bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 26: Clinical models of 30-day outcomes among Medicare beneficiaries hospitalized with heart failure and preserved or reduced ejection fraction: derivation and validation of models from the Get With The Guidelines-Heart Failure Registry and Medicare Linked Database
Authors: Eapen Zubin J , Liang Li , Fonarow Gregg C , Heidenriech Paul A , Peterson Eric D , Hernandez Adrian F
Published: July 2021

Background:
Outcomes within 30 days of a heart failure (HF) hospitalization are being promoted as metrics of hospital-level quality of care for Medicare beneficiaries. However, few clinically oriented models suitable for use at the point of care have been derived and validated in cohorts of patients with HF with reduced ejection fraction (HF-REF) and HF with preserved ejection fraction (HF-PEF).

Methods:
Patients 65 years and older who were hospitalized in the American Heart Association's Get With the Guidelines (GWTG)-HF registry were linked with Medicare claims from January 2005 to December 2009. Multivariable models using the generalized estimating equation method were developed for 30-day mortality after admission, 30-day readmission after discharge, and 30-day readmission or death after discharge. Patients transferred to another facility or with in-hospital deaths were excluded from the models of 30-day readmission or readmission/death after discharge. The predictors were selected from a derivation sample (70% of study cohort) and refit using the whole study sample; then, the refit model was validated in an independent derivation sample (30% of study cohort). C-statistic was used to evaluate model performance on discrimination and plots comparing predicted versus observed probability were used to assess calibration. The models were evaluated among patients either with HF-PEF or HF-REF.

Results:
Among 33,349 patients at 160 hospitals, 3,002 (9.1%) died within 30 days of admission, 7020 (22.8%) were readmitted within 30 days of discharge, and 8,374 (27.2%) either died or were readmitted within 30 days of discharge. The derived risk models (Table shows predictive model for 30-day death or readmission) discriminated well in patients with HF-REF (c-statistic for death: 0.77, readmission: 0.63, death or readmission: 0.67). Similarly, these models maintained their discriminative capacity in patients with HF-PEF (c-statistic for death: 0.75, readmission: 0.61, death or readmission: 0.64).

Conclusions:
In patients hospitalized at GWTG participating institutions with both preserved and reduced EF, the GWTG-HF predictive models stratify risk for 30-day outcomes in patients with HF. Further study is needed to test effectiveness of integrating these clinical risk models at the point of care.
Abstract 28: Racial Disparities In Outcomes Of Endovascular Procedures For Peripheral Arterial Disease: An Evaluation Of California Hospitals, 2005-2009
Authors: Hedayati Nasim , Brunson Ann , Li Chin-Shang , Loja Melissa N , Carson John G , White Richard H , Romano Patrick S
Published: July 2021

Background:
Endovascular procedures are being increasingly performed for peripheral arterial disease (PAD), exceeding the number of open surgical bypass procedures. Previously, it had been demonstrated that there is a disparity in access to and outcomes of PAD treatment based on race/ethnicity. Blacks have been shown to be more likely to undergo amputation and less likely to undergo revascularization procedures for limb salvage compared to whites. The aim of this study was to determine if there is disparity in the outcomes of endovascular PAD procedures based on race/ethnicity in this contemporary population-based study.

Methods:
We used the Patient Discharge Data (PDD) from California's Office of Statewide Health Planning and Development (OSHPD) to identify all patients >35 years of age who underwent a lower extremity arterial intervention from 2005 to 2009. OSHPD has been recording ambulatory surgery data since 2005. A look back period of five years was used to exclude patients with prior lower extremity endovascular or open bypass procedures. Cox proportional hazards regression was used to compare amputation-free survival and logistic regression was used to compare 12-month reintervention rate among the racial groups adjusting for age, gender, insurance status, severity of illness, and comorbidities.

Results:
Between 2005 and 2009, 41,507 individuals underwent lower extremity arterial interventions; 25,635 (61.7%) underwent endovascular procedures. There were 11,389 women (44.2%) and 14,246 men. This cohort included 17,433 (68%) non-Hispanic (NH) whites, 4,417 (17.3%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others. The Hazard ratio for amputation or death was 1.69 in Hispanics (95%CI 1.50-1.89) and 1.65 in blacks (95%CI 1.42-1.92) compared to NH whites (
p
<0.001). The 12-month reintervention rate was significantly associated with race/ethnicity (
p
=0.001). The odds ratio for 12-month reintervention was 1.18 in Hispanics (95% CI 1.06-1.31) and 1.08 in blacks (95%CI 0.95-1.22) compared to NH whites following endovascular procedures.

Conclusions:
Our study demonstrates that Hispanics and blacks have worse amputation-free survival than NH whites following endovascular PAD procedures in this contemporary state-wide database. However, Hispanics and blacks were more likely than NH whites to undergo reintervention. Further research is needed to understand if the higher reintervention rate is secondary to more severe illness and/or poor access to proper follow-up care and cardiovascular risk factor modifications.
Abstract 293: Cerebral Autoregulation May be Impaired During Cardiopulmonary Bypass
Authors: Hathaway Jessica A , Groom Robert C , Kramer Robert S , MacKenzie Todd A , Likosky Donald S ,   The Northern New England Cardiovascular Disease Study Group
Published: July 2021

Introduction:
Cerebral autoregulation ensures that the brain receives sufficient blood flow over a patient-specific range of mean arterial pressures (MAP). Given fluctuations in MAP during different phases of cardiopulmonary bypass (CPB), it is unclear to what extent cerebral autoregulation is maintained during cardiac surgery.

Hypothesis:
We can detect the lower limit of autoregulation (LLA) during the different phases of CPB using a non-invasive cerebral monitor.

Methods:
We enrolled 138 patients undergoing coronary artery bypass grafting or valve surgery with moderate hypothermic CPB at a single medical center. Near infrared spectroscopy (NIRS) and MAP were recorded every 20 seconds before and during CPB. Cerebral autoregulation was estimated by modeling the dependence of NIRS on MAP using a mixed effects model with regression splines.

Results:
The proportion of each patient's MAP below 60 mm Hg varied (10% prior to CPB, 30% during cooling, and 36% from rewarming to the end of CPB). Hematocrit diminished from 35% prior to CPB to 21% during cooling, to 25% during rewarming. The LLA, or loss of cerebral autoregulation, occurred around 60 mmHg, both before CPB and during the rewarming period. A LLA was not identified during the cooling period of CPB.

Conclusion:
We used a non-invasive cerebral monitor to define the LLA during CPB among our sample of patients. A patient's risk of cerebral dysautoregulation may increase during the rewarming period, given the higher exposure to MAPs below 60 mm Hg.
Abstract 297: Dual Antiplatelet Therapy versus Triple Therapy with Anticoagulant Following Percutaneous Coronary Intervention in High Risk Patients Requiring Long-Term Anticoagulation: A Meta-Analysis
Authors: Panchal Hemang B , Shah Tejaskumar , Singh Mukesh , Khosla Sandeep , Ramu Vijay , Arora Rohit
Published: July 2021

Background:
Dual antiplatelet therapy with aspirin and clopidogrel is the cornerstone of treatment to prevent major adverse cardiovascular events (MACE) in patients following percutaneous coronary intervention (PCI). In high-risk patients requiring long-term anticoagulant, the current literatures have controversial results in preventing MACE and bleeding events with the use of triple therapy with aspirin, clopidogrel and warfarin compared to dual antiplatelet therapy following PCI. The purpose of this meta-analysis was to compare the safety and efficacy of triple therapy with dual therapy following PCI in high-risk patients requiring long term anticoagulation.

Methods:
A literature search identified 4 prospective and 4 retrospective studies with total of 2439 patients requiring long term anticoagulation undergoing PCI. End points measured were bleeding events, deaths, ischemic stroke, myocardial infarction, stent thrombosis and MACE. The odds ratios (OR) with 95% confidence intervals (CI) were computed and two sided alpha error <0.05 considered as a level of significance.

Results:
In contrast to dual antiplatelet therapy, patients on triple therapy with anticoagulant had significantly lower stent thrombosis (OR: 0.45, CI: 0.21-0.94, p=0.03) and ischemic stroke (OR: 0.30, CI: 0.16-0.56, p<0.001) (Fig 1 - Zone A is dual therapy group, zone B is triple therapy group). No significant difference was found between two groups in overall bleeding events (OR: 1.57, CI: 0.87-2.85, p=0.14), major bleeding events(OR:1.21, CI: 0.57-2.59, p=0.62), deaths (OR:0.89, CI: 0.5-1.58, p=0.69), myocardial infarction (OR:1.31, CI: 0.85-2.02, p=0.22) and MACE (OR:0.61, CI:0.20-1.82, p=0.37).

Conclusions:
Our meta-analysis suggests that the triple therapy with anticoagulant does not increase bleeding compared to dual antiplatelet therapy. Moreover, triple therapy decreases stent thrombosis and ischemic stroke following PCI in patients requiring long-term anticoagulants. Our study did not show any difference in mortality between two groups. Triple therapy may be a favorable strategy following PCI in high-risk patients requiring long-term anticoagulation. The randomized control clinical trials are needed for further evaluation of long-term outcomes.
Abstract 330: Effect of Public and Private Health Insurance on the Access to Invasive-Procedure Hospitals and on the Outcomes in Acute Myocardial Infarction - A Brazilian Pilot Study
Authors: Ferreira Eduardo J , Barreto-Filho José A , Sousa Antnio C , Araújo Lawrence A , Souza-Júnior Acelino O , Costa Aelson F , Cunha Paulo E , Silva Jose D , Silva-Filho Claudemir M , Melo Enaldo V , Oliveira Joselina L
Published: July 2021

Background:
In 1988, the public Unique System of Health (SUS) was launched in Brazil with the promise to offer high quality healthcare for all Brazilians and to decrease disparities related to healthcare access and outcomes. Nevertheless, approximately 1/4 of the population use private health services. Whether outcomes of patients with ST-segment elevation myocardial infarction (STEMI) using SUS are similar to those occurring in patients using private services is scarcely known. This study aimed to compare the time of access to PCI hospitals and 30-day mortality in Sergipe, the smallest state in Brazil.

Methods:
From January to October 2011, we evaluated 143 consecutive patients admitted with diagnosis of STEMI and submitted to PCI in three of the four PCI hospitals in Sergipe, one reference for SUS and the other two receiving patients from the private sector. We investigated the clinical profile, rates of use of drug eluting stents and glycoprotein IIb/IIIa inhibitors and, 30-day mortality among STEMI patients stratified by the health insurance coverage.

Results:
There were no significant differences in baseline characteristics between groups. Nevertheless, we observed a trend toward increase in incidence of older patients, multivessel disease and/or left main coronary disease in the private group. The time from onset symptoms to arrival at the PCI hospital was above the recommended in both groups but even longer for SUS patients (median, 14 hours, 25
th
-75
th
percentiles, 8-24 hours) than private patients (median, 7 hours, 25
th
-75
th
percentiles, 4-17 hours; p=0.003). Nevertheless, door-to-balloon times were similar comparing SUS group (median, 97 minutes, 25
th
-75
th
percentiles, 79-108 minutes) and private group (median, 90 minutes, 25
th
-75
th
percentiles, 76-100 minutes; p=0.69). Drug-eluting stents and glycoprotein IIb/IIIa inhibitors were more frequently used in the private group. Despite similar angiographic success rates, younger age and lower prevalence of multivessel disease, SUS patients presented 5% higher 30-day mortality.

Conclusions:
Our results depicted that STEMI patients using SUS coverage arrived later to PCI hospitals, were less likely to use drug-eluting stent and glycoprotein IIb/IIIa inhibitors and, more importantly, presented higher mortality rates despite lower predicted risk. Our preliminary data suggest disparities related to health insurance coverage and will have potential implications for healthcare policies in Brazil, if we confirm these findings when increasing the sample size.
Abstract 41: Designation as “Unfit For Open Repair” is Associated with Poor Outcomes Following Endovascular Aneurysm Repair
Authors: De Martino Randall R , Brooke Benjamin J , Robinson William P , Nolan Brian W , Cronenwett Jack L , Goodney Philip P
Published: July 2021

Objective:
Endovascular aneurysm repair (EVAR) is a minimally invasive method of repair for abdominal aortic aneurysms (AAA) with a lower perioperative morbidity and mortality compared to open repair (oAAA). In many cases, EVAR is offered to patients who otherwise are not candidates for oAAA. This study attempts to describe the short and long term outcomes of patients undergoing EVAR who are consideredunfit for oAAA with moderate sized aneurysms (<6..5cm diameter).

Methods:
We analyzed 1,653 elective EVARs within the Vascular Study Group of New England (2003-2011), a regional quality improvement collaborative across 21 hospitals and 87 surgeons in New England. Endpoints included in-hospitalmajor adverse events (MAEs) and one, three, and five-year mortality. Logistic regression was used to develop a prediction model for being deem unfit for open repair. Multivariate predictors of survival were determined using Cox Proportional Hazards.

Results:
Of 1,653 EVARs, 309 (18.7%) were performed in patients deemed unfit for open repair. These patients were more likely to be over 80 years of age, have advanced cardiac disease,COPD, and a larger aneurysms. Patients deemed unfit for open repair had andhigher rates of cardiac complications (7.8% vs 3.1%, p<0.01) and pulmonary complications (3.6 vs. 1.6, p<0..01). Patients unfit for open repair had poorer survival rates at 1 (93% vs.. 96%), 3 (73% vs. 89%) and 5 years (61% vs. 80%) compared to those appropriate for open repair (logrank p<0.01). The effect of "unfit for open" designation remained significant (HR 1.6, 96% CI 1.2-2.2, p<0.01), even when adjusted for patient characteristics and aneurysm size.

Conclusions:
Clinical provider assessment provides insight into both short and long-term efficacy of EVAR, even when adjusting for age and comorbidities. Patients in whom open repair is felt to be too "high-risk" may not benefit from EVAR unless their risk of rupture is very high.
Abstract 5: A Comparison between Antihypertensive Medication Adherence and Treatment Intensification as Potential Clinical Performance Measures
Authors: Vigen Rebecca , Shetterly Susan , Magid David J , O'Connor Patrick J , Margolis Karen L , Schmittdiel Julie , Ho P M
Published: July 2021

Background:
Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care. While previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure control at the patient level, less is known about whether adherence and TI is associated with blood pressure control assessed at the clinic level.

Methods:
We included 162,879 patients from 89 clinics in the CVRN Hypertension Registry with incident hypertension who were started on antihypertensive medications. Medication adherence was calculated by the proportion of days covered for five different classes of antihypertensive medications. TI was calculated as the number of observed medication intensifications minus the number of expected medication intensifications divided by the number of clinic visits in the observation period. TI is expected whenever measured blood pressure during a clinic visit is higher than the blood pressure goal. A TI score of -1 indicates that no treatment intensification was made when the BP was elevated, a score of 0 indicates that treatment intensification was made only when the blood pressure was elevated, and a score of 1 indicates that treatment intensification was made when the blood pressure was normal. Multivariable logistic regression assessed the association between medication adherence and treatment intensification with blood pressure control at the patient and clinic levels.

Results:
The average patient age was 56 years, 13.6% had diabetes, 1.0% had previous MI, 3.8% had chronic kidney disease, 1.7% had a previous ischemic stroke, and 0.9% had CHF. Adherence measured by proportion of days covered was 0.77 ± 0.28 at the patient level and 0.78± 0.05 at the clinic level. The average patient TI score was 0.026 ± 0.23 and the average clinic TI score was 0.01± 0.04. Both adherence and treatment intensification were associated with blood pressure control at the patient level [OR for adherence of 1.28 (1.26 - 1.29) and OR for treatment intensification of 1.55 (1.53 - 1.57)]. In contrast, treatment intensification, but not adherence, was associated with blood pressure control at the clinic level [OR for TI at the clinic level 1.21 (1.17 - 1.25) and OR for adherence at the clinic level 1.01 (0.98 - 1.04)].

Conclusion:
In this study, patient adherence to antihypertensive medications was not related to blood pressure control at the clinic level and may not be suitable as a performance measure. Treatment intensification was associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.
Abstract 69: Increased Risk of Venous Thromboembolism Associated with use of Non Steroidal Anti-Inflammatory Drugs among Patients with Prior Myocardial Infarction - A Nationwide Cohort Study
Authors: Schjerning Olsen Anne-Marie , Fosbøl Emil L , Lindhardsen Jesper , Andersson Charlotte , Folke Fredrik , Køber Lars , Torp-Pedersen Christian , Gislason Gunnar H
Published: July 2021

Background:
Use of NSAID has shown to be associated with a substantially increased risk of athero-thrombotic adverse events in patients with a history of myocardial infarction. Whether a similar increase in risk is found for VTE is unknown.

Methods:
Patients aged >30 years admitted with first-time MI during 1997-2009 and their subsequent NSAID use were identified by individual-level linkage of nationwide registries of hospitalization and drug dispensing from pharmacies in Denmark. The risk of VTE associated with NSAID use was analyzed by time-dependent Cox proportional hazard models adjusted for age, gender, calendar year, concomitant drug use, and comorbidity.

Results
A total of 98,901 patients were included (mean age 68 years (SD 13.0), 64.0% men), 44.0% received NSAIDs during follow-up. There were 1847 VTEs. Relative to no NSAID use, the Cox-analyses showed increased risk of VTE with use of any NSAIDs. Overall NSAID use was associated with increased risk of VTE (Hazard ratio [HR] 1.75 95% confidence interval [CI] 1.52-2.02). In particular use of the selective cyclooxygenase-2 (COX-2) inhibitors rofecoxib and the nonselective NSAID diclofenac was associated with significantly increased risk of VTE (HR 2.56 (CI 1.60-4.08) and HR 2.03(CI.1.50-2.74), respectively).

Conclusion:
Use of most NSAIDs was associated with an increased risk of VTE. The use of rofecoxib and diclofenac was associated with highest risk. Further studies, preferably randomized clinical studies, are warranted to establish the cardiovascular safety of NSAIDs, however this study suggests that risk of VTE should be considered when prescribing NSAIDs patients with MI.
Abstract 89: Validating The Identification Of Patients At High Risk For Readmission By Examining Hospitalization History
Authors: Egorova Natalia , Vaishnava Prashant , Basso Lipani Maria , Ricks Doran , Colgan Claudia , Bernstein Susan , Nash Ira , Gelijns Annetine , Moskowitz Alan , Kalman Jill
Published: July 2021

OBJECTIVES:
To identify patients at high risk of readmission by validating a simple predictive tool based solely on hospitalization history.

BACKGROUND:
There is a federal mandate to reduce preventable readmissions. Predicting hospital readmission risk is of great interest to identify which patients would benefit most from transition interventions. Current models perform poorly. Mount Sinai Hospital (MSH) has implemented the Preventable Admissions Care Team (PACT), which has achieved significant results for patients not targeted by other transitional programs. PACT, a social worker-led transitional program, decreased 30-day readmission rate from 30% to 12%, ED visits by 63%, and achieved a 90% primary care show rate at 7-10-days post-discharge. Patients are identified for PACT solely by readmission history: one readmission in 30 days or 2 in 6 months, prior to the index hospitalization. Thus, our objective here was to determine the concordance of predictions based on hospitalization history with a more formal risk model based on factors that characterize patients through demographics and comorbidities.

METHODS:
Using logistic regression, we developed a risk prediction model for readmission within 30-days. The model, which used patient demographics and co-morbidities (alcohol abuse, AMI, afib, breast cancer, CKD, COPD, CVA, depression, hip fracture, or osteoporosis), was developed in a cohort of Medicare FFS beneficiaries with a high proportion of cardiovascular disease, hospitalized at MSH. The higher the risk score, the higher risk of readmission. Scores of 0-2 had a 7% risk of readmission; scores of 3 or 4 and above 5 had 30-day readmission rates of 19%, and 29%, respectively.

We then applied this risk scoring model to patients enrolled in PACT to determine how many of them would have been identified as high risk for readmission based on the regression model.

RESULTS:
A total of 393 patients were enrolled in PACT in a year and completed a 5 week intervention. Eighty seven percent had 1 cardiac comorbid illness (76% CAD, 66% CHF, and 17% Afib). Readmission data was available through 2010 thus, the analysis was completed for 111 patients. Ninety-five percent of PACT enrollees had a risk score greater than 3: 19 patients (17.1%) had a risk score of 3-4, and 87 patients (78.4%) had a risk score of 5 or greater.

CONCLUSIONS:
Hospitalization history alone is a reasonable proxy to more formal multivariable regression models in predicting 30-day readmission risk. If substantiated through further study, this could have national implications for real time high risk patient identification for transitional services.
Abstract 96: Facilitation of the VA Hospital To Home (H2H) Initiative to Reduce Readmissions for Heart Failure: CHF QUERI
Authors: Sahay Anju , Gholami Parisa , Oliva Nancy , Heidenreich Paul A
Published: July 2021

Objective:
Reducing readmission rates for heart failure (HF) patients is the primary goal of the VA and its' Chronic Heart Failure (CHF) QUERI. It is also the goal of Hospital to Home (H2H) national quality improvement (QI) which has 3 key focus areas: (a) medication management; (b) symptom management; and (c) early follow-up after discharge. According to Rogers’ Diffusion of Innovation Theory (2003) social networks significantly affect performance and innovation. Additionally, the Promoting Action on Research Implementation in Health Services(PARIHS, 2008) framework emphasizes the function of dynamic relationships among evidence, context and facilitation. The CHF QUERI formed the HF Provider Network consisting of 720+ providers (members) from 150 VA facilities to improve the quality of HF care. In January 2010 through the HF Network the “VA H2H” QI initiative was launched to facilitate the implementation of the national H2H initiative at the VA facilities with focus on H2H's 3 key focus areas. Through e-mails, web-based meetings and conference calls members were encouraged to (1) enroll own facility on national H2H website and (2) initiate and/or plan new projects focusing on the VA H2H initiative.

Methods:
A total of 122 VA facilities were identified with >100 discharges during 2007-2008. In Spring 2010 and then Spring 2011 members at all facilities were asked to complete surveys to find out (1) enrollment status and (2) number and description of projects initiated and/or planned for the VA H2H initiative, and other ongoing projects focusing on reducing HF readmissions.

Results:
Altogether 77 (63%) facilities enrolled on the national H2H website. With a survey response rate of 75% (92 facilities) altogether 529 projects were reported focusing on: Medication management=150 (29%); Symptom management=148 (27%); Early follow up=155 (30%); and Other areas=34 (14%). A total of 120 (22%) projects were initiated and another 93 (18%) are being planned based on the VA H2H initiative, and 316 (60%) are ongoing projects to reduce HF readmissions.

Conclusions:
Supporting the Rogers (2003) and PARIHS (2008) frameworks, these findings demonstrate the successful facilitation of the VA H2H initiative by the CHF QUERI through its HF Provider Network in terms of increased enrollment and significant number of initiated and/or planned VA H2H projects.

Impact:
Facilitation of non-mandated QI initiatives is crucial to improve the quality of care for HF patients.
Abstract 104: Survey of Emergency Physician Cardiac Imaging Technology and Guideline Knowledge
Authors: Martin Carolyn , Lacey Michael , Spalding James , Essoi Breanna
Published: July 2021

Objectives:
Chest pain is among the most common reasons for emergency room presentation. Providing emergency physicians with the tools necessary to evaluate and triage chest pain patients is a key component of health care efficiency. The study objective was to increase understanding of the clinical tools available to evaluate chest pain in the emergency setting.

Methods:
A total of 630 emergency physicians were invited to participate in a web-based survey. Eligible respondents must have had at least 3 years of experience and spend at least 30% of time providing direct patient care. Over the course of 2 days, 163 physicians responded; 101 were eligible and completed the survey. The survey consisted of 3 screening questions and 11 survey questions. Survey questions included: experience with chest pain patients, cardiac imaging technologies as well as knowledge and use of the appropriate use criteria (AUC) for cardiac radionuclide imaging.

Findings:
Over ¾ of all respondents were male, averaged 46 years of age, and had been practicing emergency medicine for nearly 15 years. On average, the respondents saw 20 chest pain patients per week and 72% of those were of unknown cardiac etiology. Diagnostic Catheterization and Stress ECG were the most common evaluation tools available in the emergency department (72% and 71% respectively). When available, stress ECG was the most commonly used evaluation tool in the emergency department. MPI-SPECT was only available to 27% of respondents, and of those, only used 44% of the time. Respondents selecting the “other” response most commonly reported that imaging evaluation was not done in the emergency department. Older physicians (> 61 years) were less likely to report access to stress ECHO; physicians with fewer years of experience (20 or less) were more likely to have access to stress ECHO and diagnostic catheterization. Rural physicians were less likely to report the availability of MPI, CT or diagnostic catheterization. Less than half of emergency physicians (42%) were familiar with the cardiac radionuclide imaging appropriate use criteria, and 80% rarely or never use them. AUC knowledge and use did not differ by years in practice but did differ by age. Physicians in rural practices were the least likely to have knowledge or use the AUC.

Conclusions:
Despite the frequency of chest pain patients presenting to the emergency department, access to imaging tools for evaluation of cardiac etiology is limited. Knowledge and use of AUC guidelines was also limited. These results question the current clinical paradigm which appears to limit the emergency physician knowledge and use of imaging technology to evaluate the chest pain patient despite the high frequency of presentation.
Abstract 14: Regional Cardiologist Density and 30-Day and 1-Year Mortality in Acute Myocardial Infarction and Heart Failure
Authors: Kulkarni Vivek T , Ross Joseph S , Wang Yongfei , Nallamothu Brahmajee K , Spertus John A , Normand Sharon-Lise T , Masoudi Frederick A , Krumholz Harlan M
Published: July 2021

Background:
Although the distribution of cardiologists and mortality for cardiovascular conditions are both known to vary across regions of the United States, no study has examined the relationship between regional cardiologist density and patient mortality for acute myocardial infarction (AMI) or heart failure (HF).

Methods:
We used 2010 Medicare administrative claims data for AMI and HF. Pneumonia (PN) was used as a control condition. Primary outcomes were death at 30 days and 1 year from admission. For each Hospital Referral Region (HRR), we used the 2010 Bureau of Health Professionals’ Area Resource File to define cardiologist density (number of cardiologists divided by population aged 65+) and 4 HRR characteristics: primary care physician density, total physician density, unemployment rate, and percent white race. We used 2-level hierarchical logistic regression models to examine the association between cardiologist density by tertile and mortality for each condition adjusting for (Model A) patient age, sex, and condition-specific comorbidities, and (Model B) patient and HRR characteristics.

Results:
Median (interquartile range) cardiologist density per 100,000 in the low, middle, and high tertiles of HRRs was 26.3 (22.9-29.9), 38.6 (36.5-43.1), and 64.5 (54.4-85.3), respectively. There were 171,126 admissions for AMI, 352,853 for HF, and 343,053 for PN. The 30-day mortality rates were 15.3% (26,290), 11.7% (41,121), and 11.9% (40,906), and 1-year mortality rates were 32.1% (55,292), 40.4% (142,612), and 35.2% (120,666), respectively (Table). For 30-day mortality, while model A showed lower mortality with higher cardiologist density for all conditions (odds ratios (ORs): 0.84-0.95), model B showed no associations. For 1-year mortality, while model A showed lower mortality in the high cardiologist density tertile for AMI (OR=0.93) and HF (OR=0.91) and no associations for PN, model B showed no associations for AMI or HF and higher mortality with higher cardiologist density for PN (ORs=1.04-1.06).

Conclusion:
After adjusting for patient and HRR characteristics, regional cardiologist density was not associated with 30-day or 1-year mortality for AMI or HF, suggesting that the uneven regional distribution of cardiologists across the United States does not affect patient outcomes.
Abstract 141: Incremental Prognostic Value Of Serial Health Status Measures For Ambulatory Patients With Heart Failure
Authors: Allen Larry A , Magid David J , Shetterly Susan , Peterson Pamela N , Brand David W , Bekelman David B , Clarke Christina L , Spertus John A , Masoudi Frederick A
Published: July 2021

Background:
Existing heart failure (HF) risk models have only moderate performance for adverse outcomes. Whether serial health status measurements can improve risk stratification is unknown.

Methods:
In 2007 and again in 2008, we administered Kansas City Cardiomyopathy Questionnaires (KCCQ) to ambulatory Kaiser Permanente Colorado enrollees with a history of HF hospitalization between 2001 and 2007 who survived through 2008. The primary endpoint was hospitalization or death in the 6 months following the 2008 KCCQ administration. C-statistics, integrated discrimination indices (IDI), and net reclassification indices (NRI) were calculated; event rate thresholds for NRI were low (30%).

Results:
Survey response rates were 71% in 2007 and 69% in 2008, resulting in a cohort of 629 patients who completed both questionnaires, of which 153 experienced the endpoint. Mean age was 75 years, 51% were women, mean LVEF was 49%, and mean KCCQ score was 69. Compared with a base model using well accepted demographic and clinical covariates (Model 3, Table), the 2008 KCCQ score appropriately reclassified a large percentage of patients (NRI 13.0%). Adding the change in KCCQ did not further improve reclassification (NRI -3.0%).

Conclusions:
A recent measure of health status, added to traditional prognostic markers, significantly improved risk stratification among a broad ambulatory HF population. Although important patient-centered outcomes in their own right, temporal trends in health status did not further improve prognostication, as compared with the most recent health status assessment. Thus serial health status assessments provide an ‘up-to-date’ assessment of a patient’s prognoses by focusing on the latest values, rather than previous ones.
Abstract 161: Presence of Vaccination Antibodies and Cardiovascular Mortality: Insights From NHANES III and Continuous NHANES
Authors: Shah Neeraj , Patel Nileshkumar J , Grover Peeyush , Chothani Ankit , Mehta Kathan , Deshmukh Abhishek , Rathod Ankit , Singh Vikas , Savani Ghanshyam , Gupta Sandeepkumar J , Badheka Apurva O , De Marchena Eduardo , Cohen Mauricio G
Published: July 2021

Background:
Prior studies have investigated the effect of influenza vaccination on cardiovascular mortality (CVM). The influence of vaccinations other than influenza and CVM has not been investigated before.

Methods:
The public dataset of National Health and Nutrition Examination Survey III (NHANES III) between the years 1988-1994 and continuous NHANES from 1999-2004 was used for this analysis. From NHANES III, we included patients >18 years old with available data on positive antibody against measles, mumps, rubella, diphtheria, pertussis or tetanus. From continuous NHANES, we included patients >18 years with available titers and vaccination history on hepatitis A, hepatitis B and pneumococcus. Protective titers were analyzed as per standardized cut offs. The primary outcome was CVM per National Death Index. Traditional cardiac risk factors along with CRP and social class (insurance, income and education level) were adjusted for in the multivariable analysis.

Results:
There were 1,848 (9.7%) cardiovascular deaths with a mean follow up of 13 years for NHANES III. There were 366 (2.3%) cardiovascular deaths with a mean follow up of 4.7 years for continuous NHANES. Multivariable analysis from NHANES III and continuous NHANES did not show any influence of individual seroprotective titers of routine vaccinations on CV mortality. In the multivariable model, significant predictors of mortality were age (p<0.01) male sex (p<0.01), CRP (p<0.01), hypertension (p<0.01), smoking (p<0.01), congestive heart failure (p<0.01), diabetes mellitus (p<0.01) & history of coronary artery disease equivalent (p<0.01). Combined effect of vaccinations was studied by combining the vaccination titers of measles, rubella, diphtheria and tetanus, however, it did not show any protective effect of 3 or more positive vaccination titers (odds ratio=0.94, p=0.6) or all 4 positive vaccination titers (odds ratio=0.93, p=0.6) compared to 2 or less positive vaccination titers as the referent group.

Conclusion:
Our observational study in a large database suggests that presence of non-influenza vaccination antibodies is not associated with decreased cardiovascular mortality in a nationally representative cohort.
Abstract 175: Evaluation of 30-day Mortality in Patients With ST-Elevation Myocardial Infarction (STEMI) Across All Hospital Centers Performing Primary Percutaneous Coronary Intervention (PPCI) in Quebec, Canada
Authors: Lambert Laurie J , Xiao Yongling , Rinfret Stéphane , Kouz Simon , L’Allier Philippe L , Segal Eli , Ross Dave , Vanasse Alain , Maire Sébastien , Nasmith Jim , Bogaty Peter
Published: July 2021

BACKGROUND:
PPCI is the predominant reperfusion treatment for STEMI in Quebec, Canada. Our systematic field evaluation, during a 6-month period in 2008-9, provided the opportunity to compare patient characteristics, processes of care and 30-day mortality across Quebec’s 13 PPCI centers.

METHODS:
All STEMI patients, who either presented directly or were transferred to one of these 13 PPCI centers, were included in the analyses. Patients transferred after fibrinolytic treatment were excluded. Since patient outcomes within the same hospital may be correlated, generalized estimating equation (GEE) models were used to compare 30-day mortality across centers, adjusting for patient-level risk factors (sex, TIMI index, anterior myocardial infarction, history of heart failure/shock) and for hospital-level characteristics.

RESULTS:
The majority of patients treated in the 13 PPCI centers were transferred for PPCI from non-tertiary centers (n=785, 62%), and these patients were unlikely to receive timely treatment (i.e., only 26% with first door-to-device time ≤90 min). Of the remaining 490 (38%) patients who presented directly to a PPCI center, 70% had timely treatment. Across the 13 PPCI centers, crude 30-day mortality varied widely (1.5% - 16.3%) and variation persisted after adjustment for patient risk factors (2.1% - 11.2%). STEMI volume per PPCI center and the presence of cardiac surgery on-site were not associated with 30-day mortality. In the final GEE model containing all patient factors considered and 3 hospital-level factors (proportion of patients treated with a radial approach, proportion of patients transferred for PPCI, proportion of patients with timely PPCI), the odds ratio for death decreased by 18% for every 20% increase in the proportion of patients treated with a radial approach, and decreased by 25% for every 20% increase in the proportion of patients with timely PPCI. Conversely, the odds ratio increased by 28% for every 20% increase in the proportion of transferred patients.

CONCLUSION:
Thirty-day STEMI mortality can vary substantially across PPCI centers within a complete system of care. Our findings suggest that 30-day STEMI mortality could be reduced if PPCI centers discouraged transfers with expected untimely delays.
Abstract 180: What is the Potential Capacity for Increasing Cardiac Rehabilitation Utilization in the United States?
Authors: Pack Quinn R , Squires Ray W , Lichtman Steven W , Lopez-Jimenez Francisco , Rodriguez-Escudero Juan Pablo , Zysek Victoria N , Thomas Randal J
Published: July 2021

Introduction:
Cardiac rehabilitation (CR) is an effective but highly underutilized therapy for heart disease. Efforts are underway to increase CR referral and enrollment, but little is known about the potential capacity for growth in CR utilization in the United States. To address this concern, we estimated the current national capacity of CR programs across the United States and assessed obstacles to potential growth.

Methods:
We surveyed all CR Program Directors listed in the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) database in November of 2012. Respondents reported current enrollment levels, current program capacity, program capacity given reasonable expansion, and obstacles to growth.

Results:
Of 812 Program Directors in the AACVPR database, 290 (36%) completed the full survey. Respondents represented somewhat larger programs compared to non-respondents (4.0 vs. 4.6 full time employees, p = 0.01), but were otherwise similar. Current enrollment levels demonstrated a median [IQ range] of 140 [75,232] patients per year and a current estimated capacity of 192 [100,300] patient per year. Respondents estimated that programs could expand services by 25% to 240 [141,380] patients annually, assuming a significant increase in patient demand and a feasible increase in resources. We estimate that if programs filled to their current capacity, national CR utilization rates would increase from 34.7% to 46.4% (95% CI, 43.9 to 48.9) of eligible US patients each year. Given feasible program expansion, utilization could increase to a maximum of 58.4% (95% CI, 55.2 to 61.6) of qualifying patients. Capacity projections based upon absolute patient numbers and national statistics revealed concordant results. The most commonly cited obstacles to increasing patient participation are shown in the figure. As seen, the majority (88%) are controllable system-related factors unrelated to patient behavior.

Conclusions:
Even with substantial expansion of all existing CR programs, there is currently insufficient capacity in current CR programs to meet national service needs. Solutions to this problem will likely include the creation of new CR programs, and new policies that improve reimbursement for CR and also embrace new models of CR delivery.
Abstract 214: Improvement Among All Hospital Types and Reduced Hospital Level Variation in Use of Intravenous tPA for Acute Ischemic Stroke 2003-2011: Findings from Get With The Guideline-Stroke
Authors: Schwamm Lee H , Ali Syed F , Reeves Mathew J , Smith Eric E , Saver Jeffrey L , Messe Steven , Bhatt Deepak L , Grau-Sepulveda Maria V , Peterson Eric D , Fonarow Gregg C
Published: July 2021

Introduction:
IV tPA delivery is challenging and use varies widely. We analyzed differences in patient and hospital characteristics at the hospital level in the Get with the Guidelines (GWTG) - Stroke database.

Methods:
We analyzed data on 73574 patients from 2003-2011 at 1231 hospitals with ≥10 tPA-eligible ischemic stroke (AIS) patients arriving
<
2 hr of onset, divided into quartiles of rates of tPA delivered within 3 hrs of onset. Median percentages are reported, and temporal trends were calculated using absolute changes from 2010-2011 vs. 2003-2005.

Results:
Patients at hospitals with lower rates of tPA treatment within 3 hrs were older, more frequently white, used EMS less often, had lower NIHSS values with very high rates of missing NIHSSS, and greater door to imaging times as compared to better performing hospitals. Hospitals with lower rates of tPA treatment were smaller and more rural, had fewer ICU beds, and were less often teaching or primary stroke centers (Table 1). IV tPA use increased across all types of hospitals from 2003-2011, but increased to a greater degree in non-primary stroke centers and those in the South and West (Table 2). Teaching status, bed size and other measured variables were not different.

Conclusion:
Significant increases in IV tPA treatment among patients arriving < 2hr have occurred over the past decade, and rates of increase vary by hospital characteristics. The profile of tPA treated eligible patients also changes across the range of hospital tPA use rates, with highest performing sites reporting NIHSS in >90% of tPA patients, and treating greater numbers of patients who are non-white or with more severe strokes. Low performing sites may benefit from greater focus on NIHSS assessment and timeliness of care. .
Abstract 218: Do mass media campaigns about stroke influence the number of calls to Emergency Medical Services Dispatch Center?
Authors: FREDERIC Muriel , Ozguler Anna , Loeb Thomas , Baer Michel
Published: July 2021

Introduction:
Raising public awareness of stroke warning signs has been attempted in several places. Studies show that stroke recognition by the public is challenging and efficiency of mass media campaigns remains uncertain. In France, national mass media campaigns have been launched since 2002, including FAST warning signs (http://www.strokeassociation.org). End October 2011, a campaign was launched with radio and TV spots. In fall 2012, radio spots were broadcasted during 10-days and were later followed by other media such as TV and press. Each campaign cost 1.5M$. Influence of these campaigns on the number of calls to Emergency Medical Services dispatch center (EMS) was evaluated during these periods in an EMS, located in Paris area and serving an urban population of 1.5 Million inhabitants.

Methods:
Data concern 1258 calls to EMS for stroke collected from 10/2/2011 to 11/23/2012. Number of calls was analyzed for this time period, with a specific focus on the 2 campaign periods. In addition, patients’ socio-economic profile and delay from symptoms’ onset to call were compared 1 month before and 1 month after these 2 campaigns.

Results:
More calls occurred during the 1
st
campaign, with a rapid normalization of calls afterwards, whereas the 2
nd
campaign did not increase number of calls (figure 1). In 2011 more males called

EMS after the campaign but with no significant difference. In 2012, younger people called more, but with no difference in gender or residential area. The patients did not call earlier after both campaigns (table 1).

Conclusion:
These 2 campaigns had no impact on the amount of calls. Moreeffort should be made on patients’ education and a new strategy to reach target population must be clearly defined.
Abstract 237: Anticoagulant Use For the Prevention of Stroke in Patients with Atrial Fibrillation: Findings From a Multi-Payer Analysis
Authors: Lang Kathleen , Bozkaya Duygu , Patel Aarti A , Macomson Brian , Nelson Winnie , Owens Gary , Mody Samir
Published: July 2021

Background:
Oral anticoagulation is recommended by the American College of Chest Physicians for stroke prevention in intermediate/high stroke risk atrial fibrillation (AF) patients. This study analyzed recent pharmacy and medical claims from Medicaid, Medicare and commercial insurance databases to estimate the risk of stroke, occurrence of stroke hospitalization, and the use of treatment guideline-recommended anticoagulants among patients with AF.

Methods:
Retrospective data analyses were performed using the Anticoagulant Quality Improvement Analyzer, a software tool designed to analyze health plan data to evaluate stroke risk and identify gaps in care in specific populations with AF. Four data sources were analyzed: 1) IMS LifeLink Database (IMS)- includes commercially insured claims; 2) MarketScan Commercial Database (MarketScanComm)- includes commercially insured claims; 3) MarketScan Medicare Supplemental Database (MarketScanMedicare)- includes employer-sponsored Medicare Supplemental plans only; and 4) Florida Medicaid Database (Medicaid). Included patients were ≥ 18 years old with a new or existing diagnosis of AF. The first observed AF diagnosis constituted the index date, with patient outcomes assessed over a maximum of two years. Study measures included stroke risk (as identified by CHADS2 Score), inpatient stroke hospitalization, and anticoagulant use (stratified by stroke risk and hospitalization).

Results:
Total samples (mean age) included 25,710 (71.6) from IMS, 21,976 (56.2) from MarketScanComm, 38,643 (79.7) from MarketScanMedicare, and 4,901 (66.8) from Medicaid. High stroke risk (CHADS2 ≥2 points) was estimated in 54% (IMS), 22% (MarketScanComm), 64% (MarketscanMedicare), and 62% (Medicaid) of the total eligible population. Overall, 35%, 29%, 38%, and 16% of all AF patients received an anticoagulant medication in IMS, MarketScanComm, MarketScanMedicare, and Medicaid, respectively. Among patients at high risk for stroke, 39% (5,414/13,955; IMS), 39% (1,934/4,935; MarketScanComm), 40% (9,822/24,776; MarketScanMedicare), and 19% (566/3,015; Medicaid) received any anticoagulant. Rates of stroke hospitalization ranged from 1 - 2% across databases. Of patients hospitalized for stroke, 28% (173/616; IMS), 37% (54/146; MarketScanComm), 37% (341/912; MarketScanMedicare) and 50% (20/40; Medicaid) were treated with an anticoagulant in the outpatient setting.

Conclusions:
Many AF patients in selected commercial, Medicare-eligible, and Medicaid populations, including those at high risk of stroke, do not receive appropriate thromboprophylaxis, as recommended by treatment guidelines. Increased use of the analyzer and similar software may support enhanced education efforts aimed at improving adherence to guidelines and quality of care.