bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P37: Evidence of Impaired Vascular Reactivity Following Dust Exposure in Participants in the World Trade Center Medical Monitoring and Treatment Program
Authors: Sawit Simonette T , McLaughlin Mary Ann , Garcia Alvarez Ana , Kazi Fahima Dewan , Maceda Cynara , Moline Jacqueline
Published: July 2021

INTRODUCTION:
Exposure to particulate matter (PM) has been investigated as an additional risk factor for cardiovascular disease (CVD). It is likely that different mechanisms, including vascular dysfunction, are responsible for acute and chronic toxic effects. In participants of the Law Enforcement Cardiovascular Screening Program (LECS), a subset of the WTC Medical Monitoring and Treatment Program, we look to characterize the relationship between PM exposure and vascular reactivity (surrogate for endothelial function), as measured by peripheral arterial tonometry (PAT).

METHODS:
PAT, a system comprised of a finger probe to assess digital volume changes accompanying pulse waves, was used. Digital pulse volume changes during reactive hyperemia was assessed in 60 patients with either high (n=33) or low (n=27) PM exposure. PAT index, a measure of reactive hyperemia, was calculated as the ratio of the digital pulse volume during reactive hyperemia divided by that at baseline. All data were prospectively obtained. We define highest inhaled PM exposure as occurring on 9/11/2001, and lower inhaled PM exposure as occurring on or after 9/13/2001. A PAT index of 1.67 or less was considered to represent abnormal vascular reactivity.

RESULTS:
Mean age was 49 years (range 45-53), 83% were male. There were no significant differences in baseline characteristics, including CVD risk factors. Median PAT was 1.87 (1.30-2.75) for subjects with lower exposure and 1.68 (1.15-3.22) for subjects with highest exposure to PM. Of subjects with highest exposure to PM, 68% (17/33) had a PAT index 1.67 or less, compared with 32% (8/27), of subjects with lower exposure (p value=0.17). The odds of having abnormal PAT index to normal PAT index was 2.1 times higher in subjects with highest exposure compared to those with lower exposure to PM (95%CI 0.7-6.2).

CONCLUSION:
We observe a trend correlating highest WTC inhaled PM exposure with abnormal vascular reactivity as measured by peripheral arterial tonometry index of 1.67 or less. The clinical impact of this finding, in this pilot study, requires further investigation.
Abstract P39: Bridging the Discharge Gap Effectively (BRIDGE)
Authors: Bumpus Sherry , Kline-Rogers Eva , Smith Cydni , Carvalhal-Tracy Andrea , Montgomery Daniel , Norville Janice , Kosteva Adam , Gakenheimer Lindsey , Stahlbaum Danielle , Gavin Jordan , Froehlich James B , Eagle Kim A , Rubenfire Melvyn
Published: July 2021

Background:
The transition from hospital-to-home is challenging for many cardiac patients (pts) in the era of shortening length of stay. Early follow up after discharge(d/c) may help reduce ED visits and readmissions. BRIDGE is a nurse practitioner based transitional care model that aims to schedule pts within 14 days of d/c and provide appropriate guideline-based care with the oversight of a cardiologist. Preliminary data has shown this model to be effective. We describe demographic and clinical differences between pts who did/did not attend BRIDGE, and describe interventions.

Methods:
Retrospective data was abstracted for all pts referred to BRIDGE Jun ‘08 to Aug ’09. Data collected: demographics, disease conditions, additional care during BRIDGE, medications, events within 6 months post d/c.

Results:
Of 407 pts referred to BRIDGE, 284 (69.8%) attended; with no significant demographic or clinical differences between attendees and nonattendees (except Afib pts). Of attendees, 97 (34.2%) received additional education on disease process, symptoms, and/or when to go to ED. Detailed diet/physical activity counseling was provided to 60 (21.1%) and 72 (25.4%) pts. Diagnostics were scheduled for 19 (6.7%); 65 (22.9%) required referrals for other services; serious medication issues addressed for 43 (15.1%) pts.

Conclusion:
The BRIDGE model is an attractive concept in transitional care with success in reducing ED visits and readmissions. Demographic and clinical characteristics do not provide rationale for a patient’s decision to attend. Our data suggest that most patients require early post-d/c education, medication counseling, and referrals beyond what was received at d/c.
Abstract P43: Frequency and Predictors of Low-Density Lipoprotein Cholesterol Control and Appropriate Response to Elevated LDL-C Levels in Patients with Cardiovascular Disease
Authors: Virani Salim S , Woodard Lechauncy D , Sookanan Supicha , Landrum Cassie R , Urech Tracy H , Wang Degang , Murawsky Jeffrey , Ballantyne Christie M , Petersen Laura A
Published: July 2021

Background:
Although current cholesterol performance measures define good quality as low density lipoprotein cholesterol (LDL-C) levels < 100mg/dl in cardiovascular disease (CVD) patients, they provide a snap shot at one time point and do not inform whether an appropriate action was taken to manage elevated LDL-C levels. We assessed frequency and predictors of this appropriate response (AR).

Methods:
We used administrative data to assess 22,902 CVD patients receiving care in a Veterans Affairs network of 7 hospitals and affiliated clinics. We determined the proportion of CVD patients at LDL-C goal <100 mg/dl, and the proportion of patients with uncontrolled LDL-C levels (>100 mg/dl) who had an AR [defined as the initiation or dosage increase of a lipid lowering medication (LLM), addition of a new LLM, receipt of maximum dosage or >1 LLM, or LDL-C reading <100 mg/dl] at 45 days follow-up. Logistic regression was performed to evaluate facility, provider and patient characteristics associated with AR.

Results:
LDL-C levels were at goal in 16,350 (71.4%) patients. An additional 2,110 (9.2%) had an AR at 45 days of follow-up. Controlling for clustering between facilities and patient's illness severity, history of diabetes (OR 1.18, 95% CI 1.03-1.35), hypertension (OR 1.21, 95% CI 1.02-1.44), patients showing good medication adherence (medication possession ratio > 0.8) [OR 2.29, 95% CI 1.99-2.64] were associated with AR. Older CVD patients (age >75 years) were less likely to receive AR (OR 0.60, 95% CI 0.52-0.70). Teaching vs. non-teaching facility (p=0.40), physician vs. non-physician provider (p=0.14), specialist vs. non-specialist primary care provider (p=0.12), and patient's race (p=0.12) were not predictors of AR.

Conclusion:
Among patients with CVD and LDL-C above guideline recommended levels, only one-third receive AR. Diabetic and hypertensive CVD patients are more likely to receive AR, whereas older Veterans with CVD receive AR less often likely reflecting providers' belief of lack of efficacy from treatment intensification in older CVD patients. Our findings are important for quality improvement and policy making initiatives as they provide more actionable information compared with isolated LDL-C goal attainment as a quality indicator.
Abstract P58: Anxiety Burden from Cardioverter Defibrillators
Authors: Magyar-Russell Gina , Tomaselli Gordon
Published: July 2021

This ongoing study identifies the prevalence of specific anxiety disorders and the clinical and self-reported functional effects of these disorders in a large sample of Implantable Cardioverter Defibrillator (ICD) recipients. To date, 143 recipients of ICDs were evaluated using the
Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID)
to establish past and current anxiety disorder diagnoses. These data represent the largest sample of ICD recipients assessed using a structured clinical interview, the gold standard in psychiatric assessment. Self-report questionnaires were also administered to assess anxiety, depression, device-related appraisals, and functional impairment in work, social, and family life.

Participants were 73% White, 80% male, 70% married and 27% currently working with a mean age of 64 (±11.5) years. Seventy shocked and 73 non-shocked ICD recipients were interviewed. History of an anxiety disorder was common. The greatest lifetime prevalence rates were for anxiety disorder due to general medical condition (GMC; 30%) and panic disorder (30%). The most common current anxiety disorders were anxiety disorder due to GMC (24%), generalized anxiety disorder (18%) and panic disorder (14%).

Shocked participants were more likely to receive lifetime diagnoses of anxiety disorder due to GMC (
t
= −2.21, p<.05) and posttraumatic stress disorder (
t
= −2.32, p<.05), as well as current diagnoses of panic disorder (
t
= −2.23, p<.05) and anxiety due to GMC (
t
= −2.42, p<.05). Shocked participants also reported greater worry related to thoughts of receiving a shock (
t
= −4.17, p<.01) and were more likely to report disability and impairment in their work (
t
= −3.02, p<.01), social (
t
= −3.38, p<.001), and family life (
t
= −2.72, p<.01) in comparison to their non-shocked counterparts. No significant differences were found in self-reported symptoms of anxiety or depression between shocked and non-shocked participants.

Findings characterize the extent, nature, and impact of clinical levels of anxiety among ICD recipients, including differences among shocked versus non-shocked individuals. Clinical applications and the development of appropriately tailored interventions will be discussed.
Abstract P64: Right Ventricular Outflow Septal Pacing as Cardiac Resynchronization Therapy in Patients with Right Bundle-Branch Block: Results in 62 Patients
Authors: Schrumpf Phillip E , Giudici Michael , Paul Deborah , Krupa Roselyn , Meirbachtol Cynthia
Published: July 2021

Background:
Cardiac resynchronization therapy has been shown to improve left ventricular performance in patients with left ventricular dysfunction and a left-sided interventricular conduction delay. This is performed by placing a pacing lead on the lateral left ventricular wall to stimulate the area normally stimulated by the left bundle branch. In patients with right bundle branch block (RBBB), pacing the right bundle branch could also result in resynchronization. Previous studies have shown that right ventricular outflow septal (RVOS) pacing does, in fact, utilize the native conduction system.

Methods:
62 consecutive patients, 46 male/16 female, aged 75 +/− 10.5 yr, with RBBB and indications for pacing, underwent RVOS lead placement using commercially available pacing systems. The patients subsequently underwent bedside A-V optimization to achieve the narrowest QRS duration and most “normal” QRS complex. Echocardiography was performed to evaluate changes in wall motion comparing baseline with optimal pacing.

Results:
Baseline mean QRS duration 146 +/− 20.9 ms Optimized mean QRS duration 111 +/− 20.5 ms Average decrease in QRS duration -35 +/− 21.5 ms p < 0.001 Echocardiography demonstrated improvement in septal contraction abnormalities.

Conclusions:
1) RVOS pacing in RBBB patients can significantly narrow the QRS complex on ECG. 2) Septal contraction abnormalities due to RBBB can be improved with RVOS pacing and optimal A-V timing. 3) Further studies are warranted to evaluate this therapy in a heart failure population.
Abstract P70: Analysis of Downstream Encounter Data Drives Quality Interventions for Acute Coronary Syndrome
Authors: Jackson E B , Fortenberry Tiercy K , Delvalle Melanie K , Frye-Anderson Amy , Ervin Thomas E , Cunningham Brittany L , Steaban Robin , Boord Jeffrey , Starmer John M
Published: July 2021

Background:
Understanding resource utilization is crucial to improving care quality in Acute Coronary Syndrome (ACS). We reviewed 6-month downstream encounters following an admission for ACS including hospitalization, emergency room visits, clinic visits and rehabilitation.

Methods:
Downstream encounter and cost data for 6 months following ACS admission to Vanderbilt University Medical Center (VUMC) were evaluated. The data set included 7,668 encounters from 2,196 unique patients for period 7/1/08-6/30/10. Analysis was stratified by patient drive time from home to VUMC, treatment pathway (surgery vs. percutaneous intervention) and encounter type. Unrelated encounters were excluded; analysis was limited to encounters at VUMC.

Outcomes:
We found 29% (1,522 of 5,318) of 6-month downstream encounters occurred within 4 weeks post-discharge, accounting for 35% of costs. Limiting data to readmissions only, 39% (255 of 661) of encounters, totaling 41% of costs, occurred during this 4-week period (
Figure
). Patients with shorter drive time had higher downstream utilization, with average 3.34 visits within 6 months for patients living ≤50 minutes from VUMC, versus 1.86 for patients living >50 minutes away. Emergency room encounters for patients ≤50 minutes away were also greater (average 0.51 versus 0.23 for patients >50 minutes).

Conclusion:
Analysis suggests that interventions targeting downstream encounters within the first 4 weeks of discharge for ACS will have greater effects on cost and quality, and those interventions should also be tailored based on patient drive time. Review of available encounter data can help direct resources to quality interventions.
Abstract P80: Lack of English Comprehension is Associated with Delays in Hospital Presentation in Patients with ST-Segment Elevation Myocardial Infarction
Authors: Eslava Dayana J , Cordova Juan P , Korniyenko Aleksandr , Nadkarni Girish N , Alviar Carlos L , Romero Jorge E , Chorzempa Amy , Fridman Vladimir , Wysoczanski Mariusz , Cianci Christopher , Kearney Kathleen , Kantrowitz Niki , Fox John , Hong Mun , Tamis-Holland Jacqueline E
Published: July 2021

Background:
Prior studies have demonstrated an association between ethnicity and symptom onset to presentation time (S2PT) among patients presenting with ST elevation MI (STEMI) in the USA, with a shorter S2PT among Caucasians when compared with other ethnicities. However, little is known regarding whether or not a patient's ability to comprehend English impacts the S2PT.

Methods:
Consecutive patients presenting to 4 hospitals in NYC with STEMI referred for primary angioplasty were included in the analysis. S2PT was recorded on the day of the infarct based on the patient's account of the onset of symptoms. We assessed a patient's ability to comprehend English through telephone interviews conducted during routine follow-up.

Results:
Among 210 patients, 83.8% (176 of 210) had either some English comprehension or were fluent in English (E) and 16.2% (34 of 210) reported no English comprehension (non-E). Of the non-E patients, 65% (22 of 34) spoke Spanish, 6% (2 of 34) spoke Russian, 6% (2 of 34) spoke Chinese and 23% (8 of 34) spoke another language. The baseline variables and mean S2PT are depicted in the table. Non-E patients had a significantly higher S2PT compared to E patients even after adjusting for differences in baseline variables. Increased odds were also observed among non-E patients with a longer S2PT (adjusted odds ratio for S2PT > 120 minutes 2.17; 95% CI 01.03-4.54; p=0.04). This association remained constant even after adjusting for confounders like age, sex, ethnicity, level of education and comorbidities (diabetes, previous history of MI and PCI).

Conclusions:
S2PT is strongly influenced by a patient's ability to comprehend English. This information emphasizes the need for more aggressive “multi-lingual” educational outreach and the use of multi-lingual emergency lines in an effort to decrease total ischemic time during STEMI.

English Comprehension Fair or Good (N=176)
No English Comprehension (N=34)
P

Age Mean (SD)
62 (14.2)
65 (11)
0.22

Male sex n (%)
129 (73)
26 (76)
0.70

Diabetes n (%)
25 (14)
9 (27)
0.09

Hypertension n (%)
107 (66)
20 (62.5)
0.70

Prior MI n (%)
21 (12)
2 (6)
0.284

Prior PCI or CABG n (%)
12 (6.8)
2 (6)
0.960

Education: n (%)
40 (23)
12 (35)
0.09

Less than HS
62 (35)
8 (23)

HS Diploma
8 (4)
0 (0)

College Diploma Unknown
66 (38)
14 (42)

Mean S2P time (SD)
225 (315)
387 (820.6)
0.05

S2P time > 120 minutes n (%)
70 (40)
20 (62.5)
0.04
Abstract P86: Predicting Mean Pulmonary Arterial Pressure Using Systemic Arterial Pressure (SPAP)
Authors: Steckelberg Rachel C , Sorajja Paul , Nishimura Rick , Ommen Steven
Published: July 2021

Background:
The assessment of pulmonary pressure is elementary in the management of patients with pulmonary hypertension. Presently, pulmonary artery systolic pressure (PASP) can be reliably estimated using non-invasive means, but mean pulmonary pressure (MPAP) cannot be derived. The aim of this study was to derive a formula to non-invasively predict MPAP from PASP.

Methods:
Invasive hemodynamic pressures at steady state were examined in 198 consecutive patients who underwent right heart catheterization in the Mayo Clinic (Rochester, MN). Simple regression techniques were used to determine the relationship between MPAP and PASP separately for derivation and validation samples. Bland-Altman analysis was performed to examine predicted vs. observed MPAP values.

Results:
Over a wide range of MPAP (10 to 80 mmHg), MPAP and SPAP were strongly related (r2=0.89, n=198). The relation of MPAP to PASP in the derivation sample (n=100; MPAP=0.6133*SPAP + 1.1; r2=0.90) was validated in the test sample with an r2 value of 0.91 for predicted versus observed MPAP (p=x). The relation of predicted vs. observed MPAP values was significant across different degrees of pressure elevation, as well as different etiologies of pulmonary hypertension.

Conclusion:
MPAP can be accurately predicted from SPAP over a wide pressure range and among different etiologies for pulmonary hypertension. This relation may help to define MPAP non-invasively and assist in the clinical management of patients with pulmonary hypertension.
Abstract 125: Is In-hospital Mortality in ST-elevation Myocardial Infarction Associated With Core Measure Compliance?
Authors: Rennyson Stephen L , Kontos Michael C , Chen Anita Y , Alexander Karen P , Roe Matthew T , Peterson Eric D
Published: July 2021

Introduction:
The Center for Medicare and Medicaid Services (CMS) publicly reports mortality as well as 8 established core measures for patients (pts) with acute myocardial infarction (AMI) in an effort to measure and improve hospital performance. Our goal was to determine if compliance with CMS measures among PCI centers correlates with in-hospital STEMI mortality.

Methods:
We studied 96,340 consecutive STEMI pts from 349 PCI capable sites from the National Cardiovascular Data Registry’s ACTION Registry from 1/07-3/11. Hospitals were separated into groups by observed risk-adjusted in-hospital mortality: low (20%), middle (60%), and high mortality (20%). For each grouping, the proportional adherence to AMI core measures were reported, along with medians and inter-quartile ranges (IQR) for the composite 7 core measure score. Spearman correlations were calculated between core measures and risk adjusted mortality.

Results:
Low mortality hospitals had a median and IQR mortality of 3.5% (3.0, 3.9%), vs 5.9% (5.2, 6.6%) and 9.0% (8.3, 10.4%) for the middle and high mortality hospitals. Differences in the rate of individual and composite CMS core measure adherence were significantly different across most of the measures among the 3 hospital groups, although these differences were clinically small (Table). Most individual core measures and the composite scores were significantly correlated with mortality, although the associations were weak.

Conclusion:
Despite a high adherence to CMS core measures for STEMI patients there is only a weak correlation with risk adjusted in-hospital mortality. Thus, these core measures may not accurately differentiate quality of hospital care.
Abstract 130: Revascularization Rates Have Decreased for Commercially-Insured Adults in Michigan, 2006-2010
Authors: Song Ji Y , Schlemmer Erin , Wasilevich Elizabeth A
Published: July 2021

Introduction:
Recently published trend studies of Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in the U.S. have used primarily Medicare data, and most focus on inpatient claims. These studies have observed a decrease in CABG, with steady or declining PCI from 2001-2009. Little is known about trends in revascularization among a non-Medicare population. This study aims to understand recent trends in rates of coronary revascularization among a commercially-insured non-Medicare population, using both inpatient and outpatient claims data. The study will describe potential areas of focus for an incentive program to engage primary care physicians (PCPs) and cardiologists.

Methods:
The study population (median 1,920,169 persons/month) included members of Blue Cross Blue Shield of Michigan aged 18-64 and residing in Michigan. Using inpatient and outpatient administrative claims data, monthly crude and sex- and age-adjusted PCI and CABG utilization rates (per 1,000 member-months) were calculated from January 1, 2006 to December 31, 2010. Trend was assessed using Spearman's Rank Correlation test. The Wilcoxon Rank Sum test was used to compare the median age for those receiving PCI and CABG services. The Pearson Chi-Square test was used to assess differences in the distribution of demographic factors by procedure type and by year (2006 vs. 2010).

Results:
The overall annual crude rate of PCI decreased by 23.5% over the study period, from 0.319 in 2006 to 0.244 in 2010; there was a greater decrease for women than men (25.2% vs 21.4%). Annual CABG rates decreased by 30.7%, from 0.077 in 2006 to 0.053 in 2010 (women: 31.1%; men: 29.1%). Compared to men, PCI accounted for a higher proportion of revascularization procedures among women (82.1% vs 79.0%,
p
<0.01). The median age for those having a PCI was lower than for those having a CABG (57 vs. 59 years;
p
<0.01). There was a significant association between type of revascularization and age group (
p
<0.01). The majority of procedures were performed in older adults aged 55-64 (CABG: 72.3%, PCI: 62.9%).

Conclusions:
Both PCI and CABG rates have decreased from 2006 to 2010 for a commercially-insured population in Michigan. Persons receiving CABG were generally older than those receiving PCI. Future studies will examine time trends by type of PCI and explore potential factors contributing to the observed decrease in revascularization rates. The current findings may be used to encourage increased discussions between PCPs and cardiologists about the care of shared patients.
Abstract 140: Majority of High-Risk Cardiovascular Device Studies Do Not Include Comparative Efficacy Data at the Time of FDA Approval
Authors: Chen Connie E , Redberg Rita F , Dhruva Sanket S
Published: July 2021

Introduction
Comparative effectiveness data is important in informing regulatory and treatment decisions with information on the clinical significance of the measured outcomes. There is increasing utilization and significance of cardiovascular devices in the United States, thus it is important to know the comparative efficacy of novel cardiovascular devices at the time they receive Food and Drug Administration (FDA) approval.

Hypothesis
We assessed the hypothesis that clinical trials results submitted to the FDA for approval of novel, high-risk cardiovascular devices often provide comparative efficacy data.

Methods
Comparative efficacy was defined as the presence of an active control. For all high-risk cardiovascular devices approved by the FDA from 2000 through 2011, we extracted information on comparative efficacy data from Summaries of Safety and Effectiveness Data (Summary) which include study data used to justify FDA approval. All identified studies were examined to determine if they relied upon active controls, historical controls, objective performance criteria, or if they had no control. The proportion of studies containing comparative efficacy data was calculated and cross-tabulated by approval year and device class. A multivariate logistic model was used to assess trends over time and the Kruskal-Wallis test was used to examine differences between device sub-types.

Results
We examined 114 Summaries which contained 340 cardiovascular device studies. Of these studies, 140 (41%) contained an active control. Historical controls 48 (14%) and objective performance 83 (24%) criteria were commonly used. Sixty-nine (20%) of the studies were single-arm studies without controls. In our Summary-level analysis, 74 (65%) devices had an active control in at least one supporting study. Approval year was not significantly associated with type of control arm after controlling for device type in our multivariate logistic analysis. Use of comparative efficacy data was significantly associated with device type. Use ranged from 15/19 (79%) of hemostasis devices to 0/3 (0%) of ventricular assist devices.

Conclusions
A minority of studies for the highest risk cardiovascular devices approved by the FDA since 2000 included comparative efficacy data through the use of an active comparator arm. Increasing use of active controls would help to better inform regulatory and treatment decisions at the point of FDA approval.
Abstract 144A: Finding High-Value Healthcare in Acute Myocardial Infarction
Authors: Borden William B , Dennison Thomas H , Freund Deborah A , Marier Allison , Cook Kevin , Mushlin Alvin I
Published: July 2021

Background:
Given the rising costs of medical care in the US, efforts at improving quality of care seek also to control expenditures with high-value healthcare - better quality and lower cost. Prior studies have used variations in Medicare reimbursements at the regional level, rather than individual hospital costs, to account for the unique patient case-mix of individual hospitals. To date, higher expenditures have been unrelated to clinical outcomes. We sought to explore variation using costs, rather than payment, and to study the links between inpatient hospital Medicare expenditures, hospital costs, and Medicare's quality indicators.

Methods:
In New York State, we analyzed hospital discharges in 2008 for acute myocardial infarction (AMI) in the New York State Planning and Resource Cooperative System (SPARCS) database. Using SPARCS reported hospital charges and the Medicare cost-to-charge ratio we calculated, at the individual hospital level, the total costs and departmental-level ancillary costs (costs of specific hospital services) for patients discharged with a primary diagnosis of AMI. We compared total inpatient cost to Dartmouth Atlas of Health Care Medicare inpatient reimbursements, analyzed variation in ancillary costs by hospital cardiac program peer groups (based on highest-level capability), and related total costs to Medicare AMI quality scores.

Results:
The study analyzed data that represented 56,000 AMI cases in 150 hospitals. When comparing total costs to Medicare inpatient reimbursements, there was high correlation with an R-squared of 0.84. The mean ancillary costs per AMI discharge were $12,006 [standard deviation (SD) $4,301, coefficient of variation (COV) 0.358] for cardiac surgery-capable, $6,452 [SD $1,732, COV 0.268] for percutaneous coronary intervention-capable, $5,104 [SD $2,548, COV 0.499] for diagnostic catheterization-capable, and $4,167 [SD $2,756, COV 0.661] for non-invasive hospitals. There was no overall correlation between AMI total costs and Medicare composite AMI quality scores, yet 19.7% (28 out of 142 hospitals with AMI quality score reporting in 2008) of hospitals had above average quality scores, with lower than average total costs.

Conclusions:
In AMI hospitalizations, regional Medicare reimbursements have a strong correlation with total hospital costs. Hospitals vary greatly in their costs of caring for AMI patients. Though there is no overall association between the level of costs and performance on standardized quality scores, high-value healthcare in AMI does exist with numerous high-quality, low-cost hospitals. Examining the expenditures of these hospitals may be useful in identifying patterns of quality and cost-effective patient care. These findings support that high-spending is not necessary for high-quality, and that high-value healthcare can be realized.
Abstract 147: Weighted Insurance Reimbursement Strategies For Cardiac Imaging Based On Appropriateness Criteria
Authors: Christian Timothy F , Rakover Jeff
Published: July 2021

Rising use of medical imaging has been a major driver in escalating health care costs. As reimbursement for imaging has declined, it is likely that some effort to expand volume into lower risk populations has occurred. Consequently, insurance payouts based on pre-test likelihood of disease can be restructured to promote effective use in intermediate risk populations where uncertainty about disease presence is highest (50%).

Objective:
to analyze the incidence of normal result imaging over 5 years and to construct insurance payout schemes that will result in a net reduction in cost while simultaneously promoting the effective use of imaging.

Methods
.This is a retrospective study of patients (pts) who underwent stress nuclear perfusion scans to detect coronary artery disease (CAD). The study is in 2 parts. Part 1: Specific years were randomly sampled: 2006 (n=2894), 2008 (n= 2843) and 2010 (n=2550) as to whether results were normal or had some abnormality in perfusion suggesting CAD. Part 2: The years 2010 and 2011 (n=2486) were then combined to fit different models of reimbursement based on the pre-test likelihood of CAD. All patients without known CAD referred for imaging were included. A risk score derived from combination of clinical risk factors known to be associated with CAD and available to all clinicians was calculated for each patient. This score was further weighted by the resting ECG status and the presence or absence of symptoms. Three appropriateness classifications were assigned based on this score (1=inappropriate (1-10% risk),2=probably appropriate (10-40% risk and more than 60%) and 3= appropriate (40-60% risk) derived from a national expert panel of physicians. The cost of imaging was set at $2000, which is an approximate national median charge

Results:
There was a significant increase in the incidence of normal imaging results with time: 2006=66%, 2008=69%, 2010=76%, p<0.0001). The median pretest risk score for CAD in the test cohort (n=2486) was 13.5% with 43% of pts tested having a risk score of <10%. Applying a weighted reimbursement scheme such that class 1 received 75% of payment, class 2=full payment and class 3=125% of payment, the following payout structure is generated(see table): The total cost of imaging the group without weighting was $5.0 million. Consequently, weighted reimbursement produced a 9% savings.

Conclusion:
This approach, based on established pretest criteria, is highly flexible and produces immediate savings. More importantly, it provides incentive to reshape ordering behavior in the future but may need to be complemented with tort reform.
Abstract 160: Paradoxical Effect of Smoking on Mortality in the patients Admitted with Acute Ischemic Stroke
Authors: Ali Syed F , Schwamm Lee H
Published: July 2021

Introduction:
Compared to those who never smoked, a paradoxical effect of smoking on reducing mortality in patients admitted with myocardial ischemia has been reported. We sought to determine if this effect was present in patients hospitalized with ischemic stroke.

Methods:
Using the local Get with the Guidelines-Stroke registry, we analyzed 4,305 consecutively admitted ischemic stroke patients (Mar 2002-Dec 2011). The sample was divided into smokers vs. ex or non-smokers. The main outcome of interest was the overall inpatient mortality. Multivariable analysis included factors significant at p<0.05 in univariate analysis.

Results:
Compared to non-smokers, tobacco smokers were younger, more frequently male and presented with fewer stroke risk factors such as hypertension, hyperlipidemia, diabetes, coronary artery disease and atrial fibrillation. Smokers also had a lower median NIHSS and fewer received tPA. Patients in both groups had similar adherence to early antithrombotics, dysphagia screening prior to oral intake and DVT prophylaxis (Table 1). Smoking was associated with lower all cause in-hospital mortality (6.6% vs. 12.4%; unadjusted OR 0.46; CI [0.34 - 0.63]; p < 0.05). In multivariable analysis, adjusted for age, gender, ethnicity, HTN, DM, HL, CAD, A.fib, NIHSS and tPA at an outside hospital, smoking remained independently associated with lower mortality (adjusted OR 0.66; CI [0.44-0.98]; p < 0.05). (Table 2)

Conclusion:
Similar to myocardial ischemia, smoking was independently associated with lower mortality in acute ischemic stroke. This effect may be due to tobacco induced changes in cerebrovascular resting tone or vasoreactivity, or may be due in part to residual confounding (e.g., differences in predicted outcome from stroke subtypes, or wishes regarding life sustaining therapies). Larger, multicenter studies are needed to confirm the finding and determine the role of in hospital complications and the effect on 30 day and 1 year mortality.
Abstract 168: Assessing The Utility Of The Modified Rankin Scale (mRS) At Discharge To Predict Day 90 Outcomes In Acute Stroke Registries
Authors: Thompson Michael P , Reeves Mat
Published: July 2021

Objective:
The modified Rankin Scale (mRS) is a commonly used measure of functional stroke recovery, which is typically measured at 30 or 90 days post event. Given the difficulty of follow-up, most hospital-based stroke registries are usually limited to assessments at discharge. Studies have shown that mRS assessed 30 days post-stroke is a sufficient proxy for 90 day mRS, but little research has explored the utility of mRS assessment at discharge. The objective of this study was to assess the utility of mRS at discharge in predicting 90 day stroke outcomes.

Methods:
Data were obtained from a follow-up study of 373 acute stroke discharges from a statewide hospital-based acute stroke registry. Discharge mRS was obtained by chart review and 90 day outcomes data measured by the Barthel Index (BI) were obtained by phone. BI data were converted to 3 mRS levels: 0-2 (low to no), 3 (moderate), and 4-5 (severe) using validated methods. Weighted kappa was used to assess agreement between discharge and 90 day mRS. Logistic regression was used to assess the independent association between discharge mRS and disability at 90 days (defined as mRS 3-5 vs. 0-2).

Results:
Average age of the patients was 65 years, 56% were female, 28% were non-white, 74% had ischemic stroke, 14% had TIA, and 12% had hemorrhagic stroke. Distribution of mRS scores for 261 patients who completed the 90 day follow up is shown in Figure 1. The weighted kappa between discharge and 90 day mRS was 0.28 (95% CI 0.18, 0.38), indicating only fair agreement. After adjustment, those with moderate (3) or severe disability (4-5) at discharge were 2.49 (1.13, 5.54) and 2.55 (1.17-5.79) times more likely to have moderate to severe disability (3-5) at 90 days. (Table 1)

Conclusion:
Although discharge mRS was a strong independent predictor of disability at 90 days, the modest agreement between discharge and 90 day mRS indicate that it is not a sufficient proxy for 90 day outcomes. Further research is needed to identify predictors of stroke recovery based on assessments at hospital discharge.
Abstract 177: National Trends in Inpatient Stroke Quality: VHA Experience
Authors: Williams Linda S , Damush Teresa , Slavin James , Yu Zhangsheng , Sager Danielle , Myers Jennifer , Daggett Virginia , Bravata Dawn M
Published: July 2021

Objectives:
In 2009, the VHA reported inpatient stroke quality indicators based on chart abstractions of fiscal year (FY) 2007 data at all VA medical centers (VAMCs). Prior to a randomized trial of a Systems Redesign-based intervention, we re-measured VA stroke quality indicators (QIs) from 2009 data in 11 of the largest volume VAMCs. The purpose of this analysis is to examine whether any significant changes occurred in inpatient stroke care in these sites between 2007 and 2009.

Methods:
Data for 10 Joint Commission (JC) inpatient stroke QIs were obtained by experienced external VA chart abstractors via review of FY 2007 electronic medical records. We abstracted 2009 data at 11 sites as baseline data for a quality improvement randomized study. We calculated eligibility and passing rates for ten inpatient stroke QIs defined similarly to the 10 JC indicators from the FY 2007 study. We compared patient demographics, clinical variables, and passing rates for each QI between the FY 2007 and CY 2009 data at the 11 sites using Student’s t-test and Chi-square tests.

Results:
Comparing 2007 (N =750) to 2009 (N =817) data, mean age (66.3, 66.6), % male (97%, 96%), and % Black (34%, 33%) were similar but mean NIH Stroke Scale score was increased in 2009 (4.2, 5.9, p < 0.001). Three QIs were unchanged over time: DVT prophylaxis, anticoagulation for atrial fibrillation, and antithrombotic at discharge (Table). Performance on four indicators was significantly improved: dysphagia screening (16%, 45%), receipt of rehabilitation consultation (62%, 89%), stroke education (17%, 31%), and receipt of tPA (17%, 47%). Performance on three indicators was significantly reduced: antithrombotic by hospital day two (98%, 87%), cholesterol lowering medication at discharge (90%, 72%), and receipt of smoking cessation counseling (100%, 89%).

Conclusions:
Prior to VHA national quality improvement efforts, both positive and negative shifts in performance occurred for common inpatient stroke QIs. Future work should examine whether focusing efforts on one aspect of stroke care can lead to reduction in quality in other areas, and on whether consistent reporting of these QIs can promote maintenance of high quality stroke care across a large national healthcare system.
Abstract 180: The Effectiveness of a HF Training Program among Primary Care Physicians
Authors: Park Linda G , Mahar Denis , Shaw Richard , Dracup Kathleen
Published: July 2021

Background:
Heart failure (HF) guidelines recommend beta-blockers (BB) to reduce morbidity and mortality. BB doses are often suboptimal, which do not provide maximum benefit for HF patients. Differences in BB management patterns may exist between family practice (FP) and internal medicine (IM) physicians due to differences in specialty interest and training.

Objectives:
1) To determine the effectiveness of a one-day training intervention for primary care physicians (PCPs) designed to optimize BB titration for patients with systolic HF. 2) To compare BB titration rates of FP and IM physicians. We hypothesized the intervention would result in increased PCP BB titration rates for experimental patients, with a more significant benefit in the FP group.

Methods:
A prospective cohort study was conducted at a county hospital with low-income, underserved HF patients (mean age 54.1±13.1, males 70%, mean ejection fraction 28.2±9.8, mean serum creatinine 1.5±1.0) for up to 7 clinic visits. Twelve participating PCPs, including 5 FP and 7 IM physicians, received a one-day training intervention on HF management with a focus on BB titration. Medical records of control patients who received care 2 years prior to the intervention (n=54) were compared to experimental patients after the intervention (n=81). A linear mixed model examined differences in BB dose between the experimental and control groups and the FP and IM physicians.

Results:
No sociodemographic or clinical differences were noted between HF patients treated before or after the intervention or between IM and FP physicians (p>0.05). The test of the group by time interaction showed no difference between the experimental and control groups in linear change trajectories for BB dose change (t= -0.12, p=0.91). However, FP physicians showed a significant change in BB titration rates for experimental patients (p=0.04) when compared to IM physicians.

Conclusions:
There was no difference in BB titration rates between the experimental and control groups following a HF training intervention for PCPs, although the clinical reasons for restricting maximal dosage were not explored. Teaching interventions targeting FP physicians may benefit HF patients in achieving higher BB doses and should be examined further.
Abstract 191: Association of Midlife Fitness with Healthcare Charges in Later Life: the Cooper Center Longitudinal Study.
Authors: Bachmann Justin M , Willis Benjamin L , DeFina Laura F , Gao Ang , Leonard David S , Berry Jarett D
Published: July 2021

Background:
The inverse association between cardiorespiratory fitness and mortality is well described. However, the association between midlife fitness in healthy adults and healthcare charges in later life has not been reported. We hypothesized that higher midlife fitness would be associated with lower healthcare charges independent of traditional risk factors.

Methods:
Linking individual participant data from the Cooper Center Longitudinal Study with Medicare claims files, we studied 20,489 healthy individuals (mean age 51, 21% women) free of prior myocardial infarction, stroke and cancer who survived to receive Medicare coverage through 1999-2009 for a total of 134,070 years of Medicare exposure. Traditional risk factors and fitness were measured at study entry. Fitness was estimated by Balke protocol treadmill time and categorized into age- and sex-specific quintiles, with quintile 1 as low fitness. Healthcare charges were cumulated using Medicare claims files and adjusted for inflation. Associations between midlife fitness and healthcare charges in later life were estimated using a Tobit censored regression model after adjustment for age, body mass index, blood pressure, cholesterol, diabetes, and smoking.

Results:
Compared to quintile 1 (low fitness), quintiles 4-5 (high fitness) measured at a mean age of 51 were associated with lower median annual healthcare charges at age ≥65 in both men ($3277 vs. $5134, p<0.001) and women ($2755 vs. $4565, p<0.001). The inverse associations between fitness and healthcare charges were consistent across levels of traditional risk factor burden (Figure) and persisted after multivariable adjustment in men [β = -0.34 (95% confidence interval -0.21 to -0.46), p<0.001, quintiles 4-5 vs. quintile 1] and women [β = -0.32 (95% CI -0.09 to -0.54), p<0.01]. Similar findings were observed when fitness was analyzed as a continuous variable (METs) in men [β = -0.07 (95% CI -0.049 to -0.091), p<0.001] and women [β = -0.12 (95% CI -0.076 to -0.16), p<0.001].

Conclusions:
Higher fitness in healthy, middle-aged adults is strongly associated with lower healthcare charges decades later in older age, independent of other traditional risk factors.
Abstract 199: Hardwiring Institutional Learning Through Team-Based Problem-Solving in a Pediatric Cardiovascular Intensive Care Unit
Authors: Williams Eric A , Ladwig Lauren , Nikolai De Ann , Matthews Gay , Graf Jeanine M
Published: July 2021

Introduction:
Our purpose was to develop a high reliability system (The SWARM) to empower frontline staff to share information regarding communication and process inefficiencies to rapidly develop solutions.

Hypothesis:
A systematic process for recognition, evaluation, and transparent feedback would increase the use of problem-solving.

Methods:
A multidisciplinary team, led by a physician and nurse, developed an email strategy to let frontline staff identify problems in real-time and solve and spread this knowledge throughout the CVICU and Heart Center. Problems submitted were outside the scope of institutional patient safety reporting. Unless immediate attention was required, the SWARM team evaluated entries weekly. Entries were categorized as: 1) Useful information to share with ICU staff; 2) More information needed to be obtained and personnel consulted; or 3) A multidisciplinary task force needed to generate consensus and evidence-based guidelines. Solutions were shared with ICU staff via direct email and a monthly newsletter. After 6 months ICU staff were surveyed with 5 questions regarding awareness, utility, and ease of use of the SWARM process. Staff were resurveyed after re-education and institution of leadership walk-rounds. Rates of SWARM entries before and after re-education were compared using Fisher’s Exact Test for proportions.*p<.05

Results:
Of the total 65 SWARM entries, 9% were level 1, 86% were level 2 and 5% were level 3. Entries were categorized into problem types and are shown in the Pareto Chart as percent of total(See Chart). Pre- and post- survey results indicated that staff awareness increased from 70% to 91% and staff understanding of utility increased from 57% to 75%. After re-education, use in CVICU increased by 417% (0.7/week to 2.9/week)*. The increased rate of use of the SWARM system has been sustained for 8 weeks post education. The current rate is 1.8/week. The top two Solutions by category were Re-Education (62%) and Practice Change (17%).

Conclusions:
A system was developed to better manage quality through real-time awareness of our performance. The formal creation of a standardized context for information sharing has resulted in a significant increase in the performance of problem-solving. This multidisciplinary effort allows for minimizing unnecessary variation in how quality improvement efforts are identified and performed.
Abstract 207: Adherence to the 2010 American College of Cardiology Foundation Appropriate Use Criteria for Cardiac Computed Tomography: Quality Analysis at a Tertiary Referral Center
Authors: Sidhu Manavjot S , Lumish Heidi , Christopher-Engel Leif , Uthamalingam Shanmugam , Abbara Suhny , Brady Thomas J , Hoffmann Udo , Ghoshhajra Brian
Published: July 2021

Background:
In November 2010, the American College of Cardiology Foundation (ACCF) published the revised appropriateness criteria (AC) for cardiac computed tomography (CCT). We decided to evaluate adherence to these criteria at our tertiary referral center.

Methods:
Reports for 383 patients who underwent clinical CCT from December 1, 2010 to July 31, 2011 were reviewed by physicians with appropriate training in CCT. Scans were classified as appropriate, inappropriate or uncertain based on the revised 2010 AC. Studies that did not fall under any of the specified indications were labeled as unclassified. Adherence to the AC was also analyzed as a function of provider type. Research scans were excluded from this analysis.

Results:
308 (80%) exams were classified as appropriate, 26 (7%) as inappropriate, 30 (8%) as uncertain, and 19 (5%) as unclassified (Table 1). Of the 19 (5%) unclassified CCT studies, the most common indication was for evaluation of suspected aortic dissection. 305 (80%) exams were referred by cardiologists, 73 (19%) by internists, and 5 (1%) by neurologists (Figure 1). Of the 305 cardiology-referred studies, 221 (73%) were ordered by general cardiologists, 28 (9%) by interventional cardiologists, and 56 (19%) by electrophysiologists. There was no significant difference in adherence to the criteria between provider specialties or between cardiology subspecialties (p>0.05)

Conclusions:
Adherence to the 2010 AC at our center was uniformly high across provider specialties. The distribution of inappropriate and uncertain studies suggests residual ambiguity in the value of CCT after stress testing and prior to noncardiac and noncoronary cardiac surgery. This highlights an area for monitoring and future educational intervention.