs, medication adherence and risk factor control were conducted at 1-, 6-, and 12-months after discharge. At these interviews, patients were asked to self-report major health events and to provide supporting materials (e.g., hospital discharge record for a readmission), which were subsequently validated by a National Coordinating Center. Blood and urine samples were obtained at baseline and 12-month follow-up, and stored for further biomarker analysis and genetic studies. To complement these patient-level data, we surveyed participating hospitals to characterize their facilities, processes and organizational learning culture. Together, these data will be used to identify factors associated with various outcomes following AMI.

Conclusion:
This study is uniquely positioned to generate new information regarding patient experience and determinants of outcomes after AMI in China.
Abstract 280: Defining Statin Intolerance Among High Cardiovascular Risk Patients: Do US Administrative Databases Lend Themselves to Identification Of Statin Intolerance?
Authors: Foody Joanne M , Lamerato Lois E , Dalal Mehul R , Sung Jennifer , Khan Irfan , Jhaveri Mehul , Koren Andrew , Mallya Usha G , Schulman Kathy L
Published: July 2021

Introduction:
The clinical and economic impact of statin intolerance (SI) in high CV risk patients is unknown due, in part, to a lack of consensus in its definition. We sought to define and validate an SI algorithm for use in an administrative database (AD) among high-CV risk patients

Methods:
Adults with ≥1 qualifying change (See Table 1) in statin therapy and ≥1 prior diagnosis of hyperlipidemia, hypercholesterolemia, or mixed dyslipidemia were identified from the AD of the Health Alliance Plan at Henry Ford Health System (HFHS). A sample of 1000 patients was drawn from the pool of eligible adults and stratified by high CV risk based on presence of comorbid conditions including diabetes, coronary heart disease, and peripheral artery disease. Statin utilization and adverse events data were abstracted both from the AD and the HFHS electronic medical record (EMR). SI was defined using both a primary definition inclusive of all possible statin related adverse events and a secondary definition that included only musculoskeletal events. SI was categorized as absolute (AI) or titration (TI) intolerance. The performance of the AD algorithm was assessed using measures of concordance (Cohen’s kappa [κ]) and accuracy (sensitivity, specificity, positive predictive value [PPV]) with the EMR as reference.

Results:
A total of 353 patients (48% female, 44% Caucasian, mean (SD) age 63 (12) years) were identified as high CV risk with 33% having a history of CHD, 77% diabetes and 2% PAD. Forty-two percent of patients were on simvastatin, 35% atorvastatin, 11% lovastatin, 7% rosuvastatin and 6% pravastatin/fluvastatin. Table 1 characterizes the validation sample. SI was identified in 19.3% and 20.7%, AI in 3.1% and 2.8%, and TI in 16.7% and 18.7% of patients in the EMR and AD, respectively. The algorithm identifying any SI had robust concordance (κ=0.73), good sensitivity (80.9%) and PPV (75.3%). The TI algorithm performed better (κ=0.78, sensitivity=86.4%, PPV=77.3%) than the AI algorithm (κ=0.56, sensitivity=54.5%, PPV=60.0%). Specificity was high (>94%) across all 3 algorithms.

Conclusion:
This study successfully defined SI among high-CV risk patients using an evidence-based validated algorithm. To our knowledge, this is the first such algorithm for use in AD to be made available to decision-makers.
Abstract 303: A Novel Multi-modal Approach to Stroke Care Quality Improvement and The Development of High-performing Stroke Care Teams
Authors: Loveless Mark O , Kamauu Aaron
Published: July 2021

Background:
The clinical outcomes and quality of care in acute ischemic stroke (AIS) are time-dependent and influenced by the effectiveness and efficiency of the care delivery system. Much attention has been given to improving process and procedure; however, the structure and inter[[Unable to Display Character: ‐]]dependencies of the stroke care teams must be integrated into any acute stroke care quality improvement process.

Objective:
The objective of this study was to apply an innovative multi[[Unable to Display Character: ‐]]modal analytic approach that combines formal epidemiologic analysis, process evaluation and social network modeling of stroke care teams to describe and improve the critical system characteristics of high[[Unable to Display Character: ‐]]performing units in real[[Unable to Display Character: ‐]]world hospital systems.

Methods:
Characteristics of individual hospital units, as well as variation of treatment delivery, were analyzed and compared. A critical path analysis was created based on a widely adopted acute stroke care process model. Stroke care team structures and inter[[Unable to Display Character: ‐]] dependencies were mapped based on the responses to a survey and the responses were analyzed using open[[Unable to Display Character: ‐]]source network graphing software.

Results:
The care team networks were overlaid on to the corresponding process pathways to create a final synthesis of the process and team structure (example below). Critical path analysis combined with mapping of the individual stroke team network interactions demonstrated additional associations between the team structures and process/clinical outcomes. Opportunities for improvement in both process and personnel organization were identified and integrated into existing CQI efforts.

Conclusion:
Multi[[Unable to Display Character: ‐]]modal systems analysis incorporating both care process and stroke care team inter[[Unable to Display Character: ‐]]dependencies offers an enhanced approach to integrated quality improvement for acute stroke care.
Abstract 309: Trends in LVAD Use and Outcomes Among Patients Admitted with Acute Myocardial Infarction
Authors: Lewey Jennifer , Secemsky Eric , Lindvall Charlotta
Published: July 2021

Background:
Mortality rates among patients with acute myocardial infarction (AMI) complicated by cardiogenic shock remain high. Implantation of left ventricular assist devices (LVAD) has become increasingly available since the approval of continuous flow devices in 2008 and in severe cases, may be used to prolong survival post AMI. Little is known about how the frequency of LVAD implantation and subsequent outcomes in AMI patients have changed over time.

Methods:
We used the National Inpatient Sample, a 20% stratified sample of all hospital discharges that uses scaled weights to approximate national estimates. We identified all patients with AMI (ICD9 code 410.1x) and LVAD implantation (ICD9 code 37.66) from 2006 through 2012.The primary outcome was in-hospital mortality. Baseline characteristics were compared over time using the chi-square test for categorical variables. Univariate logistic regression was used to examine the association between baseline characteristics and risk of mortality after LVAD.

Results:
The number of LVADs implanted for any indication increased from 713 to 2,960 during the study period whereas LVAD use among AMI patients remained stable (Figure). AMI patients who received an LVAD were predominately male and white and the average age was 56.3 years. The number of AMI patients receiving ECMO, Impella, or other short-term mechanical support devices as a bridge to LVAD increased over time whereas IABP use remained stable. Among patient and hospital factors studies, non-white race and later year of implantation were associated with lower mortality after LVAD. Use of other mechanical support devices was associated with higher mortality (OR 2.7, p=0.029). Post-LVAD mortality rates were higher for AMI compared to non-AMI patients but decreased for all patients over time: 57.1% to 21.2% for AMI patients (p <.0001) and 36.8% to 12.8% for patients without AMI, p < .0001).

Conclusion:
Among patients with AMI, LVAD use remains low and has not increased as has LVAD use for other indications. Although LVAD use in this population was initially associated with higher in-hospital mortality, our analysis suggests a narrowing of this gap. Future studies are needed to determine how long-term survival is affected and which patients are appropriate candidates for LVAD implantation after AMI.
Abstract 312: A Tablet Computer-based System to Incorporate Patient-reported Outcomes Into Routine Care for Patients Presenting for Coronary Angiography
Authors: Bruckel Jeffrey T , Wagle Neil , O’Brien Cashel , Elias Josephine , McKenna Sharon , Meyers Peter , Fifer Michael A , Pomerantsev Eugene , Yeh Robert W
Published: July 2021

Background:
Coronary revascularization by PCI is one of the most common medical procedures performed nationally. PCI for patients with chronic stable angina is performed primarily for symptomatic benefit, and has not been shown to provide survival benefit or reduction in MACE. Therefore, improvement in angina severity is an important marker of quality and procedural success for this patient population. Patient-reported outcome measures (PROMs) have been developed for chest pain and dyspnea which are valid and responsive to treatment, however they are not widely used in routine care. We present a model for use of PROMs in routine care.

Methods and Results:
Development of infrastructure to collect PROMs data and present it to medical providers was a strategic priority of Partners HealthCare. The health system funded a tablet computer software platform to efficiently collect PROMs responses from patients and integrate the responses in the electronic medical record. This platform was implemented in the catheterization laboratory at Massachusetts General Hospital, with a target population of patients with chronic stable angina presenting for diagnostic coronary angiography. Patients complete short-form Seattle Angina Questionnaires (SAQ-7), the Rose dyspnea scale, the short-form Patient Health Questionnaire (PHQ-2), and the PROMIS-10 general health-related quality of life instrument. These assessments take 5 to 10 minutes to perform while the patient is in the pre-procedure waiting room. A phased implementation resulted in a final program including pre-procedure measurement, presentation of data to clinical providers, and follow-up using an e-mail platform. The program successfully captured measures from 474 patients in the first six months of the program, comprising 57.9% of outpatient visits. The key factors for success were high-level leadership commitment, allocation of adequate resources, a user-friendly interface for patients and staff, easily interpretable measures, and clinical relevance.

Conclusions:
Our program demonstrates that the integration of patient-reported outcomes measurement is technically feasible in a real-world care environment. We share our experiences to provide others with a model for similar programs, and to accelerate implementation nationwide by helping others avoid pitfalls. We believe expansion of similar programs nationally may lead to more robust quality measurement infrastructure and higher-value care for patients.
Abstract 318: Distance From Percutaneous Coronary Intervention Site is Not Associated with 30-day Readmission Length of Stay: Insights From the Veterans Affairs Clinical Assessment, Reporting and Tracking (VA CART) Program
Authors: Valle Javier , Glorioso Thomas J , Carey Evan P , Bradley Steven M , Maddox Thomas M , Rumsfeld John R , Ho P M
Published: July 2021

Background:
Although readmission following PCI is an emerging quality measure, it is unclear to what extent readmissions post-PCI are avoidable. Many VA patients travel long distances to receive PCI, and a prior study suggests that those living closest to their PCI site are most likely to be readmitted. Using length of stay (LOS) as a proxy for readmission complexity, we explored whether this lower readmission rate reflects a higher threshold for readmission among patients living farther away from PCI sites.

Methods:
We identified all VA patients undergoing PCI from 2008-2012, excluding those with private insurance or non-VA sources of care to minimize the likelihood of readmissions outside of VA hospitals. Distance to PCI site was determined by straight-line distance (SLD) from patient residence to the site. The primary exposure was quintile SLD to PCI site. We compared risk-adjusted post-PCI readmission mean LOS by quintile, as well as the trimmed mean (excluding the top 5% LOS per quintile) to minimize outlier effects. We also grouped readmission diagnoses into 8 categories (cardiac ischemic, cardiac-nonischemic, peripheral/cerebrovascular ischemia, procedural, bleeding/anemia, respiratory, renal, and other), comparing diagnoses by SLD quintile.

Results:
Among 38,937 patients undergoing PCI, the median SLD to PCI site was 37 mi., IQR 12-85. Crude readmission rates ranged from 16.5% (Q1: 0-9 miles) to 10.2% (Q5: 99-300 mi.). Compared to Q1, the relative difference in mean LOS was significantly lower in Q3 (Q3: 0.77, p = 0.03) and unchanged in all other quintiles (Q2: 0.95, p=0.75; Q4: 0.79, p=0.07; Q5: 0.92, p=0.56; Table). Comparing trimmed means, no quintile was significantly different from Q1. Diagnosis review found higher rates of cardiac ischemia diagnoses in higher SLD quintiles without other clinically significant differences in diagnoses by SLD.

Conclusions:
We did not find an association between patient distance to PCI site and LOS for post-PCI readmissions, and readmission diagnoses were overall similar across quintiles. Thus, post-PCI readmissions across quintiles are likely of similar complexity and for similar diagnoses. Identifying other possible contributors to differences in readmission rates by distance may have important implications for policy and resource allocation.
Abstract 319: Development and Validation of a Mortality Prediction Model for Hospitalized Heart Failure Patients
Authors: Lagu Tara , Stefan Mihaela , Pack Quinn , Atreya Auras , Kashef Mohammad A , Slawsky Mara , Valania Greg , Shieh Meng-Shiou , Pekow Penelope S , Lindenauer Peter K
Published: July 2021

Background:
Clinical predication models for hospitalized patients with heart failure have good performance characteristics but require medical record review, which is both costly and time-consuming. In contrast, administrative claims data are readily available for research but have limited clinical detail.

Methods:
We used highly detailed billing data to derive a multivariable in-hospital mortality prediction model for patients with heart failure. We validated the model in a separate multi-hospital dataset derived from electronic health record (EHR) data. For the derivation, we included patients aged ≥18 years admitted to one of 433 hospitals that participate in the Premier, Inc. Data Warehouse (PDW) between January 2009 and June 2011. Patients with a principal ICD-9-CM diagnosis of heart failure or principal diagnosis of respiratory failure with secondary diagnosis of heart failure were included. After dividing the dataset into derivation and validation sets, we used generalized estimating equations to estimate the parameters of a generalized linear model that adjusted for clustering within hospitals. The model included selected patient demographics, comorbidities, history of prior heart failure admissions, and initial medications and therapies (e.g., inotropes, mechanical ventilation) administered in the first 2 hospital days. We applied the models to the validation set. Finally, we applied the coefficients from the model to a novel multi-hospital dataset, HealthFacts (Cerner Corp), which contains information about hospitalizations and is derived from the electronic health record of 76 participating sites (years 2010-2012).

Results:
In PDW, we identified 200,832 patients ≥18 years old with a diagnosis of heart failure. Of these, 80% (160,839) were randomly assigned to the derivation cohort and the remaining 20% (39,993) were assigned to the validation cohort. Mortality was 4.0%. In the derivation cohort, the model showed a c-statistic of 0.79 Factors that were most strongly associated with mortality included age over 80 years, early inotropes, early vasopressors, and diagnosis of acute kidney injury that was present on admission. In the validation cohort, the c-statistic was 0.79. We then validated the model in the HealthFacts dataset, which had a higher percentage of African American patients (28% vs. 17%). In this cohort, the c-statistic was 0.82.

Conclusions:
A heart failure mortality model based on detailed administrative data available in the first 2 hospital days had excellent performance characteristics in a derivation and an external, EHR-based validation dataset. When clinical data are not available, this model may be useful for severity adjustment in comparative effectiveness studies of heart failure patients.
Abstract 341: Cost of Care Implications for Unstable Angina and Coronary Revascularization Readmissions Following Acute Myocardial Infarction
Authors: Smolderen Kim , Kennedy Kevin , Arnold Suzanne , Chan Paul , Jang Jae-Sik , Jones Phil , Cohen David J , Zhao Zhenxiang , Spertus John
Published: July 2021

Objectives:
While mortality following acute myocardial infarction (AMI) has decreased over time, subsequent hospitalizations due to unstable angina (UA) and coronary revascularization (CR) continue to be a great source of burden both from a patient’s and a societal perspective. It is unknown, however, how AMI patients who experience these additional readmissions value their health and what the associated costs are, beyond the hospitalization itself.

Methods:
From TRIUMPH, a 24-center observational AMI registry, we identified patients readmitted for unstable angina (UA) or unplanned CR ≥1 month following index AMI discharge. Propensity matching was used to compare (1) patients who were vs. were not readmitted for UA and (2) patients who were vs. were not readmitted for CR. We examined one-year quality-adjusted life-years (QALYs) using the EQ-5D measurements at 1, 6 and 12 months, as well as post-discharge costs (office visits, cardiac rehabilitation and cardiovascular readmissions, excluding costs for the UA/CR event). Confidence intervals were calculated via bootstrap analysis.

Results:
A total of 140 (4.26%) were readmitted for UA and 112 (3.41%) patients underwent CR after their AMI. Unadjusted mean 1-year QALYs for UA and non-UA patients were 0.743 and 0.821 [propensity-matched difference -0.076 (95% CI -0.100, -0.042)]. Unadjusted mean 1-year QALYs for CR and non-CR patients were 0.798 and 0.828 [propensity-matched difference -0.032 (95% CI -0.063, -0.003]. Mean differences in costs were $8009 (95% CI $3997, $14229) for UA vs. non-UA patients and $4498 (95% CI $4046, $4966) for CR vs. non-CR patients. Cardiovascular rehospitalizations contributed most to these costs
(Table)
.

Conclusion:
In this study, over the year following AMI, patients experiencing UA or unplanned coronary revascularization were challenged in maintaining their health status as compared with those not experiencing the respective event and had significantly higher health care costs.
Abstract 348: The Association of Intravascular Ultrasound Guided Percutaneous Coronary Intervention with 30-Day Readmission
Authors: Amin Amit P , Calderon Artero Pedro , Burns Sara , Novak Eric , Singh Jasvindar
Published: July 2021

Objective:
Early readmission within 30 days (30DR) after percutaneous coronary intervention (PCI) contributes towards excessive health care costs. The use of intravascular coronary ultrasound (IVUS) during PCI and its association with hospital costs and 30-day readmission (30DR) has not been examined.

Methods:
We used the national State Inpatient Database (SID) from 8 states with 30 day follow-up to identify the association of IVUS with 30DR and hospital costs. IVUS was identified via CPT codes 37250 and 37251. The main outcome variable was 30DR. The association of IVUS with 30DR and costs was identified via a multivariable hierarchical models (with site as a random variable) adjusting for confounders of 30DR and costs. We also analyzed interactions of IVUS with PCI indication and number of vessels treated.

Results:
Among 539,045 patients undergoing PCI, IVUS was used in 7.8% cases. 30DR occurred in 68,939 (12.8%) patients. 30DR occurred in 63,721 (12.8%) patients in the non-IVUS group and 5,218 (12.2%) in the IVUS group. When adjusted for confounders, IVUS was associated with a lower risk of 30DR (OR 0.993; 95% CI, 0.896 to 0.971, P < 0.0001). Although interactions with PCI indication and number of vessel treated were not statistically significant, there was a weak trend towards lower 30DR rates among STEMI and NSTEMI patients as well as patients undergoing PCI of greater than 1 vessel (Figure 1). Finally, use of IVUS cost an incremental $2,099 when adjusted for other confounders of costs.

Conclusions:
In this large national database, we found that IVUS-guided PCI is associated with a lower rate of 30DR after PCI. We observed weak trends of greater benefit in patients with acute coronary syndromes and PCI of greater than 1 vessel. However, this advantage was offset by higher incremental costs of IVUS use. Further studies are needed to formally evaluate the cost-effectiveness of IVUS for 30DR.
Abstract 353: Patient and Provider Awareness of Unnecessary Testing, Wasteful Medical Spending, and Choosing Wisely
Authors: Winchester David E , Nguyen Linda , Kline Kristopher , Plumb Jared , Huo Tianyao , Beyth Rebecca
Published: July 2021

Background:
A substantial portion of medical spending, such as unnecessary cardiac imaging tests, does not benefit patients and is therefore wasteful. While estimates of wasteful spending and unnecessary testing are reported in the literature, the degree to which those facts are known by patients and health care providers is not well described. We conducted a survey of patients and providers awareness about waste and hypothesize that patient awareness will be less than providers.

Methods:
We developed an anonymous survey for patients and healthcare providers. Recruitment was done in primary care and cardiology clinics, in the nuclear cardiology laboratory, and included sites both at our academic medical center and our affiliated Veterans Affairs medical center. We recruited patients who either have had nuclear myocardial perfusion imaging (MPI) or may have one ordered for them. We recruited healthcare providers who commonly order nuclear MPI from primary care, hospital medicine, and cardiology including both physicians and advanced providers. Survey questions were in a variety of formats including yes/no, scale responses, multiple choice, and narrative. When possible, identical questions were asked of patients and providers. Comparisons between the groups were made by chi square test.

Results:
The survey was completed by 338 patients and 111 providers. Patients were evenly distributed between primary care (36.0%), nuclear medicine (31.9%), and cardiology (32.2%) recruitment sites, with 55.6% being Veterans. Providers were also well distributed among primary care (37.7%), hospital medicine (22.8%), and cardiology (35.1%). Providers more frequently identified the correct total cost (20.9% versus 10.4% by patients, p<0.0001) and percentage of costs (77.5% versus 39.3% by patients, p<0.0001) of wasteful spending. Patients were less likely than providers to be aware of the Choosing Wisely campaign (2.7% versus 37.2%, p<0.0001). Nearly half (137, 43.5%) of patients indicated that sometimes it is “a bad idea to get a test”; the most common narrative reasons included risk of the test (n=11), lack of symptoms (n=10), and the test not being necessary (n=10). Responses from providers regarding inappropriate reasons to order tests included lack of symptoms (n=26), patient or family demands (n=16), and malpractice fears (n=12).

Conclusion:
Both patients and healthcare providers underestimate the costs of wasteful medical spending, patients to a greater degree. Awareness in both groups of the Choosing Wisely campaign is low. Many patients and providers are cognizant of accurate reasons why a test might be unnecessary.
Abstract 354: The Effect Of Early Surgery on Outcomes in Infective Endocarditis- A Meta- Analysis of 25,732 Patients
Authors: Kayani Waleed T , Idrees Najia , Bandeali Salman , Pham Don , Khan Anam , Wong David , Hamzeh Ihab R , Virani Sallim S , Lakkis Nasser M , Alam Mahboob
Published: July 2021

Despite a rising incidence of infective endocarditis (IE), its associated mortality remains high. It is estimated that at least 30% of patients with IE undergo surgery, however data on outcomes of outcomes associated with timing of surgical intervention in this setting is limited. Existing literature mainly consists of observational studies with conflicting results, and current guidelines (ACC/ AHA and Society of Thoracic Surgeons) base recommendations largely on small retrospective studies and expert opinion. We sought to determine the effect of early surgery on outcomes after IE by performing the first comprehensive meta- analysis on the subject. A comprehensive literature search using PubMed (MEDLINE) was performed using keywords “endocarditis”, “surgery”, “mortality” and “outcome”. Early surgery was defined as surgical intervention performed during index hospitalization. Primary outcome of interest was all-cause mortality. Secondary outcomes included incidence of recurrent endocarditis and embolic phenomenon. Of 117 identified studies, 36 met the inclusion criteria (25,732 patients). Data on baseline characteristics and outcomes of interest were extracted. Meta-analysis was performed using Review Manager Version 5.0 (Cochrane Collaboration). Effect sizes for outcomes of interest were estimated using odds ratio (OR) and 95% confidence intervals (CI). Given the inherent heterogeneity among included studies, results from the random effects model are reported. Of the included 25,732 patients, 7,835 underwent early surgery compared to 17,537 who received conventional treatment. A significant reduction in both, short and long term mortality in patients who underwent early surgery OR 0.58 (95% CI 0.47-0.70; p = <0.001) and OR 0.49 (95% CI 0.37-0.65; p = 0.001) respectively was seen. The incidence of recurrent endocarditis or embolic phenomenon did not differ between the two groups. This is the first comprehensive meta-analysis to examine the impact of early surgery on outcomes in patients with IE. Our results indicate that early surgery is associated with a significant reduction in all-cause mortality in patients with IE, without an increase in incidence of recurrent endocarditis. These findings are of clinical significance given paucity of quality data on the subject.
Abstract 355: The Economic and Clinical Burden of High Risk Symptomatic Peripheral Artery Disease
Authors: Chase Monica , Friedmann Howard , Navaratnam Prakash , Heithoff Kim , Simpson Ross J
Published: July 2021

Background:
A better understanding of high risk groups of patients with symptomatic peripheral artery disease (SPAD) may improve targeting care and reducing costs.

Methods:
Patient records from Jan 1, 2006 through June 30, 2010 were extracted from the MarketScan Commercial and Encounters database (MCED) using a SPAD selection algorithm. The earliest date of a record of SPAD was the index date and a period of 1 year pre- and 3 years post-index was the study time frame. Patients with stroke/TIA, with bleeding complications and contraindications to anti-platelet therapy were excluded. Descriptive and univariate statistics comparing pre- and post-index CV and PAD related events, resource utilization and costs among the diabetic vs. non-diabetic SPAD, recent MI vs. non-recent MI SPAD, and diabetes and recent MI vs non-diabetes and recent MI SPAD patients were generated.

Results:
Out of a total of 16,663 SPAD patients, 36.0% had comorbid diabetes (N= 6,002), 5.8% had a recent MI (N=965) and 2.6% (N=425) had diabetes and a recent MI. Patient demographics appear to be similar but comorbid conditions and the Charlson Comorbidity Index (CCI) are significantly higher among high risk groups when compared to non-high risk counterparts (p<0.0001). CV related outcomes; PAD-related and CV-related procedures; other medical resource use and costs (both all-cause and PAD-related) are significantly higher among high risk SPAD patients (see Table 1).

Conclusions:
Effective secondary prevention therapies may reduce morbidity and costs associated with these high risk groups.
Abstract 356: Effect of Treatment with Rosiglitazone on High-sensitivity Cardiac Troponin Levels Among Patients with Type 2 Diabetes Mellitus
Authors: Salahuddin Usman I , Pandey Ambarish , Ayers Colby R , See Raphael , Neeland Ian J , Gore M O , Grinsfelder Bennett , Abdullah Shuaib M , Khera Amit , de Lemos James A , McGuire Darren K
Published: July 2021

Background:
Rosiglitazone has been associated with increased risk of adverse cardiovascular events, including myocardial infarction (MI) and heart failure. However, the impact of rosiglitazone on markers of subclinical myocardial injury, such as high-sensitivity cardiac troponin-T levels (hscTnT), is not known.

Objective:
Evaluate the impact of intermediate-term treatment with rosiglitazone on hscTnT levels among patients with T2DM with or at high risk for coronary artery disease (CAD).

Methods:
We measured serum hscTnT levels at baseline and after 6 months of study treatment in a randomized trial comparing rosiglitazone versus placebo in patients with T2DM and risk factors for or prevalent CAD. Multivariable adjusted linear regression analysis was performed to identify variables associated with changes in hsTnT levels from baseline to follow up.

Results:
The study included 150 participants, of whom 106 had paired baseline and end-of-study blood samples for analysis (53 placebo, 53 rosiglitazone, mean age 56 + 8 years, 42% women; 8.8 years average T2DM duration; 42% insulin treated). Almost all study participants (93%) had elevated hscTnT (≥3 ng/L) at baseline; 23% had hscTnT levels exceeding the diagnostic limit commonly used to diagnose MI (≥14 ng/L). As expected, age, male sex and left ventricular hypertrophy were independently associated with elevated hscTnT levels at baseline. HscTnT levels increased from baseline to follow up within both the placebo and rosiglitazone treated groups (Figure), with no difference between the two groups after 6 months (p =0.73). In multivariable adjusted linear regression analysis, male sex (β = 0.36; p= 0.04), baseline hemoglobin A1c (β= 0.43; p= 0.001) and baseline hscTnT levels (β= -0.69; p <0.0001) were independently associated with an increase in hscTnT from baseline to follow-up. Use of rosiglitazone was not associated with an increase in hscTnT levels in the adjusted model (p = 0.65).

Conclusion:
There is high prevalence of elevated hscTnT among patients with T2DM with prevalent or clustered risk factors for CAD, exceeding the MI detection limit in almost a quarter of such patients. Rosiglitazone did not impact hscTnT levels, adding to the growing body of literature suggesting that rosiglitazone is not associated with direct myocardial injury.