bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 133: Outcomes Associated With Perioperative Amiodarone in Cardiac Surgery Patients Receiving Metoprolol
Authors: Atreya Auras R , Priya Aruna , Stefan Mihaela S , Pack Quinn R , Lagu Tara , Lotfi Amir S , Lindenauer Peter K
Published: June 2021

Background:
Post-operative atrial fibrillation (POAF) after cardiac surgery occurs frequently and the guidelines make a Class I recommendation for peri-operative betablocker use and a Class IIa recommendation for amiodarone use in high risk patients to reduce length of stay and mortality. Our aim was to study the association between perioperative amiodarone use and clinical outcomes in patients already receiving metoprolol, in a real-world cohort.

Methods:
Using the PREMIER, Inc. data warehouse, we identified patients ≥18 years without atrial fibrillation at baseline, who underwent elective cardiac surgery during years 2013-2014. We included patients with conditions replicating prior randomized controlled studies. We then excluded all patients not receiving metoprolol. Perioperative amiodarone use was defined as administered on the day of surgery or prior to surgery within the same hospitalization. After propensity matching, we compared outcomes for patients receiving perioperative amiodarone + metoprolol vs. those who received only metoprolol. The primary outcome was POAF and secondary outcomes were in-hospital mortality, length of stay and 1 month readmission among survivors.

Results:
Among 4351 patients who underwent cardiac surgery and received metoprolol at 212 hospitals, 997 (23%) were treated with perioperative amiodarone. We matched 928 (94%) of perioperative amiodarone treated group based on the propensity score. Table 1 shows baseline characteristics and outcomes of interest in the propensity matched cohort. Median age was 66 years and 74% were male. The propensity matched cohort was well balanced on type of surgery and comorbidities and some imbalances remained in demographic variables. After adjusting for unbalanced factors in the matched cohort, perioperative amiodarone+ metoprolol was associated with reduction in POAF (ARR 5.1%; RR 0.81, 95% CI 0.69-0.95). There were no differences in in-hospital mortality, length of stay, 1 month readmission or cost of hospitalization.

Conclusions:
In this large cohort of propensity matched patients undergoing elective cardiac surgery, perioperative amiodarone use was associated with a modestly significant reduction in POAF rates, but there were no significant relationships with mortality, length of stay, 1 month readmission or costs.
Abstract 134: Implementation of Home-Based Cardiac Rehabilitation in the VA
Authors: Schopfer David W , Krishnamurthi Nirupama , Shen Hui , Whooley Mary A
Published: June 2021

Objective:
Referral to cardiac rehabilitation (CR) is one of nine performance measures for patients with ischemic heart disease (IHD), but fewer than 20% of eligible patients participate in the United States. Home-based CR programs (available in the United Kingdom, Australia, and Canada) have similar effects on morbidity and mortality as traditional (facility-based) CR, but they are not currently available or reimbursed in the US. We sought to determine whether implementing home-based programs could increase CR participation among patients with IHD.

Methods:
Using electronic health records from 134 VA medical centers, we identified 106,277 veterans hospitalized for acute myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting between 2010 and 2015. We compared the proportion of eligible patients who participated in CR at 13 VA hospitals that offered referral to either home-based CR or facility-based CR vs. 121 VA hospitals that offered referral to only facility-based CR (usual care).

Results:
The number of VA medical centers offering home-based CR increased from 2 in 2010 to 13 in 2015. Among the 20,949 eligible patients hospitalized at VA medical centers that implemented home-based CR between 2010 and 2015, CR participation increased from 11% to 26% (Figure). Among the 85,328 eligible patients hospitalized at VA medical centers that did not offer home-based CR, CR participation increased from only 8% to 11%.

Conclusion:
Among eligible patients with IHD, participation in CR more than doubled at VA medical centers that implemented home-based CR programs between 2010 and 2015, whereas participation increased by only 3% at VA medical centers that did not implement home-based CR programs. Home-based CR is an effective way of engaging patients who may otherwise decline to participate in CR.
Abstract 135: Assessing the Personalization of Glycemic Management Strategies Through the Diabetes Collaborative Registry
Authors: Arnold Suzanne V , Inzucchi Silvio E , McGuire Darren K , Tang Fengming , Mehta Sanjeev N , Goyal Abhinav , Sperling Laurence S , Maddox Thomas M , Einhorn Daniel , Wong Nathan D , Hammer Niklas , Fenici Peter , Sheehan John J , Kosiborod Mikhail
Published: June 2021

Background:
Although practice guidelines stress individualization of glucose management in patients with type 2 diabetes (T2D), the extent to which providers take patient factors into account when selecting medications is not well known. We used data from DCR to evaluate the current real-world landscape of glucose-lowering drugs in key subsets of patients with T2D.

Methods:
DCR is the first large-scale US outpatient registry of patients with diabetes recruited from cardiology, endocrinology, and primary care practices and currently encompasses 374 practices and 5114 providers. T2D medications were grouped as those which are suboptimal for patients with 1) obesity: insulin, sulfonylurea, TZD; 2) elderly (i.e., high hypoglycemia risk): insulin, sulfonylurea; 3) CKD 4/5: metformin, sulfonylurea; and 4) CV disease: sulfonylurea. We examined patient factors associated with use of these groups of meds using 4 hierarchical (for both specialty and site) modified Poisson models, adjusting for HbA1c, number of T2D meds, and insurance.

Results:
Overall, 157,551 patients with T2D were prescribed a med for glycemic control: metformin 75%, sulfonylurea 34%, insulin 28%, DPP-4i 18%, TZD 11%, GLP-1 RA 6.4%, SGLT2i 4.8%. After adjusting patient factors, glycemic control, and insurance status, patients with higher BMIs were
more
likely treated with medications prone to cause weight gain (obesity class I/II: rate ratio [RR] 1.02, 95% CI 1.00-1.03; obesity class III: RR 1.09, 95% CI 1.05-1.12). Older patients were
more
likely to be treated with meds with increased risk of hypoglycemia (RR 1.04 per 5 years, 95% CI 1.03-1.05). Patients with GFR <30 were
less
likely to be treated with meds with known risk in patients with CKD (RR 0.72, 95% CI 0.68-0.76). Patients with CAD were
less
likely to be treated with meds with known CV harm (RR 0.97, 95% CI 0.96-1.00).

Conclusion:
In a large US-based registry of T2D patients, we observed some targeted use of glucose-lowering therapy—in particular, patients with advanced CKD and CAD were not given meds known to be harmful to these patients. However, risk of hypoglycemia and risk of weight gain did not appear to factor substantially into decision making. As these are among several factors that go into drug selection for complicated patients with T2D, conclusions from these data are limited. Nonetheless, in an era of increasing number and complexity of medication choices with varying risk/benefits, databases like the DCR may allow investigators to assess these trends and to highlight potential areas for improvement in pharmacologic personalization, particularly as the use of newer drug classes grows.
Abstract 141: Increasing Storage Age of Transfused Red Blood Cell Units Is Not Associated with Cardiac Surgical Outcomes
Authors: Camaj Anton , Wu Xiaoting , Zhang Min , Engoren Milo , Haft Jonathan W , Likosky Donald S
Published: June 2021

Introduction:
First-in, first-out institutional blood management practices are based on evidence associating increased risk of sequelae from exposure to older red blood cell (RBC) transfusions. Nonetheless, research to date within the setting of cardiac surgery has been limited by previously unmeasured confounding (i.e., use of leukoreduction, timing and volume transfused).

Hypothesis:
After accounting for exposure to leukoreduction and the timing and volume of RBC units, older RBC units will not increase a patient’s odds of developing post-operative sequelae following cardiac surgery.

Methods:
We reviewed 659 adult patients undergoing CABG and/or valve operations between January 1, 2008-December 31, 2015 at a tertiary center. During this time period, all RBCs given to cardiac surgery patients were leukoreduced. To address confounding by timing and volume of RBCs, we analyzed patients receiving 1 or 2 units of RBCs intraoperatively. Logistic regression was used to model the maximum storage age of RBCs against a composite endpoint (prolonged mechanical ventilation, pneumonia, renal failure, operative mortality). We further explored any differences when modeling age of RBCs as quintiles and dichotomously (≥14 vs. <14 days). We present our results using odds ratios and 95% confidence intervals.

Results:
The average maximum storage age of RBCs ranged from 5 to 42 days (mean 20.8, sd: 7.0). The primary endpoint occurred among 122 (18.5%) subjects. There was neither a significant association between increasing age of RBCs and our composite endpoint (OR 1.0; 95% CI 0.98, 1.04), nor evidence of confounding in univariate analysis. These findings were qualitatively unchanged when modeling age of RBCs as quintiles (Figure;
ptrend
=0.50) or dichotomously (OR 1.6; 95% CI 0.88, 2.79).

Conclusion:
In this single center study, we did not detect a significant adverse effect of increasing age of RBCs contrary to prior conclusions. Our findings suggest that current institutional RBC storage policies that prioritize distribution of older age RBC units may not adversely impact patient outcomes following cardiac surgery.
Abstract 154: Adherence to Rivaroxaban Compared to Other Oral Anticoagulant Agents Among Patients With Non-Valvular Atrial Fibrillation
Authors: McHorney Colleen A , Ashton Veronica , Laliberté François , Germain Guillaume , Wynant Willy , Crivera Concetta , Schein Jeffrey , Lefebvre Patrick , Peterson Eric
Published: June 2021

Background:
Adherence to oral anticoagulant (OAC) agents is important for patients with non-valvular atrial fibrillation (NVAF) to prevent potentially severe adverse events.

Objectives:
To compare real-world adherence rates for rivaroxaban vs other oral anticoagulant agents (apixaban, dabigatran, and warfarin) among patients with NVAF using claims-based data.

Methods:
Healthcare claims from the IMS Health Real-World Data Adjudicated Claims database (01/2011-06/2015) were used to assess 6 month adherence rates defined as the percentage of patients with proportion of days covered (PDC) ≥0.8 and ≥0.9. Patients were included if they had ≥2 dispensings of rivaroxaban, apixaban, dabigatran, or warfarin at least 180 days apart (the first was termed as the index date), had > 60 days of supply, had ≥ 6 months of pre-index eligibility, had ≥ 1 AF diagnosis pre-index or at index date, and without valvular involvement. A logistic regression model was used to evaluate adherence to therapy adjusting for sociodemographic and clinical characteristics, insurance type, index month and year, previous OAC use, and mental-health risk factors for non-adherence (e.g., mental disorders, bipolar).

Results:
A total of 13,645 rivaroxaban, 6,304 apixaban, 3,360 dabigatran, and 13,366 warfarin patients were identified. A significantly higher proportion of rivaroxaban users were adherent to therapy (PDC ≥ 0.8 at 6 months vs apixaban, dabigatran, and warfarin users; Table). After adjustment, the proportion of patients adherent to therapy remained significantly higher for rivaroxaban users vs apixaban (absolute difference [AD]: 5.8%), dabigatran (AD: 9.5%), and warfarin users (AD: 13.6%; all P<0.001; Table). More pronounced differences were found with a PDC ≥0.9 (Table).

Conclusion:
Among NVAF patients, rivaroxaban was associated with significantly higher adherence rates relative to other OACs, whether using a PDC of ≥0.8 or ≥0.9, which could translate into improved patient outcomes and lower healthcare costs.
Abstract 161: Lean Process Improvements Reduce Door to CT and Door to Needle Times for Acute Ischemic Stroke Patients
Authors: McCann Cory , Tkach Aleks , de Havenon Adam , Loosli Joel , Troyer Jamie , Bennett Alicia , Wold Jana , Jex Alicia , Majersik Jennifer J
Published: June 2021

Background:
In late 2015, we assembled a multi-disciplinary team to analyze current emergency department (ED) processes and identify improvement opportunities in the current “brain attack” (BA) protocol. Using lean process engineering tools, including time study analysis, gemba walks, and cause and effect diagrams, we mapped our baseline state and identified delaying activities that did not add value to the BA process. We defined a new BA process (see Figure 1) to eliminate waste and improve team communication, including 3 Time Outs to ensure that increased speed didn’t decrease safety.

Methods:
To determine the effect of our intervention, we retrospectively reviewed patients who were admitted to our ED as a BA for evaluation of possible acute ischemic stroke and had a CT brain after ED arrival between April 2015 and August 2016. ED arrival was defined as the time that patients physically arrived at the ED and “time to CT” was the time from ED arrival to the first time stamp of the CT brain. The time from ED arrival to tPA bolus was also measured for "door to needle" time. The time to CT and door to needle times were compared between BA patients before and after lean process improvements using Student’s T-test.

Results:
Our cohort included 239 patients who presented to the ED as a BA. We included 116 BA patients from before the intervention and 123 from afterwards. The mean±SD time to CT prior to the intervention was 19.0±13.9 minutes. After our lean process improvements the time to CT was 14.2±15.6 minutes. The delta of 4.8 minutes resulted in a significant reduction in time to CT, p = 0.012. There were 14 patients who received tPA prior to the intervention and 9 afterwards, for a total of 23 door to needle times (10% of cohort). Door to needle time was significantly shortened post-intervention (46±13 minutes versus 32±12 minutes, p=0.013).

Conclusions:
Lean process improvement methodology significantly reduces door to CT and door to needle times, supporting current AHA Target: Stroke goals and allowing faster treatment of patients with acute ischemic stroke. Incorporating time-outs into standardized processes that aim to deliver care more quickly may improve patient safety without substantially slowing down DTN times. Further investigation is required to determine whether the new process improved safety and clinical outcomes.
Abstract 167: Correlation of 30-day Hospital Readmission Rates by Payer and Penalty Status
Authors: Butala Neel M , Kramer Daniel B , Strom Jordan B , Kennedy Kevin F , Yeh Robert W
Published: June 2021

Background:
Readmission rates for heart failure (HF), acute myocardial infarction (MI), and pneumonia (PNA) hospitalizations among Medicare beneficiaries are used to assess hospital quality and determine global reimbursement. However, whether these measures reflect readmission rates for other conditions or insurance groups is unknown.

Methods:
All hospitals with >30 index admissions for HF, MI or pneumonia in 2013 in the all-payer Nationwide Readmissions Database (NRD) were included. For each hospital, we estimated 30-day all-cause risk-standardized readmission rates (RSRRs) for 3 groups: (A) Medicare beneficiaries admitted with HF/MI/PNA, (B) Medicare beneficiaries admitted for other conditions, and (C) non-Medicare beneficiaries admitted for HF/MI/PNA. Pair-wise correlations of these measures were assessed using Spearman correlation coefficients. Hospitals were divided into quartiles based on their calculated RSRR for each group, and inter-rater agreement between groups was assessed using weighted kappa statistics. We then examined pair-wise Spearman correlations among subgroups based on hospital characteristics (size, ownership status, and teaching status).

Results:
Among 1,228 hospitals, wide variation in RSRRs was seen across conditions and insurance type. Groups A vs. B had moderate correlation and agreement (Spearman 0.631, quartile weighted kappa 0.440). However, A vs. C had only modest correlation and fair agreement (Spearman 0.399, quartile weighted kappa 0.243). Compared with their quartile rank for the publicly reported group A, 46% of hospitals were ranked in the same quartile for group B and 35% for group C (Figure). Correlations between groups A vs. B and A vs. C were strongest among metro teaching hospitals (Spearman 0.674 and 0.507, respectively).

Conclusions:
Risk-standardized readmission rates for HF/MI/PNA are generalizable measures of a hospital’s readmission rate for other conditions among Medicare-insured patients. However, publicly reported RSRRs for HF/MI/PNA among Medicare patients are less suitable measures of hospital performance for non-Medicare patients admitted for these conditions.
Abstract 169: Early Intravenous Beta-Blockers in Patients With ST-Segment Elevation Myocardial Infarction
Authors: Sharma Abhishek , Sharma Samin , Mukherjee Debabrata , Garg Akash , Lavie Carl , Marmur Jonathan
Published: June 2021

Background:
It remains unclear if early use of intravenous (IV) beta-blockers (iBB) improves clinical outcomes patients with ST-segment elevation myocardial infarction (MI; STEMI), especially among those who received reperfusion therapy.

Objective:
To evaluate effect of early iBB use on clinical outcomes among patients with STEMI.

Methods:
A systematic review of randomized control trials in MEDLINE, EMBASE, CINAHL, and Cochrane databases comparing early use (administered within 12 hours of presentation) of iBB with standard medical therapy/placebo among patients who presented with STEMI. The effect of iBB was assessed by stratifying studies into pre-reperfusion and reperfusion trials and pooled treatment effects were estimated using relative risk with Mantel-Haenszel risk ratio, using a random-effects model

Results:
Twenty-one studies (N=74,801) were selected for final analysis. Clinical outcomes at 30 days and 1 year are summarized in table below.

Conclusion:
In the current reperfusion era, early use of iBB in patients with STEMI was associated with reduction in the risk of recurrent MI and ventricular tachyarrhythmias without any significant reduction in all-cause or CV mortality or increase in the risk of cardiogenic shock.
Abstract 173: Simple Guidance Improves Appropriate Telemetry Utilization
Authors: Potluri Alekhya , Kudaravalli Mrudula , Defail Anthony , Prabhakaran Dilip , Prabhakaran Sangita , Reilly James B , Kapetanos Anastasios
Published: June 2021

Introduction:
Cardiac telemetry is an in-hospital monitoring tool intended for ischemia surveillance, monitor QT-interval prolongation, and detect arrhythmias. It is a costly and limited resource that is frequently misused. Inappropriate telemetry use can lead to prolonged hospital stays, patient discomfort, alarm fatigue, and increased healthcare costs. We designed and implemented a telemetry guideline independent of the electronic health record (EHR) in an attempt to increase appropriate telemetry use in non-intensive care unit (ICU) setting

Objectives:
To design and implement a telemetry guideline. To increase appropriate use of telemetry. To practice cost-conscious, high-value care

Aim: Primary Aim:
Implement a telemetry guideline using pocket cards and educational conferences and monitor telemetry assignments

Secondary Aim:
Assess patient outcomes as reflected by the number of codes before and after the intervention

Methods:
We adopted telemetry criteria based on the American Heart Association guidelines from 2004 and other published literature. Baseline data was collected in November 2015 for all medicine teaching team admissions at our institution that came through the emergency department. Exclusion criteria were ICU transfers, step-down units, and direct admissions. Guidelines were then implemented via educational conferences and pocket card distribution to ED physicians, admitting hospitalists and medicine residents. Post-intervention data was collected from February through March 2016

Results:
Of 180 admissions prior to guideline implementation, 93 patients (52%) went to non-telemetry beds and 87 patients (48%) to telemetry beds. Of the telemetry admissions, 60 patients (69%) were appropriately assigned to telemetry while 27 (31%) were not. After the guideline was implemented, 255 patients were reviewed. Of these, 110 (43%) went to telemetry beds, and 86 patients (78%) were appropriately assigned while 24 patients (22%) were not. There was no significant increase or decrease in the number of codes post intervention. Cost analysis revealed 103 telemetry-bed-days saved per month

Conclusion:
Our intervention resulted in a large (9.1%) but statistically insignificant increase in appropriate telemetry use. Although statistically insignificant, this improvement was durable across two months. Cost analysis revealed 103 telemetry-bed-days saved per month with an estimated savings of $100,000 in unnecessary charges. The relatively simple and cost-effective intervention of creating and implementing a telemetry assignment guideline was effective in changing telemetry ordering behavior. This was done without telemetry assignment logic in the EHR, which can be a tedious and time-consuming endeavor. Future efforts will include the implementation of a telemetry auditing tool, and ultimately the embedded logic to facilitate ordering practices.
Abstract 178: Byvalson Fixed-Dose Combination for the Treatment of Hypertension: A Comprehensive Review
Authors: Wight Charles E , Jara Nicole , Harlan Chelsea , Petrillo Paul , Poulakos Mara N
Published: June 2021

Purpose:
Byvalson (nebivolol and valsartan), FDA approved in June 2016 for the treatment of hypertension, is the first combination beta blocker and ARB fixed-dose combination medication available. Two-thirds of patients with hypertension require more than one drug to achieve BP control. The combination of two antihypertensive medications has been associated with greater BP control, compliance, and reduced adverse effects. Nebivolol is a highly selective β1-adrenergic receptor antagonist with vasodilator properties and valsartan is an ARB. The objective of this study is to evaluate clinical efficacy and safety of this combination of BP-lowering medications in the treatment of hypertension.

Methods:
A comprehensive literature search was conducted to date utilizing MEDLINE and PUBMED with the following search terms: “nebivolol”, “valsartan”, and “hypertension” to retrieve clinical trials. The following three studies were found: a phase I randomized, open-label study investigating pharmacokinetic and pharmacodynamic interactions between nebivolol and valsartan; and two phase III studies evaluating the safety and efficacy of combination treatment: one is an open-label, single-arm study over 52 weeks and the other is a phase III randomized, placebo-controlled study comparing fixed-dose combination to nebivolol and valsartan alone over 8 weeks. Analysis of the study designs, methods, results, statistical analyses, and conclusions were properly conducted for appropriateness and validity.

Results:
The pharmacokinetic and pharmacodynamics parameters in the phase I study involving 30 patients had statistically significant steady-state PK interactions deemed not clinically significant, significant reductions in blood pressure (p≤0.005) and other PD interactions. A phase III trial (n=4161) showed significantly greater reductions from baseline at 8 weeks in DBP in the fixed-dose combination group than both nebivolol 40 mg (mean difference –1.2 mm Hg [95% CI, –2.3 to –0.1; p=0.030] and valsartan 320 mg (–4.4 mm Hg [95% CI, –5.4 to –3.3]; p<0.0001). SBP reductions were also significant (p<0.01). Another phase III trial (n=810) showed significant reductions from baseline at 52 weeks for SBP (-25.5±15.9 mm Hg) and for DBP (-19.0±8.7 mm Hg). 75.7% of nebivolol/valsartan and 57.8% of nebivolol/valsartan/HCTZ patients achieved a BP goal of <140/90.

Conclusion:
Both phase III trials evaluating the combination treatment of nebivolol and valsartan demonstrated long term safety, efficacy, and tolerability with significant reductions in systolic and diastolic blood pressure compared with monotherapy. The phase I study showed limited PK interactions, additive PD effects, and tolerability in healthy volunteers. As an initial therapy in patients with inadequately controlled blood pressure, Byvalson 5/80 mg taken orally once daily is a safe and effective treatment for the hypertension.
Abstract 184: Quality Improvement of Statin Therapy Appropriateness in Type 2 Diabetic Patients
Authors: Li Dan L , Diaz Narvaez Erika , Onyekwelu Chioma , Weinstein Eleanor M , Faillace Robert T
Published: June 2021

Objectives:
The 2013 ACC/AHA guidelines recommend statin therapy for all diabetic patients between the ages of 40 to 75. The intensity of statin therapy is guided by the 10-year atherosclerosis cardiovascular disease (ASCVD) risk for a given patient. A quality-improvement project was carried out in the Jacobi Medical Center (JMC) Primary Care Medicine clinic to help clinicians improve statin therapy appropriateness. Interventions included: Intense education to house staff and clinic faculty members beginning in November 2015; Establishment of a pre-visit planning system beginning in August 2016 whereby nursing staff would preview the lipid panel of diabetic patients and alert providers when the LDL was above 100 mg/dl. A retrospective study was carried out to evaluate statin therapy appropriateness before and after this quality improvement project.

Methods:
Type 2 Diabetes Mellitus (T2DM) patients (age between 40-75) were selected from the JMC Medicine Clinic visits in September 2015 (baseline), May 2016 (after intense education), and September 2016 (after launching the pre-visit planning system). Exclusion criteria included: heart failure, ESRD on hemodialysis, active malignancy, and missing information for ASCVD risk calculation. In patients with LDL > 70 and with no history of CVD, the 10-year ASCVD risk was calculated and statin appropriateness was determined by comparing the actual statin prescription with the statin intensity suggested by the 2013 ACC/AHA guidelines. For patients who had an established diagnosis of CVD, statin therapy appropriateness was evaluated by whether the patients were on high-intensity statin therapy. Comparisons among groups were performed using chi-square analysis.

Results:
The numbers of patients in each of the three months after the exclusions were 371, 346 and 358; among which, 68, 70 and 77 patients had existing CVD respectively. Overall, 38.8% of the patients seen in September 2015 were prescribed an appropriate statin dose; the number rose to 42.2% in May 2016, and further to 50.0% in September 2016 (
p
= 0.0086).

For primary prevention of CVD, 35.3% of patients received an appropriate statin dose in September 2015; this number improved to 38.5% in May 2016, after intense education; and to 44.2% in September 2016. (
p
= 0.089)

For secondary prevention of CVD events in patients with clinical CVD, 54.4% of the patients in September 2015 were given high-intensity statins. The high-intensity statin prescription rate was 57.1% in May 2016, and subsequently increased to 70.1% in September 2016. (
p
= 0.11)

Conclusions:
Significant improvement in compliance with the 2013 ACC/AHA guideline-based statin dose for lipid management in the JMC Primary Care Medicine Clinic was found to be associated with the implementation of a quality-improvement project consisting of intense physician education and a pre-visit planning system.
Abstract 190: Risk Factors and Outcomes of Hyperbilirubinemia Following Transcatheter Aortic Valve Replacement
Authors: Jou Stephanie , Zhang Li , Bulibek Batyrjan , El-Hajjar Mohammad , Delago Augustin , Torosoff Mikhail
Published: June 2021

Background:
It has been established that postoperative hyperbilirubinemia is associated with increased mortality and morbidity after cardiac surgery. However, hyperbilirubinemia after transcatheter aortic valve replacement (TAVR) has not yet been a subject of clinical research. We evaluated the incidence and risk factors of post-TAVR hyperbilirubinemia, and aimed to determine its prognostic significance.

Methods:
A retrospective observational study was conducted on 241 consecutive TAVR patients between January 2011 and December 2014 in our institution. We excluded 15 patients with documented chronic hepatic or biliary disorders, or prior liver transplant. Hyperbilirubinemia was defined as any value above the upper limit of normal total bilirubin within 1 week of TAVR.

Results:
Eighty-two patients out of 226 (36.3%) had post-TAVR hyperbilirubinemia. After adjustment for confounders, there was no significant difference in in-hospital mortality (3.7% (3 of 82) vs. 1.4% (2 of 144); p-value = 0.26) and 1-year mortality (7.3% (6 of 82) vs 5.6% (8 of 144); p-value = 0.60) between patients with and without elevated bilirubin following TAVR. However, there was a trend for hyperbilirubinemic patients to have a longer intensive care unit stay (145.3 +/-202.2 hours vs. 113.2 +/-93.4 hours; p-value = 0.14) and hospital stay (14.1 +/-11.2 days vs. 12.1 +/-8.6 days; p-value = 0.16). Multivariable analysis revealed that preoperative hyperbilirubinemia (hazard ratio 62.88, 95% confidence interval 15.80 to 250.32; p-value <0.0001) and preoperative atrial fibrillation (hazard ratio 2.40, 95% confidence interval 1.21 to 4.78; p-value = 0.01) were strongly associated with post-TAVR hyperbilirubinemia.

Conclusions:
The cause of post-TAVR hyperbilirubinemia may be multifactorial. It is not a rare event and may impact the short-term outcomes. Thus, monitoring bilirubin should be considered an integrated part of TAVR patient care. Optimal management of post-TAVR hyperbilirubinemia remains challenging.
Abstract 197: Root Cause Analysis of 30-day Heart Failure Readmission Elucidates Acute Kidney Injury as a Common Offender
Authors: Loewenstein Devin , Scott Brandon , Afsarmanesh Nasim , Dermenchyan Anna , Fonarow Gregg
Published: June 2021

Background:
Hospitalization for heart failure (HF) and heart transplant is associated with a high likelihood of readmission within 30 days of discharge. Our study objective was to identify risk factors and causes for readmission at a high acuity tertiary academic medical center in order to develop targeted interventions aimed at HF readmission reduction.

Methods:
We retrospectively reviewed 49 sequential cases of patients readmitted within 30 days of hospitalization for HF (41) or heart transplant (8) between Q3-Q4 2014. Two unblinded reviewers determined the root causes of readmission, likelihood of readmission prevention, and interventions most likely to prevent similar readmissions from recurring.

Results:
HF exacerbation was the primary reason for readmission in 47% (23/49) of cases. Also in 47% (23/49) of the readmissions, the possibility for preventing the readmission had an appropriate intervention been implemented was determined to be at least 50%. The other 53% (26/49) of readmissions were considered unlikely to have been readily preventable. Medical complications were the primary cause of readmission in 14% (7/49) of cases, of which acute kidney injury (AKI) was the most common. Over one-fourth (13/49) of all readmissions were found to have at least a 15% increase in creatinine level from time of discharge to time of readmission. Dietary indiscretion (8% i.e. 4/49), psychosocial factors (8%), and progression of disease (8%) were other notable root causes for readmission. When assessing the most likely part of patient care to address to prevent readmission, more proactive follow-up/monitoring was considered to be the most high-yield intervention in 14% of cases i.e. 7/49. Also of note, reclassifying admissions as observation status based on length of stay would have prevented 33% (16/49) of cases from meeting readmission criteria.

Conclusion:
Our study supports a multifaceted, multidisciplinary approach to reducing HF readmissions, given the array of readmission causes and targeted areas for intervention identified. It also demonstrates that AKI may be an underappreciated cause for readmission, with 28% of all-cause readmissions presenting with creatinine elevations of at least 15%. Therefore, in addition to a multidisciplinary approach to discharge planning, we recommend institutions implement specific strategies to reduce AKI.
Abstract 201: Distribution of Initial Treatment and First Modification of HF
r
EF Pharmacotherapy in a Medicare Managed Care Cohort
Authors: Albert Nancy M , DeClue Richard , Antol Dana Drzayich , Waldman Casebeer Adrianne , Li Yong , Stemkowski Stephen , Chang Chun-Lan
Published: June 2021

Introduction:
Heart failure (HF) and reduced ejection fraction (HF
r
EF) requires timely ACC/AHA guideline recommended treatment (Tx) with multiple pharmacotherapies, including renin-angiotensin system and sympathetic nervous system blockers. The relationship between initial pharmacotherapies (IPT) and treatment modifications ([TM]: add-on or switch to a new class, or discontinuation of IPT) in real world practice is not well understood.

Methods:
This retrospective cohort study identified Humana Medicare managed care patients (pts) with ≥2 claims for HF from 8/2010-7/2015. The 1st HF claim was the index date. Patients had 1-year (yr) continuous enrollment, no HF diagnosis prior to index, and continuous enrollment 2-yrs post-index or until death. A claims-based algorithm was used to derive HF
r
EF status. IPT were mono- or combo-use of ACE-inhibitor (ACEI), angiotensin II receptor blocker (ARB), beta blocker (BB), hydralazine-nitrate (HN), and aldosterone antagonist (AA) in 1 yr post-index. No IPT was no drug use, only 1 fill, or <28-day supply in the 1st yr. Time from IPT to 1
st
TM in 2 yrs post-index and subsequent therapies were identified.

Results:
Of 14,359 HF
r
EF pts, mean (SD) age was 75 (±8) yrs; 45% were female. Post-index, 32% had no IPT after 1 yr, 61% had IPT within 1 month, and 7% initiated IPT after the 1
st
month. Of pts with IPT (n=9705), 48% received mono vasodilators (ACEI/ARB or HN), 17% mono BB, 23% vasodilator+BB, and 4% triple therapy [(ACEI/ARB)+BB+(HN or AA)]. Among pts on IPT, 52% had 1
st
TM within 2 yrs post-index, with 26% adding a new class, 7% switching to a new class, 9% discontinuing a class of IPT, and 9% discontinuing all IPT. Mean (SD) time from IPT to 1
st
TM was 9 (±7) months. For pts with subsequent therapies after 1
st
TM, vasodilator+BB was most common (41%), followed by mono vasodilator (15%); then triple therapy (12%). (Table 1)

Conclusion:
Despite national HF
r
EF Tx guidelines recommending combo use of vasodilator+BB, nearly 1/3 of pts had no IPT within 1 yr post-index and over ½ received mono Tx as IPT. Of pts on IPT, mean time to 1
st
TM was 9 months and few initiated triple therapy. In clinical trials, dual (vasodilator+BB) or triple therapies improved health outcomes. Consequences of HF pharmacotherapy gaps warrant further study.
Abstract 203: Gender Differences in PCSK9 Inhibitor Prescribing
Authors: Boklage Susan , Elassal Joseph , Gervasio Joseph , Gupta Rishab
Published: June 2021

Background:
Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) alirocumab (Sanofi and Regeneron) and evolocumab (Amgen) were approved by the FDA in the summer of 2015 for use in patients on maximally tolerated statins with clinical atherosclerotic cardiovascular disease (ASCVD) and heterozygous familial hypercholesterolemia (HeFH) who require additional lowering of low-density lipoprotein cholesterol (LDL-C). Both clinical trial programs were skewed towards male participants so little is known about the characteristics of female patients treated with PCSK9i in real-world settings.

Objective:
To understand the demographic and clinical differences between male and female patients prescribed a PCSK9i in real-world settings.

Methods:
All patients 18 years of age and older with evidence of a PCSK9i prescription (Rx) between July 27, 2015 and November 1, 2016 were included from Accenture’s “Predictive Health Intelligence Environment”, a database consisting of electronic medical records (EMR) from 26 integrated delivery networks in the US. Patients were also required to have at least one encounter in the EMR in the 24-month period prior to the first PCSK9i Rx. Demographic and clinical characteristics of these patients were evaluated as well as the Rx history prior to the first PCSK9i Rx.

Results:
The inclusion criteria were met by 1,754 patients with 906 (51.7%) being female. Mean (SD) age was 65.9 (10.4) for females compared to 64.3 (10.3) for males; however, a higher proportion of females (59.6%) were over age 65 as compared to males (51.5%, difference not significant). Females were statistically less likely to have a prior event for ASCVD (54% vs. 73%, p<0.0001). Additionally, females were significantly more likely to have a BMI < 25 kg/m
2
compared to males (19.1% v. 11.0%, p<0.001). No differences were observed in prescribing specialty, prior lipid modifying treatment or history of smoking. Finally, females had a significantly higher mean baseline LDL-C as compared to males (149.4 mg/dL [58.2] v. 123.9 mg/dL [56.6], p<0.001).

Conclusions:
Despite the clinical trial programs of both PCSK9i’s being skewed toward male participants, this real-world data consisted of nearly equal numbers of males and females. In this study, females were more likely to be identified as FH, as indicated by their significantly higher levels of LDL-C, despite similarities in prior treatment regimens as compared to males. Further research is warranted to understand diagnosis and treatment patterns in women as compared to men as well as how their cardiovascular health can be improved.
Abstract 205: Reassessing the Impact of Hospital PCI Volume on STEMI Outcomes
Authors: Langabeer James R , Helton Jeffrey , Kim Junghyun , Fowler Raymond
Published: June 2021

Background:
Guidelines and Class I AHA/ACCF recommendations suggest that high volume percutaneous coronary interventions (PCI) centers produce better patient outcomes than lower-volume centers. Although limited research suggests that volume matters, most of this research is not current, and was not conducted using hospitals from a fully developed regionalized system of care.

Objective:
To assess the relationship between hospital PCI volumes and two key patient outcomes: door-to-balloon (D2B) and mortality.

Methods:
We examined 9,674 STEMI patients who underwent primary percutaneous intervention and 18,539 non-STEMI patients. We relied on data from a developed regional system of care in Dallas County, which has been organized for the last five year and represents 33 PCI-capable hospitals. We used data extracted from the National Cardiovascular Data Registry Action Registry from the 2010-2015. Center volume was divided into three groups: low (<200 PCIs/year), intermediate (between 200-400 PCIs/year), and high (>400 PCIs /year) volumes. We analyzed the data using general linear regression model and logistics regressions. We incorporated institutional covariates as controls, including hospital size (number of beds), teaching status, geographic location (suburban, urban), and percent of managed care. Further, we controlled for patient-level differences by incorporating type of transportation (self, EMS), patient age and gender, and patient’s condition on presentation (shock, heart failure).

Results:
Mortality and door-to-balloon time were examined for each group. Unadjusted mortality rate and door-to-balloon time were significantly higher in low-volume hospitals compared with high-volume hospitals (6.2% versus 4.2%, p<0.001; 187 min. versus 114 min., p<0.005, respectively). Statistically significant association was found between volume of PCIs and D2B for those who underwent ST-elevation myocardial infarction groups. Intermediate- and high-volume centers are more likely to shorten the D2B compared to low-volume centers (OR: 3.08, P<0.04; OR: 1.29, P<0.001). Mortality was no longer significant in the multivariate analysis, adjusting for other covariates. Overall, high volume operators had better outcomes than low volume operators.

Conclusions:
The higher-volume PCI hospitals have significantly reduced treatment times. This analysis of contemporary PCI suggests that volume persists as a significant influence on outcomes for STEMI, even in amidst growth of sophisticated, regional systems of care.
Abstract 211: Implications of the PEGASUS-TIMI 54 Trial for U.S. Clinical Practice
Authors: Bradley Steven M , Hess Gregory , Stewart Patrick , Armstrong Ehrin , Farmer Steven , Wasfy Jason , Valle Javier , Sandhu Amneet , Maddox Thomas
Published: June 2021

Background:
The PEGASUS trial demonstrated a reduction in ischemic events following P2Y
12
inhibition with ticagrelor among patients with a prior MI. The implications of these findings for clinical practice are unknown.

Methods:
We sought to determine the proportion of real-world myocardial infarction (MI) patients who would have been eligible for the PEGASUS-TIMI 54 trial, to characterize their current use of P2Y12 inhibitors, and to explore the estimated costs and ischemic event consequences of increasing P2Y12 inhibitor use among these patients. In the U.S. national ACTION Registry-GWTG, We identified 273,328 MI patients and determined the proportion that would have met the eligibility criteria for the PEGASUS trial. We described longitudinal P2Y
12
inhibitor use among PEGASUS eligible patients and estimated the cost and ischemic consequences of increasing P2Y
12
use among eligible patients.

Results:
A total of 112,222 (41.1%) MI patients in ACTION Registry-GWTG met eligibility for the PEGASUS trial. Among 83,871 eligible patients with pharmacy claims data, 23,042 (27.5%) were on a P2Y
12
inhibitor at 1 year, 9,661 (11.5%) at 2 years, and 5,246 (6.3%) at 3 years (see Figure), with the majority (79.2%) of these patients on clopidogrel. Use of ticagrelor in eligible patients not already on a P2Y
12
inhibitor at 1-year post MI would cost an estimated $885,000 per myocardial infarction, stroke, or cardiovascular death averted over a 3-year time horizon, while use of clopidogrel would cost an estimated $19,800 per ischemic event averted.

Conclusions:
In contemporary clinical practice, a minority of patients are on a P2Y
12
inhibitor beyond 1-year post-MI. Applying PEGASUS trial findings to clinical practice would result in a large increase in P2Y
12
inhibitor use with a cost per ischemic event averted that is strongly influenced by the choice of therapy.
Abstract 219: Interdisciplinary Education and Relationship Building Improve Communication and Coordination in Stroke Care
Authors: Thorson Shila , Sather Jeffrey , Alexander Jerilyn , Cook Mindy
Published: June 2021

Introduction:
Acute stroke care involves collaboration among multiple disciplines across the continuum of care. Interdisciplinary education consist of two or more disciplines collaborating in the learning process with the objective of promoting interprofessional coordination that improves the patient care provided by each discipline. The North Dakota Stroke System of Care (NDSSoC) Taskforce was legislatively was legislatively created in 2009 and is composed of a multidisciplinary group that collaborates to provide recommendations in the development of the North Dakota Stroke System of Care.

Hypothesis:
Interdisciplinary education and relationship building among hospital nursing staff and emergency medical services (EMS) staff will lead to an increase in advanced notification of stroke patients by EMS to the receiving hospital and result in an increase of stroke patients receiving a computed tomography (CT) scan within 25 minutes of arrival to hospital.

Method:
EMS and hospital staff is provided education at the statewide level through educational modules, regional conferences, an annual state stroke conference beginning in 2012, and at least sixteen occurrences of Primary Stroke Center stroke coordinator outreach. The NDSSoC Data was analyzed through use of the Get With the Guidelines® Patient Management Tool using 2010 as baseline data and comparing to 2015 data.

Results:
The percent of stroke cases with advanced notification by EMS for patients transported by EMS from scene in North Dakota increased from 56% in 2010, to 77.4% in 2015, surpassing the national average of 55.9%. Percent of patients arriving via EMS from home/scene who receive brain imaging (CT) within 25 minutes of arrival to hospitals in North Dakota increased from 23.8% in 2010 to 48.8% in 2015.

Conclusion:
Through providing education to EMS providers and building relationships between EMS and hospitals, there has been a significant increase in pre-notification by EMS therefore improving timeliness of CT scans in acute stroke patients.
Abstract 230: A Personalized Shared Decision Making Process Improves the Quality of Decision Making by Older Patients Referred for Cardiac Surgery
Authors: Gainer Ryan , Begum Jahanara , Wilson-Peace Emma , Hirsch Greg
Published: June 2021

Background:
Comprehension of risks, benefits, and alternative treatment options is poor among patients referred for cardiac interventions. We have demonstrated that an increasing proportion of frail and elderly patients are undergoing complex cardiac surgical procedures with increased risk of both mortality and prolonged institutional care. The objective of the current study is to explore the impact of a formalized shared decision making (SDM) on patient comprehension and decisional quality.

Methods:
A decision aid for cardiac surgery was developed and evaluated within the context of a pre-post study design. Surgeons were trained in SDM. Research team members acted as decisional coaches, going through the decision aids with the patients and their families. Patients (65 and over) undergoing isolated valve, Coronary Artery Bypass Graft (CABG) or CABG+Valve surgery were eligible. Participants in the pre-intervention phase (n=100) were followed through the standard course of care to establish a baseline. Participants in the interventional group (n=100) were presented with a decision aid following cardiac catheterization populated with individualized risk assessment, personal profile, and co-morbidity status. Surgeon training in SDM occured just prior to instituting the post intervention phase. Decisional coaching only applied to the post intervention phase. Both groups were assessed pre-operatively on comprehension, decisional conflict, decisional quality, anxiety and depression, Primary outcomes were comprehension and decisional quality scores.

Results:
Patients who received decision aids through a formalized shared decision making approach scored higher in comprehension (median: 15.0; IQR: 12.0-18.0) compared to those who did not (median: 9.0; IQR: 7.0-12.0) (p < 0.001). Decisional quality was greater in the interventional group (median: 82.2; IQR: 73.0-91.0) compared to those in the pre-intervention group (median: 75.6; IQR: 62.0-82.0) (p < 0.05). Anxiety and depression scores showed no significant difference between pre-intervention (median: 9.0; IQR: 4.0-12.0) and post-intervention groups (median: 7.0; IQR: 5.0-11.0) (p < 0.28).

Conclusions:
Institution of a formalized shared decision making process including Individualized decision aids improve comprehension of risks, benefits and alternatives to cardiac surgery, decisional quality, and did not result in increased levels of anxiety.