bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P214: Managing multiple risk factors among adults with heart disease; Does arthritis play a role? Behavioral Risk Factor Surveillance System United States, 2005 and 2007
Authors: Bolen Julie , Murphy Louise , Greenlund Kurt , Moss Susan , Keenan Nora , Qi Xiaopeng
Published: July 2021

Purpose:
Modifiable risk factors including high blood pressure, high cholesterol, diabetes, obesity, physical inactivity and smoking can increase the risk of heart disease (HD). Arthritis is a common comorbidity among people with HD and may interfere with the control of these risk factors by limiting physical activity due to arthritis-associated joint pain. We describe the prevalence of multiple risk factors among adults with HD and arthritis compared to those with HD only for the US population and by state.

Methods:
Using 2005 and 2007 combined Behavioral Risk Factor Surveillance System data for all 50 states and DC, we estimated the prevalence of 1) 6 risk factors: high blood pressure, high cholesterol, diabetes, smoking, obesity and physical inactivity and 2) 2 or more risk factors among 4 subpopulations of adults: those with HD and arthritis; HD only; arthritis only; or neither condition. Prevalence estimates were generated for the US population overall and by state

Results:
Arthritis affects 57% of adults with HD, compared with 27% of adults in the general population; in 48 of 50 states, over 50% of adults with HD have arthritis. Among adults with HD and arthritis, the age-adjusted prevalence of hypertension (63.9%), high cholesterol (64.3%), diabetes (27.5%,) physical inactivity (26.0%), obesity (43.7%) and smoking (36.3%) was significantly higher compared to those with HD only, arthritis only, or neither condition. The age-adjusted prevalence of 2 or more risk factors for adults with arthritis and HD was 77.4% compared to 55.8% for adults with HD only, 45.3% with arthritis only and 24.6% for those with neither condition. .

Conclusions:
Adults with both arthritis and HD are more likely to have multiple risk factors. Arthritis might pose a special barrier, particularly for physical activity and obesity, which may impact multiple HD risk factors such as those examined here. These findings demonstrate how different chronic diseases may interact, and provide evidence for greater integration of chronic disease prevention efforts.
Abstract P222: Percutaneous Coronary Intervention in Hospitals Without Surgery on Site: One Year Follow-Up From a Longitudinal Registry
Authors: Gonzalez Jorge , Gupta Ankur , Alkhouli Mohamad , Kashem Abdul , Scheiring Kristy , Bove Alfred A
Published: July 2021

Background:
The safety of performing elective percutaneous coronary intervention (PCI) in hospitals without surgery on site (SOS) has been questioned. We assessed the safety of this practice in a one year follow up study.

Methods:
485 patients underwent elective (PCI) in two network hospitals without (SOS) were followed for one-year in a longitudinal registry. Baseline demographics, hemodynamics, and renal function were recorded for each patient before and after PCI. Clinical data were obtained at 6 weeks, 3, 6, 9, and 12 months.

Results:
Baseline demographics: Mean age was 68±12 years, 67% were male, BMI: 28.9±5.3. Comorbidities included heart failure-8.4%, carotid artery disease-7%, hypertension-80%, IDDM-9%, NIDDM-20%, PAD-6%, smoking-22%, prior PCI-31%. Systolic BP: 146±24 mmHg, diastolic BP: 79±15 mmHg, creatinine: 1.1±0.7mg/dl, Total Cholesterol: 157±40 mg/dl, EF: 52±14%. Total number of stents used was 558 (28% Bare-metal stents and 72% Drug eluted stents). Death, all cause readmissions, repeat PCI, CABG, and angina symptoms were recorded at each time interval (See
table1
). At one year 95% were taking aspirin and 89% were taking clopidogrel. No correlation was noted between clopidrogel use and repeat PCI.

Conclusions:
One year follow up after PCI in hospitals without SOS demonstrates acceptable rates of immediate complications and long term outcomes. The data suggest that elective PCI can be performed safely in hospitals without surgery on site.

Time Interval
Death
Readmit
Repeat PCI
CABG
Angina Symptoms

6 weeks
1%
7%
1.2%
1%
6.4%

3 months
0.4%
5%
0.6%
1%
6.9%

6 months
0.8%
7%
1.1%
0%
9.4%

9 months
0.4%
4%
9.3%
1%
10.4%

12 months
0.4%
3%
6.8%
0%
7.4%
Abstract P226: The German Invasive Cardiology Quality Registry QuIK
Authors: Levenson Benny J , Albrecht Alexander , Goehring Stefan , Haerer Winfried , Reifart Nicolaus , Ringwald Gerd , Troger Bernhard
Published: July 2021

Background
In 1996 the association of German Cardiologists in private practice (BNK) installed a computer based quality registry that collects all diagnostic (DHC) and therapeutic heart catheterization (PCI) procedures. Today, 20 % of these procedures are performed by cardiologists in private practice. The participation in the registry is voluntary, and self financed. QuIK is the German acronym for “Quality Assurance in Invasive Cardiology”.

Method:
Procedural quality related data are collected in the cath lab and the corresponding data set exported regularly to a central data administration centre. Data are analyzed every quarter and every year. Participating cardiologists are provided with a single centre and a combined group result table and picture report including a centre/group comparison.

Results:
The QuIK registry, though not obligatory, accounts for almost 80 % of procedures, done by cardiologists in private practice. Since 1996 over 1 million (800,000 DHC and 230,000 PCI) procedures have been collected (as at 30 September 2009). The development of datasets and statistical analysis is discussed by all participating cardiologists. Data quality and reliability is proved in a yearly monitoring process in the participating cath lab, also facultative, but done in 70 % of private practices. In 1996, eight centres sent their data, in 2008, there were 123 participating institutions. In 2008, in 65 % of 76,513 cases, a coronary heart disease (CHD) was confirmed, but 40 % had already CHD and were symptomatic, again. Even 12 % showed signs of an acute coronary syndrome (ACS). In 40 % revascularization was indicated (11 % surgery and 29 % PCI). Of the PCI decisions, 80 % were done ad hoc. The 21,438 PCI cases had an acute complication rate of 1.5 %, most of were acute thromboses, 0.1 % of patients died in cath lab. 4 of 5 cases were treated with a stent, 1 of 5 with a drug eluting stent. Angiographic success rate was 93 %.

Conclusion:
One characteristic of the idea of quality management with the aim of “pay for performance” (p4p) is the voluntary and self-directed initiative in a competitive environment to confirm and raise the quality of care. It is done with the intention to help patients and their family doctors when choosing a cardiologist.
Abstract P23: Age Disparities in Quality of Care and Clinical Outcomes in US Veterans With Ischemic Stroke
Authors: Chumbler Neale R , Jia Huanguang , Li Xinli , Phipps Michael , Ordin Diana , Vogel Bruce , Castro Jaime , Myers Jennifer , Williams Linda S , Bravata Dawn
Published: July 2021

Background
This is the first study of age disparities in ischemic stroke care quality and post-stroke outcomes across the Department of Veterans Affairs (VA) system.

Methods
This was a retrospective study of a national sample of US veterans admitted to VA medical centers for ischemic stroke between 10/1/06 and 9/30/07. The following 14 inpatient stroke quality indicators were assessed: 1) dysphagia screening before oral intake; 2) NIH Stroke Scale completion ; 3) thrombolysis; 4) DVT prophylaxis; 5) early antithrombotic therapy; 6) early ambulation; 7) fall risk assessment; 8) pressure ulcer risk assessment; 9) rehabilitation consultation); 10) antithrombotic therapy at discharge; 11) atrial fibrillation management; 12) lipid management; 13) smoking cessation counseling; and 14) stroke education. Post-stroke outcomes included: risk-adjusted mortality (in-hospital and 6-month post-stroke); and hospital readmission (30-day and 6-month). Four age categories were assigned (<65, 65-74, 75-84, and ≥85 years). We modeled each quality indicator (defined as pass or fail among eligible patients) using multivariable logistic regression adjusting for race, stroke severity, comorbidity, smoking status, APACHE II score, hospital geography, complexity and volume.

Results
Among the 3,937 US Veterans with ischemic stroke, the overall pass rate among the quality indicators was > 70% for 9 of the 14 processes of care. Patients ≥85 years old were less likely than younger patients to receive atrial fibrillation management, smoking cessation counseling, NIHSS documentation, and early ambulation (p < .05). Patients aged ≥85 years were more likely to have dysphagia screening (p < .05). Risk adjusted mortality was higher among patients aged ≥85 years compared with each of the younger patient groups in both in-hospital mortality (p < .0001) and 6-month mortality (p < .0001). The oldest patients also had higher 6-month hospital re-admission rates than each of the younger patient groups (p = .002).

Conclusions
Despite overall good quality of inpatient stroke care within the VA system, further work is needed to investigate possible associations between patient age, disparities in quality indicators and outcomes of post-stroke.
Abstract P247: Culturally Appropriate Cardiovascular Risk Management - Are Physicians Prepared for the Task?
Authors: Yancy Clyde W , Foster Jill A , Salinas Gregory D , Sanchez Andrew R , Casebeer Linda L
Published: July 2021

Background:
The CDC advocates improved physician cultural competence to reduce disparities in cardiovascular (CV) health. Cultural competence may be particularly important to establish an effective therapeutic alliance to mitigate CV risk. This study sought to better understand physician elements of cultural competence that can be targeted to improve cardiovascular health in minority populations.

Methods:
Family physicians, internists, cardiologists and neurologists practicing in the southern US were queried in this survey. Participants assessed their cross-cultural knowledge, skills, attitudes, and training using 5-point scales. Office managers of respondents were then invited to complete a separate survey assessing compliance with 3 Culturally and Linguistically Appropriate Services (CLAS) standards relevant to the office setting.

Results:
Among 697 respondents, 57% considered sociocultural issues important in patient interactions. Prior training was reported by 76%, but 18% considered multicultural health training of little importance. On average, self-assessed knowledge (10 items) and skill (15 items) were moderate. More than 3 of 4 physicians reported little or no knowledge of CLAS standards; more than half reported limited knowledge of traditional healing. Striking differences were noted among physicians of different racial groups with blacks consistently reporting greater self-awareness, knowledge and skill compared to whites (p< .01). Significant differences did not emerge between primary care and specialist physicians. A subset of 124 office practices participated in the CLAS assessment. Though physicians were largely unaware of CLAS standards, compliance was 98% for Standard 1 (culturally appropriate care), 67% for Standard 2 (workforce diversity) and 25% for Standard 3 (staff CLAS training).

Conclusions:
Physicians and their office staff have modest levels of cultural sensitivity as well as moderate cross-cultural knowledge and skills, but deficits, especially among physicians and particularly as a function of physician race, are present in important areas. Building upon this foundation to achieve greater proficiency in cross cultural care may improve the quality of care and reduce disparities in CV health.
Abstract P265: Low Hemoglobin Predicts Poor 1-Year Outcome in Acute Coronary Syndrome
Authors: NEGI SMITA , Salt Zarina , Miller Craig Michael
Published: July 2021

Background
There is lack of evidence to assess the impact of hemoglobin level at presentation on long term prognosis after ACS. We investigated if hemoglobin on presentation affected cardiovascular outcomes in ACS over a 12- month period.

Methods
Clinical data at baseline and over a 12 month period were extracted for 160 consecutive patients admitted with a diagnosis of ACS. Primary endpoints were repeat event and all-cause mortality. Secondary endpoints were recurrence of significant angina (requiring ER visit/hospitalization), new onset left ventricular failure (LVF), new arrhythmia, composite of all cardiovascular complications, prolonged index hospitalization and repeat admission for cardiovascular causes.

Results
On univariate analysis, low hemoglobin was associated with prolonged index hospitalization (OR: 0.85, 95% CI: 0.74-0.98, p=0.02), repeat admissions (OR: 0.77, 95% CI: 0.66-0.90, p=0.001), composite cardiovascular complications (OR: 0.75, 95% CI: 0.63-0.88, p=0.005), recurrent angina (OR: 0.65, 95% CI: 0.54-0.78, p<0.001) and repeat event (OR:0.75, 95% CI: 0.59-0.97, p=0.03). There was no significant association of low haemoglobin with new-onset LVF (OR: 0.76, 95% CI: 0.60-1.01, p=0.08), new-onset arrhythmias (OR: 0.99, 95% CI: 0.62-1.56, p=.97) and all-cause mortality (OR: 0.84, 95%CI: 0.68-1.04, p=0.1).

On a multivariate regression, low hemoglobin retained significant association with repeat admissions (r:0.4, p=0.02), composite cardiovascular complications (r:0.3, p=0.007), recurrent angina (r:0.5, p<0.001) and repeat events (r:0.2, p=0.06). Receiver-operating characteristic (ROC) curves showed significant discriminative ability of low hemoglobin for prolonged index hospitalization (area, 0.67; p=0.002), repeat admissions (area, 0.71; p<0.001), composite complications (area, 0.70; p<0.001), recurrent angina (area, 0.74; p<0.001) and repeat event (area, 0.70; p=0.01).

Conclusions
Low baseline hemoglobin in ACS patients predicts 12-month risk of repeat admissions, composite cardiovascular complications, recurrent angina and repeat event. This association appears independent of the infarct size and would justify closer follow up for these patients.
Abstract P273: Does Coronary Vessel Dominant System Dictate False Positive Results in Nuclear Stress Imaging?
Authors: Jazrawi Ayad S , Jain Amruthlal , Kumar Sachin , Idris Almuhannad , Gorges Rony , Shaw Michael , Zughaib Marcel
Published: July 2021

Objective:
We sought to investigate whether the coronary vessel dominance dictates the false positive results in nuclear stress imaging.

Background:
Atherosclerotic coronary artery disease is the leading cause of morbidity and mortality in men and women in the United States. Myocardial perfusion imaging (MPI) has provided incremental diagnostic and prognostic information in evaluation of patients with suspected or known coronary artery disease. It has a sensitivity of 87% but specificity of 64%. Tissue attenuation secondary to diaphragm or breast have been documented as a cause of false positive tests. It is also believed that patients with a left dominant coronary system are more prone to have a false positive test, however there is no conclusive literature available supporting this.

Methods:
A retrospective analysis was performed of all patients who underwent coronary angiography from January 2006 to December 2008, who had intermediate to high probability of ischemia as assessed by MPI. The location and the size of ischemia were documented. Patients were classified as either true positive (TP) or false positive (FP) based on presence of significant coronary stenosis (>50%) by angiography. Furthermore, coronary vessel dominance (right, left or mixed) was documented.

Results:
A total of 991 patients were included in the analysis. 901 patients had a TP test (91%). As expected, females had a significantly higher FP rate compared to males (16.1% vs. 4.6%, p<0.05).The population was divided into three groups, right, left and co-dominant system: 855, 93 and 43 patients respectively. There was no difference in the FP rate between the right and co-dominant systems (8.1% vs. 7.5%, p=0.7). Patients with left dominant systems were noted to have higher rate of false positive (12.9%) however, this did not achieve statistical significance (p=0.1). When location of lesion was taken into consideration, the far majority (92%) of anterior wall FP cases were females, regardless of system dominance.

Conclusion:
This is preliminary study supported previous study that female have a higher FP test on their MPI. Furthermore, patients with left dominant system are more prone for FP than either co dominant or right dominant system, especially in females.
Abstract P28: Awareness and Management of CVD Risk Factors and Area-Level Mortality Regions in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study
Authors: Safford Monika M , Parmar Gaurav , Brown Todd M , Hovater Martha , Roth David , Halanych Jewell H , Shikany James M , Prineas Ronald J , Samdarshi Tandaw , Durant Raegan W
Published: July 2021

Background:
Federally designated Health Professional Shortage Areas (HPSA) receive extra resources, but recent reports suggest that HPSAs may not consistently identify areas of need. We examined an alternative approach to designating areas of need based on county-level ischemic heart disease (IHD) and stroke mortality rates.

Methods:
We examined participants in the REGARDS Study, a national cohort of 30,239 US community-dwelling adults (42% African Americans) aged ≥45 recruited 2003-7. “Need” was defined by awareness, treatment or control of hypertension (n=21,118), diabetes (6,355) or hyperlipidemia (21,096). Awareness and treatment were self-reported, and control was defined as BP <140/90 mmHg (<130/80 for diabetes or chronic kidney disease) for hypertension; fasting blood sugar <140 mg/dL (<200 if non-fasting) for diabetes; and LDL cholesterol <130 mg/dL for hyperlipidemia. Each county was categorized into race-specific tertiles of IHD and, separately, stroke mortality, using 1999-2006 CDC data (based on death certificates). Sociodemographics, health behaviors, physical functioning and insurance status were included in separate multivariable models describing the relationships between IHD and stroke mortality and each element of need.

Results:
Participants resided in 1821 US counties, 578 in the lowest IHD mortality tertile (597 for stroke), 628 in the medium (586), and 627 in the highest (638). Awareness and treatment of CVD risk factors were similar for residents in counties across IHD and stroke mortality tertiles, but control tended to be lower in counties in the highest mortality tertiles (Table).

Conclusions:
Research is needed to elucidate why some CVD risk factor control is worse in areas of high CVD mortality despite similar levels of awareness or treatment of disease between high and low mortality areas. High stroke and IHD mortality may be one way to designate areas of need for resource allocation…

Table.

Adjusted
*
OR (95% CI) for Residence in a County in the Highest vs. Lowest (ref) IHD and Stroke Mortality Tertiles,
**
for Awareness, Treatment, and Control of Hypertension, Diabetes and Hyperlipidemia.

Outcome
Hypertension
Diabetes
Hyperlipidemia

IHD
Stroke
IHD
Stroke
IHD
Stroke

Awareness
1.14 (0.97,1.35)
1.07 (0.90,1.28)
1.02 (0.78,1.34)
0.98 (0.73,1.31)
1.05 (0.94,1.17)
0.98 (0.87,1.10)

Treatment
1.10 (0.85,1.43)
0.80 (0.61,1.04)
1.21 (0.96,1.52)
1.12 (0.88,1.42)
1.06 (0.94,1.20)
1.02 (0.90,1.15)

Control
1.00 (0.89,1.12)

0.88 (0.78,0.99)

0.79 (0.64,0.96)

0.82 (0.64,1.05)

0.83 (0.70,0.98)

0.95 (0.80,1.14)

*

Adjusted for age, race, gender, education, income, urban/rural residence, alcohol/tobacco use, medication adherence, exercise, BMI, and functional status.

**

Race-specific tertiles.
Abstract P31: Medicare Reimbursement and Patterns of tPA Utilization for Acute Ischemic Stroke Patients
Authors: Comins Meg M , Sultan Dawood H , Wathington Deanna J
Published: July 2021

Background.
Tissue plasminogen activator (tPA) is recommended for stroke patients presenting within 3 hours of symptom onset. Patients treated with tPA have been shown to experience superior outcomes over other thrombolytics. Higher costs for tPA are said to be offset by savings from shorter lengths of stay and lower likelihoods of being discharged to rehabilitation or long-term care. Encouraged by the American Stroke Association (ASA), CMS created DRG 559 in FY 2006, increasing the reimbursement for stroke patients receiving tPA by an average of $6,700 to advance tPA utilization. In FY 2007, CMS replaced DRGs with severity-adjusted DRGs (MS-DRGs); three MS-DRGs replaced DRG 559, lowering the reimbursement rate for tPA treatment. The primary data source was the HCUP 2005-2007, Nationwide Inpatient Sample, a 20% sample of up to 700 hospitals per year in 27 states. Discharge records were analyzed for patients aged 45 and older, with a discharge diagnosis for cerebral infarction (ICD-9 codes 362.3, 433.x1, 434.x1, and acute, but ill-defined, cerebrovascular disease (ICD-9 code 436) and excluding secondary diagnoses of traumatic brain injury (codes 800-804, 850-854). Patients were stratified by age, payer, and DRGs 61, 62, 63 or 559 with a primary ICD-9 procedure code of 99.10.

Results.
From 2005 to 2006, tPA utilization increased 68.1%, but increased only 1.36% from 2006 to 2007. tPa uitilization increased for Medicare and Medicaid patients overall, but declined for privately insured patients from 2006 to 2007.

Discussion.
The Brain Attack Coalition endorses statewide stroke systems of care, including certification of comprehensive and primary stroke centers. Comprehensive centers must be capable of providing the full range of stroke care including tPA to patients. Seven states were developing, or had in place stroke systems of care in 2007. The decline in reimbursement may act as a disincentive to other states to create systems of care.

Stroke patients with tPA as the primary procedure, number and percentage of tPa patients by row.

2005 (n=60,009)
2006 (n=57,298)
2007 (n=55,669)

tPA Patients
789 (1.31)
1326 (2.32)
1344 (2.41)

DRG 14
480 (60.84)
-
-

DRG 559
306 (38.78)
1,317 (99.3)
977 (72.7)

DRG 61
-
-
96 (7.1)

DRG 62
-
-
170 (12.6)

DRG 63

92 (6.8)

Medicare
506 (1.15)
883 (2.16)
899 (2.3)

Medicaid
32 (1.09)
58 (1.86)
67 (2.08)

Private Insurance
213 (2.13)
309 (3.26)
296 (3.05)
Abstract P363: Incremental Prognostic Value of Exercise Capacity in Patients With Advanced Renal Insufficiency
Authors: Zaidan Mohammad , Alqarqaz Mohammad , Swadia Tanmay , Qureshi Waqas , Lanfear David , Khalid Fatima , Shamieh Mohamad , Yaghmour Bassam , Al-Mallah Mouaz H
Published: July 2021

Background:
Exercise capacity has been shown to predict outcomes in the general population. However, patients with advanced renal failure have been typically excluded from these studies. The aim of this analysis is to evaluate the incremental prognostic value of exercise capacity in patients with Stage III and IV renal insufficiency.

Methods:
We included 3733 consecutive patients with glomerular filtration rate<60 ml/min who underwent exercise testing between 1991 and 2008. Baseline characteristics and exercise data were collected prospectively at the time of testing including Metabolic Equivalents (METS). The primary endpoint is all cause mortality confirmed by the social security death index.

Results:
A total of 946, 2026 and 761 patients achieved >10, 4-10 and <4 METS respectively. Patients with poor exercise capacity (< 4 METS) were older, more often females (54% vs. 49%), less often whites (66% vs. 77%) with higher prevalence of hypertension (90% vs. 78%) and prior coronary disease (37% vs. 17%). After a median follow-up duration of 6.4 years (range 1-15 years), 1032 patients (28%) died. Using multivariable Cox hazard regression, exercise capacity added incremental prognostic value over clinical variables and renal function (Increase in global Chi square from 778 to 921, p<0.0001, METS achieved HR per 1 METS 0.83, 95% CI 0.81-0.85, p<0.0001).

Conclusions:
In this large cohort of advanced renal insufficiency patients, decreased exercise capacity adds incremental prognostic information and is independently associated with decreased survival over long follow-up duration.
Abstract P366: Apical Ballooning Syndrome in Women and Outcome
Authors: Kandala Jagdesh , Uthamalingam Shanmugam , Ballari Sarika , Daley Marilyn , Capodilupo Robert
Published: July 2021

Background:
Apical ballooning syndrome (ABS) management has not been extensively studied. These patients are often managed as those with acute coronary syndrome. The objective of our study is to examine the role of medications like selective beta-blockers, statins, clopidogrel, and angiotensin converting (ACE) inhibitors post-discharge.

Methods:
From January, 2002 to December, 2007 18 consecutive patients were treated for ABS. Each patient was assessed by history, physical exam, electrocardiogram, laboratory investigations, telemetry, echocardiogram, coronary angiogram and later, by a follow up echo in 4-8 weeks.

Results:
All patients were female, the majority were caucasian and postmenopausal. The most common presentation was angina. Common EKG findings were T wave inversions, and prolonged QTc. Echocardiogram images demonstrated mid-ventricular and apical wall motion abnormalities and reduced ejection fraction, this was later confirmed by angiogram. All patients were alive at the time of discharge. Medications these patients received post discharge were selective beta-blockers 87.5 % (14/16), aspirin 100% (16/16), statins 62.5% (10/16), ACE inhibitors 81.2% ( 13/16), and clopidogrel 12.5% (2/16). After discharge from the hospital 31.2% (5/16) had recurrent chest pain on the above medical management. Recurrent chest pain developed in three out of five patients discharged on selective beta-blockers (p < 0.08, Fisher exact) and in three out of five patients who were discharged on statins (p < 0.65, Fisher exact). Patients who developed recurrent chest pain discharged on ACE inhibitors were four out of five (p<0.70, fisher exact test), and on clopidogrel were 0 out of five (p <0.45, fisher exact).

Conclusion:
Patients from our study have a higher rate of recurrent chest pain than previously reported. Chronic treatment with selective beta-blockers, ACE inhibitors, clopidogrel, and statins did not reduce the frequency of recurrent chest pain post-discharge. Although there is no evidence demonstrating a benefit, these patients are often treated as per guidelines for acute coronary syndrome. Our study demonstrates that ABS patients are subjected to ineffective treatment and there is an emergent need for management guidelines
Abstract P44: Does Race Influence Disability and Hospital Disposition After Cerebral Hemorrhage? Results From a Community Wide Stroke Registry
Authors: Pandey Dilip K , Aiyagari Venkatesh
Published: July 2021

Background:
Compared to Non-Hispanic whites (NHW), intracerebral hemorrhage (ICH) has a higher incidence among African Americans (AA) where it also occurs at a younger age. Previous studies have concluded that there are no racial differences in hospital mortality after ICH, but the influence of race on disability and discharge disposition after ICH has not been studied.

Methods:
The Illinois Capture-Stroke registry is a prospectively collected database of patients admitted with a stroke to 56 acute care hospitals in Illinois. We performed a retrospective analysis of the association between race, and in-hospital mortality, modified Rankin Scale (mRS) score at discharge and discharge disposition in 804 patients with ICH enrolled in the registry between 2005 and 2007.

Results:
We studied 530 NHW and 175 AA patients with radiologically proven ICH. Compared to NHW, AA patients were younger (mean age NHW: 73±14 vs AA: 58±12 yrs, p <0.001) and had a higher incidence of hypertension, smoking and coronary artery disease. Although there was no racial difference in hospital mortality, incidence of moderate to severe disability (mRS 4-5) was significantly higher in NHW (69%) compared to AA (55%). Among patients <65 years old, a trend (p=0.102) towards a higher disability in NHW was observed (60% in NHW vs. 45% in AA). In this age group, 41% of NHW and 33% of AA were discharged to rehabilitation facilities while 37% of NHW and 44% of AA were discharged home.

Conclusion:
A very large proportion of patients with ICH are discharged from hospitals with moderate or severe disability. Compared to NHW, a higher proportion of younger AA patients are discharged home after ICH. The long term outcomes of survivors after ICH in the United States is not well studied, and the influence of racial and socioeconomic factors on long-term treatment and outcome after ICH needs to be explored.
Abstract P50: IV Alteplase Use Predicts Favorable Discharge Disposition in Patients With Acute Ischemic Stroke: Insights From the UTHSC Houston Stroke Registry
Authors: Ifejika-Jones Nneka , Harun Nusrat , Noser Elizabeth , Grotta James
Published: July 2021

Introduction:
Acute ischemic stroke patients receiving IV alteplase (t-PA) within 4.5 hours of symptom onset are 30% more likely to have minimal or no disability at 3 months. During hospitalization, short-term disability is subjectively measured by discharge disposition, whether to home or Inpatient Rehabilitation (IR), Skilled Nursing Facility (SNF) or Sub-acute Care (Sub). There are no studies assessing the role of IV t-PA as a predictor of short-term disability, evidenced by post-stroke disposition.

Hypothesis:
Low NIHSS is a predictor of high functional status. We assessed the hypothesis that similar to low NIHSS, t-PA predicts post-stroke disposition to a level of care suggestive of high functional status.

Methods:
All patients with acute ischemic stroke admitted to the UT Service between January 2004 and October 2009 were included. Stratification occurred for age>65, NIHSS and stroke risk factors. Using multivariate logistic regression, the data was analyzed to determine whether there were differences in post-stroke disposition among patients who received t-PA.

Results:
Patients with mild (NIHSS<8) and moderate (NIHSS 8 to 16) stroke were discharged to the highest level of care in each analysis.
Home vs. Other Level of Care
Of 2261 patients, 1032 were discharged home, 1229 to another level of care. Patients who received t-PA were
1.7
times more likely to be discharged home (P = <.0001, OR 1.663, 95% CI 1.326 to 2.085).
IR vs. SNF
Of 1111 patients, 731 patients were discharged to acute IR, 380 to SNF. There were no statistically significant differences in disposition between patients who received t-PA. (P = .0638, OR 1.338, 95% CI 0.983 to 1.822).
SNF vs. Sub
Of 498 patients, 380 were discharged to SNF, 118 to Sub. There were no significant differences in disposition between patients who received t-PA.

Conclusion:
Acute stroke patients who receive IV t-PA are more 1.7 times more likely to be discharged home. If post-stroke care is necessary, there is a trend toward rehabilitation at a level reflective of improved functional status (IR vs. SNF). This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge. Prospective studies of time to t-PA therapy in relation to post-stroke disposition are warranted.
Abstract P96: Pacemaker Reutilization is a Safe and Effective Means of Delivering Electrophysiological Healthcare in Third World Countries a Meta-Analysis
Authors: Romero Joshua , Meier Pascal , Gakenheimer Lindsey , Kirkpatrick James N , Sovitch Patricia A , Oral Hakan , Eagle Kim A , Baman Timir S
Published: July 2021

Background:
The inequality of healthcare between rich and poor countries appears to be escalating. Several small studies have suggested that pacemaker reutilization is an effective means of delivering healthcare for those with limited resources. This meta-analysis sought to evaluate the safety and efficacy of pacemaker reuse.

Methods:
We searched medical databases from January 1
st
1975 to July 1
st
2009 for studies that compared pacemaker reuse with a control population of new device implantation. Random-effects models were used to calculate summary odds ratios (OR). The primary endpoint was overall complication rate.

Results:
A total of 4 trials enrolling 603 subjects were integrated into this analysis. Compared to new pacemaker implantation, reutilization of previously implanted devices were not associated with a significant increase in overall complications (OR 0.98 [0.64 - 1.49]; p= 0.914). Furthermore, there was no increased risk of infection (OR 0.81 [0.41 - 1.62]; p=0.552), physiological complications (OR 1.06 [0.54 - 2.07]; p= 0.868), or device malfunction (OR 1.29 [0.51 - 3.29]; p=0.590). Device-related deaths were observed in neither group.

Conclusions:
Pacemaker reutilization, when compared to new device implantation, is not associated with higher rates of infection, physiological malfunction, or device malfunction. Pacemaker reuse is a safe, efficacious, and ethical alternative to address the medical needs for those in 3
rd
world countries who could not afford therapy otherwise.
Abstract P97: Operational Redesign of an Outpatient Anticoagulation Management Program- The Vanderbilt Experience
Authors: Boord Jeffrey B , Leutgens Wendy S , Churchwell Keith B
Published: July 2021

The 2008 Joint Commission National Patient Safety Goals required healthcare organizations to adopt practices to reduce the likelihood of harm associated with use of anticoagulation therapy. Assessment of our anticoagulation programs in 2008 demonstrated gaps that did not meet these new requirements. Patients were enrolled in two large anticoagulation clinics (separately managed by pharmacy and cardiology) with smaller programs linked to their clinical service lines. Identified gaps included: separate programs that were not standardized and had no integrated governance/oversight, inadequate budget and staffing models to meet growing demand, lack of unified practice policy and anticoagulation information systems, and lack of standardized quality measures and reporting. Vanderbilt leadership commissioned an Anticoagulation Executive Steering Committee to perform an operational redesign of the anticoagulation programs to meet National Patient Safety Goals. The committee appointed working groups to: evaluate and redesign clinical operations and finance, perform a technology assessment to develop standard anticoagulation information systems, and develop standardized reporting of quality metrics. The key redesign features were: 1) merging of the existing anticoagulation clinics into a single unified program; 2) dedicated institutional budget for ambulatory anticoagulation services with costs shared across the clinical enterprise; 3) implementation of standard policies and protocols for anticoagulation management and education; 4) creation of dedicated oral anticoagulation management software (AMS) fully integrated into the electronic health record; 5) creation of medical director and program manager positions for operational oversight of the unified program, and an Anticoagulation Oversight Committee for clinical practice supervision; 6) development of a bundle of quality metrics and operational/clinical data reports derived from the AMS. Our redesign experience provides a blueprint for other organizations that provide anticoagulation management to meet National Patient Safety Goals.
Abstract P98: Patient Impressions and Cost-Savings Associated With Home-Based International Normalized Ratio Monitoring in a Prospective Clinical Trial
Authors: Forcade Nicolas A , Frei Christopher R , Walker Marie B , Bussey-Smith Kristin L , Daniels Kelly , Bussey Henry I
Published: July 2021

OBJECTIVE:
The aim of this study was to evaluate patient impressions and cost-savings associated with home INR monitoring as compared to usual INR monitoring at a medical clinic.

METHODS:
This was a “before and after” study that was conducted in a local clinical research center. Patients were enrolled from twelve sites with a variety of indications for chronic oral anticoagulation. Patients began a program of INR self-testing and automated online management provided by one of the investigators (HIB). Patients completed a survey that asked for demographics, monitoring preference, miles driven, and time spent for monitoring; the Duke Anticoagulation Satisfaction Scale (DASS) was completed at baseline and follow-up. Only patients with baseline and follow-up surveys were included in the analysis. Chi-square was used to compare nominal variables. Responses from a five-item likert scale for monitoring preference, income, and amount willing-to-pay were dichotomized. Time spent, miles driven for monitoring, and DASS scores were compared using Wilcoxon signed-rank.

RESULTS:
Of the 44 patients who completed both surveys, most were male (24/44), married (33/44), Caucasian (36/44), and had finished at least some college (40/44). Nearly half were retired (21/43) and had an annual household income of at least $50,000 (21/44). Patients spent more time for clinic versus home monitoring (median, interquartile range): clinic 108 (60-150) min versus home 10 (7-15) min, p<0.0001. Home monitoring reduced miles driven by a median of 20 (10-50) miles. Almost all patients agreed or strongly agreed with the statement that “home INR monitoring is preferable to clinic monitoring” (38/42). Most patients reported that they would pay for home monitoring to eliminate one clinic visit (28/37). Income greater than $50,000 was associated with an amount willing-to-pay greater than $25 (p=0.02). Overall satisfaction (p=0.007) and patient recommendation of anticoagulation management (p<0.0001) improved at follow-up compared to baseline. Perceptions of monitoring difficulty (p=0.04), complexity (p=0.03), and inconvenience (p=0.02) all decreased.

CONCLUSION:
Home INR monitoring is preferred by patients and saves time and money compared to clinic monitoring.
Abstract 13: Disparities in Carotid Imaging Among Persons Presenting with Acute Ischemic Stroke
Authors: Cheng Eric , Keyhani Salomeh , Ofner Susan , Williams Linda , Bravata Dawn
Published: July 2021

Background:
Atherosclerosis from internal carotid artery stenosis is a major cause of stroke. It is identified through imaging of the carotid arteries, which should be routinely performed in the diagnostic workup for acute ischemic stroke. In prior research, we identified black race as an independent predictor of the underuse of carotid imaging. We explored factors that may explain this racial disparity.

Methods:
Data were obtained from a retrospective study of 3965 persons admitted to 129 Veterans Administration Medical Centers (VAMC) with ischemic stroke in 2007. To identify a sample who should definitely receive imaging, extensive exclusion criteria were applied such as transfers, inpatient deaths, and high levels of comorbidity. Among 1432 whites versus 610 blacks, we compared receipt of carotid artery imaging between 12 months before admission to 2 months after discharge in bivariate and multivariate analyses. We then compared patient characteristics, hospital characteristics, and the distribution of underuse and disparities across VAMC among whites versus blacks to identify explanations for the racial disparity.

Results:
Blacks were less likely to receive carotid imaging than whites (81% vs. 89%, p<0.001). In multivariate hierarchical models, blacks remained less likely to receive carotid imaging (odds ratio 0.67, 95% confidence interval [0.48 to 0.93] after adjustment for age, presence of atrial fibrillation, Charlson Comorbidity Index, and NIH Stroke Scale, suggesting that clinical factors were not the reason for the disparity. Black patients were more likely to attend larger, higher complexity, urban hospitals, suggesting that hospital characteristics were not responsible for the disparity. The racial disparities at the VAMC level were greatest among those that had the lowest use of carotid imaging. Two VAMCs accounted for 25% of the system-wide magnitude of disparity in the VA. When these two VAMCs were removed from the sample, race was no longer an independent predictor of underuse.

Conclusions:
Racial disparities of carotid imaging were not mediated by other patient or hospital characteristics. Improving overall receipt of carotid imaging at a few VAMCs can substantially reduce the system-wide magnitude of disparities in the VA.
Abstract 6: Temporal Shifts in Antithrombotic Therapy Help Explain Reduction in Bleeding Complications Among Patients Undergoing Percutaneous Coronary Intervention: Results from an NCDR® Report
Authors: Subherwal Sumeet , Peterson Eric D , Dai David , Thomas Laine , Messenger John C , Marso Steven P , Klein Lloyd W , Senter Shaun , Feldman Dmitriy N , Roe Matthew T , Rao Sunil V
Published: July 2021

Background
Though studies suggest post-PCI bleeding has decreased over time, the factors associated with this temporal reduction remain unclear.

Methods
Using the CathPCI Registry®, we examined temporal trends in bleeding between 2005-2009 in elective PCI (E-PCI) (n=599,524), UA/NSTEMI (n=836,103), and STEMI (n=267,632). We quantified the linear time trend in bleeding using three sequential logistic regression models: (Model 1) Clinical factors associated with PCI bleeding; (Model 2) Model 1 + vascular access strategies(femoral vs. radial, closure devices); (Model 3) Model 2 + anticoagulation treatments (anticoagulation ± GP 2b/3a). Changes in the adj. OR for time trend were then compared. Table illustrates changes in expected annual bleeding events using 2005 event rates as reference (n=1375 bleeds in E-PCI, n=3327 in UA/NSTEMI, n=1978 in STEMI).

Results
Between 2005-2009, there was an approximate 20% decline in PCI bleeding: absolute crude change for E-PCI (1.4% to 1.1%), for UA/NSTEMI (2.3% to 1.8%), for STEMI (4.9% to 4.5%). In this period, vascular access via radial remained low (<3%) and closure devices use was steady (45-50%). In contrast, bivalirudin use increased from 17% to 30%, while heparin + GP2b/3a decreased from 41% to 28%. After adjusting for clinical variables, there was a 6-8% per year reduction in adj OR of bleeding for E-PCI & UA/NSTEMI (Table). While there was only a small reduction in bleeds per year after adjusting for changes in vascular access strategies, adjusting for antithrombotic strategies accounted for nearly half of the temporal annual reduction in bleeding (Table): from 97 to 48 expected bleeds per year for E-PCI, 164 to 95 in UA/NSTEMI, and 49 to 23 in STEMI.

Conclusion
There has been a modest temporal reduction in post-PCI risk of bleeding. Nearly half of this reduction can be attributable to changes in antithrombotic choices. Adoption of the radial approach, combined with pharmacological strategies, may further reduce bleeding.

Elective PCI Model
Unstable Angina/NSTEMI
STEMI

OR
p-value
Estimated reduction bleeding events per year
OR
p-value
Estimated reduction bleeding events per year
OR
p-value
Estimated reduction bleeding events per year

Model 1
0.92 (0.90-0.95)
<0.001
97
0.94 (0.92-0.96)
<0.001
164
0.98 (0.95-1.00)
0.088
49

Model 3

0.96 (0.93-0.99)
*

0.002
48

0.97 (0.95-0.99)
*

0.012
95

0.99 (0.96-1.02)
*

0.525
23

*

p<0.001 for comparing adj OR between Model 1 and Model 3
Abstract P106: Variation in the Incidence of Hospital-Acquired Anemia During Admission with Acute Myocardial Infarction Across 57 US Hospitals
Authors: Salisbury Adam C , Alexander Karen P , Reid Kimberly J , Masoudi Frederick A , Spertus John A , Kosiborod Mikhail
Published: July 2021

Background:
New onset, hospital-acquired anemia (HAA) during acute myocardial infarction (AMI) may be related to hospital-based processes of care. HAA is associated with poor outcomes, but little is known about the extent of hospital variation in the incidence of HAA or the hospital characteristics associated with HAA.

Methods:
We studied 17,676 AMI patients not anemic at admission, defining moderate-severe HAA as a hemoglobin decline to < 11 g/dl. Shrinkage estimates of moderate-severe HAA incidence were generated to account for low volume sites. Multivariable models were used to identify adjusted variation in moderate-severe HAA across hospitals, using median rate ratios (MRR - median value of the relative risk of moderate-severe HAA for two identical patients presenting to two randomly selected hospitals) and fit a separate model to test the association between hospital characteristics (# beds, region, urban/rural, teaching status) and moderate-severe HAA adjusting for patient factors.

Results:
Overall, 3,551 (20%) developed moderate-severe HAA. The incidence of moderate-severe HAA varied substantially across sites (Figure) and was significant after multivariable adjustment (MRR 1.3 [1.2-1.4]). The only site factors independently associated with moderate-severe HAA were teaching status (RR 0.7 [0.6-0.9] vs. non-teaching) and region (South vs. Midwest: RR 1.3 [1.0-1.5]).

Conclusions:
We found significant variation in the incidence of moderate-severe HAA and a lower risk of HAA in teaching hospitals. Further study of the relationship between HAA and specific processes of care is needed to identify actionable targets for quality improvement.
Abstract P109: Predictors of Hemoglobin A1c Trajectories in a Cohort of Patients with Diabetes
Authors: Schroeder Emily B , Bayliss Elizabeth A , Newcomer Sophia R , Steiner John F
Published: July 2021

Background:
Predictors of different hemoglobin A1c (HbA1c) trajectories in diabetes have not been adequately studied.

Methods:
In a cohort of 8,669 individuals with incident type 2 diabetes from a managed care system from 2000 to 2009, we determined HbA1c trajectories over the 5 years following diagnosis using a procedure which isolates distinct trajectories and fits a mixture model to calculate the probability of membership in each latent class for each patient.

Results:
A five HbA1c trajectory model provided the best balance of fit and parsimony (Figure). The largest groups had HbA1c's below 7% (At Goal, 62%, 5472 of 8669) or near 8% (Near Goal, 23%, 1957 of 8669). Smaller groups had HbA1c's that rapidly improved and then remained near 7.5% (Improving, 6%, 502 of 8669), or were elevated and either gradually worsened (Worsening, 5%, 412 of 8669) or improved slightly (Poor Control, 4%, 326 of 8669). In multivariate models, compared to the At Goal group, individuals in the other groups were generally younger, more likely to be male, and more likely to have diagnosed hyperlipidemia. The Worsening and Poor Control groups had lower adherence to oral diabetic medications (OR (95% CI) for 10% increase in the proportion of days covered: Worsening vs. At Goal, 0.77 (0.73-0.81) and Poor Control vs. At Goal, 0.79 (0.75-0.84)), and were much more likely to be on insulin. The Improving and At Goal groups had indistinguishable adherence levels.

Conclusions:
Trajectory analysis holds promise as an approach for defining subgroups of diabetics who may require different care strategies, and may help focus clinical conversations on behaviors such as adherence that are necessary to achieve glycemic control.