bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 176: Association Between Hospital-Level Cost of Cardiovascular Care and Socioeconomic Characteristics
Authors: Sandhu Alexander T , Do Rose , Heidenreich Paul A
Published: April 2019

Background:
The socioeconomic status (SES) of a hospital’s patients is an important predictor of outcome measures. Patients with low SES may also require increased healthcare resources. The relationship between the SES of a hospital’s patient cohort and cost of care is less clear.

Objective:
We compared the association between the cost of acute myocardial infarction (AMI) and heart failure (HF) admissions with measures of the hospital community’s SES.

Methods:
We used hospitals’ average 30-day, standardized, risk-adjusted payments for Medicare patients admitted for AMI or HF from 2014-2017 from Hospital Compare. We used hospital rates of Medicare-Medicaid dual use from 2014-2017 and Medicaid and Supplemental Security Income ratios (SSI) for 2016. We also constructed hospital community SES characteristics using census data by mapping hospital Medicare patients’ ZIP codes to census ZIP data. We determined the association between cost and SES using linear regression with the cost of care as the dependent variable and standardized SES variables as independent variables. We included significant SES variable in a multivariable model to calculate the proportion of variance explained.

Results:
The mean hospital-level 30-day AMI cost was $23,905 (standard deviation [SD]: $1,581) among 2,281 hospitals. The mean hospital-level 30-day HF cost was $16,664 (SD $1,394) among 3,499 hospitals.

Dual use rates were not significantly associated with the cost of care, but higher SSI ratio was associated with increased cost (Table 1). Hospitals with communities with higher prevalence of local poverty consistently had lower costs. Similarly, higher community median income was associated with increased costs. Non-economic markers of community disparity - limited English proficiency and low educational attainment - predicted greater cost. A model with all significant SES variables had an adjusted r
2
of 0.06 for AMI costs and 0.17 for heart failure costs.

Conclusion:
Cost measures may not consistently penalize hospitals that care for economically disadvantaged patients. SES characteristics appear to have a stronger association with HF costs than AMI costs. The association between disadvantaged patients and cost of care is likely impacted by care access, demand elasticity, and care quality.
Abstract 177: The Burden of Sternal Wound Infections Following Coronary Artery Bypass Graft Surgery in Medicare Patients
Authors: Saunders Rhodri , Blüher Maximilian , Lankiewicz Julie
Published: April 2019

Objectives:
Since 2008, the Centers for Medicare and Medicaid Services (CMS) have not reimbursed costs associated with sternal wound infections (SWI) that follow coronary artery bypass graft surgery (CABG). Beginning FY 2015, the Hospital-Acquired Condition (HAC) Reduction Program, mandated by the Affordable Care Act, requires the CMS to reduce hospital payments by 1 percent for hospitals that rank among the lowest-performing 25 percent with regard to HACs. SWI resulting from CABG was added to the program in FY 2016. The cost of treating SWIs is thus absorbed by the hospital, making optimized SWI prophylaxis an important part of hospital care. Here the burden of SWI following CABG in the Medicare population is calculated and the impact of improved prophylaxis quantified.

Methods:
Literature review identified publications presenting the incidence of surgical site infections (including superficial and deep SWIs), the time required to treat SWIs, and the costs of providing post CABG care. Key parameters to estimate the burden of SWIs were: CABG procedures per year, SWI rate, ratio of superficial to deep SWIs, length of stay, hospital time to treat SWIs, and the cost per day of intensive care unit (ICU) and general ward. A previously presented Markov model was adapted to estimate the yearly burden of SWIs after CABG procedures, with costs in 2016 USD. As antibiotic prophylaxis is essentially ubiquitous for patients undergoing CABG, data on other methods of reducing the SWI were considered. Single-patient-use electrocardiogram cable and lead (ECG) systems have recently been shown to significantly reduce the incidence of surgical site infection after CABG. The risk reduction at 30-days post CABG was 18.8% over reusable ECG.

Results:
The number of Medicare beneficiaries totals approximately 55.3 million people, with an annual rate of CABG of circa 178 procedures per 100,000 beneficiaries. Isolated CABG procedures under Medicare thus total 98,434. The SWI rate was reported to be between 1 and 4%, with deep SWI representing up to 40.75% of SWI cases. Using an SWI rate of 2.5% at 30 days, 20% of which are DSWI, indicated the burden of SWIs was $88.5 million. This included an additional 4,443 ICU and 21,443 general ward days, as well as over 1,000 readmissions. At the higher end of estimates, SWI could be costing providers $115.0 million. Assuming a 18.8% reduction in the SWI rate at 30 days, providers could save $12.6 million going up to $26.8 million ($271 per procedure) at the higher end of estimates. At a $6 incremental cost, single-patient-use ECG could represent a 45-fold return on investment.

Conclusions:
Superficial and deep SWIs after CABG procedures in the Medicare population come at considerable cost to providers. Preventing SWI has advantages for both patients and providers.
Abstract 184: “I’m Gonna Have the Baby and It’s Gonna Go Away:” Communicating Cardiovascular Risk After a Pregnancy Complicated by Preeclampsia
Authors: Stokes Natalie , Mahraj Katy , Levine Lisa , Lewey Jennifer
Published: April 2019

Background:
Preeclampsia (PE) affects 5-8% of all pregnancies and is an underappreciated risk factor for hypertension after delivery and cardiovascular (CV) disease and stroke later in life. Women with PE are at a 2-fold higher risk of CV death and those with severe PE are at highest risk. The AHA recommends early risk factor screening and lifestyle modification in this at-risk population. Our objective was to understand barriers and facilitators of healthy lifestyle in an urban, racially diverse population of postpartum women with PE.

Methods:
We conducted qualitative, semi-structured interviews among women with a pregnancy complicated by severe PE in the past year. We randomly selected 10 women who had completed postpartum follow-up with an obstetrics (OB) and cardiology provider at the Hospital of the University of Pennsylvania within a 12-month period. Interviews were conducted at home or by phone and transcribed. Transcripts were coded and analyzed by 2 researchers using a grounded theory framework to identify major themes.

Results:
Of the 10 participants, 5 were black. The mean (SD) age was 33.0 (8.9) years and interviews were conducted on average 7.9 months postpartum (range 3.8-11.5 months). Mean BMI at the 6-week postpartum OB visit was 34.6 kg/m
2
(range 19.9-42.6 kg/m
2
). Participants demonstrated understanding that PE was a hypertensive state during pregnancy but did not generally acknowledge long-term CV risk. Participants uniformly identified exercise as an important component of a healthy lifestyle but were unsatisfied with current levels of physical activity. Barriers to exercise included lack of time, childcare, and motivation. Identified facilitators included having a workout buddy, working with a trainer, and having an extrinsic source of accountability. On average women reported being 12 pounds above their pre-pregnancy weight. Patient understanding of the association between weight gain and health risk varied widely. Participants reported obtaining health information for their child from the pediatrician but were more likely to use information from the internet or family and friends for issues related to PE and their own health.

Conclusion:
In this urban, racially diverse population of postpartum women, understanding of the long-term CV risks of severe preeclampsia were poor despite established follow-up with OB and cardiology. Postpartum women may be responsive to exercise interventions designed with social support, structured work-out plans, and accountability. Further research is needed around how to promote weight loss and improve understanding of CV risk.
Abstract 186: Securing Cardiology Follow Up Appointments Through Sustained Utilization of Electronic Medical Record-Based Order
Authors: Telukuntla Kartik , Sobol Tim , Abdallah Mouin , Hulseman Michael , Barzilai Benico , Starling Randall , Stephens John , Khot Umesh
Published: April 2019

Background:
The merits of creating follow up appointments at discharge are increasingly recognized, but interventions rarely translate to sustained improvements. We implemented an EMR-based appointment order to secure cardiology appointments prior to discharge and measured its long-term sustainability over four years.

Methods:
We performed an analysis of 26,358 patients discharged from the cardiology services within an academic center between 2014 and 2017. The electronic follow up order went live on January 1
st
, 2014. Once the order was entered by a provider in the medical record system, it was routed to a scheduling pool. A scheduler created the appointment, text paged the provider with confirmation, and entered the information in the patient’s discharge paperwork. We analyzed order utilization for four years using Kendall Tau B analysis to understand the impact and sustainability of this process.

Results:
Average age of the patient was 68.7 years and 61% were male. In the 26,358 patient discharges, 18,068 discharges had a follow up order placed (69%). Between 2014 and 2017, order utilization steadily increased from 50% to 77% (p=0.01). In 2014, 3,216 of 6,446 discharges utilized the order (50%). In 2015, 4,795 of 6,651 discharges utilized the order (72%). In 2016, 4,981 of 6,643 discharges utilized the order (75%). In 2017, 5,079 out of 6,621 discharges utilized the order (77%).

Conclusion:
The EMR-based follow up order is a sustainable mechanism for securing cardiology follow up appointments after hospital discharge. Higher rate of appointments created could translate into meaningful improvement of outcomes and reduce readmissions.
Abstract 192: Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes
Authors: Wang Xiaowen , Luke Alina A , Vader Justin M , Maddox Thomas M , Joynt Maddox Karen E
Published: April 2019

Background:
Prior studies have demonstrated disparities in access to cardiovascular procedures on the basis of socioeconomic status (SES). Left ventricular assist devices (LVADs) are used as a bridge to transplant or as destination therapy in heart failure. Our objective was to determine whether there is a relationship between SES and receipt or outcomes of LVAD implementation. We assessed whether Medicaid expansion was associated with an increase in LVAD implantation among likely poor individuals.

Methods:
We studied all patients <85 years of age admitted with heart failure or cardiogenic shock in the State Inpatient Database (SID) in AZ, AK, CO, FL, MA, MD, MI, NE, NJ, NV, NY, VT, WA, WI, and IA between 1/1/2012 and 9/30/2015. Elixhauser comorbidities, age, gender and hospital characteristics were used for multivariate regression analyses. Difference-in-difference analyses were conducted to evaluate changes in Medicaid expansion versus non-expansion states.

Results:
Among 889,377 patients, 64.6% were > 65 years old; 43.3% were women; and 64.2% were Caucasian. Overall, 0.42% of patients received LVADs. After adjusting for age, gender, comorbidities, and hospital characteristics, African Americans (odds ratio [OR] 0.72, 95% CI 0.65-0.80) and Hispanics (OR 0.62, 95% CI 0.53-0.72) were less likely to receive LVADs compared to Caucasians. Compared to privately insured patients, those with Medicare (OR 0.72, 95% CI 0.65-0.79), Medicaid (OR 0.43, 95% CI 0.38-0.49), and uninsured (OR 0.10, 95% CI 0.06-0.15) were less likely to receive LVADs. Patients residing in the lowest-income ZIP codes were less likely to receive LVADs (OR=0.74, 95% CI 0.67-0.82) than those in higher-income quartiles. Among patients who received LVADs, African Americans (OR 0.75, 95% CI 0.73-0.77) and Hispanics (OR 0.84, 95% CI 0.81-0.87) had lower risk-adjusted mortality compared to Caucasians. Patients with Medicaid (OR 0.94, 95% CI 0.90-0.99) had lower mortality, uninsured patients had higher mortality (OR = 1.23, 95% CI 1.16-1.31), and Medicare patients had similar mortality (OR 1.01, 95% CI 0.98-1.05) compared to privately insured patients. Mortality did not differ by ZIP code income. The rate of LVAD implantation among likely poor patients (Medicaid, uninsured, or low-income ZIP) at baseline in Medicaid expansion states was 0.35%; this increased to 0.40% post-expansion (p=0.037). In non-expansion states, the baseline rate was 0.23%, which remained unchanged post-expansion at 0.23% (p=0.88), for a difference-in-differences of 0.05% (p=0.47).

Conclusion:
Patients with low income, no insurance or Medicaid insurance, and racial/ethnic minorities were less likely to receive LVADs. Among patients who received LVADs, African Americans and Hispanics had lower in-hospital mortality. Medicaid expansion was not associated with a differential change in access to LVADs among likely poor patients.
Abstract 193: Who Group III Pulmonary Hypertension Patients With Lower Socioeconomic Status Are Diagnosed at a Younger Age
Authors: Wasserman Amanda , Morgan Spencer , Weinstein David , Neshewat Julian , McDevitt Susanne , Kline-Rogers Eva , Cascino Thomas , McLaughlin Vallerie
Published: April 2019

Background:
Previous research has shown that socioeconomic status (SES) is a contributing factor toward a patient’s health. Lower SES has been associated with later presentation and worse outcomes in both chronic lung disease (CLD) patients and World Health Organization (WHO) group I pulmonary arterial hypertension patients. It is unknown if lower SES is associated with differing clinical characteristics at the time of diagnosis of group III pulmonary hypertension (secondary to CLD).

Methods:
Using WHO Group III pulmonary hypertension (PH) patients in our Michigan Medicine database (n=147), patients were divided into high (n=77) and low (n=70) SES groups by zip codes according to the 2012-2016 Michigan census data. Univariable analysis between cohorts was performed comparing demographic data, Pulmonary Arterial Pressure mean (PAPm), 6-minute walk (6MW), and Diffusion Capacity for Carbon Monoxide (DL
CO
) at the time of diagnosis.

Results:
Patients were similar in regard to gender (55.8% v. 65.7% female;
p=
0.221), average body mass index (33.35±9.42 v. 33.84±10.57;
p
=0.769), and average WHO functional class (2.87±0.56 v. 3.00±0.63;
p
=0.414). Lower SES patients presented at a significantly younger age than higher SES patients (63.79±13.35 v. 69.22±12.37;
p
=0.011). In regard to diagnostic testing, there were no significant differences between the low and high SES cohorts in average PAPm (42.31±10.76 v. 41.74±11.07;
p=0.827)
, 6MW (243.60±145.29 v. 296.00±179.83;
p
=0.310), and DL
CO
(13.00±12.71 v. 11.53±5.94;
p
=0.502).

Conclusion:
Lower SES patients were diagnosed with group III PH at a younger age than higher SES patients. It is reassuring that clinical characteristics associated with worse outcomes were similar. Further work is needed to understand reasons for the observed earlier age at the time of diagnosis.
Abstract 195: External Validations of Clinical Prediction Models for Cardiovascular Disease: A Field Synopsis
Authors: Wessler Benjamin S , Lundquist Christine , Brown Kristen D , Beeravolu Harshita , Ayub Asha , Berggren Elizabeth , Kowalski Leigh , Brown Andrew , Williamson Tatum , Lutz Jennifer , Paulus Jessica , Kent David M
Published: April 2019

Background:
Clinical prediction models (CPMs) hold the potential to improve decision-making and individualize care for patients with cardiovascular disease (CVD); however, it is increasingly recognized that CPM performance may decrease when validated externally. Here we systematically describe published external validations of CPMs for patients with CVD, with specific attention to changes in CPM performance.

Methods:
A systematic review was conducted using a citation search to identify external validations of CPMs in the Tufts Predictive Analytics and Comparative Effectiveness (PACE) CPM Registry, a comprehensive database of CPMs for patients with CVD published between 1990 and May 2015. Information on CPM performance in the original derivation database as well as during subsequent external validations (through March 2017) was extracted. The percent change in discrimination was calculated as [(Validation AUC - 0.5) - (Derivation AUC - 0.5) / (Derivation AUC - 0.5) * 100].

Results:
The Registry includes 1083 CPMs for CVD. 1555 external validations were identified. On average there were 1.4 validations/ de novo CPM (range 0-83). 758 (70%) of the CPMs have never been externally validated. The median external validation sample size was 1215 (IQR 430, 6509) and the median number of events 59 (21, 209). 88% (1368) of the external validations report area under the receiver operating characteristic curve (AUROC). 59% (917) report some measure of CPM calibration. The median external validation AUROC was 0.74 (0.69-0.81) and the median percent change in discrimination was -14.7% (-34.1%, +0.8%). 29.3% (455) of model validations showed CPM discrimination at or above the performance reported in the derivation dataset.

Conclusion:
While numerous CPMs exist for patients with CVD, most have never been externally validated. CPMs generally show substantially worse discrimination in external validations compared to the derivation datasets.
Abstract 201: Evaluating Time from Electrocardiogram (ECG) Acquisition to ST-Elevation Myocardial Infarction (STEMI) Activation for Inpatients: Deployment of a Preliminary Automated ECG Reading System
Authors: Ahlers Michael , O’Leary Jared , Zbydniewski Stephen , Jenkins Barbara , Hamm Holly , Kronenberg Marvin W , Muñoz Daniel
Published: April 2019

Background:
Inpatients with STEMI experience lengthier symptom-to-intervention times, decreased likelihood of invasive management, and an estimated 3-10-fold increased mortality risk compared to outpatients. Launched in October 2018, the Chest Pain - MI Registry™ now includes inpatient STEMIs, further motivating improvement of care for this vulnerable population. We investigated whether deployment of an automated ECG reading system across the inpatient enterprise at a large academic hospital is associated with improvement in time from ECG acquisition to STEMI activation.

Methodology:
From May 2018-December 2018, a pre-existing automatic ECG interpretation software on all inpatient ECG machines (Philips PageWriter TC70) was activated at our institution. The interpretation level on the software was changed from “none” to “measurements and interpretations.” This change affected all inpatient ECGs. A protocol for response to acute STEMI auto-interpretations was developed, which instructed all ECG technicians to hand ECGs ordered “stat” directly to a member of the patient’s clinical team within 5 minutes of acquisition. A run chart (
Figure
) was analyzed per the IHI “Four Rules for Interpreting Run Charts.” Baseline and intervention samples were assessed by Wilcoxon rank-sum test.

Results:
From May 2016-May 2018, median time from ECG acquisition to STEMI activation for inpatients at our institution was 23 minutes (N=14) [range 5, 90] with mean time of 35 minutes (+/- 30 per SD). During the subsequent seven-month study period, median time from ECG acquisition to STEMI activation was 21 minutes (N=5) [range 11, 64] with mean time of 34 minutes (+/- 26 per SD, p = 0.36). Of note, there was no reported increased workload or consultation to cardiology due to erroneous preliminary automated ECG reading.

Conclusions:
Following deployment of an automated inpatient ECG reading system for seven months, there was no significant decrease in the time from ECG acquisition to STEMI activation. Due to the relative infrequency of inpatient STEMIs and the resulting small number of cases during the study period, our results may be under-powered (power of 6.4%) to detect an improvement in STEMI activation times. This data suggests more aggressive and efficient strategies are required for timely diagnosis of acute inpatient STEMI.
Abstract 206: Coronary Artery Bypass Graft - Postoperative Atrial Fibrillation: Does Statin Type or Dose Matter?
Authors: Aryal Sudeep R , Dhungana Rajat , Cournoyer Nicole , Tudor Gail , Vekima Nina , Boyle Anna , Carmack David , Sorondo Barbara
Published: April 2019

Background:
Atrial fibrillation (AF) is the most common coronary artery bypass graft (CABG) post-operative arrhythmia. This complication can increase the patient’s chances for a more extended hospital stay, stroke, or death; resulting in additional healthcare costs. Prescribing statins (3-hydroxy-3-methylglutaryl COA reductase inhibitors) to reduce the risk of postoperative AF (POAF) is well studied, as they provide an anti-inflammatory and antioxidant benefit within hours of initiation. However, whether the statin type or dose is the origin for these benefits remains unknown; as research is conflicted.

Methods:
This ten-year retrospective observational study at a single institution, included all patients who underwent an isolated CABG; between January 1, 2005 - December 31, 2015 (n=3,226). For multiple CABG procedure cases, only the first incidence was included. Cases with a pacemaker, history of AF before CABG, or inflammatory disease that requires chronic steroid therapy, were excluded. The final population totaled 1,842 (non-AF n=867; AF n=975) cases, respectively. We analyzed the data using two-sample t-tests and chi-square tests to identify which patient characteristics were significantly associated with having POAF. To keep a representative sample of our study population, variables missing more than 80% of values were excluded. Multiple logistic regression was used to identify which combination of characteristics were most significant and then statin dose and type were each added to the model, individually and together. These two variables were highly correlated, thus for our final model, we used a professional statin dose comparison resource guide to create a dose-intensity variable that considered the type of statin and dose. Patients prescribed no statin was classified as a no dose group, while those prescribed statins were classified into a low, medium or high-intensity dose group.

Results:
The characteristics associated with a risk of POAF were age, history of vascular disease, and cardiomegaly. While, history of carotid disease, IV heparin within 24 hours of pre-op, and aspirin use were associated with a lower risk of POAF. Patients receiving a high-intensity dose had the lowest rate of POAF (46% vs. 67% for no statin, 57% for low and 53% for moderate, p<.001), and a one day shorter hospital stay. Statin-type became important after adjusting for a dose; simvastatin had the lowest and atorvastatin had the highest incidence of POAF.

Conclusion:
According to this CABG population analysis, a history of carotid disease, IV heparin within 4 hours of pre-op, and aspirin use were associated with a lower risk of POAF and both statin dose and type are essential factors in POAF prevention. High-intensity dose statins had the lowest rate of POAF, and a one day shorter hospital stay whereas simvastatin had the lowest and atorvastatin had the highest incidence of POAF.
Abstract 208: Improvement in Prediction of Readmission after CABG with Cause-Specific Readmission Models
Authors: Assi Roland , Shnall Jill , Chen Jinbo , Williams Matthew
Published: April 2019

Background:
Hospital readmissions after cardiac surgery occur in up to 20% of cases and are associated with significant cost and morbidity. Most statistical models for readmission have poor predictive power, and hence very little clinical value to identify at-risk patients. We hypothesized that the predictive value of readmission models could be improved upon when cause-specific readmission is examined.

Methods and Results:
Data from a large statewide registry was queried for all patients who underwent isolated coronary artery bypass grafting (CABG) between Oct 1, 2005 and September 30, 2015. A total of 32,694 patients were included. There was a total of 4,745 (14.5%) hospital readmissions. Seven hundred and eighty-four (16.5%) readmissions were due to infection, 680 (14.3%) due to heart failure, and 3,281 (69.2%) due to other causes. A total of 80 variables were included in the analysis. Multivariate logistic regression analysis was utilized for all-cause readmission and for cause-specific readmission (heart failure and infection). Risk factors for all-cause readmission were: Older age, female gender, ASA 4/5, low hemoglobin (<11.1 g/dL), diabetes with complications, chronic lung disease, chronic liver disease, heart failure, history of stroke, sleep apnea and earlier year of surgery. AUC was 0.6418. Risk factors for readmission for heart failure were: Older age, diabetes with complications, chronic lung disease, history of heart failure, and high glucose (>135 mg/dL). AUC was 0.7252. Risk factors for readmission for infection were: Older age, female gender, chronic lung disease, morbid obesity, high glucose (>135 mg/dL) and hypertension. AUC was 0.6292.

Conclusions:
The predictive value for readmission after isolated CABG improved when readmission for heart failure was examined, but not for infection. However, data from cause-specific models was more likely to yield clinically relevant risk factors than with all-cause readmission.
Abstract 213: Percutaneous Coronary Intervention at Centers with and without On-Site Surgical Backup: A Meta-Analysis and Meta-Regression
Authors: Buhari Olajide , Onyekwelu Chioma , Villablanca-Spineto Pedro , Kakkar Amit
Published: April 2019

Background:
Guidelines recommend that Percutaneous coronary intervention (PCI) should be performed in hospitals with onsite cardiac surgery (CS). However, emerging data suggest that there is no significant difference in clinical outcomes following primary, or elective PCI between the two groups. We performed a meta-analysis and meta-regression to assess the safety and efficacy of performing PCI in centers with, and without on-site CS.

Methods:
We conducted electronic database searches in PubMed, CENTRAL, EMBASE. The Cochrane Register, Google Scholar databases, and the scientific session abstracts were searched for eligible studies. Risk ratios and 95% confidence intervals were computed with the Mantel-Haenszel method. Fixed-effect models were used; if heterogeneity (I
2
)>25 was identified, effects were obtained with random models. Meta-regression analyses were performed to determine whether the effects of PCI without on-site CS were modulated by pre-specified study-level factors

Results:
Twenty-seven studies were included with total n=8,558,618 patients. No significant difference was observed for all-cause mortality (RR 1.02, 95% CI 0.86-1.21, p=0.82, I
2
=97.2%), cardiovascular mortality rates (RR 1.18, 95% CI 0.93-1.50, p=0.17, I
2
2.98%), myocardial infarction rates (RR 0.89, 95% CI 0.62-1.29, p=0.55, I2= 88.5%), repeat revascularization (RR 0.87, 95% CI 0.43-1.76, p=0.69, I
2
=98.8%), stroke (RR 1.28, 95% CI 0.56-2.91, p=0.55, I
2
98.8%), shock (RR 0.76, 95% CI 0.43-1.35, p=0.35, I
2
= 93.7%), mechanical circulatory support (RR 0.83, 95% CI 0.46-1.50, p=0.53, I
2
99.8%), bleeding (RR 0.88, 95% CI 0.43-1.81, p=0.73, I
2
=99.6%), and emergency CABG (RR 0.97, 95% CI 0.64-146, p= 0.87, I
2
=84.1%). In a meta-regression analysis, the effect of PCI without on-site CS, baseline clinical features did not affect the long-term all-cause mortality outcome.

Conclusion:
There was no significant difference in complications rates, and clinical outcomes for PCI performed at centers without on-site CS compared to centers with on-site CS.
Abstract 219: Health System Integration: Heart Failure Processes of Care Vary Significantly in a Large Academic Network
Authors: Dong Rachel , Domingo Jane , Saito Erica , Anderson Allen S , Davidson Charles , Montpetit Michelle , Yancy Clyde W , Mutharasan R. Kannan
Published: April 2019

Background:
As hospitals consolidate into networks, systems grapple with standardization of care delivery. As part of a comprehensive quality improvement program, our health system developed a process bundle comprising 5 interventions for hospitalized heart failure patients. We studied the baseline variation in fidelity of process delivery across our network comprising an academic medical center, tertiary community center, and community hospitals.

Methods:
Through a series of meetings and literature review, key cardiology, operational, and quality leadership from 5 hospitals developed a bundle of process interventions designed to support optimal, patient-centered care for hospitalized heart failure patients. The 5 bundle interventions were: 1) cardiology consultation, 2) heart failure education, 3) 7-day follow-up appointment with primary care or cardiology printed on discharge instructions, 4) 72-hour post-discharge telephone call placed, and 5) arrived to 7-day follow-up visit. For patients having a principal diagnosis of heart failure, systematic chart review was used to assess metric completion. One-way ANOVA on ranks was used to analyze variation of metric completion among the hospitals, and the Mann-Whitney U test with Bonferroni correction was used to compare hospital pairs.

Results:
During the 3 month study period, 780 heart failure patients across our network were discharged alive. We noted significant variation in fidelity among interventions, ranging from an 81% (634 of 780) rate of cardiology consultation, to a 36% (210 of 581) rate of 7-day follow-up with primary care or cardiology across the network. All five processes were completed in 12% (52 of 426) of patients, with 51% (217 of 426) of patients receiving 2 or 3 interventions. Furthermore, analysis by one-way ANOVA on ranks demonstrated highly statistically significant variation among the 5 hospitals within each of the 5 process bundle metrics. Pairwise comparisons demonstrated significant differences among pairs of hospitals on these metrics.

Conclusions:
This study demonstrates that in a large academic health system, significant variation exists in fidelity of care delivery for a 5 component heart failure care bundle. Future work will focus on eliminating barriers to care delivery, and understanding the impact of the process bundle on outcomes including 30-day readmissions, home days, and patient satisfaction. Opportunity exists to share best practices among hospitals to improve system-wide performance and outcomes.
Abstract 23: Patient Level Prediction Models Developed With Large Observational Databases Outperformed Existing Clinical Prediction Scores For Stratifying Bleeding Risk In Patients With Atrial Fibrillation
Authors: Blacketer Clair , Reps Jenna , Wang Lu , Li Qingqin , Bernholz Juliane , Larbi Leila , Foody JoAnne , Moore Kenneth , Hermanowski-Vosatka Anne , Peters Gary , Yuan Zhong , Ryan Patrick
Published: April 2019

Background:
Vitamin K antagonists (e.g., warfarin) and direct oral anticoagulants (DOACs; e.g., rivaroxaban, apixaban, dabigatran, edoxaban) are effective therapies for lowering the risk of thrombotic outcomes including stroke in patients with atrial fibrillation (AF). Like all anticoagulants, they are associated with an increased risk of bleeding. Several models (e.g., ATRIA, ORBIT, HAS-BLED, CHADS
2
and CHA
2
DS
2
-VASc) are available to predict the risk of major bleeding but their performance has not been widely evaluated in observational databases.

Objective:
To develop patient-level bleeding risk prediction models and evaluate their performance compared to existing clinical models of bleeding.

Methods:
Based on tools available through the Observational Health Data Science and Informatics Collaborative and Observed Medical Outcomes Partnership Common Data Model framework, we developed patient-level prediction (PLP) models to predict the risk of major bleeding events in patients with non-valvular AF who were new users of warfarin or DOACs. A LASSO regularized logistic regression technique including over 100,000 baseline covariates was performed across each of 4 US databases: IBM MarketScan
®
(Commercial (CCAE), Medicaid (MDCD), and Medicare Supplemental (MDCR)) and Optum Clinformatics
®
Extended Data Mart (Optum). We evaluated the performance of the PLP models compared with the existing models using the Area Under the Curve (AUC), with 75% training and 25% testing sets. The models were then externally validated by applying them to the other three databases.

Results:
In each database, all the PLP models achieved higher internal validity (AUCs 0.69 - 0.83) compared with the existing clinical models. The highest AUC among the existing clinical models was 0.76 for CHA
2
DS
2
-VASc run on the DOACs new user population in the CCAE database; the comparative AUC for the PLP model was 0.79. The external validation of the PLP models was somewhat lower, the lowest being the new user DOACs models learned on the MDCD database and applied to the other three databases with AUCs between 0.56 and 0.58. This is possibly in part due to differences between patients in MDCD versus other databases (e.g., age, disability, socioeconomic status). The highest performing was the new user warfarin model learned on the Optum database validated on the CCAE database with an AUC of 0.75.

Conclusion:
A patient level prediction model outperforms many existing clinical bleeding risk models currently in use.
Abstract 231: Outcome Variations Between Patients Prescribed Direct Oral Anticoagulant or Warfarin
Authors: Harden Lucas , Krallman Rachel , Feldeisen Delaney , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: April 2019

Background:
Patients with cardiovascular disease (CVD) require antithromobotic therapy to reduce risk of embolization. Direct oral anticoagulants (DOAC) were introduced to widespread clinic use in 2010. This study explores differences in demographics and outcomes (readmission, ED visit, death) between patients on a DOAC or warfarin, and the impact of attending a cardiac transitional care appointment (BRIDGE) on outcomes between groups.

Methods:
Data from patients in the BRIDGE dataset from 2010-2017 were analyzed, excluding those with an adverse event prior to their BRIDGE appointment. Demographics and outcomes of patients prescribed warfarin were compared with those prescribed a DOAC. Outcomes for each group were further compared by BRIDGE clinic attendance.

Results:
Prescribing of DOACs has linearly increased from 2010-2017. Of 666 anticoagulated patients, 22.5% (n=150) were prescribed a DOAC and 77.5% (n=516) were prescribed warfarin, for any indication. Warfarin patients had higher CHA2DS2-VASc scores and were more likely to visit the ED within 30 days than DOAC patients. DOAC patients were more likely to be readmitted within 6 months. Both warfarin and DOAC patients who attended BRIDGE were less likely to have a readmission within 6 months than patients who did not attend. DOAC patients who attended BRIDGE were also less likely to have an ED visit within 6 months than DOAC patients who did not attend. However, patients with a 30 day adverse event were more likely to have attended BRIDGE (readmission: DOAC 90%, 9/10; warfarin 73.8%, 31/42; ED: DOAC 100%, 5/5; warfarin 78.7, 37/47).

Conclusion:
Since introduction, DOAC prescription has continuously increased. Warfarin patients had higher CHA2DS2-VASc scores and higher rates of early adverse events (ED visit) than DOAC patients. DOAC patients had higher rates of late adverse events (readmission in 6 months). The differences in early and late readmissions may be partially explained by the necessity of early follow up for those prescribed warfarin at discharge. However, early readmissions overall were more likely to have attended BRIDGE. This suggests that early follow up frequently identifies anticoagulated patients in need of hospitalization, and the importance of prompt transitional care among this population.
Abstract 234: Remote Monitoring Utilization and Medicare Spending for Pacemakers and Implantable Cardioverter-Defibrillators
Authors: Holtzman Jessica N , Wadhera Rishi K , Fraiche Ariane M , Choi Eunhee , Shen Changyu , Kramer Daniel B
Published: April 2019

Background:
Remote monitoring (RM) may improve outcomes and the value of care by reducing the need for in-person visits. No study has evaluated national trends in utilization of remote and in-office interrogation services, nor associated Medicare spending.

Objective:
To assess national trends in the utilization and Medicare spending related to RM and in-office interrogations for pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs).

Methods:
Medicare carrier claims and outpatient files (2012-2015) were evaluated for the volume of remote vs in-person professional and facility claims submitted for the interrogation of PMs and ICDs. Payments were quantified by identifying line payments, which specify Medicare reimbursements/claim. As carrier claims represent a 20% national sample, volume and cost of services were multiplied accordingly to represent the entire population.

Results:
Professional RM claims increased for PMs (420,758 to 682,345) and ICDs (440,223 to 466,733) from 2012-2015. Medicare spending on RM (professional and facility combined) also increased from $45.7 million to $57.4 million annually (FIGURE). During the same period, volume and spending for in-office interrogations decreased both in absolute numbers and proportionally compared with RM. For example, the proportion of interrogations performed in-office decreased from 81.5% (1,848,825/2,269,305) to 72.5% (1,793,905/2,476,105) for PMs and from 68.6% (964,220/1,401,350) to 66.2% (913,785/1,380,390) for ICDs.

Conclusion:
Use of RM and associated Medicare spending increased from 2012-2015. Over the same period, in-office services and associated spending declined. Continued adoption of RM may further reduce the need for in-office services and associated costs.
Abstract 240: A Heart Failure Collaborative to Accelerate Improved Patient Outcomes in Three Metro Markets
Authors: Kiser Robin , Mallas-Serdynski Lynn , Tomei Jacqueline , O’Neill Kathleen , Scharnott Michelle , Bolles Michele
Published: April 2019

Background & Objectives:
Nearly 6.5 million Americans are living with heart failure (HF), the leading cause of hospitalization among adults aged 65 and older. Despite advancements in medical therapy, HF patient outcomes remain of concern. HF readmission rates remain high and only half of patients diagnosed with heart failure are expected to live beyond 5 years of diagnosis. Increasing prevalence and poor outcomes provide significant opportunities for improvement. Hospital participation in a quality initiative to improve care by promoting adherence to the scientific guidelines, measured using Get With the Guidelines®-Heart Failure (GWTG-HF), assists hospitals in effectively delivering high quality care to improve patient outcomes. The objective of this initiative is to form multidisciplinary collaboratives that will rapidly implement evidence-based guidelines, develop and share best practices to improve heart failure patient outcomes.

Methods:
The AHA will lead a quality improvement initiative for transforming heart failure care in three major metropolitan cities including Chicago, Milwaukee and St. Louis. A retrospective review was conducted using GWTG-HF on measures with low adherence from participating hospitals in the metro markets. Baseline data of specific HF measures from Quarter 1, 2018 were analyzed to determine areas of improvement needed. Using regional and 1:1 hospital meetings, AHA will lead a quality improvement initiative to transform HF patient care. The HF project will focus on professional education, enhancing systems of care and facilitating the sharing of best practices.

Measures:
The patient population will include patients from GWTG-HF with a primary diagnosis of heart failure and focus on improving 7 HF measures.

Results:
The project goal within the 2-year timeframe of this initiative is to achieve 20% improvement from baseline data OR achieve AHA’s 85% adherence threshold in each measure. AHA Quality staff will observe and monitor market-level data within GWTG-HF to uncover and recommend improvements, provide consultation to clinicians, deliver targeted training and resources such as webinars, conferences, toolkits, care pathways, educational materials and to foster best-practice sharing to address common barriers.

Limitations:
Participating hospitals vary in size, discharge volume, GWTG participation tenure, FTE support and resources. There is incomplete baseline date for the three thirty day follow up measures. Initiative implementation may vary slightly in 3 metro markets

Conclusions:
The two-year multi-city quality initiative will bring together multiple hospitals to share best practices, develop resources and analyze Get With The Guidelines data for performance improvement to accelerate heart failure patient outcomes. Further investigation is merited evaluating the effectiveness of quality collaboratives to enhance care.
Abstract 248: Redesign of Order Entry to Improve Noninvasive Cardiac Test Selection
Authors: Mahtta Dhruv , Alani Anas , Cutting William B , Kramer Joshua B , Brown Garrett H , Winchester David E
Published: April 2019

Background:
CCTA offers an exceptional negative predictive value when evaluating patients with suspected coronary disease. Many non-cardiology clinicians remain unaware of this test option and patients for which CCTA is appropriate. We hypothesized that a redesign of the noninvasive imaging ordering menu in our electronic health system, paired with didactic education, could increase ordering of CCTA.

Methods:
We designed a new ordering menu to guide noninvasive cardiac testing. A series of yes/no questions guided clinicians through a decision tree about which test modality would be best for a given patient: CCTA, myocardial perfusion scintigraphy (MPS), or exercise treadmill test (ETT). This menu change was paired with education in the form of flyers, PowerPoint-guided lectures, and question-answer sessions. We measured the volume of each test modality (CCTA, ETT, and MPS) ordered for 6 months prior and 4 months after our intervention in two-week intervals, mapped on a runchart. We compared the median number of tests for each modality before and after the intervention. We surveyed clinicians’ opinions about ordering CCTA before and after the intervention and also asked their opinions about the change in a post-intervention survey.

Results:
Before the intervention, the median numbers of CCTA, ETT, and MPS ordered per two-week interval were 8.5, 10, and 60, respectively. Post-intervention, CCTA, ETT, and MPS were ordered 14, 10, and 60 times per two-week period, respectively. We saw a 67% increase in ordering of CCTA post-intervention (p=0.001, 95% CI: 3.0-12.0) while there were no significant changes in ordering patterns for ETT or MPS. Based on the surveys, 38% of clinicians were not comfortable ordering cardiac CTA prior to our intervention which decreased to 32% of clinicians after our intervention (p=0.64). 36% of providers reported that they liked the new ordering menu, while 52% were neutral, and 12% of providers expressed their dislike.

Conclusion:
A simple change in the ordering menu for noninvasive cardiology testing resulted in a substantial increase in CCTA ordering. A large majority of clinicians felt either neutral or positive towards the changes. We did not observe an offsetting decrease in other test modality ordering raising the question as to whether clinicians changed their test choice or increased the amount of testing being performed.
Abstract 253: Talk to Me About Your Medication Nonadherence: Stories from Older Adults with Heart Failure
Authors: Meraz Rebecca
Published: April 2019

Background:
More than half of all heart failure (HF) patients do not take medications as prescribed, resulting in substantial negative health outcomes. Research has shown that medication adherence may be more a consequence of individual decisions rather than the ability to follow prescribed regimens, yet very little is known about older adults’ decision-making regarding nonadherence to medications for HF.

Objective:
The purpose of this study was to gain understanding and insight into older adults’ decision-making experiences and perceptions in choosing not to take HF medications as prescribed in the community setting.

Methods:
Using a narrative inquiry approach, the personal narratives of eleven adults aged 65 and older who took at least two daily medications for HF were gathered using in-depth, semi-structured interviews. The data in this study were organized and analyzed using Riessman’s framework for narrative analysis.

Results:
This study suggests that medication nonadherence in older adults with HF is primarily attributed to intentional decisions, based on personal values, to deviate from the prescribed regimen. Although participants made decisions to take selected medications differently than prescribed, they did not perceive themselves to be nonadherent. Participants perceived their decisions for medication nonadherence as logical and necessary to maintain their health. None of the participants discussed their medication-taking decisions with their practitioner and described consulting resources, such as the Internet, for medication information.

Conclusions:
Assessments should aim to understand actual medication-taking routines and patient preferences. The development of interventions that utilize resources that are readily accessible to patients may promote decisions for medication adherence.
Abstract 26: The Corrie Myocardial infarction, COmbined-device, Recovery Enhancement (MiCORE) Study: 30-Day Readmission Rates and Cost-Effectiveness of a Novel Digital Health Intervention for Acute Myocardial Infarction Patients
Authors: Marvel Francoise A , Spaulding Erin M , Lee Matthias , Yang William , Martin Seth S
Published: April 2019

Purpose:
Determine if acute myocardial infarction (AMI) patients using a novel digital health intervention, the Corrie Health Digital Platform (Corrie), have reduced 30-day hospital readmissions and related healthcare costs compared to a historical comparison group.

Methods:
Corrie is deployed to patients admitted to Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Massachusetts General Hospital, and Reading Hospital for an AMI (STEMI or type 1 NSTEMI), as early as possible during their hospitalization in the inpatient cardiac units. AMI patients are enrolled if they are: over 18 years old; English-speaking; without auditory, visual, cognitive, or physical impairment; and own a smartphone. Corrie is deployed to patients using a standard operating procedure and consists of the following: (1) a smartphone medication, education, vitals, and follow-up appointments self-management app, (2) smartwatch for reminders and heart rate and physical activity tracking, and (3) a Bluetooth-enabled blood pressure cuff. Patients are either enrolled with their personal iPhone or a loaner iPhone, if they own any other type of smartphone, and a loaner smartwatch for usage during the 30 day study period. The historical comparison group consists of AMI patients, admitted at the same hospitals from October 1
st
2015-2016, who did not receive Corrie. All-cause readmission rates will be evaluated at 30 days after discharge in both groups and Cox proportional hazard models will be used to test differences in time to all-cause first readmission within 30 days between groups, controlling for covariates. To assess cost-effectiveness of Corrie, a Markov Model of cost-effectiveness will be built, based on 30-day readmission rates, to assess the Incremental Cost-Effectiveness Ratio of adopting Corrie.

Results/Conclusions:
The MiCORE study is being completed and results will be available for AHA QCOR by April 2019.