bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 251: Gender Equity in Rates of Guideline-Directed Medical Therapy Prescription at Discharge for Hospitalized Heart Failure Patients
Authors: Cleveland Erin R , Berkowitz Carla , Pissaris Adam , Valencia Victor , Mutharasan R K
Published: July 2021

Background:
Heart failure (HF) is an increasingly prevalent condition with significant morbidity and mortality. Guideline-directed medical therapy (GDMT) reduces morbidity and mortality in heart failure with reduced ejection fraction, but continues to be under-prescribed. There is a paucity of data on the impact of patient gender on the quality of HF care, although it has previously been shown that women with other cardiovascular conditions, such as coronary artery disease, receive less intensive treatment. We sought to determine whether there is a difference in rates of prescription of GDMT for patients hospitalized with heart failure by gender with the hypothesis that rates of GDMT prescription in women would be lower than that in men.

Methods:
Over a six month study window, we identified 246 patients discharged from an urban academic medical center with a primary discharge diagnosis of systolic heart failure. Systematic chart review was performed to identify whether patients were discharged with the following medications: angiotensin converting enzyme inhibitor (ACE-I), angiotensin receptor blocker (ARB), beta blocker (BB), mineralocorticoid receptor antagonist (MRA), hydralazine and a nitrate, and neprilysin inhibitor/ARB. Statistical analysis was performed to evaluate for an association between rates of GDMT prescription and gender. Regression analysis was then performed to adjust for age, weight, serum potassium, and 1/(discharge creatinine).

Results:
At the time of discharge, there was no statistically significant difference in the rate of GDMT prescription for females compared to males in either the unadjusted or adjusted models. ACE-I or ARB prescription rates were 59% in females and 50% in males (p=0.11); BB prescription rates were 89% in females and 84% in males (p=0.27); MRA prescription rates were 43% in females and 52% in males (p=0.19). Prescription rates of combination therapy of ACE-I or ARB with BB and MRA were 30% in females and 31% in males (p=0.78). There was a significant difference in 30 day all-cause unadjusted readmission rates in females (22%) compared to males (37%) (p<0.05).

Conclusions:
In this sample of hospitalized heart failure patients, no difference was found in rates of GDMT prescription for women as compared to men. Readmission rates were significantly higher for men than women, consistent with national data. Further investigation will determine the extent to which equity in prescription rates translates into improved outcomes for women hospitalized with heart failure.
Abstract 253: The Importance of Spiritual Authorities in Critical Care Field: An International Survey Analysis
Authors: Alshami Abbas , Romero Carlos , Avila America , Einav Sharon , Surani Salim , Varon Joseph
Published: July 2021

Purpose:
Belief is a major aspect of every human being, especially in critical situations. We aimed to investigate if physicians think that religion should be implemented in the communication and/or management of the critical patient. We assessed their opinion about the need to have spiritual figures among the healthcare team in the Intensive Care Unit (ICU).

Methods:
An anonymous 30-question survey was conducted over a period of 7 months among health care providers in 174 different institutions around 40 different countries. The Questionnaire addressed religion and how it may affect the management and/or interaction with patients. Specifically, we inquired if the presence of a religious figure (e.g. Rabbi, Priest/Pastor, Imam, etc.) would enhance the communication and/or management of the patients.

Results:
Of the 10,106 surveys that were submitted, 30.6% (n=3092) were physicians, 22.4% (n=2262) were nurses, and the rest were medical students and other health care providers. The opinions on the impact on managing patients and communicating with them and their families in the presence of a spiritual authority, such as a Pastor, Priest, Rabbi, Imam or any other religious figure, as part of the ICU team, revealed that 47.9% (n=1480) of physicians thought it could be beneficial, 14% (n=433) said that it could be harmful, and 36.6% (n=1131) affirmed no impact. Regarding nurses, 51.4% (n=1163) indicated that it is beneficial, 10.1% (n=228) indicated that it is harmful, and 35.6% (n=806) think there is no impact. Of the physicians, 20.3% (n=628) of practicing members of a religion, 16.7% (n=519) of those who are believers but not practicing, 7.8% (n=242) of those spiritual but not religious, 2.1% (n=65) of those who do not believe in god or gods, consider that religious figures incorporated in the ICU team can improve patient outcome. While 26.0% (n=557) of nurses who are practicing members, 20.3% (n=435) of those who are believers but not practicing, and only 1% (n=116) of the other two categories (the spiritual but not religious and the non-believers) share the same opinion, p <0.001.

Conclusions:
One in every two physicians/nurses in this study considered spiritual authorities, as part of the ICU team, beneficial in managing the patients and communicating with them and their families. We also found a correlation between the religious practice of the physicians/nurses and their opinion about its impact on the care of the patients. Physicians who are committed to a religious practice, tend to state that this could be beneficial; while nurses who are spiritual but not religious indicated no impact on the management.
Abstract 257: Improving Digital ECG Acquisition-to-Visualization Time Using EMR and Institutional Standard Operating Procedures
Authors: Lambert Cameron T , Sobol Tim , Kravitz Kathleen , Pengel Shannon , Bhargava Ajay , Fares Maan , Barzilai Ben , Khot Umesh N
Published: July 2021

Introduction:
Integration of electrocardiogram (ECG) tracings into the electronic medical record (EMR) is a challenge in the modern era. Delays in EMR-based ECG visualization negatively impact the care of patients with suspected cardiac disease. We aimed to measure the impact of a standardized process for acquiring and uploading ECG to the EMR on ECG acquisition-to-visualization time (AtV).

Methods:
We studied all ECG obtained at our hospital system from 1/1/13-12/31/16, and we stratified the study into baseline (1/1/13-1/31/14), transition (2/1/14-2/28/15), and full implementation (3/1/15-12/31/16) groups. In the baseline group, an ECG was only viewable in the EMR after it was formally read by a cardiologist. In the transition group, technical modifications made it possible for a preliminary ECG to immediately upload into the EMR after acquisition without a cardiologist’s interpretation. In the full implementation group, a standardized process encouraged timely upload to the EMR by setting a 30 minute AtV goal and establishing individual and inpatient unit performance tracking. The primary outcome of AtV was compared across groups with one-way analysis of variance.

Results:
During the study period, 628,322 ECGs were obtained (45% baseline, 47% transition, 8% full implementation). Mean AtV was 379 hours in the baseline group, 235 hours in the transition group, and 4 hours in the full implementation group. Compared to baseline, the transition group was associated with a 144 hour decrease in AtV (95%CI 137 - 151 hours, P<0.001) and the full implementation group was associated with 375 hour decrease in AtV (95% CI 362 - 388 hours, P<0.001) (Figure).

Conclusion:
A standardized process for ECG acquisition and EMR upload dramatically reduces AtV time allowing for rapid EMR viewing of ECGs. The stepwise improvement in AtV observed in our study stresses the importance of both technical and operational components to this process.
Abstract P134: Creating and Sustaining a Reliable Door to Balloon Process: The VHVI Experience
Authors: Huang Robert L , Cunningham Brittany , Zhao David X , Steaban Robin , DiSalvo Thomas G
Published: July 2021

Background:
Door to balloon time (D2B) ≤ 90 min reduces mortality in STEMI. Although many articles outline how to achieve a D2B ≤ 90 min, few address how to create a reliable D2B process longitudinally.

Methods:
We engaged in an institution-wide effort to yield iterative process and outcome improvement in D2B performance since 2006. A multidisciplinary team of ER physicians, interventional cardiologists, catheterization lab and ER nurses, hospital administrators, and emergency medical technicians (EMT) met monthly to redesign processes and systems and to review individual cases within 24 hours and aggregate data (monthly and yearly). Individual and aggregate case reviews interviewed EMTs, nurses, and physicians to capture specific clinical details in each case and employed statistical process control (SPC) charts to identify intervals of delay. Major outcome measures were total D2B time and % of patients with D2B ≤ 90 min.

Results:
From 2006-2009, our annual median D2B times were 75 min (n=11), 69.5 min (n=34), 65.5 min (n=38), and 55 min (n=49), respectively. Using an SPC proportions (p)-chart, we followed the performance of our system graphing the % of patients with a D2B ≤ 90 min. From 7/2006-4/2008, our process showed variation with regard to reliability despite improvement in median D2B. However, from 6/2008-1/2010 (19 months), we have achieved 100% reliability demonstrated on the p-chart.

Conclusions:
A sustainable D2B process can be achieved by a team of multidisciplinary stakeholders, iterative process redesign and SPC charts for individual and aggregate case review. Using SPC p-chart methodology, we achieved a higher level of reliability and performance.
Abstract P149: Self versus Emergency Medical Service Transport for Patients With ST-Elevation Myocardial Infarction: Findings From the National Cardiovascular Data Registry ACTION - Get With the Guidelines
Authors: Mathews Robin , Peterson Eric D , Li Shuang , Roe Matthew T , Wiviott Stephen D , Saucedo Jorge F , Antman Elliott M , Wang Tracy
Published: July 2021

Background:
Guidelines recommend expedited transport via emergency medical services (EMS) to facilitate early triage and reperfusion of patients with ST-elevation myocardial infarction (STEMI). Yet, a significant proportion of patients still present to the hospital via self-transportation.

Methods:
We examined rates of self- vs. EMS-transport for 33,678 STEMI patients treated at 348 hospitals in the ACTION Registry-GWTG between Jan 07 and Jun 09. Patients transferred in from outside hospitals to ACTION participating hospitals were excluded. Using generalized estimating equations (GEE) logistic regression model, we examined independent factors associated with patient self (vs. EMS) transportation. We further compared differences in reperfusion use and timing between these two groups.

Results:
A total of 13,479 STEMI patients (40%) self-transported to the hospital. Sociodemographic factors associated with self- (vs. EMS-) transportation include younger age, male sex, Hispanic ethnicity, and non-white race (
Table
). In contrast, the presence of cardiovascular risk factors were largely associated with EMS- rather than self-transport. Self-transport patients had longer delays from symptom onset to hospital arrival (median time 120 vs. 90 min, p<0.0001), lower rates of reperfusion (93.0 vs. 94.5%, p<0.0001), and longer delays to reperfusion (median door-to-balloon time 76 vs. 64 min, p<0.0001, median door-to-needle time 30 vs. 23 min, p<0.0001).

Conclusion:
A substantial proportion of STEMI patients in contemporary practice self-transport to the hospital and this mode of transport is associated with delays in reperfusion therapy compared with EMS transport. Since younger age, non-white race, and male sex are significantly associated with self-transport, community education efforts should target these groups and should be integrated with system-wide strategies designed to improve timely access to reperfusion care.

Factors associated with self-transport versus EMS-transport

Sociodemographic variables
Adjusted χ2
OR
95% CI
p-value

Age ( per 5 yr. decrease)
187
1.06
1.05-1.08
<0.0001

Male (vs. female)
46
1.19
1.13-1.26
<0.0001

Hispanic ethnicity
32
1.37
1.23-1.52
<0.0001

Race (vs. white)
12

0.0022

Black/African American

1.21
1.09-1.34

Asian/American Indian

1.12
0.95-1.34

Insurance status (vs. private)
22

<0.0001

Medicare/Medicaid/Military/VA

0.89
0.84-0.94

Self/none

0.86
0.80-0.93

Clinical variables

Heart failure symptoms on presentation
89
0.68
0.62-0.73
<0.0001

Prior PCI
24
0.84
0.78-0.90
<0.0001

Prior stroke
23
0.78
0.70-0.86
<0.0001

Prior CABG
13
1.18
1.08-1.29
0.0003

*

Other variables included in this model: prior CHF, DM, prior MI, BMI, dyslipidemia, currently on dialysis, and HTN
Abstract P161: Relationship Between Clinical Availability of Hemoglobin A1c and Glucose Therapy Intensification in Patients With Diabetes Hospitalized for Acute Myocardial Infarction
Authors: Stolker Joshua M , Spertus John A , McGuire Darren K , Inzucchi Silvio E , Rathore Saif S , Maddox Thomas M , Masoudi Frederick A , Tang Fengming , Jones Philip G , Kosiborod Mikhail
Published: July 2021

BACKGROUND
Hemoglobin A
1c
(A1C) assessment is recommended for hospitalized patients (pts) with diabetes (DM). Whether in-hospital A1C levels are associated with glucose therapy intensification (GTI) after MI is unknown.

METHODS
TRIUMPH is a multicenter MI registry which enrolled 1343 pts with established DM between 2005-08. Of 1149 pts with DM and measured A1C, 886 (77%) were assessed as part of clinical care, and an additional 263 (23%) had A1C assessed in the research core laboratory (results unavailable to clinicians). GTI was defined as new or increased doses of antihyperglycemic agents, or increased daily insulin dose by ≥20% at discharge. Pts were divided into those with vs. without clinically available A1C and stratified by A1C subgroup (<7, 7-9, >9). Poisson regression models evaluated if clinically available A1C was independently associated with GTI.

RESULTS
Overall, 420 of 1149 pts (36%) with measured A1C had levels <7, 423 (37%) were between 7-9, and 306 (27%) were >9. GTI was prescribed in 367 pts (32%). Clinically available A1C was associated with more frequent GTI in pts with suboptimal (A1C 7-9) and poor (A1C >9) glycemic control, but not in those with adequate control (A1C <7;
Figure
). After multivariable adjustment (including blood glucose), clinically available A1C was an independent predictor of GTI (RR 1.27, 95% CI 1.08-1.51).

CONCLUSION
Nearly two-thirds of pts with DM have suboptimal or poor long-term glucose control at the time of acute MI, and fewer than 50% of these pts are prescribed GTI at hospital discharge. Availability of A1C levels to clinicians may facilitate intensification of glucose therapy after MI in pts with inadequate long-term DM control.
Abstract P20: Exploring Psychosocial Pathways Between Neighborhood Characteristics and Stroke in Older Adults: the Cardiovascular Health Study
Authors: Yan Tingjian , Escarce Jose , Liang Li-Jung , Longstreth Will , Merkin Sharon , Ovbiagele Bruce , Vassar Stefanie , Seeman Teresa , Sarkisian Catherine , Brown Arleen
Published: July 2021

Background:
Studies have not investigated whether psychosocial pathways mediate the effect of neighborhood exposures on stroke.

Methods:
We used data from the Cardiovascular Health Study, a longitudinal population-based cohort study of adults >= 65 years, to construct race-stratified Cox proportional hazard models for time to first ischemic stroke. The key explanatory variable in the baseline model was an index of neighborhood socioeconomic status (NSES), constructed at the census-tract level from six measures of population income, education, employment and wealth. Covariates were individual sociodemographic characteristics (age, gender, marital status, education, and income). In subsequent models, we added psychosocial (depression, social support, social networks, and stressful life events), behavioral (smoking, physical activity, and alcohol), and biologic factors (EKG abnormalities, subclinical cardiovascular disease, hypertension, diabetes, and hyperlipidemia) separately and simultaneously to assess mediation of the effect of NSES on stroke.

Results:
Of the 3834 participants with no prior stroke, 548 had an incident ischemic stroke over the 11.5-year follow-up. Among the psychosocial factors, only depression was independently associated with higher stroke hazard (Hazard Ratio [HR]=1.26; 95% CI:1.02-1.59). However, addition of psychosocial factors to the baseline model slightly reduced the HRs among residents in the lowest relative to highest NSES quartile from 1.32 (1.01-1.74) to 1.30 (0.98-1.71). Depression ceased to be statistically significant in the model with behavioral and biological factors adjusted. We found no association between NSES and stroke incidence among African Americans.

Conclusions:
Psychosocial factors played a minimal role in mediating the effect of NSES on stroke incidence among whites.
Abstract P213: Association Between Depression and Leukocyte Telomere Length in Patients With Stable Coronary Heart Disease: Data From the Heart and Soul Study
Authors: Hoen Petra , de Jonge Peter , Na Beeya , Farzaneh-Far Ramin , Epel Elissa , Whooley Mary
Published: July 2021

Background
Shortened telomere length has been associated with mortality in patients with coronary heart disease (CHD) and is considered an emerging marker of biological age. Whether short telomere length is associated with depression in patients with CHD has not been evaluated.

Methods
In a cross-sectional study of 952 outpatients with stable CHD, we ascertained the presence of major depressive disorder using the Computerized Diagnostic Interview Schedule. Relative mean telomere length was measured from leukocyte DNA using a quantitative polymerase chain reaction assay. We examined the association between depression and leukocyte telomere length using linear and logistic regression models.

Results
Of the 952 participants, 206 (22%) had current (past month) depression. Patients with depression had lower mean ± SE telomere length than those without depression (
Table
). Likewise, patients with MDD had a 70% greater odds of having telomere length in the lowest vs. highest quartile (adjusted OR 1.70. 95% CI, 1.05-2.76; p=0.03).

Conclusion
Major depressive disorder is associated with reduced leukocyte telomere length in patients with stable CHD. The potential mechanisms underlying this association deserve further study.

Mean +/- SE telomere length by presence of major depressive disorder

Adjusted for

Current major depression N=206

No current major depression N=746

P value

age, sex
0.86±0.02
0.90±0.1
.02

age, sex, diabetes, BMI, smoking
0.86±0.02
0.89±0.01
.04

age, sex, diabetes, BMI, smoking, LVEF, statin use
0.85±0.02
0.89±0.01
.03
Abstract P215: Decreased Pre-Operative Risks and Increased Post-Operative Mental Functioning as Benefits of Regular Physical Activity for Patients Undergoing Cardiac Surgery
Authors: Stone Lori E , Holmes Sari D , Martin Lisa M , Hunt Sharon L , Ad Niv
Published: July 2021

Background:
Regular exercise is a known primary and secondary defense against cardiovascular disease. Additionally, the American Heart Association has shown that regular exercisers have a decreased physiological response to stress, exhibit less anxiety and depression, and have better self-esteem.

Objective:
To examine the pre-operative risk factors and post-operative course of recovery for regular exercisers in cardiac surgery patients.

Methods:
A review was done of patient generated history forms and medical data for 281 patients that underwent isolated CABG at our institution since 2007. Only 166 patients had complete history forms: 98 patients were determined to be regular exercisers prior to CABG surgery, compared to 68 non-exercisers. A subset of patients (64 exercisers and 44 non-exercisers) also completed the SF-12 to measure health related quality of life (HRQL) at baseline and 12 months post-operatively.

Results:
Analyses found that the regular exercisers presented with better pre-operative risk factors than the sedentary patients, including lower BMI (t=2.6, p<0.02), lower STS morbidity/mortality risk score (t=3.3, p<0.003), lower logEuroScore (t=1.9, p=0.058), and fewer patients with diabetes (OR=0.47, p<0.04). The regular exercise group was also less likely to report depression (6% vs. 16%; Chi-square = 4.2, p<0.04) and presented with a higher physical composite HRQL at baseline than the non-exercisers (t=-3.6, p<0.001). Post-operative HRQL scores indicated that while both groups increased significantly from baseline to 12 months on physical composite scores, only the regular exercisers significantly improved on the mental composite scores (t=2.2, p<0.04).

Conclusion:
The importance and overall cost-benefit of regular physical activity can not be overemphasized. Regular exercisers have been shown to be at reduced risk for an adverse cardiac event. For those that must undergo cardiac surgery, the physically active present with reduced pre-operative risk and superior physical HRQL. Regular exercisers also experience greater post-operative improvements in mental HRQL as compared to their sedentary peers.
Abstract P232: Screening Past B-Type Natriuretic Peptide (BNP) Values to Identify Candidates for Treatment of Systolic Dysfunction
Authors: Gholami Parisa , Lin Shoutzu , Heidenreich Paul
Published: July 2021

Background:
BNP testing is now common though it is not clear if the test results are used to improve patient care. A high BNP may be an indicator that the left ventricular ejection fraction (LVEF) is low (<40%) such that the patient will benefit from life-prolonging therapy.

Objective:
To determine how often clinicians obtained a measure of LVEF (echocardiography, nuclear) following a high BNP value when the left ventricular ejection fraction (LVEF) was not known to be low (<40%).

Methods and Results:
We reviewed the medical records of 296 consecutive patients (inpatient or outpatient) with a BNP values of at least 200 pg/ml at a single medical center (tertiary hospital with 8 community clinics). A prior diagnosis of heart failure was made in 65%, while 42% had diabetes, 79% had hypertension, 59% had ischemic heart disease and 31% had chronic lung disease. The mean age was 73 ± 12 years, 75% were white, 10% black, 15% other and the mean BNP was 810 ± 814 pg/ml. The LVEF was known to be < 40% in 84 patients (28%, mean BNP value of 1094 ± 969 pg/ml). Of the remaining 212 patients without a known low LVEF, 161 (76%) had a prior LVEF >=40% ( mean BNP value of 673 ± 635 pg/ml), and 51 (24%) had no prior LVEF documented (mean BNP 775 ± 926 pg/ml). Following the high BNP, a measure of LVEF was obtained (including outside studies documented by the primary care provider) within 6 months in only 53% (113 of 212) of those with an LVEF not known to be low. Of those with a follow-up echocardiogram, the LVEF was <40% in 18/113 (16%) and >=40% in 95/113 (84%). There was no significant difference in mean initial BNP values between those with a follow-up LVEF <40% (872 ± 940pg/ml), >=40% (704 ± 737 pg/ml), or not done (661 ± 649 pg/ml, p=0.5).

Conclusions:
Follow-up measures of LVEF did not occur in almost 50% of patients with a high BNP where the information may have led to institution of life-prolonging therapy. Of those that did have a follow-up study a new diagnosis of depressesd LVEF was noted in 16%. Screening of existing BNP and LVEF data and may be an efficient strategy to identify patients that may benefit from life-prolonging therapy for heart failure.
Abstract P236: Health Care Costs and Resource Utilizations of Acute Coronary Syndrome in a Cohort of Medicare Patients With and Without Diabetes Mellitus
Authors: Zhao Zhenxiang , Peng Xiaomei , Faries Doug , Gaich Carol , McCollam Patrick , LeNarz LeRoy
Published: July 2021

Objective:
Diabetes is an independent prognostic factor for increased risk for ischemic heart disease. This study evaluates differences in resource utilization and health care costs for acute coronary syndrome (ACS) patients with and without diabetes mellitus (DM).

Methods:
A retrospective cohort study was conducted using a large US administrative claims database. Patients, ≥65, hospitalized with a primary diagnosis of ACS between 01/01/2007 and 12/31/2007 were identified and categorized into 2 groups: 1) with DM (ACS patients had ≥ 2 outpatient office visits or 1 hospitalization with the DM diagnosis during the 1 year before/within the index hospitalization) and 2) without DM. Patients with complete insurance coverage 1-year pre- and post- index hospitalization were included. Annual health care costs and resource utilization were compared usingChi-square tests for categorical variables and Wilcoxon rank-sum tests for continuous variables (all p<.05 unless otherwise stated).

Results:
Of 5,840 identified patients, 1,609 (28%) were diabetic and 4,231 (72%) were non-diabetic. A higher percentage of diabetic patients had at least one all-cause rehospitalization event (44.4% vs. 35.7%) or CV-related rehospitalization event (27.0% vs. 19.5%). Mean length of stay (LOS) was longer for DM patients during the index hospitalization (6.3 days vs. 5.5 days), as well as during the CV-related rehospitalization (5.7 days vs. 4.8 days). In addition, patients with DM had more physician's office visits (18.3 vs. 15.0), ER visits (0.6 vs. 0.5), and outpatient hospital visits (7.4 vs. 6.1) during the 12-month follow-up period. Both cohorts had similar index ACS hospitalization costs ($18,532 vs. $17,609) but DM patients incurred higher rehospitalization costs (all-cause: $21,064 vs. $13,821; CV-related: $11,086 vs. $7,260), outpatient costs (all-cause: $28,167 vs. $19,815; CV-related: $7,193 vs. $5,686), and pharmacy costs (all-cause: $5,537 vs. $3,815; CV-related: $3,522 vs. $3,143). One-year follow-up health care costs were significantly higher for patients with DM compared with those without DM ($54,768 vs. $37,451).

Conclusion:
The presence of DM is significantly associated with greater resource utilization and health care costs for ACS patients.
Abstract P240: Economic Impact of Major Adverse Cardiac Events (MACE) in Individuals Undergoing Invasive Cardiac Catheterization Procedures (CCP) With Low or Iso-Osmolar Contrast Agents
Authors: Meissner Brian , Spalding James
Published: July 2021

Objective:
To assess the economic impact of MACE during cardiac catheterization procedures in both high and low risk patients and to apply literature estimates of MACE rates the iso-osmolar iodinated contrast media iodixanol versus low-osmolar contrast media (LOCM).

Methods:
We performed a retrospective analysis using the Premier Perspective™ database, which contains patient-level data including primary and secondary diagnosis and procedure codes. Inpatient adults without prior hemodialysis who underwent invasive cardiac catheterization procedures with contrast media during 2007-2008 were studied. MACE was defined as acute MI, ischemic heart disease, or angina. Resource utilization, re-admittance rate, length of stay (LOS), and cost were collected. High-risk patients were defined as have an AMI or angina as the admitting diagnosis. Aggregate MACE outcomes were then applied to MACE rates from multi-center studies found in the literature comparing iodixanol to LOCM.

Results:
Among 521,437 patients in the Premier Perspective™ undergoing CCP, 13,149 (2.52%) experienced a MACE. Of those experiencing MACE, high-risk patients had longer LOS, 4.2 vs. 3.3 days, p <0.0001, longer ICU LOS. 2.6 vs. 2.3 days, p= 0.0028, greater total costs, $15,020 vs. $12,413, p <0.0001, and a greater frequency of MACE readmission due to re-catheterization, 58.66% vs. 50.68%, p= <0.0001. For readmissions within 30 days post-discharge, LOS and cost remained statistically significant for high-risk patients, but ICU LOS was not significantly different. In applying literature-based MACE rates, isosmolar iodixanol versus LOCM iopamidol potentially saves on average $600 per patient in inpatient MACE-related costs but no difference for 30 days post-discharge MACE. Additionally, iodixanol may save up to $616 on average per patient vs. Ioxaglate in high-risk inpatient MACE-related costs, but no difference in non high-risk patients.

Conclusions:
MACE is a complication in CCP with substantial resource utilization, cost, and mortality associated with it. The iso-osmolar contrast agent iodixanol may reduce the rate of MACE in certain instances and therefore reduce the MACE-related cost and resource utilization associated with cardiac catheterization procedures.
Abstract P241: One-Year Cost-Effectiveness of Cytochrome P450 2C19 Genotype-Guided Antiplatelet Therapy in Patients With Acute Coronary Syndromes
Authors: Charland Scott L , Agatep Barnabie C , Malone Daniel C , Stanek Eric J
Published: July 2021

OBJECTIVES:
Cytochrome P450 2C19 (CYP2C19) genotype has been shown to affect cardiovascular (CV) outcomes for clopidogrel but not prasugrel. This study evaluates the cost-effectiveness of CYP2C19-guided vs. routine antiplatelet therapy in ACS patients.

METHODS:
We constructed a literature-based, decision analytic, Markov model (TreeAge 2009) to estimate the cost-effectiveness of CYP2C19-guided aspirin plus either clopidogrel or prasugrel therapy vs. no genotyping. Post-initial ACS CV events were based on the TRITON-TIMI 38 study and related costs were derived primarily using 2007 Healthcare Cost and Utilization Project DRGs for nonfatal MI and stroke, CV death, intracranial hemorrhage, other life-threatening bleed, and minor bleed. Additional costs and disease-state utilities were obtained from other published sources. All costs were adjusted to 2009 $US using the Consumer Price Index medical care component. The model allowed for clopidogrel/prasugrel discontinuation and aspirin monotherapy. Model sensitivity was assessed using 1-way and multi-way analysis of influential parameters.

RESULTS:
The base case model demonstrated that CYP2C19 genotype guided antiplatelet therapy yielded lower overall annual cost and greater efficacy vs. no genotyping (
Table
). The model was sensitive to (in declining order): clopidogrel cost/day ($1 to $5.78), prasugrel cost/day ($4.09 to $ 6.81), % CYP2C19 extensive metabolizers on clopidogrel (60% to 100%), CYP2C19 test cost ($60 to $250), and monthly CV event management cost. A threshold value for clopidogrel at <$2.14/day favored the no genotyping strategy. However, the genotyping strategy was dominant when clopidogrel cost =$1/day and a CYP2C19 test cost threshold of <$125 on 2-way analysis.

CONCLUSIONS:
CYP2C19 genotype-guided clopidogrel or prasugrel therapy is cost-effective for up to 1 year in ACS patients, and can remain a preferred strategy at a hypothetical generic clopidogrel cost of $1.00/day.

Table

Strategy1
Annual Cost
Incremental Cost
Quality Adjusted Life Year (QALY)
Incremental QALY
Cost/QALY
Incremental Cost Effectiveness (ICER)

CYP2C19 Genotype-Guided
$ 3,211

0.7212

$ 4,452

No Gentoyping
$ 3,331
$120
0.6767
- (0.0445)
$ 4,921
(Dominated)

1Base case values:Drug wholesale acquisition cost/day: clopidogrel $4.62, prasugrel $5.45; Baseline post-ACS utility = 0.83; Monthly cost for post-CV event management = $351; CYP2C19 genotyping =$185; After genotyping: 80% of extensive metabolizers, 20% of intermediate metabolizers and 10% of poor metabolizers on clopidogrel; 80% on clopidogrel without genotyping; Willingness to pay = $200
Abstract P25: Identifying Socioeconomic Gradients and Racial/Ethnic Disparities in Outcomes From Ischemic Stroke Hospitalizations
Authors: Hanchate Amresh D , Hylek Elaine , Bell Griffith
Published: July 2021

OBJECTIVE
Even though there are over half a million hospitalizations for acute stroke nationally each year, little attention has been paid to examining racial and ethnic disparities in outcomes, especially inpatient mortality and paralysis. The limited evidence available presents a somewhat confusing picture that is confounded by systematic differences in socioeconomic status (SES) across racial and ethnic populations.

STUDY DESIGN
We stratified all inpatient admissions for ischemic stroke in all civilian Texas hospitals in 2007 (N=21,203) by sex, age (44-64, 65-74, 75-84 and 85+), race/ethnicity (white, black, Hispanic and other) and zip-code median income (low income = poorest quartile zip codes). Inpatient mortality and paralysis were the outcomes of interest. Secondary diagnosis codes (ICD-9) were used to identify patient risk factors (including atrial fibrillation, hypertension, heart failure and diabetes). Pooled multilevel logistic regression models were estimated to measure mean differences in outcomes across SES and racial/ethnic cohorts.

FINDINGS
The overall outcome rates -- inpatient mortality=4.9%, paralysis=28.4% -- mask considerable systematic variation. Differences by race/ethnicity are relatively small and not statistically significant: 3.5% (whites), 2.9% (blacks) and 3.8% (Hispanics). However, lower income is associated with a substantially large increase in this risk. Same-race/ethnicity counterparts from lower income zip codes had 47% (whites), 67% (blacks) and 22% (Hispanic) higher inpatient mortality rate (p-value<0.05). Differences in risk adjusted rates of paralysis by race/ethnicity were also not statistically significant - 26% (whites), 29% (blacks) and 30% (Hispanics). But counterparts from lower income zip codes had 20% (whites), 7% (blacks) and 23% (Hispanic) higher rates of paralysis (p-values<0.05).

CONCLUSION
Among whites, blacks and Hispanics, those residing in poorer zip codes experienced substantially worse rates of inpatient mortality and paralysis.

IMPLICATIONS
Further study needs to explore the potential pathways connecting lower SES with poorer healthcare outcomes, including, greater patient severity, delayed treatment and access to quality care.
Abstract P252: Health Professional Shortage Areas and Their Association With Cardiovascular Risk Factor Prevalence, Awareness, and Control: Findings From the Coronary Artery Risk Development in Young Adults (CARDIA) Study
Authors: Allen Norrina B , Carnethon Mercedes , Gordon-Larsen Penny , Kiefe Catarina , Diez-Roux Ana , Goff David C , Steffes Michael , Daviglus Martha
Published: July 2021

Background:
Over 65 million Americans live in Primary Care Health Professional Shortage Areas (HPSAs) which are associated with less preventive care, poorer general health and an increased risk for hospitalizations. However, little is known about how living in a HPSA impacts primary prevention for CVD.

Methods:
We used data from CARDIA, a multi-center cohort study of black and white men and women. Participants who had risk factor data and geocoded addresses available at year 20 (2005) were included in this analysis (n=3479). Primary care HPSAs were defined using data from US HRSA. Diabetes, hypertension and hyperlipidemia prevalence and control were defined according to ADA Guidelines 2000, JNC VI, and ATP III, respectively. Individuals who reported being diagnosed or reported use of medications were considered aware of the risk factor. The prevalence of smoking and obesity was also examined. Neighborhood (census block) characteristics were derived from Census 2000 and ACCRA. Multivariable Poisson models were used to examine the independent association of HPSA residence with each outcome.

Results:
Over 11% of CARDIA participants live in a HPSA. Residents of HPSAs were more likely to be female (64% vs 56%), African American (81% vs 43%), have low education, and low income. HPSA residents had more difficulty paying for food/basics and medical care, had poorer access to medical care and lived in areas with a higher cost of healthcare and low neighborhood SES. HPSA residents had a higher prevalence of hypertension (PR 1.39, 95% CI 1.18-1.65), obesity (1.30, 1.16-1.45) and smoking (1.72, 1.46-2.03) and were less likely to have their hypertension (0.79, 0.66-0.95) or hyperlipidemia (0.66, 0.44-0.99) controlled as compared to non-residents. The association between HPSA and risk factors prevalence was explained by race and neighborhood SES. The cost of medical care and having a usual source of care were the largest mediators of the association between HPSA residence and risk factor control.

Conclusion:
The increased prevalence and poorer control of CVD risk factors in HPSAs, can be explained by the demographic and neighborhood characteristics of their residents. Future interventions should be targeted to these high-risk populations found within HPSAs.
Abstract P254: Dementia and Use of Cardiac Catheterization and Angioplasty in Elderly ST-Elevation Myocardial Infarction Patients
Authors: Ketterl Marianne , Mortimer James A , Pathak Elizabeth B
Published: July 2021

Introduction_
Percutaneous coronary intervention (PCI) is the first line of treatment for ST-elevated myocardial infarction (STEMI). Few studies addressed dementia as a barrier to receiving PCI. We evaluated disparities in the use of cardiac catheterization and PCI in STEMI patients with dementia.

Methods_
A retrospective analysis was performed of Florida's comprehensive inpatient surveillance system for the years 2006-2007 with admission diagnosis of STEMI (ICD-9-CM codes 410.0 - 410.6, 410.8). Data were limited to patients ≥65 years admitted to hospitals with a high annual volume of PCIs (≥400), and transfer patients were excluded. We used a broad definition of dementia (ICD-9-CM codes 294.0, 294.1, 294.8, 294.9, 331.0-331.2, 331.7, 331.81, 331.82, 331.89, 331.9, 780.93, 780.97, 797). Logistic regression analysis was used to identify disparities in the use of cardiac catheterization and PCI among all STEMI patients, and in the use of PCI only among STEMI patients who received cardiac catheterization.

Results_
A total of 8,310 STEMI patients who met our inclusion criteria were identified. Of these, 77.2% were catheterized and 67.1% received PCI. The mean age of the cohort was 76.3 years (SD 7.8 yrs); with 43.3% female; 83.4% white, 4.6% black, and 12% Hispanic/other. A total of 605 (7.3%) were demented. After adjustment for age, gender, and race/ethnicity, patients with dementia were less likely to be catheterized (RR 0.4, 95% CI 0.3-0.5), and less likely to receive PCI (RR 0.4, 95% CI 0.4-0.5) than non-demented patients. However, among patients who were catheterized, there was no difference in the use of PCI for demented vs. non-demented patients (p=0.32).Women were less likely to be catheterized than males (RR 0.7, 95% CI 0.7-0.8), but if catheterized, were more likely to receive PCI then men (RR 1.3, 95% CI 1.1-1.6). After adjustment for age, gender, and dementia, blacks were less likely to be catheterized (RR 0.5, 95% CI 0.4-0.6) and less likely to receive PCI (RR 0.6, 95% CI 0.5-0.7) than whites.

Conclusions_
STEMI patients with dementia were much less likely to receive cardiac catheterization and consequently PCI. Our study confirms that treatment disparities exist for elderly demented patients after controlling for age, gender and ethnicity.
Abstract P281: Impact of Transradial Approach on Quality of Care for Percutaneous Coronary Intervention: A Single Center Experience
Authors: Wu Chuntao , Liao Duanping , Dyer Anne-Marie , Chen Helen , Gilchrist Ian C
Published: July 2021

Background:
Transradial cardiac catheterization has only been used in a small fraction of percutaneous coronary intervention (PCI) procedures in the United States, despite of the evidence that it may be associated with a lower risk of bleeding and mortality following PCI compared to the transfemoral approach.

Objective:
To evaluate the impact of the transradial approach on adverse outcomes following PCI and its potential of being a process to improve the quality of care for PCI in a single-center practice.

Methods:
We compared the risks of post-procedural adverse outcomes including in-hospital mortality, bleeding, and vascular complications between the 462 transradial and the 625 transfemoral cases who had undergone PCI procedures between January 2007 and March 2009. The difference in length of stay following PCI between the two entry approaches was also examined.

Results:
Compared to the transfemoral approach, the transradial cardiac catheterization was associated with significantly lower risk of bleeding (2.60% (12 of 462) vs. 6.08% (38 of 625); adjusted odds ratio (aOR)=0.34, 95% confidence interval (CI): 0.17-0.68, P=0.002) and vascular complications (0% vs. 1.44% (9 of 625), P=0.01). Although the trend was that the transradial approach was associated with lower risk of in-hospital mortality, the difference was not statistically significant (0.87% (4 of 462) vs. 2.24% (14 of 625); aOR=0.55, 95% CI: 0.14-2.10, P=0.38). Transradial patients were more likely to be discharged on the same day of procedure (14.2% vs. 2.2%, P<0.0001).

Conclusion:
The transradial approach is related to lower risk of bleeding and vascular complications. Introducing this approach to practice could improve the quality of care for PCI.
Abstract P295: Performance Management and Improvement: One Way to “ImPact” Outcomes
Authors: Boord Jeffrey B , Byrd Jeannie , DiSalvo Thomas , Cunningham Brittany L
Published: July 2021

Background:
Continuous quality improvement (CQI) in health care systems necessitates an approach to review care delivery processes, systems, group and individual performances, incidents and outcomes. A robust process should 1) be multidisciplinary, 2) occur in “real-time”, 3) provide detailed review and discussion of care processes, performance and outcomes and 4) generate actionable rapid cycle improvement opportunities.

Aim:
To craft a sustainable management process for CQI for all clinical operational units of the Vanderbilt Heart and Vascular Institute (VHVI).

Methods:
We convened a standing multidisciplinary biweekly managerial forum (termed ImPact - “Improving Patient Care Together”) of quality medical directors, key clinical physicians and nurses, nursing unit managers, hospital administrators, and quality consultants. ImPact follows a standing structured agenda: 1) all mortalities since last meeting, 2) morbidity including “major misses” and major adverse events, 3) rapid response team calls, 4) out of ICU “codes”, 5) events reported by staff in our hospital's anonymous reporting system, 6) events brought forward by any clinician or unit manager, 7) interval progress on ongoing rapid cycle improvement projects.

Results:
The topics for rapid cycle improvement that have surfaced to date are listed in the
Table
. In addition to facilitating and prioritizing rapid cycle quality improvement and patient safety efforts, ImPact provides a link to our regular morbidity and mortality (M&M) conferences in cardiology and cardiac surgery. We have been able to identify common issues that extend beyond individual clinical care areas, allowing better understanding of vulnerabilities in systems of care

Conclusions:
A multidisciplinary, structured, regularly scheduled meeting of physician and nursing clinical and quality leaders, unit managers and administrators is a critical component of performance management and improvement.

Quality Topics Identified

Topics
Contribution, n
Percent

Handoff and communication
9
27

Equipment
7
21

Medication administration
5
15

Education to staff (M&M)
4
12

Patient transport
3
9

Blood product administration
2
6

Risk management
2
6

Vascular service integration
1
3
Abstract P304: Effect of Benchmarking Projects on Outcome of Cabg Surgery: Challenges and Prospects Regarding Quality Improvement Initiative
Authors: Miyata Hiroaki , Motomura Noboru , Murakami Arata , Takamoto Shinichi ,   Japan Cardiovascular Surgery Database Organization
Published: July 2021

Background:
To improve quality of cardiovascular surgery, Japan Cardiovascular Surgery Database (JCVSD) was established since 2000 and started benchmarking profect. Though importance of quality improvement initiative has been emphasized in many researches, little study has reported those effects on outcomes.

Methods and results:
To examine the time-trend effects in initial JCVSD participants (n=44), we identified 8224 isolated CABG procedures performed between 2004 and 2007. The impact of surgery year was examined using a multiple logistic regression model setting previously identified clinical risk factors and surgery year as fixed effects. To examine the difference of outcomes between initial participants (n=44) and halfway participants (n=55), we identified 3882 isolated CABG procedures performed in 2007. The difference between two hospital groups were examined using a multiple logistic regression model setting clinical risk factors and hospital procedure volume, hospital groups as fixed effects. As for operative mortality, odds ratio of surgery year was 0.88 (p = 0.083). OE ratios of operative mortality were 0.71 in 2004, 0.73 in 2005, 0.63 in 2006, and 0.54 in 2007. As for composite mortality and major morbidities (reoperation, stroke, dialysis, infection, and prolonged ventilation), odds ratio of surgery year was 0.97 (p = 0.361). OE ratios of composite mortality and morbidities were 1.01 in 2004, 1.04 in 2005, 1.04 in 2006, and 0.94 in 2007. Compared with halfway participants, initial participant had significantly lower rate of operative mortality (OR=0.527, p=0.008) and composite mortality and major morbidities (OR 0.820, p = 0.047).

Conclusions:
This study demonstrated that quality improvement initiative for cardiovascular surgery has positive impact on risk-adjusted outcomes. While the primary target of benchmarking was 30-day mortality in Japan, major morbidities were less affected by those activities.

Preoperative risk and risk adjusted mortality in initial participants

surgery year
2004
2005
2006
2007

number of procedure
1831
2211
2125
2057

raw operative mortality rate
2.30%
2.50%
2.30%
1.80%

expected operative mortality rate
3.25%
3.43%
3.65%
3.35%

observed/expected mortality ratio
0.71
0.73
0.63
0.54