bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P73: Social Support and Adherence to Cardiac Risk Factor Management Instructions during the First Year after Acute Myocardial Infarction
Authors: Leifheit-Limson Erica C , Reid Kimberly J , Kasl Stanislav V , Lin Haiqun , Jones Philip G , Buchanan Donna M , Peterson Pamela N , Parashar Susmita , Spertus John A , Lichtman Judith H
Published: July 2021

Background:
Adherence to risk factor management (RFM) instructions after AMI can promote recovery. The prognostic importance of social support for adherence is not well understood. We examined the relationship between baseline social support and post-AMI RFM adherence, and tested whether depression moderates this association.

Methods:
Using data from 2202 AMI patients enrolled in the 19-site PREMIER study, we longitudinally examined whether low baseline social support (index hospitalization; score <=18 on 5 items from ENRICHD Social Support Inventory) is associated with poor adherence to 13 RFM instructions (medication adherence, warfarin use, follow-up plan/appointments, whom to call, cholesterol monitoring and therapy, diabetes management, weight monitoring and loss, smoking cessation, diet, exercise, cardiac rehabilitation) within the first year of recovery. Patients were asked at 1, 6, and 12 months if they received any of the RFM instructions since their last interview. Poor adherence was defined
a priori
as adhering “very carefully” to less than 50% of the patient-appropriate instructions. Hierarchical repeated-measures Poisson regression evaluated the association between support and adherence, with adjustment for site, sociodemographics, clinical history and presentation, hospital and outpatient care, and depression. Whether depression (PHQ-9 score >=10) modified the association was evaluated by stratifying the risk-adjusted model by depression status and including a support*depression interaction term.

Results:
Patients with low social support had greater unadjusted risk of poor adherence than patients with high social support (RR 1.46, 95% CI 1.27-1.67). This association did not vary with time and remained significant after full risk adjustment (RR 1.24, 95% CI 1.05-1.47). In depression-stratified analyses, the risk-adjusted association of low support with poor adherence was significant among nondepressed (RR 1.44, 95% CI 1.26-1.66) but not depressed (RR 1.03, 95% CI 0.79-1.33) patients (p<0.001 for support*depression interaction).

Conclusion:
Good social support may improve adherence among nondepressed AMI patients, but more research is needed to understand the role of social support among depressed patients.
Abstract P83: Predictors of Length of Stay for HF Patients: Results from Get With the Guidelines
Authors: Whellan David J , Zhao Xin , Hernandez Adrian F , Peterson Eric D , Bhatt Deepak L , Heidenrich Paul A , Schwamm Lee H , Fonarow Gregg C
Published: July 2021

Background:
Heart failure (HF) admissions are frequent and result in significant expenditures. Identifying predictors of increased length of stay (LOS), particularly above the median LOS, may help providers set expectations for patients and target resources effectively.

Methods:
We analyzed HF admissions (n= 70,094) from January 2005 through April 2007 from 246 hospitals in the AHA's Get With The Guidelines-HF program. In a subset with BNP (n=44,535), baseline characteristics, admission vital signs and selected labs (BNP, creatinine, BUN, hemoglobin, and sodium) were included in a multivariable regression analysis to determine factors associated with LOS ≥4 days.

Results:
Patients were median age of 72, 45% female, 53% had ischemic etiology, and median LVEF was 35%. Median LOS was 4 days (25
th
,75
th
2,6). The most significant predictors of LOS ≥ 4 days were a higher admission BUN, higher heart rate, and lower SBP (Table 1). Age, insurance, race, creatinine, and LVEF were not.

Conclusion:
Upon admission for HF, certain vital signs, comorbidites, and laboratory values are associated with an increased likelihood of a LOS ≥ 4 days. These observations may be of value in the implementation of interventions aimed at reducing LOS and improving quality of care in HF.

Variables Associated With Hospital LOS >/= 4 Days

Variable
Chi-Square
OR
Lower (95% CI)
Upper (95% CI)
P-value

Admissioun BUN (/1 unit increase)
221.8
1.01
1.01
1.01
<.001

Admission SBP (/ 10-unit increase)
129.6
0.96
0.95
0.96
<.001

Heart Rate (/ 10-unit increase)
122.4
1.07
1.06
1.09
<.001

History of COPD/Asthma
45.8
1.19
1.13
1.25
<.001

Admission BNP (per 100-unit increase)
37.6
1.01
1.00
1.01
<.001

Female vs. Male
29.7
1.12
1.08
1.17
<.001

History of renal insufficiency
27.4
1.17
1.10
1.24
<.001

History of heart failure
18.0
0.89
0.85
0.94
<.001

Region: (MW vs. NE)  (S vs NE)  (W vs. NE)
17.3
0.71  0.91  0.71
0.60  .077  0.56
0.85  1.08  0.88
<.001
Abstract P101: The Association of Hypertension and Antihypertension Medication Use with Sexual Health: A Study from the National Social Health and Aging Project (NSHAP)
Authors: Spatz Erica S , Canavan Maureen E , Desai Mayur M , Krumholz Harlan M , Lindau Stacy T
Published: July 2021

Background
Hypertension (HTN) and its treatment are commonly associated with sexual problems; yet, data are discordant in men and lacking in women. We investigated the association of HTN and its treatment with sexual health in older adults, and whether the association varied by gender and medication class.

Methods
Data are from the NSHAP, a nationally-representative observational study of men and women aged 57-85 yrs. Adults were stratified by HTN status: No HTN; HTN-Treated; and HTN-Untreated. HTN was defined by self-report or a mean blood pressure ≥140/90mmHg. HTN-Treated adults reported taking ≥1 of the following medications: diuretics, beta-blockers, calcium-channel blocker, ACE inhibitors or angiotensin receptor blockers, and alpha blockers. We report the prevalence of partnered sexual activity and problems by HTN status. Models testing the association of medication class were examined, stratified by gender, and adjusted for other antihypertensive medication classes (Model 1), and Model 1 plus age, partner status, insurance, diabetes, heart disease, smoking, and functional status (Model 2).

Results
Comparing HTN-treated to HTN-Untreated and No HTN, the prevalence of sexual activity in men was 60.7% v. 74.3% v. 71.5% (p=.002) and in women 35.4% v. 38.3% v. 58.0% (p<.001). The prevalence of sexual problems in men was 69.3% v. 53.8% v. 51.4% (p=.005) and in women 73.9% v. 66.7% v. 71.7% (p=.367). Most commonly cited were erectile problems (41%) in men with HTN. Diuretics (unadjusted: OR=0.68, p 0.02; Model 1: OR=0.69, p=.03; Model 2: OR=0.72, p=.17) and beta blockers (unadjusted: OR=0.69, p 0.02; Model 1: OR=0.67, p=.03; Model 2: OR=0.79, p=.33) were associated with sexual inactivity in men with treated HTN; diuretics, only, were associated with sexual inactivity in women (unadjusted: OR=0.81, p 0.25; Model 1: OR=0.76, p=.14; Model 2: OR=0.58, p=.02). There were no significant associations with sexual problems.

Discussion
HTN and its treatment are associated with sexual inactivity; diuretics more than other medication classes. In men but not women, treatment is also associated with sexual problems but medication class has no effect. More research investigating gender-specific mechanisms linking HTN and its treatment with sexual health is needed.
Abstract P129: Building Capacity with Opinion Leaders to Implement the VA Hospital-to-Home Initiative: CHF QUERI
Authors: Sahay Anju , Heidenreich Paul A
Published: July 2021

Objectives:
Reducing readmission rates for heart failure (HF) patients is the primary goal of the Department of Veteran Affairs and its' Chronic Heart Failure (CHF) QUERI. It is also the goal of Hospital to Home (H2H) national quality improvement (QI) initiative cosponsored by the American College of Cardiology and the Institute for Healthcare. In January 2010 the CHF QUERI through its HF Provider Network launched the “VA H2H” QI initiative to implement the national H2H initiative at the VA facilities. Based on the PARIHS framework and Rogers Diffusion of Innovation Theory the specific aim was to identify local opinion leaders (OLs) at each facility to help facilitate the implementation of the VA H2H initiative at own facility.

Methods:
Prior to launching the VA H2H we used the sociometric method to identify OLs. HF Network members from 61 facilities were asked to nominate up to 2 providers at own facility (physician / nurse / other) including self as the local OL. Based on their nominations OLs were identified preferably with a physician and nurse team and they were asked to participate in the VA H2H. In Month 4 and Month 6 all members were asked to complete a survey providing information about the projects (or interventions) recently initiated based on the VA H2H, planned based on the VA H2H, or ongoing not based on VA H2H initiative.

Results:
70% of the facilities (n=43) responded with 1-2 nominations for OLs (n=82) and the remaining 30% facilities had no identified OLs. Survey results show that among the facilities with OLs, 79% initiated/planned projects based on the VA H2H initiative; 9% did not initiate/plan project based on the VA H2H initiative; and 12% were non-responders. These facilities with OLs reported a total of 161 projects: 27 initiated planned based on the VA H2H, 52 planned based on the VA H2H, and 82 ongoing projects not related to VA H2H. Facilities without identified OLs reported having only a total of 6 projects.

Conclusions:
Most VA facilities were able to identify OLs and then successfully implement the VA H2H initiative.

Impact:
Use of OLs may be effective in implementing non-mandated QI initiatives to improve care for all VA HF patients.
Abstract P147: Sexual Problems Experienced by Women After an MI
Authors: Lindau Stacy T , Abramsohn Emily , Chan Paul , Garavalia Brian , Garavalia Linda , Krumholz Harlan M , Spatz Erica , Spertus John A , Decker Carole
Published: July 2021

Objective:
Describe sexual problems experienced by female patients following an MI to inform best practices for prevention and treatment.

Methods:
Women in the U.S. TRIUMPH MI registry who reported being sexually active before and 12 months after their MI were randomly selected. In-depth telephone interviews 18-24 months post-MI were conducted until thematic saturation occurred. Transcripts were coded and content analyzed by a multidisciplinary team including a nurse, psychologist, public health researcher, anthropologist, and gynecologist.

Findings:
Mean age was 58 years (range 43 to 75). Most subjects (13/17) said sexual activity was important before and after the MI. Although frequency of sexual activity was generally lower, the majority had resumed sexual activity by 6 months post-MI. Three women had resumed sexual activity within 3 weeks of the MI. Common, bothersome sexual problems after MI included: 1) low desire and arousal: “Since I had my heart attack the desire is not there anymore, not like it was. And I don't get the same feeling that I used to get from it.”, 2) vaginal dryness: “It's so bad. But I don't know what to do with that.” and 3) fear or worry that sex will trigger another MI: “My first experience, I was trying so hard, I had a real heart palpitation. You know, real strong and my heart beat real fast and it scared me.” Patients described their own and their partner's fear about sex as a hindrance: “I had to convince my husband that I wasn't going to die in bed.” Women indicated that physician-initiated attention to sexual concerns following an MI is lacking. Some attributed their sexual problems to medications that were initiated after the MI. Despite sexual problems experienced by MI patients and their partners, several women reported pleasure, physical closeness, normalcy, and “living life to the fullest” in the face of a life-threatening condition as motivations for continued sexual activity.

Conclusions:
Many women continue to be sexually active following an MI, in spite of bothersome sexual problems and worry about MI recurrence triggered by sex. Sexual activity, including fear of recurrent MI, should be addressed during post-MI care. These findings are being used to develop an intervention to improve sexual outcomes in women following MI.
Abstract P163: Psychological Distress in Cardiac Rehabilitation Participants
Authors: Gracik Theresa , Krishnan Sangeetha , Jackson Elizabeth , Rubenfire Melvyn
Published: July 2021

Background:
Psychological(psych) disorders are risk factors for coronary events and each may affect behavior and compliance. We sought to characterize the psych and clinical profiles of CAD patients (pts) entering cardiac rehabilitation (C. Rehab).

Methods:
The psych profiles of 440 CAD pts were assessed on entry to C. Rehab using the Symptom Check List-90. The questionnaire screened for levels of depression, anxiety, hostility, and a global severity index (GSI). The mean SCL-90 T-score for each parameter in the adult population is 50+10.

Results:
Of the 440 pts, 28.4% were female, 75.7% married and 89% Caucasian; 25.5% were hypertensive, 20.5% diabetic and 47% had a BMI>30. Mean age was 61.5+10.7. Clinical indication for C. Rehab was 56.4% PCI/CABG, 8.4% Stable Angina (SA) and 35.2% ACS. There was a high prevalence of depression, anxiety, and overall psych distress as measured by the GSI (see table). There was no difference in SCL-90 scores by gender, age, education, BMI or diabetes. Unmarried pts were significantly more anxious compared to married pts (p=0.0341). SA pts had significantly higher prevalence of anxiety (p=0.0182) and hostility (p=0.0096) compared to PCI/CABG and ACS. There was a strong correlation between the four measures of psych distress.

Conclusions:
Psych distress is common at entry to C. Rehab and can't be identified with clinical characteristics with the exception of indication for C. Rehab and marital status. Consideration should be given to routine psych profiling at entry to C. Rehab.
Abstract P182: Comparing Blood Pressure Control in Diabetic Versus Nondiabetic Veterans Following Percutaneous Coronary Intervention
Authors: McGraw Sloane A , Healy Chris , Mohamedali Burhan , Shivaraju Anupama , Shroff Adhir
Published: July 2021

Background:
Blood pressure control in patients with coronary artery disease (CAD) or diabetes is essential to decrease morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends systolic blood pressure (SBP) <130 and diastolic blood pressure (DBP) <80. These values can be attained using beta-blockers, angiotensin antagonists, calcium channel blockers, diuretics and nitrates.

Methods:
We conducted a retrospective cohort study focusing on the attainment of the JNC-7 guidelines, comparing 331 diabetic to 524 non-diabetic patients who underwent percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL.

Results:
Among the diabetic population, the mean SBP decreased 135 to 131mmHg (p = 0.0014) and mean DBP decreased 72 to 70mmHg (p= 0.0014). In non-diabetics, the mean SBP decreased 133 to 128mmHg (p<0.0001) and mean DBP decreased 73 to 71mmHg (p<0.0007). The percent of diabetics at JNC-7 SBP goal increased from 41 to 50% (136 to 166 of 331) (p= 0.0041), however the percent change at DBP goal was not significant. In non-diabetics, percent at goal for SBP increased 45 to 57% (236 to 299 of 524) (p<0.0001) and for DBP increased 69 to 76% (362 to 398 of 524) (p=0.0075). At six months, among diabetics, the medication usage increased for beta-blockers, from 80 to 92% (265 to 305 of 331) (p<0.0001) and for nitrates from 32 to 37% (106 to 122 of 302) (p=0.0465). Among non-diabetics, use of beta-blockers increased from 68 to 87% (356 to 456 of 524) (p<0.0001) and nitrates from 20 to 25% (105 to 131 of 524) (p=0.0054). Use of angiotensin antagonists also increased from 52 to 71% (272 to 372 if 524) (p<0.0001) among non-diabetics.

Conclusions:
There were improvements in blood pressure among both populations at six months post-PCI. Both groups attained JNC-7 SBP goals; only non-diabetics achieved DBP goal. Medication use increased for both groups with beta-blockers and nitrates. Angiotensin antagonists only increased significantly among non-diabetics. This demonstrates that post-intervention, tighter control of blood pressure is attempted however levels are not yet optimal.
Abstract P194: Depression Screening in Heart Failure: Preliminary Clinical Trial Results
Authors: Piamjariyakul Ubolrat , Smith Carol E , Thompson Noreen
Published: July 2021

Purpose:
To explore factors contributing to depression identified by patients and mental health nurse specialists.

Background:
Heart failure incidence approaches 10 per 1,000 Americans after age 65 years. Nearly half of all patients with heart failure experience depression, an independent risk factor for increased cardiovascular morbidity and mortality.

Methods:
Patients with heart failure (
n
= 175; mean age = 63.1 years,
SD
= 13; range age 25-over 89 years) were screened for depression, using the PHQ-9 and CESD. Mental health clinical nurse specialist referrals were made based on a combination of questionnaire scores (i.e., moderate to severe depression) and patient narratives, including expressed feelings of depression, loneliness, sadness, or suicidal thoughts. Content analysis research methods were used to categorize patient and mental health nurse specialist consultation narratives and identify factors contributing to depression.

Results:
Using the PHQ-9 and CESD screening questionnaires, 75 (43%) patients reported having felt depressed during the previous month, resulting in 47 (27%) patient referrals to the mental health clinical nurse specialist. Patients most often reported depressive symptoms due to complex illness care, loss of independence or function, self-care demands, financial concerns, and life stressors. The advanced practice mental health nurse consultations revealed patients most often experienced fatigue and insomnia, grief and situational depression, anger, and regret reactions. Patients were more likely to disclose mental health illnesses, domestic and family issues, and illicit substance use to the mental health clinical nurse specialist than to investigators administering the PHQ-9 and CESD.

Implications:
Exploring patient and expert mental health nurse narratives identified unique contributing factors of depression in heart failure, which warrant further study. The mental health clinical nurse specialist determined whether patients experienced grief responses or depression, an important distinguishing factor in screening for depression, with implications for research and clinical practice.
Abstract P2: Medical Resource Utilization and Costs Following Hospitalization of Patients with Chronic Heart Failure in the United States
Authors: Korves Caroline , Eldar-Lissai Adi , Rodermund Doug , Swallow Elyse , Cummings Alice Kate , Ariely Rinat , Duh Mei Sheng
Published: July 2021

Background:
The study objective was to determine medical resource utilization and direct and indirect costs following hospitalization with chronic heart failure (HF).

Methods:
Patients (Pts) with ≥1 hospitalization with a chronic HF claim (ICD-9 428.22, 428.32 or 428.42) were identified in a US commercial insurance claims database from 2004-2008. Pts were observed from beginning of first hospitalization (index hospitalization) for chronic HF until disenrollment or end of data availability. Inpatient, outpatient, and prescription drug data were used to estimate per patient per month (PPPM) utilization rates. Costs (2009 USD) were calculated per hospitalization and PPPM for patients ≤65 years, and included insurers’ reimbursement, patient out-of-pocket (OOP) and sick leave.

Results:
There were 7,814 pts (mean age 73.2 years, 55.7% (4,355/7,814) male) meeting inclusion criteria. Mean HF hospitalization length of stay increased from 6.7 days at index hospitalization to 8.2 days at fourth re-hospitalization. Rate of HF-related re-hospitalization remained over 0.045 PPPM throughout 24 months of follow-up, accounting for the majority of all-cause hospitalizations. Rate of all-cause and HF-related outpatient visits peaked at 4.0 and 0.59 visits PPPM, respectively, within the three months after index hospitalization. Index hospitalization was most expensive (Table). Patient OOP costs accounted for less than 10% of direct costs (Table) and sick leave costs were less than $1,800 at any hospitalization. During the study period, outpatient cardiovascular drugs accounted for a small proportion of total pharmacy costs; average PPPM cost varied from $88 to $124, less than 1% of the average cost of a HF-related hospitalization.

Conclusions:
Treating chronic HF pts is resource intensive. The greatest burden occurs within the three months after index hospitalization and pts continue to be burdened after hospitalization by high inpatient and outpatient visit rates.

Index hospitalization
HF-related re-hospitalization

1st
2nd
3rd
4th

Total direct medical costs
$31,998
$22,047
$23,946
$24,839
$24,517

Reimbursement by insurers
$31,023
$21,521
$23,103
$23,781
$23,971

Patient out-of-pocket
$975
$526
$843
$1,058
$546

Indirect costs (sick leave)
$1,194
$1,194
$1,281
$1,703
$1,764

Total

$33,192

$23,241

$25,227

$26,542

$26,281
Abstract P205: Comorbities Predict Future Hospitalization Risk in Incident Myocardial Infarction Survivors
Authors: Dunlay Shannon M , Weston Susan , Killian Jill M , Jaffe Allan S , Bell Malcolm R , Roger Veronique L
Published: July 2021

Background:
Patients are surviving longer after myocardial infarction (MI), but little is known about the occurrence and predictors of subsequent hospitalizations.

Methods:
We identified all Olmsted Count residents with incident MI from 1987-2008 and evaluated Olmsted County hospitalizations through 2009. ICD-9 codes were used to determine the primary reason for hospitalization. To account for repeated events, Andersen-Gill models were used to examine the predictors of hospitalization post-MI. Patients were censored at death or last follow-up.

Results:
A total of 2617 patients (mean 67 years, 41% female, 32% with ST-elevation MI) were diagnosed with incident MI from 1987-2007 and survived MI hospitalization. Over a mean follow-up of 7.1 years, 10116 hospitalizations occurred equating to a median of 3 (range 0 to 43) per person. Only 37.5% (n=3793) of hospitalizations were due to cardiovascular causes, and of these, most were due to ischemic heart disease (n= 1865, 49.2%) and heart failure (n= 733, 19.3%). The proportion of non-cardiovascular hospitalizations increased over time and was higher in women than men, but did not differ by ST-segment status. Several factors were associated with the risk of hospitalization after adjusting for year of diagnosis and sex (Figure). Biomarker levels were not predictors of hospitalization risk.

Conclusions:
Two-thirds of hospitalizations among incident MI survivors in the community are for non-cardiovascular reasons, and this proportion has increased. Comorbidities are important predictors of recurrent hospitalizations. Therapies focused solely on MI management may be insufficient to prevent the majority of future admissions.
Abstract P215: Primary Cardiology Service Versus Cardiology Consultation: Differences in Heart Failure Patients' Medication Regimens on Discharge
Authors: Patel Ankitkumar K , Logue Ray , Weinstock Perry J , Illiadis Elias A
Published: July 2021

Introduction:
Patients with congestive heart failure (CHF) exacerbation are increasingly admitted to a hospitalist service with a cardiology consultation (CC) versus a primary cardiology service (PCS). Our study investigates differences in discharge medication regimens, heart rate (HR) and blood pressure (BP) between these two groups. We hypothesize that PCS patients are more likely to be discharged with appropriate CHF medication regimens and have lower HR and BP.

Methods:
All patients admitted to Cooper University Hospital with CHF exacerbation from 9/1/03 to 8/30/05 were included. A total of 415 consecutive admissions were included. Demographic, past medical history, admission and discharge medication regimens, and discharge vital signs were collected. Chi-square analysis and student's t-test were used for statistical analysis.

Results:
Forty percent of our study population was female. The mean age was 65.9 years and forty five percent were White. Two thirds of patients were managed on a PCS. Both groups had 40% female patients and an average age of 65 years, however there were significantly more White patients on the PCS. Rates of atrial fibrillation, hypertension and diabetes mellitus were equivalent between the two groups. However, renal disease was more frequent in CC group. The mean length of stay was equivalent between both groups as was systolic function. PCS patients were more likely to be admitted with ACE inhibitors, diuretics and aldosterone inhibitors than CC patients. On discharge, PCS patients were more likely to be discharged with digoxin (p<0.01), diuretics (p<0.001), beta-blockers (p<0.05) and aldosterone antagonists (p<0.01). On discharge, PCS patients had lower HR (p<0.01) and BP (p<0.05) than CC patients.

Conclusions:
Our study shows that discharge medication regimens for CHF vary significantly between patients taken care under a PCS as compared to a CC service. We hypothesize by being on the PCS, patients are more frequently reassessed and thus have greater opportunities for inpatient medication adjustment. These medication regimen differences manifest in clinical vital sign changes upon discharge between the two groups. Further study is warranted to see if these differences from 5-7 years ago continue to the present day.
Abstract P216: Heart Failure Readmission Rates: Experience of St John's Physician Group Practice Demonstration
Authors: Drozda Joseph P , Smith Donna A , Freiman Paul C , VanSlette Jeffrey A , Smith Timothy R
Published: July 2021

Objective:
The appropriateness of using readmission rates alone as markers of the quality of Heart Failure (HF) care has been questioned. The HF program of St. John's Health System's Physician Group Practice (PGP) Demonstration provided an opportunity to assess a number of outcomes that help to put readmission rates in context. The HF program included disease and case management and a disease registry in the PCP office.

Methods:
Several data sets were analyzed including the EHR, an inpatient database, the disease registry, and the Social Security Death Master File. Traditional Medicare patients admitted to St. John's Hospital from 2000 to 2010 with a diagnosis of HF, were included resulting in data for 5 years before (Period 1) and 5 years after (Period 2) the 2005 inception of PGP.

Results:
Total admissions were 3559 in Period 1 and 3514 in Period 2. The prevalence of 3 co-morbid conditions in admitted patients increased during Period 2 [diabetes 35.3% (1256/3559) to 42.7% (1499/3514), p<0.001; hypertension 54.8% (1952/3559) to 70.4% (2475/3514), p<0.0001; and coronary artery disease 62.7% (2253/3559) to 66.4% (2332/3514), p=0.015] indicating that patients were getting more complex. HF admissions trended down significantly from Period 1 (709 annual average) to 2009 (637, p=0.007). The 30 day all cause readmission rate dropped in 2005 [16.9% (137/809)] from Period 1 [annual average 18.8% (671 / 3559), p=0.04] and remained stable thereafter [annual average 16.9% (595/3514)]. The 30 day mortality rate was flat from 2000 to 2009 [2.7(15/550)-5.0% (30/597), p=0.3] and increased in 2010 [8.6% (28/327), p<0.0001]. The use of pacemakers and ICDs was unchanged during Period 2 but ACE inhibitor and beta blocker use increased in PGP practices during 2005 and was constant thereafter.

Conclusions:
The HF program implemented by this PGP project was associated with decreased HF admissions and with increased clinical complexity of admitted patients. Despite this increasing complexity, the 30 day all cause readmission rate dropped in the first year of the program and remained stable thereafter. Finally, 30 day mortality rates were not adversely affected until the last year of the program. The increased mortality in 2010 may be due to a change in case mix but remains unexplained.
Abstract P217: A Planning Tool for Implementing Stroke Systems of Care: Mercy Attitude Scale for Stroke
Authors: Drozda Joseph P , Smith Timothy R , Veremakis Christopher M , Jensen Judd M
Published: July 2021

Background.
National recommendations exist to implement stroke care through linking the fundamental components of a comprehensive stroke system that are often fragmented or isolated. Since attitudes appreciably affect behavior, the need exists for a tool to measure provider attitudes towards stroke and its management in order to plan and implement effective stroke systems of care.

Methods.
Rigorous psychometric methodology was used to develop a valid and reliable survey instrument to assess provider attitudes towards stroke. Two different forms of the 18 item Mercy Attitude Scale for Strokes (MASS) were administered to a total of 354 stroke care providers representing multiple specialties in urban and rural areas across four states and who in some way touch stroke care.

Results.
The results of multiple correlation values revealed statistically significant levels of agreement among variables that might influence perceptions regarding stroke care, e.g., gender, hospital size, geographic location, year of highest degree, source of compensation, and healthcare specialization among most of the 18 survey items. The highest ranked item dealt with the need for an urgent and timely response to stroke onset and the lowest ranked item concerned the administration of tPA as the “gold standard” of treatment.

Conclusions.
Ironically, while the respondents agreed that timely intervention is critical, they seemed reluctant to endorse tPA as a timely intervention approach despite a decade of supporting research. This finding raises questions the answers to which are a matter of speculation. The methodological approach taken in this project is applicable to other local and regional systems attempting to build or expand a stroke system of care. This technique allows one to customize a local approach to ensuring timely identification and treatment of stroke patients. Seven steps are identified to implement stroke systems of care and provider training programs.
Abstract P223: Cost-Effectiveness of Adding Aliskiren to Losartan and Optimal Antihypertensive Therapy in Patients with Hypertension, Type 2 Diabetes and Nephropathy with Residual Proteinuria
Authors: Delea Thomas E , Taneja Charu , Moynahan Aaron , Lau Helen , Lian Jean , Sullivan Sean D
Published: July 2021

Background:
AVOID was a randomized, double-blind, 6-mo. trial of adding aliskiren to losartan and optimal antihypertensive therapy in patients with hypertension, type 2 diabetes, and nephropathy with residual proteinuria (urinary albumin creatinine ratio [UACR]>100mg/g) after ≥3 mo. of 100mg/d losartan. Aliskiren reduced mean UACR by 20% vs. placebo (P=.009). A previous study examined cost-effectiveness of aliskiren, but did not examine the potential effects of aliskiren on risks, costs, and quality of life effects of cardiovascular disease (CVD).

Methods:
A Markov model was used to project lifetime incidence of cardiovascular disease (CVD) and end-stage renal disease (ESRD), life years (LYs), quality-adjusted life years (QALYs), and expected lifetime costs (US healthcare system perspective) with losartan plus optimal antihypertensive therapy +/− aliskiren. Albuminuria progression by treatment was projected by generalized linear model regression equations fit to UACR from AVOID. Probabilities of CVD/ESRD by UACR and death without CVD/ESRD by age were obtained by calibrating the model to results for losartan and placebo in the RENAAL study. Other parameters were from published sources.

Results:
With losartan, mean UACR is projected to increase from approximately 790 mg/g at baseline to approximately 1700 mg/g at 3.5 years and to remain at this level for the duration of the model. Assuming the beneficial effects of aliskiren on the rate of progression of UACR persist for as long as patients remain on therapy, mean UACR with aliskiren plus losartan is projected to decline from 790 mg/g at baseline to 730 mg/g after 1 year, then increase to 740 mg/g after 4 years and remain at that level for the remainder of the model. Under these assumptions, adding aliskiren to losartan and optimal antihypertensive therapy is projected to reduce lifetime incidence of ESRD by 5% and CVD by 4%, increase LY by 0.19 and QALYs by 0.13. Expected lifetime costs are reduced by $7700, as savings from averted CVD ($1500) and ESRD ($12 800) more than offset additional costs associated with aliskiren treatment ($5400).

Conclusion:
Adding aliskiren to losartan in this setting leads to reduced cost and increased QALYs.
Abstract P225: Impact of a Comprehensive Cardiovascular Risk Reduction Program on Treatment and Outcomes of Participants at High Risk for Cardiac Events
Authors: Shaw Richard E , Kishore Sirish , Pang Darren , Shaw Matthew A , Tsachres Haris , Brewster Jamal , Ristow Bryan , McAleer Linne , Kersh Edward
Published: July 2021

With increased emphasis on prevention in recent healthcare reform initiatives, more information is needed to validate the effectiveness of programs designed to diagnose and treat individuals at high risk for cardiac events and increased mortality. The purpose of this study was to evaluate early and late outcomes of a community-based cardiovascular risk reduction program (CRRP).

Methods:
Individuals at high risk for cardiovascular events were referred from community primary care physicians for advanced diagnostic testing and medication management at a hospital-based CRRP. Between March 1, 2005 and August 1, 2007, 182 participants were enrolled and had advanced lipid testing, chemistry panels, stress testing, CT calcium scoring, vascular elasticity studies, and comprehensive assessment of cardiovascular risk factors, family history, diet, activity level and psychological status. Participants had on average 4 visits. Mortality and need for hospitalization were assessed at a mean follow-up time of 45±14 months.

Results:
On CRRP entry, 84% had elevated lipids, 70% had hypertension, 31% had diabetes, 32% had metabolic syndrome, 10% were current smokers, 17% had an abnormal stress test, 36% had depression, 44% had sleep disturbances, and over 50% were not exercising. Over 30% had conditions that had not been recognized or were left undertreated. By last visit, over 95% of participants were on appropriate medications and had received life-style interventions. Late mortality occurred in 9 (5%) participants and 15 (8%) had at least one hospitalization for cardiac reasons. Those who died were older (67 vs. 56; p=0.007), had significantly higher CT calcium scores (998 vs. 114; p<0.0001) and elevated homocysteine levels (14 vs. 9; p<0.0001). Multivariate analyses showed that homocysteine level was the only independent predictor of mortality. No one with metabolic syndrome died (p=0.038). The only factor related to hospitalization was higher NCEP Framingham Age/Sex-adjusted risk score (18 vs. 12; p=0.037).

Conclusions:
A comprehensive community-based risk reduction program can provide enhanced evaluation and treatment for individuals who are at high risk for cardiovascular events. Appropriate medications and risk modification may impact late events.
Abstract P245: Relationship of Vitamin D Status to Cardiac Valvular Disease in Veterans
Authors: Joshi Hetvi K , Bailey Beth , Peiris Alan N
Published: July 2021

Vitamin D deficiency has reached pandemic proportions and has been closely linked to coronary and peripheral vascular disease. Moreover, vitamin D replacement may play a role in improving ejection fraction with the potential to influence cardiac valvular function. To investigate this relationship further we studied 32 veterans without a diagnosis of coronary artery disease. A retrospective study evaluated veterans with both a 25(OH) D determination and an echocardiogram. The echocardioraphic parameters were identified through chart review. Vitamin D deficiency was significantly “(P< 0.05)” associated with mitral insufficiency, aortic sclerosis and pulmonary hypertension as shown in the table below.

Mitral Regurgitation
% Vitamin D deficient

Absent
23

Present
*

56

Aortic Sclerosis
% Vitamin D deficient

Absent
32

Present
*

61

Pulmonary Hypertension
% Vitamin D deficient

Absent
32

Present
*

67

* is P<0.05. To our knowledge, this represents a novel association between vitamin D deficiency, cardiac valvular function and pulmonary Hypertension. The possibility of modulating cardiac valvular structure and function through achieving a vitamin D replete state is an exciting area for future research. Affiliation Mountain Home VA and ETSU Departments of Internal Medicine and Family Medicine.
Abstract P257: Getting to the Golden Hour: Correlating “Door-To” Times with 60-Minute Administration of tPA in an Academic Medical Center
Authors: Leonhardt Ann M , Benesch Curtis G , Young Kate C
Published: July 2021

Introduction:
The efficacy of intravenous tPA for the treatment of acute stroke diminishes over time. The AHA/ASA and NINDS recommend a goal door to needle time of 60 minutes or less. Objective: Identify potential barriers to tPA administration within 60 minutes of arrival.

Methods:
Retrospective review of tPA adsinistration using “Get With the Guidelines” (GWTG) and institutional records from January 1, 2009 through December 31, 2010 (n=100). Spearman rank correlation coefficients were calculated for the NINDS recommended time standards, age and NIH Stroke Scale (NIHSS) score. We used a receiver-operator curve (ROC) to identify the door to CT time predictive of tPA administration ≤ 60 minutes.

Results:
Median door to physician, door to CT, and door to stroke team times were within the recommended goals. Door to CT (ρ=0.53, p<0.0001), and door to stroke team (ρ=0.33, p<0.01) times were positively correlated with door to tPA times. Last known well to arrival (ρ= -0.28, p<0.01) and NIHSS (ρ= -0.32, p<0.01) were negatively correlated with door to tPA times; patients with higher NIHSS and longer last-known-well to arrival times received tPA in a shorter time frame. Age and door to physician time were not correlated with tPA treatment times. After adjusting for the other benchmarks and NIHSS, only door to CT remained significantly correlated with door to IV tPA (partial correlation coefficient=0.40, p<0.001). The ROC curve showed that a goal time of 20 minutes or less for door to CT initiation had the best sensitivity and specificity for predicting tPA administration within 60 minutes.

Conclusion:
In keeping with the recommended time goals, median times for the intermediate steps were within target. Our median tPA times, however, did not meet the 60 minute goal. Door to CT initiation was the variable that most strongly correlated with door to needle times. Process issues such as order entry and scheduling protocols may be barriers to obtaining CT within the 20 minute time frame identified by our analysis. Other barriers after the CT scan is obtained must be identified to facilitate faster tPA administration. Further evaluation of these factors is warranted to better ensure the timely delivery of tPA to stroke patients, thereby improving patient outcomes.
Abstract P265: Percutaneous Endoscopic Gastrostomy in Patients Discharged After Stroke in Washington State
Authors: Schepp Sara K , Longstreth W T , Tirschwell David L
Published: July 2021

OBJECTIVE:
Explore the use of percutaneous endoscopic gastrostomy (PEG) in patients discharged after hospitalization for stroke in Washington State (WA).

METHODS:
Patients were identified from administrative data for WA hospitals and included those discharged between 1995 and 2008 with stroke ICD-9 codes. PEG was defined by the presence of ICD-9 procedure codes. Using multivariate logistic regression, we sought independent associations with PEG for age, gender, stroke type, intubation, discharge year, co-morbid conditions, urban vs. rural home, and hospital type (stroke center or not).

RESULTS:
A total of 118,785 stroke patients were discharged alive, 88% ischemic, 8% intracerebral hemorrhage (ICH), and 4% subarachnoid hemorrhage (SAH). Mean age was 73 years (SD 14), 54% were women, 44% were admitted to a stroke center, and 4.1% had PEG. Other complications of stroke included hemiplegia (28%), pneumonia (8%), and intubation (2%). Patient residence was urban for 83% and rural for 17%. Significant (p < 0.0001) independent associations with PEG included older age (OR ranging from 1.1, 95% CI .96-1.2, to 1.4, 95% CI 1.3-1.6, depending on age group), intubation (2.6, 2.3-2.9), hemiplegia (2.3, 2.1-2.4), stroke type (vs. ischemic stroke: ICH 2.0, 1.8-2.2; SAH 1.6, 1.3-1.8), atrial fibrillation (1.4, 1.3-1.5), congestive heart failure (1.2, 1.1-1.3), acute myocardial infarction (1.2, 1.0-1.4), pneumonia (6.0, 5.6-6.4), stroke center (1.1, 1.1-1.2), and rural home address (.76, .70-.83). PEG was not associated with discharge time period, but this effect was modified by eventual stroke center status (p < 0.0001).

CONCLUSIONS:
In this large population-based study, we found a lower frequency of PEG in stroke survivors than previously reported, possibly reflecting misclassification in our study, selection bias in prior studies, or both. PEG was significantly associated with stroke type and medical complications, particularly pneumonia and endotracheal intubation, likely reflecting stroke severity. The rising probability of PEG at stroke centers may suggest that severely affected patients are increasingly being transferred to stroke centers. Additional studies are need to understand better the criteria for and the utility of PEG in stroke survivors.
Abstract P28: Comparison of Short- and Long-Term Mortality Between Older Asian and White Patients with Non–ST-Elevation Myocardial Infarction: Findings from CRUSADE-CMS Database
Authors: Xu Weixian , Holmes DaJuanicia N , Becker Richard C , Roe Matthew T , Peterson Eric D , Wang Tracy Y
Published: July 2021

Background:
While previous studies have shown similar in-hospital mortality between Asian and White patients with non-ST elevation myocardial infarction (NSTEMI), little is known about their longer-term mortality differences.

Methods:
We linked Medicare claims data to detailed clinical data for 37702 NSTEMI patients ≥65 years of age from 444 CRUSADE hospitals between 2003 and 2006 to examine longitudinal outcomes. All-cause 30-day and 1-year mortality were compared between Asian and White patients by Cox proportional hazards modeling adjusting for differences in baseline patient characteristics.

Results:
Compared with White patients, Asians (n= 307) were younger, more frequently had hypertension, diabetes, and renal insufficiency, and less likely to have had a prior MI or coronary revascularization. There were no significant differences in rates of cardiac catheterization (60.7% vs. 58.0%, p=0.26), PCI (32.2% vs. 31.6%, p=0.73), and CABG (9.2% vs. 8.5%, p=0.62) between Whites and Asians respectively. While the difference in risk-adjusted mortality was not statistically significant between Asian and White patients at 30-days (HR 0.70, 95% CI 0.48 - 1.01), lower 1-year mortality (adjusted HR 0.62, 95% CI 0.48 - 0.79) and 1-year mortality conditional on surviving 30 days (adjusted HR 0.56, 95% CI 0.40 - 0.78) were observed among Asians (Figure).

Conclusions:
While short-term outcomes were similar between Asian and White NSTEMI patients ≥65 years of age, Asians had better outcomes at 1 year. Further study is needed to determine whether more complete follow-up and use of secondary prevention strategies in Asians help to explain these long-term differences in outcome.
Abstract P40: The Impact of a COSEHC Physician Education Program on Patient Cardiovascular Disease Risk Variables in a Large South Carolina Medical Practice
Authors: Joyner JaNae , Forrest Brian , Yu-Isenberg Kristina , Simmons Debra R , Moore Michael A , Lackland Daniel T
Published: July 2021

COSEHC is conducting an 18-month prospective nested cohort design study, COSMIC [
CO
SEHC Cu
S
tomized Model of Intervention and Care], which evaluates the effectiveness of a physician process improvement education program to reduce gaps in physicians’ application of cardiovascular disease (CVD) guidelines in a primary care South Carolina (SC) practice. The COSMIC project evaluates patient CVD risk variable outcomes as a measure of physician improvement. This study evaluates changes in patient CVD risk between baseline (BL) and 6 months (6-mo) among physician cohort 1 (CH1; n=1200 patient records) receiving COSMIC physician education and the control group (cohort 2 (CH2); n=1200 patient records). The COSMIC program involves educational modules that promote clinical care systems changes using JNC 7 and ATP III revised guidelines followed by a repeat process based on reassessed outcomes. At 6-mo, there was statistically more improvement in diastolic blood pressure (DBP) for CH2 than CH1. However, no other CVD outcomes changes were noted between CH1 and CH2 for systolic blood pressure (SBP) total, LDL, or HDL cholesterol (TC, LDL-C, HDL-C), triglycerides, hemoglobin A1c (HgA1c), creatinine, or body mass index (BMI)] using the last observation carried forward method (
Table 1
). While improvements in TC, triglycerides, and HgA1c increased for both groups at 6-mo, CH1 tended to have smaller increases than CH2, respectively. Changes in LDL-C showed improvement for CH1 at 6-mo while CH2 did not improve. Additionally, CH1 had a higher percentage of total patients with return values/visits for each CVD risk factor. This project, while showing no statistically significant changes over 6-mo other than DBP, reveals a trend for modest improvements with physician education for 6-mo in a SC primary care practice. Continuation of this program inclusive of improved clinical care systems will determine the ultimate impact on improving CVD risk in the Southeast United States.

Table 1.

A comparison of changes in CVD risk factors between BL and 6-mo among CH1 and CH2.

* p < 0.05
Cohort 1 (mean ± SD)
Cohort 2 (mean ± SD)

Changes in Systolic Blood Pressure (mm Hg)
-0.91 ± 15.56
-1.79 ± 15.11

Chanegs in Diastolic Blood Pressure (mm Hg)
-0.76 ± 9.47 *
-1.74 ± 8.63

Changes in Total Cholesterol (mg/dL)
0.92 ± 22.79
1.57 ± 22.39

Changes in LDL Cholesterol (mg/dL)
-0.34 ± 19.58
0.08 ± 18.15

Changes in HDL Cholesterol (mg/dL)
1.04 ± 5.87
1.01 ± 5.34

Changes in Triglycerides (mg/dL)
0.55 ± 37.01
0.74 ± 37.81

Changes in Hemoglobin A1c (%)
0.003 ± 0.59
0.062 ± 0.68

Changes in Creatinine (mg/dL)
-0.03 ± 0.16
-0.03 ± 0.13

Changes in Body Mass Index (BMI)
0.07 ± 2.12
0.08 ± 1.69