bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 76: Meaningful Use Of Electronic Medical Records Provides A More In-depth Assessment Of Quality Of Hypertension Care
Authors: Odunukan Olufunso W , Orhurhu Vwaire , Nwojo Macaulay , Rahman Ahmed S , Naessens James M , Nyman Mark A , Taler Sandra J
Published: July 2021

Background:
Hypertension (HTN) control rate is a core clinical quality measure. It is presently assessed by manual review of a random sample of patients with HTN billing claims. There is an increasing push by regulators towards the use of electronic medical records (EMR) to assess quality of care.

Purpose:
To use EMR to obtain a more in-depth assessment of quality of hypertension care.

Methods:
Cross sectional study involving adults with HTN seen at 2 or more office visits in 2009 by eligible primary or specialist providers at a large medical group practice. We measured the proportion of HTN patients with blood pressure (BP) at goal (BP < 140/90 mm Hg) at their last hypertension visit (LHV).

Results:
Of a total of 10,401 patients, 5970 (57%) were controlled and 1959 (19%) were uncontrolled at their LHV. Control could not be assessed in 2472 (24%) as BP values were unavailable from the vital signs section of the visit notes in the EMR. Of a random sample of 250 patients with unavailable BP, only 94 (37.6%) had BP values documented in other parts of the visit note. In 29 patients (11.6%) billing for HTN was done without adequate evidence that it was addressed at that visit. Control rates were highest for primary care providers where measurement and documentation of BP was a focus - Family Medicine 77% controlled, 1% unavailable; Primary Care Internal Medicine 71% controlled, 4% unavailable. A considerable proportion of patients in the other four provider groups did not have BP available from their last hypertension visit - Cardiology 59% controlled, 22% unavailable; Nephrology 38% controlled, 47% unavailable; Preventive Medicine 48% controlled, 39% unavailable; General Internal Medicine 41% controlled, 45% unavailable. Control rates were similar across provider groups when patients with unavailable BP were excluded: Family Medicine 78%, Primary Care 74%, Cardiology 75%, Nephrology 73%, Preventive Medicine 79%, and General Medicine 75%.

Conclusions:
Up to a quarter of HTN patients did not have properly documented BP in the EMR at their LHV. For those with measurements recorded, control rates were similar across primary care and specialty clinics, but measurement rates were higher for primary care practices. Use of the EMR facilitates efficient and granular assessment of the measurement process and control rates for HTN among various provider groups.
Abstract 77: Balancing Risks and Benefits of Anticoagulation Therapy in Atrial Fibrillation in Community Practice: Results from the ORBIT-AF Registry
Authors: Cullen Michael W , Kim Sunghee , Piccini Jonathan P , Go Alan S , Fonarow Gregg C , Ansell Jack , Mahaffey Kenneth W , Kowey Peter R , Lopes Renato D , Peterson Eric D , Gersh Bernard J
Published: July 2021

Background
Oral anticoagulation (OAC) can reduce stroke risk at the cost of increased bleeding risk in those with atrial fibrillation (AF). Observational data have shown that higher-risk patients with AF most likely to benefit from OAC are less likely to receive OAC at hospital discharge.

Methods
We used data from ORBIT-AF Registry, a cohort of 9,589 AF patients enrolled among 173 participating outpatient practices. OAC was defined as warfarin or dabigatran use at study enrollment. Stroke and bleeding risk were calculated using the CHADS2 and ATRIA scores, respectively.

Results
The study population had a mean age of 73.5 years; 57.8% were men. Overall, 76.4% of patients received OAC. Use of OAC rose with increasing CHADS2 stroke risk, from 67% for CHADS2 <1 to 80% for CHADS2 ≥2 (p<0.0001). OAC use fell slightly with increasing ATRIA bleeding risk, from 77% for ATRIA score ≤3 to 74% with ≥5 (p=0.002 for trend). Among patients with low bleeding risk, rates of OAC increased commensurate with stroke risk (p<0.0001 for interaction; see figure). Higher bleeding risk tended to decrease rates of OAC among patients with a CHADS2 score ≥2 (p=0.13 for interaction).

Conclusions
In community-based outpatients with AF, use of OAC rose with increasing thromboembolic risk and declined with higher bleeding risk. These findings suggest that the risk-treatment paradox may be less that previously reported. Provision of OAC in community practice appears to appropriately consider patients' stroke and bleeding risks. Further research is required to understand how quality improvement initiatives can further improve stroke prevention.
Abstract 106: Concomitant Contrast Dependent Procedures are Predictors of Increasing PCI Assoicated Renal Complications among Medicare Beneficiaries
Authors: Kugelmass Aaron , Brown Phillip P , Reynolds Matthew R , Cohen David J , Culler Steven D , Simon April W
Published: July 2021

Objective:
This study examines the trends in inpatient rates of renal complications (RCs) among Medicare Beneficiaries (MB) undergoing PCI from Fiscal Year (FY) 2009 to FY 2011, and the potential role of repeated contrast exposure during an admission, as well as other clinical factors that impact this trend.

Methods:
A retrospective analysis was conducted using annual MedPar data files for three FYs: 2009, 2010 and 2011. The study sample consists of 977,398 MB hospitalizations for PCI without CABG or valve surgery. Renal complications of interest were New Onset Hemodialysis (HD), ARF Complication, or either Renal Complication. Multi-variable logistic regression equations, controlling for 40 demographic and co-morbid conditions, as well as evidence of repeated same admission contrast administration (other peripheral or carotid interventions/procedures, and contrast CT scan) were estimated for each complication.

Findings:
The table identifies that renal complications (compared to 2009) are increasing, with MBs 1.53 times more likely to experience any renal complication. Concomitant contrast dependent imaging and therapeutic procedures, as well as established clinical risk factors, increase the likelihood.

Conclusion:
The adjusted incidence of renal complications following PCI among hospitalized MBs is increasing over time. In addition, repeated contrast exposure during an admission independently increases the likelihood of renal complications.
Abstract 120: Regional Variation in Infection Rates after Coronary Artery Bypass Grafting
Authors: Likosky Donald , Kommareddi Mallika , Boeve Theodore , Harrington Steven , Holmes Robert ,   Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
Published: July 2021

Introduction:
Healthcare acquired infections (HAIs) are a leading cause of morbidity and mortality after cardiac surgery. Prior work has identified a number of patient-related risk factors associated with HAIs.

Hypothesis:
We hypothesized that rates of HAIs would differ across institutions, in part attributed to differences in case mix.

Methods:
We enrolled 27,663 patients undergoing isolated coronary artery bypass grafting (CABG) surgery at 33 medical centers in Michigan between 1/1/2008 - 6/30/2012. Overall HAIs included pneumonia, sepsis/septicemia, deep sternal wound, thoracotomy, and harvest/cannulation site infections. We excluded patients presenting with endocarditis. Predicted rates of HAIs were estimated using multivariable logistic regression.

Results:
Overall rate of HAI was 5.3% (1454 of 27,663) [pneumonia: 3.7% (n=1020), sepsis/septicemia: 1.0% (n=266), deep sternal wound: 0.7% (n=184), harvest/cannulation site: 0.6% (n=163), multiple infections: 0.6% (n=169)]. While predicted risk of HAI differed in absolute terms by 4.1% across centers (4.2% - 8.3%, min:max), observed rates varied from 1.3% to 20.8%, p<0.01 (Figure).

Conclusions:
There was a 16-fold variability in rates of HAIs across medical centers among patients undergoing isolated CABG surgery. This variability could not be explained by patient case mix. Future work should focus on the impact of other factors (e.g. organizational and systems of clinical care) on risk of HAIs.
Abstract 127: Novel Approach to the Management of Clinical Alarm Fatigue
Authors: Whalen Deborah , Covelle Patricia , Piepenbrink James , Villanova Karen , Cuneo Charlotte , Awtry Eric
Published: July 2021

Is the answer to clinical alarm fatigue to silence an increasing number of alarms as many centers have done to improve staff sensitivity to alarms or to layer additional technology such as viewing stations or alarm alert paging systems to capture clinician attention? An Alarm Management Pilot at Boston Medical Center shows a different strategy.

BMC clinicians observed that RN staff frequently did not respond to Arrhythmia and HR violation Warning Alarms allowing these often to self reset. They were almost always continuously present in the background competing with other alarms even call lights. A QI initiative was proposed for a Pilot on a 24 bed general cardiology floor to remove Warning Alarms for Arrhythmia and HR Limit violations.

We chose not to silence HR violations as had been done in other medical centers but to elevate these to Crisis Alarm slightly widening their defaults. We did this having seen bradycardia or tachycardia alarms precede life threatening events not caused by sudden death from VF. As a Crisis Alarm these alarms would now require RN staff to view and act on the alarm in real time either responding to the patient or modifying alarm limits .

The Pilot was an overnight success the noise reduction immediately noticed by staff and as this occurred alarm culture changed.

We saw a startling 87% decrease in the total number of audible alarms from 87823/ week Pre Pilot to 9967/ week Post Pilot on pilot unit with the average number of daily alarms dropping from 12546 to 1424. The decibel level too decreased from an average peak value in the mid 80s Pre Pilot to the mid 60s Post Pilot.

RNs queried with a Monkey Survey tool when asked “ Do you believe that the Pilot has improved the noise level on the unit?", 100% of respondents said yes. Among their comments

~The monitors were an irritant. Now they no longer seem that way.

~I can spend more time on patient care instead of answering meaningless alarms.

~I feel so much less drained going home at the end of my shift.

Patient Satisfaction scores Post Pilot showed significant improvement :
noise level in and around room
increasing by 7%,
nurse domain
increasing by 30%,
promptness to call light
increasing by 31% and
overall assessment
increasing by 59%. Since there had been no interventions targeted specifically at improving the scores it suggest that the improvement in scores had been effected by the alarm changes and perhaps clinical alarm fatigue played a role as a major patient dissatisfier as well.

Boston Medical Center is among the hospitals nationally attempting to tackle clinical alarm fatigue. This Alarm Management Pilot now rolling out to the rest of BMC provides a strategy for managing clinical alarm fatigue without adding additional technology or costs and demonstrates such a strategy not only can improve patient safety but can have a measurable positive effect on staff and patient satisfaction .
Abstract 130: Do Demographic Differences Persist in a Large Radial Artery Access Center for Cardiac Catheterization?
Authors: Patel Ankitkumar , Chaudhry Kunal , Kabadi Rajesh , Cartwright Travante , Patel Ankita , Iliadis Elias
Published: July 2021

Background:
Though cardiac catheterization via the radial artery (RA) as compared to the femoral artery (FA) access site is on the rise, most centers perform less than 10% cases via RA based on the National Cardiovascular Data Registry. RA is associated with lower rates of complications; however, in smaller centers it has been reported to be underutilized in women and elderly patients. We investigate what demographic differences exist in a large RA volume center.

Methods:
A retrospective chart review assessed all cardiac catheterization cases performed at a large tertiary care academic center from 2010-2011 (n=5344). Access site (RA/FA) is defined as the site of successful vascular entry. Case demographics were collected.

Results:
The RA was utilized in one-fifth of cases. RA patients had the same percentage males and Whites as FA access (Table 1). RA patients were younger, more likely to have commercial insurance, diabetes and hypertension. FA patients had more renal failure. The mean body mass index (BMI) was higher in the RA group. This was driven by a higher likelihood of obese patients (BMI >30) undergoing RA access than FA access.

Conclusion:
RA access is utilized more often in patients with younger age, diabetes, hypertension and obese BMIs. FA access is used more often in renal failure patients perhaps due to concern about contrast load.
Abstract 139: Angina Frequency, Quality of Life and Functional Status in Patients with Stable Ischemic Heart Disease: Data from the Heart and Soul Study
Authors: Beatty Alexis L , Whooley Mary A
Published: July 2021

Background:
Angina is a common symptom among patients with ischemic heart disease (IHD), but its long-term effects on quality of life and functional limitation have not been quantified. We sought to evaluate the longitudinal association of angina frequency with quality of life and functional limitation in patients with IHD.

Methods:
We enrolled 1023 outpatients with stable IHD in a prospective cohort study between 2000 and 2002. Participants completed the Seattle Angina Questionnaire (SAQ) at baseline and annually for five years. The longitudinal associations of SAQ angina frequency with overall quality of life (fair or poor vs. excellent, very good, or good), SAQ quality of life score, SAQ physical limitation score, and New York Heart Association (NYHA) functional class (III or IV vs. I or II) were estimated using mixed effects regression models with adjustment for clinical risk factors.

Results:
At baseline, 633 participants (62%) reported no angina, 279 (27%) reported monthly angina, and 111 (11%) reported daily or weekly angina. At baseline, participants with daily or weekly angina were more likely than those without angina to report fair or poor overall quality of life (46% vs. 18%, P<.001) and NYHA class III or IV symptoms (58% vs. 13%, P<0.001). During five years of follow-up, participants with daily or weekly angina had worse mean SAQ Quality of Life scores (51.7 vs. 89.2, P<.001) and SAQ Physical Limitation scores (62.4 vs. 84.9, P<.001) than participants without angina. After adjusting for age, sex, race, smoking, hypertension, history of heart failure, physical inactivity, depressive symptoms, and medication use, daily or weekly angina remained associated with worse mean SAQ Quality of Life scores (54.7 vs. 88.7, P<.001) and Physical Limitation scores (66.8 vs. 85.0, P<.001). In adjusted analyses, participants with daily or weekly angina had higher odds of reporting fair or poor quality of life (OR 1.78, 95%CI 1.18, 2.69, P<.001) and higher odds of reporting NYHA class III or IV symptoms (OR 6.17, 95%CI 4.34, 8.77, P<.001) during the follow-up period.

Conclusions:
Angina frequency was associated with longitudinal measures of quality of life and functional limitations in outpatients with IHD.
Abstract 158: Heart Failure and Outcomes after Acute Coronary Syndrome in a Representative Medicare Population
Authors: Chen Shih-Yin , Crivera Concetta , Stokes Michael , Boulanger Luke , Schein Jeff
Published: July 2021

Background:
Heart failure (HF) is a common comorbid condition of elderly patients with acute coronary syndrome (ACS). The objective of this study is to compare the incidence of death and cardiovascular (CV) events among Medicare beneficiaries hospitalized for ACS) with and without comorbid HF.

Methods:
Patients hospitalized for ACS between 3/1/2002 - 12/31/2006 were identified from the Medicare Current Beneficiary Survey (date of first such admission denoted as the index date). Incident patients were selected defined as those with no ACS event in the 6 month pre-index period. Patients were stratified based on the presence (HF+) or absence (HF-) of medical claims for HF during the 6 months pre-index period. Comparisons of incidence of death and CV-related hospitalization were made between HF+ and HF-cohorts descriptively via Kaplan Meier curves and also with Cox proportional regressions adjusting for differences in patient characteristics. Sample population weights were applied accounting for multi-stage sampling design to obtain nationally representative estimates for the US Medicare population.

Results:
A final sample of 795 incident ACS patients were included (mean age 76 years; 49% male), of which 198 were HF+ (weighted prevalence=24.9% from the 2.5 million beneficiaries that these patients represent). The incidence of death after ACS admission among HF+ and HF- patients was 580 and 240 per 1,000 person years, respectively (p<0.01). If patients were discharged alive, HF+ patients had a significantly higher risk of subsequent CV events (812 vs. 355 cases; p<0.01) when 1,000 patients were followed for 6 months. After regression adjustment, there was a significant increased risk of mortality (HR=1.45; 95% CI: 1.09 - 1.93) and CV events (HR=1.72; 95% CI: 1.35 - 2.19) associated with comorbid HF.

Conclusion:
Our real-world findings suggest significantly poorer outcomes associated with HF among Medicare beneficiaries hospitalized for ACS. Personalized interventions targeting patients with both HF and ACS may improve the outcomes and quality of care.
Abstract 17: Racial and Ethnic Differences in Outcomes in Older Patients with Acute Ischemic Stroke
Authors: Qian Feng , Fonarow Gregg C , Smith Eric E , Xian Ying , Pan Wenqin , Hannan Edward L , Shaw Benjamin A , Glance Laurent G , Peterson Eric D , Hernandez Adrian F , Schwamm Lee H , Bhatt Deepak L
Published: July 2021

Background:
Past studies suggest racial and ethnic differences in quality of care and in-hospital outcomes for acute ischemic stroke. Using the American Heart Association Get With The Guidelines-Stroke (GWTG-Stroke) registry linked to Medicare claims data, we examined whether 30-day and 1-year outcomes differed by race or ethnicity in those aged 65+ with acute ischemic stroke.

Methods:
We analyzed 200,900 acute ischemic stroke patients age 65 years or older (170,694 non-Hispanic whites, 85.0%; 20,514 non-Hispanic blacks, 10.2%; 6632 Hispanics, 3.3%; 3060 Asian Americans, 1.5%) from 926 U.S. centers participating in the GWTG-stroke program between 2003 and 2008. Both 30-day and 1-year unadjusted and risk adjusted outcomes from admission were examined.

Results:
Compared with whites, other racial and ethnic groups were on average younger and had higher median score on NIH stroke scale (NIHSS). There were significant racial and ethnic differences in 30-day unadjusted mortality rate (white: 15.0%, black: 9.9%, Hispanic: 11.9%, Asian: 11.1%), 1-year unadjusted mortality rate (white: 31.7%, black: 28.6%, Hispanic: 28.1%, Asian: 23.9%), and 1-year unadjusted all-cause rehospitalization after discharge (white: 54.7%, black: 62.5%, Hispanic: 60.0%, Asian: 48.6%). A slightly increasing trend for 30-day and 1-year unadjusted mortality from admission was observed in the overall sample. White patients had the highest unadjusted and risk adjusted 30-day mortality. By 1 year, white, black, and Hispanic patients all had similar adjusted outcomes yet Asian patients had persistently better results. With regard to 1-year all-cause rehospitalization rates, relative to whites, blacks and Hispanics had higher adjusted 1-year all-cause and stroke associated rehospitalization rates whereas Asians had lower adjusted rates (see Table).

Conclusion:
White older ischemic stroke patients have the highest 30-day mortality rates of any race/ethnicity group. By one year, only Asian patients have differentially lower mortality risk. In contrast, black and Hispanic patients have higher readmission risk to one year.

1
Abstract 170: Effect of Hospital Case Volume, Number of Hospitals, and the Predictive Accuracy Of Risk-adjustment Models (c-statistic) on the Accuracy of Hospital Report Cards
Authors: Reeves Mathew J , Austin Peter C
Published: July 2021

Background:
The generation of report cards to compare hospital outcomes is increasingly common. Many researchers use the c-statistic of the risk-adjusted logistic regression model as a measure of the accuracy of the report cards, while often ignoring factors such as hospital case volumes and the number of hospitals. Through the use of Monte-Carlo simulations, we assessed the relative importance of these 3 variables (hospital case volume, number of hospitals,and model c-statistic) on the accuracy of hospital report cards.

Methods:
Using a previously developed 30-day mortality prediction model, we used data from 31,183 patients hospitalized with AMI in 159 Ontario hospitals between 2008 and 2010 to construct a data-generating process that allowed us to generate simulated datasets in which the actual hospital rankings (based on 30-day risk-adjusted mortality) were known with certainty. The simulated datasets had the same variability in case mix as was observed in the 159 hospitals (intra-class correlation ICC= 0.037). Using Monte Carlo simulations we varied the 3 variables across plausible ranges i.e., number of patients per hospital (50, 100, 200), number of hospitals (50, 100, 200), c-statistic (25 values ranging from 0.53 - 0.96), producing 225 different scenarios (i.e., 3 x 3 x 25) and created 500 simulated datasets for each scenario. The
observed
rank order of hospitals in each simulation was determined by generating observed vs. expected (O-E) ratios using indirect standardization as well as predicted vs. expected (P-E) ratios using hierarchical regression models. We determined the influence of the 3 factors on the accuracy of the report cards by calculating the Spearman-rank correlation (r
s
) between the known and observed (O-E and P-E) hospital rank orders.

Results:
Of the 3 factors examined, only the number of patients per hospital had a meaningful influence on the correlation between known and observed rank order. To illustrate, in one typical simulation, as the case volume increased from 50, to 100, and then to 200 patients, the correlation increased from 0.37, 0.50, and 0.62, respectively. In contrast, the model c-statistic had a very modest impact on the accuracy of hospital report cards; across the full range of the c-statistic (0.53-0.96) correlations increased by <5% in all scenarios. The number of hospitals included in the simulations had no meaningful effect (change in r
s
≤1%). The fact that none of the simulations produced correlations >0.70 and many were <0.50, serves to highlight the substantial amount of error that can occur when attempting to profile hospitals, even in the favorable environment of simulated datasets.

Conclusions:
The c-statistic of a risk-adjustment model should not be used to assess the accuracy of hospital report cards, rather, more attention should be paid to hospital case volumes which directly impact the accuracy of hospital rankings.
Abstract 172: Projected Number of HF Admissions Per Heart Failure Patient In The Medicare Population
Authors: Hunt Phillip R , Wu Ning , Veath Barbara K , Tsintzos Stelios , Burton Mark L , Mollenkopf Sara A
Published: July 2021

OBJECTIVES:
Heart Failure (HF) is a leading cause of morbidity and mortality. Hospitalization for HF appears to be steadily increasing. We sought to identify HF patients and understand their patterns of care in the “real-world” through analysis of a retrospective observational database.

METHODS:
Patients in the Medicare 5% database with a primary inpatient diagnosis of HF (428.0, 428.9, 428.20-23, 428.30-33, 428.40-43) during CY05-08 were included. Maximum follow-up was 33 months (6 months baseline, 3 month index and 24 months follow-up ). Minimum follow-up was 9 months . To exclude prevalent cases, patients were required to have no HF diagnoses during baseline. The quarter of the initial HF inpatient diagnosis was designated the “index”. Patients were followed for up to 2 years (8 Quarters) after the “index” or until death or enrolment end. Sub-cohorts were defined based on HF events experienced during follow-up: 0, 1, or 2 or more.

RESULTS:
43,819 patients with new primary HF inpatient claims were identified in the study period. Within the 27 month follow-up (includes “index”), the identified HF patients had 140,802 inpatient hospitalizations (3.2 per patient), of which 67,339 (1.54 per patient) had a primary HF diagnosis (includes index HF hospitalization). Out of the 43,819 patients included, only 10,166 (23.2%) had one or more HF hospitalization within two years after the index period. Patients who experienced one or more than one HF admission after “index” tended to have experienced more all-cause admissions. Mortality was 10.3% during “index”; 25.3% in Year 1 and 14.0% in Year 2. Total mortality was 42.4% (18,562 out of 43,819).

CONCLUSIONS:
These results suggest that an early HF patient could be expected to get admitted on average 3.2 times for any cause over the next 2 years; 1.54 times for HF (47.8% of total). Mortality after the index HF admission was >40% over the same period. Our results further underline HF as a major clinical and economic burden in the US. More importantly, our results demonstrate that most of the economic burden is driven by a relatively small percentage of patients (23.2%); successful intervention in this subgroup could drastically reduce the burden of HF to Medicare.
Abstract 174: Comparison of Performance Measures and 30-Day Patient Outcomes among Hospitals that Do and Do not Participate in ACTION Registry- Get With The Guidelines
Authors: Mathews Robin , Fonarow Gregg C , Li Shuang , Peterson Eric D , Rumsfeld John S , Heidenreich Paul A , Roe Matthew T , Oetgen William J , Jollis James G , Cannon Christopher P , de Lemos James A , Wang Tracy Y
Published: July 2021

Background:
ACTION Registry-GWTG (ARG) is a clinical registry and Quality Improvement (QI) program co-sponsored by the American College of Cardiology and the American Heart Association, designed to measure and improve the treatment and outcomes of patients with acute myocardial infarction (AMI). However, it is unknown whether hospital participation in ARG is associated with better performance on publicly reported AMI quality metrics and 30-day outcomes.

Methods:
Using Hospital Compare, we matched hospitals participating in ARG from 2007-2010 to non-ARG participating hospitals based on teaching status, hospital size, percutaneous coronary intervention capability, and composite adherence to AMI performance measures in 2007. We then used linear mixed modeling to compare 2010 performance measure adherence, 30-day mortality, and all-cause readmission among ARG and non-ARG hospitals. As secondary analyses, we repeated the matching process without using baseline adherence to AMI measures and also stratified the hospitals according to duration of ARG participation and level of baseline performance.

Results:
We successfully matched 502 hospitals participating in ARG to 502 non-ARG hospitals. Adherence to AMI process measures was very high overall with minimal differences between ARG and non-ARG hospitals for most performance measures. In pairwise mixed modeling, ARG hospitals were more likely to achieve primary PCI within 90 minutes, though the absolute difference was small (Table). Overall, 30-day mortality and readmission rates were similar among ARG and non-ARG centers. Results were consistent whether hospitals were matched based on baseline performance or if centers were stratified by duration of ARG participation.

Conclusion:
Hospitals across the U.S. report very high achievement rates for nearly all current performance measures for AMI care. These data suggest ongoing local and national QI efforts are having success within and beyond the ARG program. More sensitive process and outcome performance metrics with longer term outcomes may be needed to differentiate quality of care and drive the next phase of improvement in outcomes after acute coronary syndrome.
Abstract 177: Impact of a Drug-eluting Stent Guideline on Clinical Practice
Authors: Lee Vanessa , Cox Nicholas
Published: July 2021

Introduction:
In Victorian public hospitals drug-eluting stents (DES) are reserved for patients at high-risk of in-stent restenosis. A hospital guideline was developed in consultation with cardiologists following systematic review of the literature to improve the consistency of percutaneous coronary intervention (PCI) practice and the clinical decision-making behind stent implantation. Indications for DES deployment were Diabetes Mellitus; Lesion Length >20mm or Diameter <2.5mm; Chronic Total Occlusion; In-stent Restenosis; Saphenous Vein Graft; Left Main; Proximal Left Anterior Descending Artery; Bifurcation or Ostial Lesion; Chronic Renal Failure.

Method:
Retrospective study involving a 4-week audit conducted pre-guideline implementation in April 2009 and two subsequent audits post-guideline implementation in September 2011 and April 2012. The guideline was introduced in February 2011.

Results:
The number of patients in each cohort was 38 (2009), 45 (2011) and 47 (2012). Overall there was an increase in DES usage from 39.5% (2009) to 62.2% (2011) and 59.6% (2012). However, the percentage of patients meeting one or more indication for DES use without a documented contraindication also increased from 31.6% (2009) to 62.2% (2011) and 59.6% (2012). Following guideline implementation the percentage of patients that received a DES without indication decreased from 7.9% to 0% (both 2011 and 2012), and those indicated for DES who subsequently received a bare-metal stent (BMS) also decreased from 18.4% to 2.2% (2011) and 2.1% (2012).

Conclusion:
Introduction of the guideline did not reduce the rate of DES deployment. However, it significantly improved clinical practice and appropriateness of DES and BMS usage. This improvement was again measurable and sustained 12 months following guideline implementation.
Abstract 187: Value of Percutaneous Coronary Intervention in the VHA Integrated Health Care Delivery System: Insights from the VA CART Program
Authors: Ho Michael , O’Donnell Colin , Bradley Steven M , Grunwald Gary , Hlefrich Christian , Chapko Michael , Liu Chuan-Fen , Maddox Thomas M , Tsai Thomas T , Jesse Robert L , Fihn Stephan D , Rumsfeld John S
Published: July 2021

Background:
Value in health care has been defined as outcomes achieved relative to costs for the full cycle of care. To date, it has not been operationalized and applied to specific patients. Percutaneous coronary intervention (PCI) is one important aspect of the care of patients with ischemic heart disease. PCI and the longitudinal care provided to patients following the procedure provides an opportunity to measure health care value.

Methods:
We analyzed data from the VA National CART Program that includes all 76 cardiac catheterization laboratories and all patients undergoing PCI along with longitudinal follow-up and cost data from 2008 to 2010. Costs were obtained from the VA’s Decision Support System, a cost accounting system that tracks costs for each patient. To assess 1-year value following each PCI procedure, patient costs and mortality were attributed to the index hospital in which PCI occurred. Risk standardized outcomes of mortality and log cost ratios were calculated using standardized covariates and adjusting for cardiac and non-cardiac co-morbidities.

Results:
There were 59 hospitals (n=19,139 patients) that performed more than 20 PCIs during the study period with mean of 324 and median of 258 PCIs. One-year unadjusted mean mortality rate was 6.1% and median of 6.4%. There were 3 sites above and no sites below the 1-year risk standardized median mortality rate (Figure; red bars). Mean and median total costs at 1-year were $62,142 and $59,262 (IQR $42,438 to $131,526) per patient, respectively. Risk standardized 1 year total costs demonstrated 17 hospitals above and 18 hospitals below the risk standardized average (Figure; green bars). Cardiac costs accounted for slightly more than half of the total costs at the hospital level, 51.4% of the mean and 50.4% of the median total costs.

Conclusion:
There were overall low 1 year mortality rates following PCI and small variation across sites. In contrast, there was significantly greater variability in 1 year costs following PCI, suggesting opportunities to reduce the costs of longitudinal PCI care without compromising outcomes.
Abstract 190: Understanding Delivery of Heart Failure Care by Provider Teams
Authors: Sahay Anju , Heidenreich Paul
Published: July 2021

Objective:
There is strong evidence to support the contention that interdependence and collaboration among providers improves staff and patient outcomes. The Department of Veterans Affairs’ (VA) Chronic Heart Failure (CHF) QUERI examined how care is provided to HF patients by “HF Care Groups” at the VA facilities. A “HF Care Group” is a group of providers at a VA facility dedicated to HF care for the facility’s patients.

Method:
In 2009
c
ross-sectional surveys were administered to members (providers) of the CHF QUERI’s Heart Failure (HF) Provider Network which consists of providers interested in improving the quality of HF care. 217 providers completed these surveys.

Results:
Altogether, 99% (n=215) of the respondents reported that they provided HF care at their VA facility. A majority of these providers (59%) started providing HF care before 2003. Overall 63% (n=135) of these providers participated in a local HF Care Group which consisted of 1-3 providers (85%) to 4-7 providers (15%).

Among the providers who participated in their HF Care Group almost all (99%) felt physicians and nurses in their team worked closely together, they identified and fixed problems in work processes (96%), focused on team-building and coaching (89%) and acquiring necessary resources for HF care (92%). But they reported experiencing difficulty in coordinating HF care outside their HF Care Group with non-HF physicians (77%), discharge nurses (71%) and home telehealth (55%). Looking at contextual factors, they reported receiving good support from own facility in terms of providing necessary physical space (84%), staffing (80%), quality improvement support (86%) and training and education (87%). Overall, 84% of these providers felt satisfied with their job providing HF care and similarly, 86% felt satisfied with the care they provide to their HF patients.

Conclusions:
Heart failure providers commonly participate in local teams of 1-3 people. The barriers to team care that we identified will be important to address in order to improve patient outcome for heart failure.
Abstract 200: Cost-Effectiveness of Newer Anticoagulants for Stroke Prevention in Atrial Fibrillation
Authors: Limone Brendan L , Baker William L , Coleman Craig I
Published: July 2021

Background:
A number of new anticoagulants for stroke prevention in atrial fibrillation (SPAF) have gained regulatory approval or are in late-stage development. We sought to conduct a systematic review of economic models of dabigatran, rivaroxaban and apixaban for SPAF.

Methods:
We searched the Medline, Embase, National Health Service Economic Evaluation Database and Health Technology Assessment database along with the Tuft’s Registry through October 10, 2012. Included models assessed the cost-effectiveness of dabigatran (150mg, 110mg, sequential), rivaroxaban or apixaban for SPAF using a Markov model or discrete event simulation and were published in English.

Results:
Eighteen models were identified. All models utilized a lone randomized trial (or an indirect comparison utilizing a single study for any given direct comparison), and these trials were clinically and methodologically heterogeneous. Dabigatran 150mg was assessed in 9 of models, dabigatran 110mg in 8, sequential dabigatran in 9, rivaroxaban in 4 and apixaban in 4. Adjusted-dose warfarin (either trial-like, real-world prescribing or genotype-dosed) was a potential first-line therapy in 94% of models. Models were conducted from the perspective of the United States (44%), European countries (39%) and Canada (17%). In base-case analyses, patients typically were at moderate-risk of ischemic stroke, initiated anticoagulation between 65 and 73 years of age, and were followed for or near a lifetime. All models reported cost/quality-adjusted life-year (QALY) gained, and while 22% of models reported using a societal perspective, no model included costs of lost productivity. Four models reported an incremental cost-effectiveness ratio (ICER) for a newer anticoagulant (dabigatran 110mg (n=4)/150mg (n=2); rivaroxaban (n=1)) vs. warfarin above commonly reported willingness-to-pay thresholds. ICERs (in 2012US$) vs. warfarin ranged from $3,547-$86,000 for dabigatran 150mg, $20,713-$150,000 for dabigatran 110mg, $4,084-$21,466 for sequentially-dosed dabigatran and $23,065-$57,470 for rivaroxaban. In addition, apixaban was demonstrated to be an economically dominant strategy compared to aspirin and to be dominant or cost-effective ($11,400-$25,059) vs. warfarin. Based on separate indirect treatment comparison meta-analyses, 3 models compared the cost-effectiveness of these new agents and reported conflicting results.

Conclusions:
Cost-effectiveness models of newer anticoagulants for SPAF have been extensively published. Models have frequently found newer anticoagulants to be cost-effective, but due to the lack of head-to-head trial comparisons and heterogeneity in clinical characteristic of underlying trials and modeling methods, it is currently unclear which of these newer agents is most cost-effective.
Abstract 205: New Onset Heart Failure and Adverse Ischemic Events Associated with Amiodarone and Dronedarone Use among Atrial Fibrillation Patients
Authors: Sylwestrzak Gosia , Liu Jinan , Rosenberg Alan , White Jeffrey , Barron John , Redberg Rita , Malenka David
Published: July 2021

Background:
Dronedarone is a non-iodinated form of amiodarone that may not cause some of serious adverse effects associated with amiodarone. However, it is less effective than amiodarone in maintaining normal sinus rhythm, and it does not improve success of electrical cardioversion. Additionally, dronedarone use has been associated with new onset or worsening of heart failure (HF), including a doubling of the risk of death in patients with symptomatic heart failure. We aimed to compare the incidence of newly diagnosed HF and HF hospitalizations among dronedarone and amiodarone users. Secondary outcomes of interest included rates of acute ischemic stroke (IS) and transient ischemic attack (TIA).

Methods:
This retrospective study utilized administrative claims data between 1/1/2007-9/30/2011 from the HealthCore Integrated Research Environment (HIRE
®
). Patients were required to have at least one claim for atrial fibrillation. Propensity score matching was employed to adjust for differences between the cohorts. Incidence rate of HF, HF hospitalizations, IS and TIA events were compared between matched cohorts using Poisson time-to-event model.

Results:
The cohort consisted of 6,013 amiodarone and 1,534 dronedarone patients. Dronedarone patients were younger, healthier per Deyo-Charlson Index (DCI) and CHADS2 score, and less likely to have underlying heart disease (all p-values<0.05). In the propensity score matching process 838 patients with comparable baseline characteristics were selected in each group. Median follow up was 552 days in the amiodarone cohort and 412 days in the dronedarone cohort. Among patients without HF history, new onset HF incidence rate was 34.6 per 100 person-year in amiodarone cohort and 19.1 per 100 person-year in dronedarone cohort (IRR=1.61, 95% CI: 1.30-2.01, p<0.01). The incidence rate for HF hospitalization was also higher in amiodarone patients-- 10.7 per 100 person-year against 7.8 per 100 person-year for dronedarone (IRR=1.39, 95% CI: 1.02-1.85, p=0.03). For IS, the incidence rate was 1.68 per 100 person-year in amiodarone vs. 0.84 in dronedarone but results did not reach statistical significance (IRR=1.91, 95% CI: 0.84-4.30, p=0.12); for TIA, it was 3.67 vs. 2.35 for amiodarone and dronedarone respectively (IRR=2.01, 95% CI: 1.14-3.57, p=0.02).

Conclusions:
In a propensity score matched observational cohort study, amiodarone use was associated with higher incidence rate of new onset HF, HF hospitalizations, and TIA as identified from claims. This finding differs from other clinical studies. Future observational cohort studies should incorporate medical record review for validation since information from claims might be insufficient to fully account for underlying patient risk status, or accurately determine if HF was new onset.

Key words:
amiodarone; dronedarone; atrial fibrillation; heart failure.
Abstract 215: Differing Perspectives Between Physicians, Patients And Caregivers On The Value Of An Individualized Estimate Of The Benefits Of Thrombolysis At The Time Of Acute Ischemic Stroke: Designing The Resolve (Rapid Evaluation for Stroke Outcomes using Lytics in Vascular Event) Decision Aid
Authors: Decker Carole J , Chhatriwalla Emily , Garavalia Brian , Spertus John A , Chen Er , Gialde Elizabeth
Published: July 2021

Background:
Explaining the risks and benefits of recombinant tissue plasminogen activator (rt-PA) occurs in a hurried conversation in the emergency department and may not be fully grasped by patients and their caregivers. Risk models describing the heterogeneity of benefits from rt-PA in acute ischemic stroke (AIS) have been created, but are not used in routine clinical practice. To develop a tool (RESOLVE) for modeling each patient’s benefits and risks for rt-PA, we conducted qualitative interviews with survivors, their caregivers and emergency physicians to inform the design and improve usability.

Methods:
A multidisciplinary research team conducted qualitative research through 10 focus groups of survivors and caregivers. We obtained feedback on their preferred role, desired information and their impressions of alternative formats for presenting risk and benefits. Three emergency physicians from 2 sites have been interviewed (with >15 additional physician interviews being currently conducted, the results of which will supplement these preliminary data at the time of presentation).

Results:
Survivors and caregivers (63 participants: 39 stroke survivors; 43% male) express a need for more information, including specific risks and benefits to treatment. In general, both groups desired an active role in the acute stroke treatment decision. In contrast, the initial physician interviews indicated a hesitancy to provide NINDS data to patients and caregivers, skepticism of the existing data and cultural barriers to the use of rt-PA in AIS, the latter acquired through residency training or the opinions of their clinical colleagues. The interviewed clinicians, however, felt more positive about using rt-PA when a neurologist was readily available to support the decision.

Conclusions:
Preliminary findings suggest reluctance by emergency physicians to share data about the benefits of rt-PA to stroke patients and their caregivers, despite the desire of the latter for such information. While the additional planned interviews will be needed to confirm these findings, preliminary insights suggest a compelling need to overcome the reticence of emergency physicians to use clinical data to better engage patients in making a shared decision about rt-PA in AIS.
Abstract 22: STEMI Trends in the United States 2002-2010: Increasing Use of PCI and Declining Mortality
Authors: Shah Rashmee U , Rutten-Ramos Stephanie , Garberich Ross , Tighiouart Mourad , Henry Timothy D , Bairey Merz C. Noel
Published: July 2021

Objective:
We sought to quantify changes in STEMI mortality and percutaneous coronary intervention (PCI) use in the United States (US) from 2002 to 2010.

Methods:
We used the Nationwide Inpatient Sample (NIS), an all-payer discharge database, to create estimates of STEMI, STEMI in-hospital mortality, and PCI use. The NIS includes hospitals selected to approximate 20% of all non-federal US hospitals and includes weights to create national estimates. STEMI cases were identified based on primary diagnostic code. High volume STEMI-PCI centers were defined as >36 cases/year, according to PCI guidelines. Temporal trends were evaluated with logistic regression, adjusted for patient and hospital characteristics. Discharges to other acute care facilities were excluded for outcomes analyses.

Results:
We identified 1,944,112 STEMI discharges in the US; mean age was 64 years, 34% were women, and 46% were Medicare insured. The absolute number of STEMI discharges declined from 299,441 in 2002 to 167,929 in 2010 (Figure). The number of hospitals performing zero STEMI-related PCIs decreased from 75% (3633/4840) to 68% (3514/5134) between 2002 and 2010. The number of high volume centers increased from 20% (949/4840) to 24% (1235/4840) over the same period. Overall, 64% (1,145,196/1,783,825) of discharges received PCI and 8.5% (151,528/1,783,825) died during hospitalization. PCI use increased and mortality decreased over time (Figure). The adjusted odds of PCI use for STEMI discharges increased over three fold during the study period (OR 3.51 in 2010 versus 2002, 95% CI 3.21 to 3.83). The adjusted odds of death decreased by one fifth (OR 0.81 in 2010 versus 2002, 95% CI 0.75 to 0.87). Inclusion of PCI in the model attenuated the effect of year on death (OR 1.06 in 2010 versus 2002, 95% CI 0.98 to 1.14).

Conclusions:
In this study we demonstrate favorable trends in STEMI outcomes. Between 2002 and 2010, the absolute number of STEMIs in the US decreased, while more hospitals provided PCI for STEMI. Over time, more discharges were treated with PCI and fewer died during hospitalization.