bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the Renal Arteries of 2,144 Living Kidney Donors Using Computed Tomography Angiography and Comparison with Intraoperative Findings
Authors: Sarier Mehmet , Callioglu Mehmet , Yuksel Yucel , Duman Enes , Emek Mestan , Usta Sibel Surmen
Published: May 2020

Objectives: A carefully chosen and suitably prepared kidney donor is essential in living-donor kidney transplantation. Computed tomography angiography (CTA) is an effective imaging method for evaluating the renovascular morphology of donor candidates. The aim of this study was to evaluate renal artery variations in kidney donors using CTA and compare the findings with the number of arteries detected during laparoscopic donor nephrectomy. Materials and Methods: The study included 2,144 living donors who underwent pretransplant renovascular assessment using CTA and laparoscopic donor nephrectomy in our center between August 2012 and October 2018. The number of renal arteries to the donor kidney detected on CTA was compared with the number of arteries discovered intraoperatively. Results: The mean age of the 2,144 living kidney donors included in the study was 47.19 ± 13.3 (18–87) years. According to CTA findings, 81.1% (n = 1,738) had a single renal artery, 17.2% (n = 369) had double renal arteries, 1.6% (n = 35) had triple renal arteries, and 0.1% (n = 2) had quadruple renal arteries. The same number of renal arteries were detected by CTA and in laparoscopic donor nephrectomy in 97.9% (n = 2,099) of the donors. In the other 2.1% (n = 45), fewer renal arteries were detected intraoperatively compared to their CTA findings. None of the donors included in the study had a greater number of renal arteries discovered during nephrectomy than by CTA. Conclusion: CTA is a highly accurate method for the evaluation of renovascular variations in donor candidates for living-donor kidney transplantation. However, it must be kept in mind that double or multiple renal artery variations may be detected on CTA in 18.9% of donor candidates.
DNA Damage Response
Authors: Duer Melinda , Cobb Andrew M. , Shanahan Catherine M.
Published: May 2020

Vascular calcification is a ubiquitous pathology of aging. Oxidative stress, persistent DNA damage, and senescence are major pathways driving both cellular and tissue aging, and emerging evidence suggests that these pathways are activated, and even accelerated, in patients with vascular calcification. The DNA damage response—a complex signaling platform that maintains genomic integrity—is induced by oxidative stress and is intimately involved in regulating cell death and osteogenic differentiation in both bone and the vasculature. Unexpectedly, a posttranslational modification, PAR (poly[ADP-ribose]), which is a byproduct of the DNA damage response, initiates biomineralization by acting to concentrate calcium into spheroidal structures that can nucleate apatitic mineral on the ECM (extracellular matrix). As we start to dissect the molecular mechanisms driving aging-associated vascular calcification, novel treatment strategies to promote healthy aging and delay pathological change are being unmasked. Drugs targeting the DNA damage response and senolytics may provide new avenues to tackle this detrimental and intractable pathology.
Comparison of Robotic Percutaneous Coronary Intervention With Traditional Percutaneous Coronary Intervention
Authors: Patel Tejas M. , Shah Sanjay C. , Soni Yash Y. , Radadiya Rajni C. , Patel Gaurav A. , Tiwari Pradyot O. , Pancholy Samir B.
Published: May 2020

Background:

Robotic percutaneous coronary intervention (R-PCI) has been shown to benefit the operator but has not shown any significant benefit to the patient. We sought to compare a large cohort of R-PCI to traditional percutaneous coronary intervention (PCI) procedures performed at a tertiary care center in the same time frame.

Methods:

A total of 996 consecutive patients referred for PCI between December 2017 and March 2019 were studied, of which 310 (31.1%) patients were selected to undergo R-PCI and 686 (68.9%) patients underwent traditional PCI. The coprimary study outcome measures were air kerma, dose-area product, fluoroscopy time, volume of contrast, and total procedural time. Caliper propensity-matching technique was used (caliper, 0.05) to match each R-PCI patient to the nearest traditional PCI patient without replacement.

Results:

Air kerma (mGy; median [interquartile range];
P
; 884 [537–1398] versus 1110 [699–1498];
P
=0.002) and dose-area product (cGycm
2
; 4734 [2695–7746] versus 5746 [3751–7833];
P
=0.003) were significantly lower in the R-PCI group. There was no difference in fluoroscopy time (minutes; 5.51 [3.53–8.31] versus 5.48 [3.31–9.37];
P
=0.936) and contrast volume (mL; 130 [103–170] versus 140 [100–180];
P
=0.905). Total procedural time (minutes) was significantly higher in the R-PCI group (27 [21–40] versus 37 [27–50];
P
<0.0005).

Conclusions:

R-PCI is associated with a significant decrease in radiation exposure to the patient with no increase in fluoroscopy time, as well as contrast utilization, and a minor increase in procedure duration compared with traditional PCI.
Abstract 101: Variation in Patient Characteristics and Outcomes Between Clinical Settings for Endovascular Femoropopliteal Artery Revascularization
Authors: Raja Aishwarya , Choi Eunhee , Shen Changyu , Wadhera Rishi , Figueroa Jose , Yeh Robert W , Secemsky Eric A
Published: May 2020

Background:
After CMS modified reimbursement rates for outpatient peripheral vascular intervention (PVI) in 2008, clinicians began to increasingly perform PVIs in hospital outpatient centers and ambulatory surgery centers (ASCs)/office-based laboratories (OBLs). Little is known about the characteristics of patients treated in freestanding ASCs/OBLs and their respective long-term outcomes compared to those treated in other settings.

Methods:
Medicare fee-for-service beneficiaries ≥66 years undergoing femoropopliteal artery PVI between 4/1/15-12/31/17 in ambulatory settings and 10/1/15-12/31/17 in inpatient centers were identified using carrier files linked to institutional outpatient files and MedPAR data. The vital status file was used to determine mortality through 4/30/19. Patients required ≥1 year of data prior to PVI to allow for ascertainment of comorbidities. An area deprivation index of ≤15
th
percentile was used to identify those who reside in regions of lower socioeconomic status (SES).

Results:
Of 147,573 patients undergoing femoropopliteal PVI, 62,673 (42.5%) were treated as inpatients, 82,135 (55.7%) in hospital outpatient centers, and 2,765 (1.9%) in ASCs/OBLs. Patients treated in ASCs/OBLs had a greater burden of comorbidities, and were more likely to be Black (20.5% vs 11.6% outpt vs 14.1% inpt), dually-enrolled in Medicaid-Medicare (32.7% vs 18.5% outpt vs. 24.8% inpt), and reside in lower SES regions (44.8% vs 26.6% oupt vs 34.4% inpt). The unadjusted cumulative incidence of long-term mortality was similar between patients treated at ASCs/OBLs and inpatient centers, whereas hospital outpatients had higher survival (Figure 1). After adjusting for patient characteristics (demographics, comorbidities, and markers of SES), individuals treated in ASCs/OBLs had lower mortality rates than inpatient centers (HR 0.67, 95% CI 0.61-0.73) and attenuated mortality rates compared to outpatient centers (HR 1.10, 95% CI 1.01-1.20).

Conclusions:
Medicare beneficiaries undergoing femoropopliteal PVI at ASCs/OBLs are more socioeconomically disadvantaged and have a higher burden of comorbidities compared with other clinical settings. These differences in patient characteristics largely explain heterogeneity in long-term survival between facilities.
Abstract 103: A Meta Analysis of Antibiotic Envelope Use to Prevent Cardiac Implantable Electronic Device Infections
Authors: Khan Muhammad U , Lone Ahmad Naeem , Khan Muhammad , valavoor shahul , Munir Muhammad , Khan Safi U
Published: May 2020

Introduction:
Cardiac Implantable Electronic Device (CIED) infections are a major source of morbidity, mortality and increased healthcare cost. There are several well established risk factors associated with increased infection. An antibiotic coated envelope has been developed as an infection prevention intervention.

Hypothesis:
Whether antibiotic coated envelope is an effective preventive strategy against Cardiac Implantable Electronic Device Infections.

Methods:
6 trials comparing use of antibiotic envelope to control, including 1 randomized trial and 5 cohort studies were selected using PubMed and Embase data bases through May 2019. The efficacy end point was prevention of CIED Infection. Outcomes were combined using random effects model and estimated by odds ratio with 95% confidence intervals (CI).

Results:
In our analysis of total 12,024 patients undergoing CIED implantation, 5,844 patients received antibiotic envelope while 6,180 patients were included in the control group. Antibiotic envelope was superior to control in reducing the risk of device infection (OR 0.40 CI [0.17-0.95], p=0.04).

Conclusions:
The use of antibiotic envelope in Cardiac Implantable Electronic Devices (CIED) is associated with reduced incidence of CIED infection.
Abstract 11: Geographic Inequalities in Cardiovascular Mortality: Impact of Public Health Initiatives
Authors: Parcha Vibhu , Kalra Rajat , Patel Nirav , Wang Thomas J , Arora Garima , Arora Pankaj
Published: May 2020

Introduction:
Improvements in therapy and prevention have led to declining cardiovascular mortality in the United States, but it is not clear whether these improvements have narrowed geographic disparities in cardiovascular outcomes. We sought to compare mortality due to cardiovascular disease, heart failure, stroke, and ischemic heart disease in the stroke belt cluster of 11 states versus the rest of the United States.

Methods:
A retrospective cross-sectional analysis of the CDC WONDER database was done to evaluate the nationwide mortality trends derived from the death certificates of all American residents from 1999 to 2017. Mortality trends for death due to heart failure, stroke, ischemic heart disease or any cardiovascular cause, were identified in the stroke belt and non-stroke belt populations using ICD-10 codes. Piecewise linear regression was used to assess the change in mortality trends.

Results:
Among 16,111,775 deaths due to cardiovascular causes during the study period, the age-adjusted mortality rates (AAMR) were highest among non-Hispanic Black, males from non-metropolitan areas, living in the stroke belt. In the stroke belt, AAMR due to all cardiovascular causes [Average Annual Percentage Change (AAPC): -2.5 (95% CI:-2.9 to -2.0); p<0.001], stroke [AAPC: -2.9 (95% CI: -3.7 to -2.1); p<0.001] and ischemic heart disease [AAPC: -3.9 (95% CI: -4.3 to -3.5); p<0.001] declined from 1999 to 2017. Similarly, a decrease in cardiovascular [AAPC: -2.6 (95% CI:-3.1 to -2.1); p<0.001], stroke [AAPC:-2.9 (95% CI: -3.2 to -2.2); p<0.001] and ischemic heart disease [AAPC: -4.1 (95% CI: -4.5 to -3.6); p<0.001] mortality was seen in the non-stroke belt region from 1999 to 2017. There was no overall change in heart failure mortality in either regions (p for AAPC >0.05). The gap in age-adjusted mortality estimates for cardiovascular cause of death was 11.8% in 1999 and was 16% in 2017 across the two regions (
Figure 1
). The mortality gaps were persistent across sub-groups of age, sex, race, and level of urbanization.

Conclusions:
Despite the overall decline in cardiovascular mortality, significant geographic disparities in cardiovascular mortality persist. Preventive efforts targeting risk factors and improved disease management may attenuate the longstanding geographical heterogeneity in cardiovascular mortality.
Abstract 12: National Surveillance of Stroke Quality of Care and Outcomes Using Post-stratification Survey Weights on the Get With the Guidelines-stroke Patient Registry
Authors: Ziaeian Boback , Xu Haolin , Matsouaka Roland , Xian Ying , Khan Yosef , Schwamm Lee H , Fonarow Gregg C , Smith Eric E
Published: May 2020

Background:
The U.S. lacks an appropriate stroke surveillance system. This study developed and validated post-stratification weights for an existing stroke patient registry to represent the entire U.S. population across the nine U.S. Census divisions.

Methods:
Two statistical approaches were used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample to model the burden of acute ischemic stroke. Post-stratification survey weights were estimated using a raking procedure and Bayesian interpolation methods. Both strategies for developing weights were compared. Weighting methods were adjusted to limit dispersion of weights and make reasonable national estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national population estimates were reported between the two post-stratification methods. Color treemaps were used to visualize the distribution of post-stratification weights across relevant sub-populations. Primary measures evaluated were patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge.

Results:
There were a total of 1,388,296 acute ischemic strokes between 2012 and 2014. Raking and Bayesian estimates of clinical data not recorded in administrative databases were estimated within 5 to 10% of the margins of reference values. Median weights for the raking method were 1.366 and the weights at the 99
th
percentile were 6.881 with a maximum weight of 30.775. Median Bayesian weights were 1.329 and the 99
th
percentile weights were 11.201 with a maximum weight of 515.689.

Conclusions:
Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. Post-stratification weighting may be used as a basis for more advanced modeling relevant to understanding the burden of acute ischemic stroke and the quality of care delivered in U.S. hospitals. These methods may be applied to other diseases or settings to better monitor population health.
Abstract 13: Patient-reported Health Status Changes are Associated With Subsequent Clinical Outcomes After Transcatheter Valve Therapies: Insights From the Sts/tvt Registry
Authors: Hejjaji Vittal , Li Zhuokai , Cohen David J , Carroll John , Vemulapalli Sreekanth , Nelson Adam J , Malik Ali O , Mack Michael , Spertus John , Arnold Suzanne V
Published: May 2020

Background:
The goals of TAVR and transcatheter mitral valve repair (TMVr) are to prolong survival, reduce heart failure (HF) hospitalizations, and improve health status. Most patients report large improvements in health status within 30 days of these procedures. While this is an important patient-centered outcome on its own, if these changes were also associated with subsequent clinical outcomes, this would further support using short-term health status as a quality metric for valve procedures.

Methods:
Among patients who underwent transfemoral TAVR or TMVr, had KCCQ data at baseline and 30 days, and could be linked to CMS for 1-year outcomes; we constructed sequential models examining the association of KCCQ with death and HF hospitalization from 30 days to 1 year: 1) baseline KCCQ, 2) 30-day KCCQ, 3) baseline and 30-day KCCQ, 4) change in KCCQ from baseline to 30 days. In each model, we tested the interaction between procedure type and KCCQ, examined the linearity of the association of KCCQ with outcomes using restricted cubic splines, and adjusted for patient factors (Figure footnote).

Results:
Our cohort included 73,699 patients who underwent TAVR or TMVr from 2011-18 (median age 83 [IQR 77-87], 53% men, 92% TAVR). There were no significant interactions between procedure type and KCCQ, so all analyses used the combined cohort. Higher baseline KCCQ (model 1) and 30-day KCCQ (model 2) were both strongly associated with lower risk of death and HF hospitalization (Figure). When both were included in the model (model 3), each assessment was independently associated with subsequent outcomes, with the 30-day being most predictive. Change from baseline to 30 days was nonlinearly associated with outcomes (model 4), with increases up to 25 points associated with lower risk of death or HF hospitalization but no further risk reduction beyond 25 points. There were no meaningful changes in the associations after adjusting for patient factors.

Conclusion:
Short-term improvements in patient-reported health status after TAVR or TMVr were strongly associated with lower risk of death or HF hospitalization, with the 30-day assessment having a stronger association than baseline. These results support the routine use of 30-day KCCQ as a potential measure of quality after TVTs and to identify those at higher risk for adverse outcomes.
Abstract 15: Patient-Reported versus Physician-Estimated Angina in Patients Undergoing Percutaneous Coronary Intervention
Authors: Tran Andy T , Saxon John S , Chan Paul S , Jones Phillip G , Angraal Suveen , Nassif Michael E , Grantham James A , Maron David J , Spertus John A
Published: May 2020

Background:
The primary indication for coronary revascularization in patients with stable ischemic heart disease (SIHD) is relief of angina and improvement in quality of life. In current clinical practice, the Canadian Cardiovascular Society Classification (CCSC) system is used to quantify angina. However, the CCSC is a subjective estimate of angina burden from the perspective of the physician, rather than the patient. Although previous studies have demonstrated discordance between physician-estimated and patient-reported assessment of angina, whether this discordance exists in patients undergoing percutaneous coronary intervention (PCI) is unknown.

Methods:
We prospectively collected the Seattle Angina Questionnaire Angina Frequency (SAQ AF) scores on 769 patients undergoing PCI for SIHD and 895 patients undergoing PCI for unstable angina (UA) between 2009-2011 across 10 U.S. hospitals, and compared the SAQ AF categories of daily (SAQ AF 0 - 30), weekly (SAQ AF 31 - 60), monthly (SAQ AF 61 - 99) and no angina (SAQ AF = 100) over the past 4 weeks with the CCSC as captured in the National Cardiovascular Data Registry (NCDR) for PCI (Table 1).

Results:
In patients with SIHD, 267 (35.2%) of 769 patients reported a SAQ AF score of 100 (no angina). Of those with no self-reported angina, 33 (12.4%) and 20 (7.5%) were assessed by physicians as having moderate (CCSC II) or severe (CCSC III or IV) angina, while 197 (73.8%) were reported to have no angina (CCSC 0). In patients with UA, 110 (12.3%) of 895 patients reported a SAQ AF of 100, despite being categorized as having unstable angina.

Conclusions:
These data suggest a discordance between patient-reported and physician-assessed angina burden among patients undergoing PCI and may impact ratings of procedural appropriateness in the NCDR. Collecting patient-reported outcome measures with the SAQ may be a useful clinical tool for selecting patients who are likely to experience quality of life benefit after coronary revascularization.
Abstract 16: Sex Disparities in Organ Donation: Finding an Equal Donor Pool
Authors: Yee Erika , Hosseini Seyedeh Maryam , Duarte Bianca , Knapp Shannon , Sweitzer Nancy K , Breathett Khadijah
Published: May 2020

Introduction:
The majority of living organ donors are women, and the majority of deceased organ donors are men. This poses a problem for transplant candidates who have worsened survival with sex mismatched organs. The objective of this study was to identify reasons for disparities in organ donation between sexes and identify strategies to increase organ donors.

Methods:
We conducted a fifteen question survey using a crowdsourcing marketplace, Amazon’s Mechanical Turk, in September 2019. The survey assessed how participants make decisions about becoming an organ donor. The survey was distributed to U.S. adult participants, including eight write-in questions and two Likert scale questions. Qualitative descriptive analyses were used to understand reasons for and against becoming an organ donor. Quantitative results were compared with t test.

Results:
Among the 667 eligible participants representing 49 states, 54.9% were women and 63.1% were in the 18-40 age group. The majority of men (64.8%) and women (63.4%) were registered organ donors. Among men and women donors, three themes guided their willingness to donate: desire to help others, personal experience with organ donors/recipients, and believing organs would have no use to the donor once dead. Among men and women non-donors, decisions were guided by three themes: no reason, medical mistrust, considering becoming a donor. Themes varied by sex when considering whether to donate organs of a deceased family member. Women were guided equally by two themes: family member’s wishes and believing the deceased family member had no further use for organs. Men had similar themes but valued the family member’s wishes more. Women’s willingness to donate their own organs to family members (p=0.03) and strangers (p=0.02) was significantly higher than men. Among non-donors, both sexes would consider becoming organ donors if more information was provided.

Conclusion:
In a national survey of adults, women and men had similar reasons for becoming and not becoming an organ donor. However compared to men, women were more willing to donate their organs and more altruistic in the donation of family members’ organs. Women’s deceased organ donation may increase with further communication of women’s wishes before death and by improved public education about organ donation.
Abstract 18: Patient-administered Home Inotrope Therapy: A Proof of Concept
Authors: Omar Wally A , Mathew Chris , Bhavan Kavita , Das Sandeep R , Joglar Jose A
Published: May 2020

Background:
Palliative use of continuous IV inotrope therapy has shown to improve quality of life and reduce hospital readmissions for patients with end-stage heart failure (HF) who are otherwise ineligible to receive advanced therapies. Administration of home inotrope therapy generally requires a hospice or home-health agency, placing this option out of reach for patients who lack funding. As such, underinsured patients are relegated to the difficult choice of either remaining in the hospital to receive IV inotropes, or going home without the therapy for as long as their symptoms allow. To address this issue at our large county safety-net hospital, we developed and implemented a patient self-administered home inotrope therapy program.

Methods:
A multidisciplinary team of physicians, pharmacists, nurses, and social workers was assembled to pilot the program. Eligible patients were provided with a peripherally inserted central venous catheter (PICC) and a portable infusion pump. They were then instructed on proper use of the pump, medication administration, medication bag changes, and IV line care using a nursing teach-back technique. After proper understanding was demonstrated, patients were discharged home with weekly follow up in heart failure clinic for PICC-care and medication exchanges.

Results:
During the initial 12 months of the program, 5 patients were deemed eligible for enrollment. Total hospitalized days for these patients was 277 (mean = 55.4 days) in the one year prior to enrollment and 12 (mean = 2.4 days) while enrolled for a cumulative period of 288 days (Figure 1). One patient was able to secure funding for advanced therapies, two patients died while enrolled, and two patients are currently enrolled and alive.

Discussion:
A self-administered home IV inotrope therapy program is a feasible alternative for palliation in unfunded patients with end-stage HF who are otherwise not candidates for advanced therapies, allowing for more days at home in the end of life. Thus far, the cost impact of the program has been mitigated by the cost savings for inpatient hospitalizations. Studies to assess patient-centered outcomes, and overall cost savings are ongoing.
Abstract 20: Use of Administrative Claims to Ascertain Outcomes in Randomized Clinical Trials for Transcatheter Aortic Valve Replacement: Findings From the Extending Trial-based Evaluations of Medical Therapies Using Novel Sources of Data (EXTEND) Study
Authors: Strom Jordan B , Zhao Yuansong , Faridi Kamil F , Butala Neel , Tamez Hector , Valsdottir Linda , Brennan J Matthew , Shen Changyu , Popma Jeffrey J , Kazi Dhruv S , Yeh Robert W
Published: May 2020

Introduction:
Administrative claims may be a low cost alternative to traditional clinical trial event adjudication, but whether claims data can validly substitute for adjudicated outcomes to reproduce trial-derived treatment effects is uncertain.

Methods:
We linked adults aged ≥65 in the US CoreValve Pivotal High Risk (HiR) and Surgical or Transcatheter Aortic Valve Replacement in Intermediate-Risk Patients (SURTAVI) Trials to 100% Medicare inpatient claims (2003-2016). Primary (i.e. death and stroke) and secondary trial endpoints (i.e. bleeding, acute kidney injury, cardiogenic shock, pacemaker implantation, aortic valve reintervention, myocardial infarction, and major adverse cerebrovascular and cardiovascular events [MACCE]) were compared across treatment arms (i.e. TAVR vs. SAVR) using outcomes derived from claims at 1 year (HiR) or 2 years (SURTAVI), and compared with trial-adjudicated outcomes.

Results:
Among 600 linked HiR participants (linkage rate 80.0%), the rate of the trial’s primary endpoint of all-cause mortality at 1-year was 13.7% for TAVR and 16.4% for SAVR using both trial data (HR 0.84, 95% CI 0.65-1.09; p = 0.33) and claims data (HR 0.86, 95% CI 0.66-1.11; p = 0.34; interaction p-value = 0.80) (
Figure
). Among 1004 linked SURTAVI trial participants (linkage rate 60.5%), the trial’s primary endpoint of combined death and stroke at 2-years was 12.9% for TAVR and 13.1% for SAVR using trial data (HR 1.08, 95% CI 0.79-1.48, p = 0.90), and 11.3% for TAVR and 12.5% for SAVR patients using claims data (HR 1.02, 95% CI 0.73-1.41, p = 0.58; interaction p-value = 0.89) (
Figure
). Procedural secondary outcomes (e.g., aortic valve reintervention, pacemaker implantation) were more concordant between trials and claims than non-procedural outcomes (e.g. bleeding, cardiogenic shock, stroke). Acute kidney injury, myocardial infarction, and MACCE outcomes were also concordant between data types.

Conclusions:
In both HiR and SURTAVI trials, ascertainment of trial primary endpoints using claims reproduced both the magnitude and direction of treatment effect observed in adjudicated event data. Non-fatal secondary outcomes displayed variable concordance. Use of claims to substitute for adjudicated outcomes in traditional trial treatment comparisons may be a valid alternative for some endpoints.
Abstract 205: Does Overuse of Telemetry Impede Cost-effective Patient Care?
Authors: Brownell Kenneth B , Yenigalla Sowjanya , Shah Parth , Kudron Evan B , Amanzai Abasin , Mamauag Miguel , Bollam Rahul , Kiazand Mehrshid , Abhishek Fnu
Published: May 2020

Background:
Telemetry was first introduced in the 1950s in cardiac intensive care units (ICU) and has since expanded to beyond the ICU setting. With this expansion, concerns regarding the overutilization of telemetry have emerged. In response to these concerns, the American Heart Association (AHA) and the American College of Cardiology (ACC) released guidelines for evidenced-based telemetry utilization in 2004. Following this publication, numerous studies have shown that a significant number of non-ICU patients on telemetry do not meet evidenced-based indications leading to costly overutilization of a valuable resource. This overutilization is expensive in both the direct costs of equipment and labor as nurses spend an average of 20 minutes per patient day on telemetry related tasks. As healthcare expenditures in the United States continue to rise, efforts are needed to contain these rising costs if we wish to continue to provide high quality, affordable care.

Methods:
Using the electronic medical record (EMR) at our urban, tertiary-care, 482 bed teaching hospital, we performed an observational study looking at all admissions to a medical floor that were ordered telemetry in June 2019. We investigated if telemetry was ordered based upon the 2004 AHA guidelines. We then examined the total duration of telemetry utilized for non-AHA guideline indications. Next, we applied the average additional daily cost of $53.44, as reported in the literature, for monitored vs. non-monitored patients and then calculated an estimated total monthly expenditure for inappropriate use to cardiac monitoring. Annual costs were then projected based upon this figure.

Results:
There were 395 patients admitted in June 2019. After all inclusion criteria were applied, our sample consisted of 226 patients. Seventy-nine of these patients had telemetry ordered for an AHA guideline-based indication, while 147 patients had telemetry ordered for a non-AHA guideline indication for a total of 711 patient days, which adds $37,995.84 to monthly healthcare expenditures. Of the 147 patients that had telemetry ordered for non-AHA guideline indications, only one patient had a documented benefit, which was the detection of new-onset paroxysmal atrial fibrillation.

Conclusions:
Telemetry monitoring is frequently overused for patients admitted to non-critical care services. An effort to educate House Staff about the indications for ordering telemetry based on AHA guidelines can reduce healthcare-associated costs and help provide cost-effective, high-quality care to our patients.
Abstract 207: Cardiovascular Outcomes of Sodium-glucose Co-transporter 2 Inhibitors: A Meta-analysis
Authors: Lone Ahmad Naeem , Khan Muhammad , Khan Muhammad U , Khan Mohammad S , Khan Safi U
Published: May 2020

Background:
Concerns exist that mortality benefit might vary across different drugs (canagliflozin, empagliflozin, dapagliflozin) belonging to sodium-glucose cotransporter-2 (SGLT2) inhibitors.

Methods:
Twenty-two randomized controlled trials (n=59,018) having at least 500 participants and follow-up ≥1 year were selected from MEDLINE and EMBASE databases through October 2019. Meta-analysis was performed using fixed effect model (for
I
2
< 25% {25 out of 100}) or random effects model.

Results:
SGLT2 inhibitors decreased risk of all-cause mortality (Hazard Ratio (HR) 0.85, [95% {95 out of 100} confidence interval, 0.79-0.91]). This benefit was consistent for canagliflozin (HR, 0.86, [0.76-0.97]), empagliflozin (HR, 0.70, [0.79-0.91]) and dapagliflozin (HR, 0.90, [0.82-0.99]) (P-interaction = 0.06). SGLT2 inhibitors reduced the risk of cardiovascular mortality (HR, 0.82 [0.74-0.90]), myocardial infarction (MI) (HR, 0.88 [0.80-0.97]), major adverse cardiovascular events (HR, 0.84 [0.78-0.91]), and heart failure hospitalizations (HR, 0.68 [0.62-0.75]).

Conclusion:
Canagliflozin, empagliflozin, dapagliflozin were associated with significant reduction in all-cause mortality. SGLT2 inhibitor was also associated with cardiovascular benefits in type 2 diabetes mellitus.
Abstract 21: Heart Failure and Shared Decision-making: Patients’ Perspectives Regarding Medication-related Cost Discussions
Authors: Rao Birju , Dickert Neal W , Morris Alanna A , Speight Candace , Smith Graham , Shore Supriya , Moore Miranda
Published: May 2020

Background:
Patients with heart failure with reduced ejection fraction (HFrEF) take on average 6 medications daily and can face considerable out-of-pocket medication costs. This issue has become particularly salient as newer medications such as sacubitril-valsartan have emerged as beneficial. As clinicians attempt to maximize benefits for this population, discussions of medication costs between patients and clinicians are critical. However, cost discussions are known to be infrequent and often suboptimal.

Objective:
To explore patients’ perspectives on discussing out-of-pocket medication costs with clinicians.

Methods:
49 adults, aged 44-70, with HFrEF meeting general eligibility criteria for sacubitril-valsartan were recruited from outpatient heart failure clinics and inpatient services. Descriptive quantitative analysis of closed-ended and multiple-choice responses was conducted. Qualitative descriptive analysis of open-ended text data was performed.

Results:
About half (49%) of participants reported any previous discussion with clinicians about out-of-pocket cost related to medication. These participants described their experience with cost discussions at the time of prescription as generally positive. Specific ways these discussions were helpful included clarifying cost-benefit tradeoffs and identifying opportunities for cost reduction. Most participants (96%) were open to cost discussions with their clinician, and many (69%) specifically preferred that clinicians initiate discussions regarding medication cost. There were no differences in cost discussion preferences between participants who employed different decision-making approaches about initiation of sacubitril-valsartan or across levels of financial burden.

Conclusion:
Out-of-pocket cost is a relevant component of patient-centered medical decisions, particularly for patients with HFrEF. These data suggest patients with HFrEF are receptive to incorporating cost discussions into care and identify some of the ways these discussions may be helpful. Further research is needed to clarify how best to identify patient-specific cost at the time of clinical encounters and how to work with patients to make cost-benefit assessments.
Abstract 213: A Comparison of Patient Profiles and 1-year Health Status Outcomes Following a Diagnosis of Peripheral Artery Disease in Two High-income Countries: Insights From the Portrait Registry
Authors: Jelani Qurat-ul-ain , Smolderen Kim G , Gosch Kensey , Halpin David , Tutein Nolthenius Rudolf , De Vries JPPM , Chaar Cassius , Heyligers Jan , Spertus John , Mena-hurtado Carlos
Published: May 2020

Background:
Peripheral artery disease (PAD) prevalence is increasing by age in high-income countries. It is unknown whether patient characteristics, treatment profiles, and 1-year PAD-specific health status outcomes differ across health care contexts in high-income countries such as the ones in the United States (US) vs. the Netherlands.

Methods:
Patients were identified from the Patient-centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) study which is a prospective, multicenter, international registry of patients presenting to vascular specialty clinics for new onset, or an exacerbation of PAD symptoms. PAD-specific health status was measured by Peripheral Artery Questionnaire (PAQ) at presentation, and at 3, 6 and 12 months follow-up using adjusted generalized repeated measurement models.

Results:
Out of a total of 1,114 patients,748 patients (67.1%) were from the US and 366 (32.9%) were from the Netherlands. US patients with PAD were significantly older and had a higher cardiovascular risk factor burden including smoking (Table) with more Netherlands patients being referred to supervised vs. unsupervised exercise therapy (SET) as compared with the US cohort after enrollment. US patients presented with significantly lower PAD-specific health status scores (PAQ summary scores) upon presentation (-41.59 vs 49.58, p<0.0001) as well as at 12 months following their vascular work-up (61.05 vs 74.66, p<0.0001). US patients also had lower rates of improvement that consistently lagged behind the Netherlands at all time points (p<0.001). The interaction between country*time was significant at all time points.

Conclusion:
US patients seeking care for PAD have a different risk profile upon presentation from Dutch patients, including worse health status profiles, and had less exposure to SET. Even after adjustment, worse PAD-specific health status outcomes were seen in the US cohort at baseline throughout 12 months of follow-up. Contrasting risk exposure patterns and health care systems across high-income care settings may highlight mutual learning opportunities to advance the care for PAD.
Abstract 214: The Association of Surgeon Experience With Expected Mortality of Coronary Artery Bypass Graft Surgery in New York State
Authors: Raman Swathi , Nathan Ashwin , Khatana Sameed Ahmed M , Desai Nimesh D , Atluri Pavan , Szeto Wilson Y , Groeneveld Peter W , Giri Jay
Published: May 2020

Purpose:
Public reporting of surgical outcomes can promote quality improvement. However, this could also incentivize surgeons to avoid high-risk patients. Senior surgeons, with established referral networks, may select lower-risk cases than their junior colleagues. This study aimed to assess the relationship between surgeon experience and expected mortality rate of cases performed.

Methods:
Publicly available data on coronary artery bypass graft (CABG) surgeries between 2011-2013 were obtained from the New York State Department of Health. The 30-day expected mortality rate (EMR) for each CABG was calculated from validated models. Additionally, we obtained data on each surgeon’s medical school gradation year and board certification status from Internet sources, such as Doximity. Surgeon experience was calculated by subtracting the medical school graduation year from 2011, the start of the study period. A multivariable linear regression model was used to estimate the association between EMR and surgeon experience, adjusting for case volume and board certification status.

Results:
Between 2011-2013, there were 132 cardiac surgeons that performed CABG at 39 hospitals across New York State. The mean surgeon experience was 25.1 years (SD 9.1 years) and the overall mean EMR of CABG surgeries was 1.46% (SD 0.38%). The unadjusted analysis showed a 0.005% increase in EMR per additional year of surgeon experience. However, this was not statistically significant (p=0.25, 95% CI -0.0036 to 0.0013). Through the multivariable linear regression model, we did not find evidence of a significant association between operator experience and the EMR of cases performed (0.0040% per year, p=0.35, 95% CI -0.0044 to 0.012%). There was a significant association between the number of cases performed during the study period and the EMR, with an increase in EMR by 0.0005% per additional case performed (p=0.04, 95% CI 0.00004 to 0.001). There was no significant association between board certification status and EMR (p=0.10).

Conclusion:
Despite public reporting of CABG outcomes, our findings suggest that more experienced surgeons may not be exhibiting risk-avoidant behavior. Future research could focus on supplementing publicly reported physician-level data with patient-level datasets to better understand the association between surgeon experience and expected mortality rate of cases performed.
Abstract 219: Use of Machine Learning Models to Identify Atherosclerotic Cardiovascular Disease Patients at Very High Risk for Future Events in a Multi-state Health Care System
Authors: Li Hsin-Fang
Published: May 2020

Background:
In the 2018 AHA/ACC Blood Cholesterol Guideline, it is recommended that ASCVD patients be classified as very high-risk (VHR) vs not-VHR (NVHR) to guide treatment decisions. This has important implications for ezetimibe and PCSK9 inhibitor eligibility. We aimed to develop a tool that could assist in more easily identifying VHR patients based on machine learning (ML) techniques. This approach offers a powerful, assumption-free alternative to conventional methods, such as logistic regression, to identify potential interactions among risk factors while incorporating the hierarchy of interaction among variables.

Method:
We used EHR-derived ICD-10 codes to identify patients within our health system with ASCVD. VHR was defined by ≥2 major ASCVD events (ACS ≤12 months, history of MI >12 months, ischemic stroke, or symptomatic PAD) or 1 major ASCVD event and ≥2 high-risk conditions (age ≥65, diabetes, hypertension, smoking, heterozygous familial hypercholesterolemia, CKD, CHF, persistently elevated LDL-C ≥100 mg/dl, or prior CABG/PCI). Patients not meeting these criteria were classified as NVHR. We randomly assigned patients into a training set and a testing set. Classification and regression tree (CART) modeling was performed on the training set and validated on the testing set. The results were compared with a random forest model. Variables in both models included age, sex, race, ethnicity, and each of the VHR criteria above. The primary outcome for both models was VHR classification. Performance of the two models were compared using area under the curve (AUC).

Result:
A total of 180,669 ASCVD patients were identified in 2018: 104,123 (58%) were VHR and 76,546 (42%) were NVHR. Mean age and sex were 73.1±11.9 years, 55% male and 70.1±13.4 years, 54% male for the VHR and NVHR groups, respectively. Half the population was randomly selected as the training dataset (n=90,334) and the other half was used as the testing dataset (n=90,335). Both CART and random forest models identified recent ACS, ischemic stroke, hypertension, PAD, and history of MI as the top five predictors of VHR status. Ninety-six percent of patients with recent ACS were classified as VHR. Among patients with no recent ACS, 95% were classified as VHR if they had a stroke and hypertension. Among patients with no ACS or stroke, 89% were classified as VHR if they had PAD. Finally, among patients with no ACS, stroke or PAD, 90% were classified as VHR if they had a history of MI. The misclassification rate of the CART model on the testing set was 4.3%. The AUC for the CART and random forest models was 0.949 and 0.968, respectively.

Conclusion:
Both ML methods were highly predictive of VHR status among those with ASCVD. Use of this approach affords a simplified means to drive clinical decision making at the point of care.
Abstract 221: How an ICD-10 Code for Type 2 Myocardial Infarction Impacts Patient Inclusion in Acute MI Cohorts for Value-based Programs
Authors: Rudofker Eric W , Hammes Andrew , Kirkpatrick Scott , Ream Karen S , Levy Andrew E
Published: May 2020

Background:
The Center for Medicare and Medicaid Services uses primary discharge ICD-10 codes for Acute Myocardial Infarction (AMI) to define inclusion in value-based payment programs such as the hospital readmissions reduction program. Prior studies have shown that a significant number of hospitalizations with an ICD-10 code for AMI actually represent a Type 2 MI (T2MI) or non-ischemic myocardial injury (NIMI). Yet, the care of such patients may differ from those with AMI, and their inclusion in value-based payment programs risks inaccurately assessing hospital care and even unwarranted financial penalties. In October 2018, a new ICD-10 code for T2MI was introduced (I21.A1). It is unclear what effect, if any, this new code has had on Type 1 MI (T1MI) representation among discharges assigned an ICD-10 code for AMI.

Methods:
We screened all discharges from 8 UCHealth hospitals between January 1, 2017 and June 30, 2019 for a primary discharge ICD-10 code of AMI (n=3,445). Hospitalizations occurring during a six month period prior to the introduction of I21.A1 (January 1, 2017 to June 30, 2017) and a six-month period after the introduction of I21.A1 (January 1, 2019 to June 30, 2019) were selected for chart review. Using the 4th Universal Definition of MI, hospitalizations were assigned a gold-standard clinical diagnosis of T1MI, T2MI, or NIMI. The cohorts were compared according to the primary outcomes of readmission and mortality at 30 and 90 days.

Results:
Of 1,364 discharges reviewed, 676 occurred in the pre-I21.A1 period and 667 occurred in the post-I21.A1 period. In the pre-I21.A1 cohort, 86% (585 of 676) of discharges met clinical criteria for T1MI, 10% (67 of 676) were deemed T2MI and 4% (24 of 676) represented NIMI. In the post-I21.A1 group, 93% (626 of 676) were deemed T1MI, while 5% (33 of 667) were deemed T2MI and 2% (12 of 667) met criteria for NIMI. The post-I21.A1 cohort had significantly fewer readmissions at 30 and 90 days when compared to the pre-I21.A1 cohort, but had similar rates of mortality.

Conclusions:
After the introduction of an ICD-10 code for T2MI, fewer patients with T2MIs and NIMIs were eligible for inclusion in value-based programs. Concomitantly, we observed lower readmission rates among patients with an ICD-10 code for AMI after the T2MI code was introduced.
Abstract 223: The Role of Confidence in Home Care Workers' Contribution to Heart Failure Patients' Self-care: Testing a Structural Equation Model
Authors: Sterling Madeline R , Barbaranelli Claudio , Riegel Barbara , Stawnychy Michael , Ringel joanna , Cho Jacklyn , Vellone Ercole
Published: May 2020

Background:
Home healthcare workers (HCWs) frequently care for adults with heart failure (HF). Prior studies have found that HCWs promote HF patients’ self-care, but are poorly prepared to do so and lack confidence. Also, how mutuality (the positive quality of the relationship) between HCWs and HF patients contributes to care is unknown. We investigated these issues quantitatively, guided by the Situation-specific Theory of Caregiver Contribution to HF self-care. We hypothesized that HCW preparedness and mutuality influenced HCW contribution to HF self-care maintenance (behaviors to maintain HF stability) and management (response to HF symptoms), with confidence mediating the relationship.

Methods:
We conducted a cross-sectional survey of English-speaking HCWs employed by 23 home care agencies who cared for a HF patient in the last year in New York, NY. HCWs completed a sociodemographic questionnaire, the Caregiver Preparedness Scale (CPS), the Mutuality Scale (MS), and the Caregiver Contribution to Self-Care of HF Index (CC-SCHFI), which assesses caregiver contribution to self-care maintenance, management, and caregiver confidence. We tested our hypotheses with structural equation modeling (SEM). Mediation analysis was done to test indirect effects.

Results:
The 317 HCWs had a median age of 50, 94% were women, 44% were Non-Hispanic Black, 79% had ≥ high school education, 71% were foreign-born, and all spoke English. The HCW had a median of 8.5 years of caregiving experience. Overall, HCWs felt prepared for HF caregiving (CPS mean 3.86 [SD: 0.93]) and had moderately positive relationships with patients (MS mean 3.87 [SD: 0.76]). 63% contributed adequately to self-care maintenance, 22% to self-care management, and 44% felt confident with HF caregiving. The tested model fit the data well (CFI=.98; RMSEA=.04) and showed the following significant relationships: mutuality and preparedness covaried (r=.47); preparedness influenced HCW confidence (b=.79); mutuality influenced HCW contribution to self-care maintenance (b=.25); HCWs confidence influenced their contributions to self-care maintenance (b=.22) and management (b=.52). HCWs’ contribution to self-care maintenance influenced their contribution to self-care management (b=.47). Analysis of the indirect effects showed that HCW confidence fully mediated the relationship between preparedness and contributions to self-care maintenance (effect=.17) and management (effect=.41).

Conclusions:
While HCWs’ preparedness heavily influenced their contribution to HF self-care, HCWs’ confidence, mediated this relationship. Thus, confidence, a modifiable factor, plays a key role in HCWs’ contribution to HF self-care. As this workforce increasingly cares for HF patients, the mechanisms underpinning the relationships among HCWs’ preparedness, mutuality, confidence, and self-care warrant further study.