bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 143A: Does Insurance Type Predict Quality of Anticoagulation Care in a Boston Safety Net Hospital System?
Authors: Kapoor Alok , Kressin Nancy R , Hanchate Amresh D , Lin Mengyun , Chu Chieh , Lasser Karen E , D'Amore Meredith , Rose Adam
Published: July 2021

Background:
Boston Medical Center (BMC) is the primary safety net hospital for Eastern Massachusetts and has a diverse patient population with diverse insurance types. Such types include commercial and public insurance (Medicare and Medicaid) and Free Care, limited coverage funded by money distributed to safety-net institutions to care for uninsured patients. In 2006, the state expanded Medicaid eligibility and began offering Commonwealth Care, comprehensive subsidized coverage with retail pharmacy benefits, for uninsured patients. The impact of these insurance types on individual cardiovascular conditions has not been studied. Venous thromboembolism (VTE), comprised of deep venous thrombosis and pulmonary embolism, is a condition whose clinical course is dependent on high quality anticoagulation care including easy access to medication and providers. Time in the therapeutic range (TTR), the percentage of time a patient spends with INR between 2 and 3, has emerged as the preeminent way to measure quality of anticoagulation care. In this study, we compared quality of anticoagulation among different insurance types.

Methods:
Using clinical data, we identified adults aged 18 to 64 with a new episode of VTE diagnosed in the years 2003 to 2010 at BMC or its affiliated health centers. To be eligible for inclusion, each patient had to have an ICD-9-CM code for VTE and an INR test in the month following VTE diagnosis. We computed TTR using all INR values from diagnosis to 12 months according to the Rosendaal method. We then measured the mean TTR for each of six insurance categories based on primary insurance at time of diagnosis. Using multiple linear regression, we adjusted measurements for sex, age, race, language preference, area poverty, VTE type, recent surgery, and number of Elixhauser comorbidities.

Results:
We identified 1099 patients with VTE. Twenty-three percent had commercial insurance, 37% Medicaid, 16% Medicare, 4% Commonwealth care, 18% Free Care, and 2% other. Mean TTR was 39.3%. Patients with Free Care and Commonwealth Care had similar TTR compared to those with commercial insurance. Patients with Medicaid, Medicare or other insurance had significantly lower TTR, compared to those with commercial insurance.

Conclusion:
Quality of anticoagulation care was low in this population. Residual confounding such as from healthy worker effect may account for higher TTR in patients with commercial insurance. In future work we plan to expand measurement of insurance effects to patients receiving anticoagulation for indications other than VTE and adjust our measurements for temporal bias
Abstract 154: Acute Stroke Recognition by Paramedics after Regionalization of Stroke Care: Outcomes Based Study
Authors: Govindarajan Prasanthi , Ghilarducci David , Shiboski Steve , Grimes Barbara , Cook Larry , Johnston S C
Published: July 2021

Background:
Early evidence supports preferential transport of patients with stroke symptoms to primary stroke centers. While validated stroke tools exist for screening of stroke symptoms in the prehospital setting, system wide triage performance of prehospital providers in a regionalized system has not been reported. The objective of this study is to assess the diagnostic ability of prehospital providers, before and after regionalization of care, using outcomes based approach.

Methods:
This is a cross-sectional study of all patients who were transported to hospitals in two Northern California counties by providers of a single EMS agency during a three year period. One county remained non-regionalized (NR) during the study period and the other initiated and completed regionalization(R) of the system during the study period. Patient demographic data, prehospital provider clinical assessment was obtained from the computerized prehospital transport records and physician diagnosis was obtained from statewide administrative patient discharge data. The data sources were linked using probabilistic linkage methodology. Patients ≥18 years of age with validated ICD- 9 code for stroke were included. We excluded inter-facility transports and direct admissions. Sensitivity, specificity and predictive values for were determined before and after implementation of regionalization. Data analysis was performed using SAS version 9.2.

Results:
The total number of medical related EMS transports for 3 years was 310,731 and the number of patient discharges with a primary diagnosis of stroke was 10,298. We were able to link 3736 stroke records which indicate EMS use by 36% (3736/10,298) stroke patients. The sensitivity, specificity, PPV and NPV in the pre-regionalization phase was 28%, 80%, 53%, 58% and during the implementation phase of regionalization was 39% 78%,57% and 63% (p <0.05). The performance in the NR County during the entire period was 23%, 76%, 40% and 58%.

Conclusions:
Diagnostic accuracy remained low although improved prehospital provider performance was observed after regionalization of stroke care.
Abstract 169: Bleeding Incidence By Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population
Authors: Deitelzweig Steven B , Pinsky Brett , Buysman Erin , Lacey Michael , Makenbaeva Dinara , Wiederkehr Daniel , Graham John
Published: July 2021

Introduction
Stroke prevention among patients with nonvalvular atrial fibrillation (NVAF) requires careful assessment of both the risk of stroke and bleeding.

Hypothesis
We hypothesized that in a real-world managed care population of patients with NVAF, bleeding incidence increases with CHADS2 stroke risk.

Methods
Administrative claims data were used for this retrospective study. Adults with healthcare claims related to AF (ICD-9-CM 427.31) between Jan 2005 and Jun 2009 but no evidence of valvular disease were included. Patients were followed until the earliest of death, disenrollment from the health plan, or 30 Jun 2010. Patients were categorized based on CHADS2 scores of 0, 1, 2, or ≥3, with higher scores indicating more risk factors. A bleeding event was considered major if it was associated with any of the following: inpatient care, blood transfusion, decreased hemoglobin or hematocrit, death, physician guided medical or surgical treatment, or intracranial bleed. Serious non-major events were those involving vascular injury or critical site bleeding and were associated with outpatient hospital care or an emergency department visit. Minor bleeds were those associated with noncritical anatomical sites and an emergency department, outpatient hospital, or office visit.

Results
The mean (SD) age of the study sample (N=48,260) was 67±13 years and 62% of the patients were male. Mean follow-up duration was 802±540 days (median 673 days). Mean (SD) baseline CHADS2 score was 1.48±1.15. Event rates for each bleeding category increased with increasing CHADS2 scores (Table).

Conclusions
Patients with NVAF in a real-world managed care setting who had high stroke risk also had a high rate of bleeding events, including major events. Patients at high risk for stroke might require more careful selection of anticoagulation therapy to avoid bleeding events.
Abstract 171: Warfarin Use And Stroke Risk Among Patients With Nonvalvular Atrial Fibrillation In A Large Managed Care Population
Authors: Deitelzweig Steven B , Buysman Erin , Pinsky Brett , Lacey Michael , Jing Yonghua , Wiederkehr Daniel , Graham John
Published: July 2021

Introduction
Warfarin discontinuation among real world nonvalvular atrial fibrillation (NVAF) patients is common.

Hypothesis
We hypothesized that in a managed care population, warfarin discontinuation is associated with increased stroke risk.

Methods
Patients who initiated warfarin therapy between Jan 2005 and Jun 2009 and had a healthcare claim related to AF within 30 days prior to the first warfarin claim, but no evidence of valvular disease, were included. Warfarin discontinuation was defined as a supply gap of >60 days without evidence of International Normalized Ratio (INR) measurements. Follow-up was divided into periods of warfarin treatment and discontinuation. Stroke events were identified based on claims for inpatient stays with a primary diagnosis for stroke or transient ischemic attack (TIA). Cox proportional hazards models were constructed to assess the relationship between warfarin discontinuation and incident stroke while adjusting for baseline demographics, stroke and bleeding risk, and comorbidities, as well as time-dependent antiplatelet use, stroke, and bleeding events in the prior warfarin treatment period.

Results
The mean (SD) age of the study sample (N=16,253) was 67±12 years; 64.8% was male. Mean CHADS2 score was 1.84±1.30; mean HAS-BLED score was 2.00±1.18. Half (51.4%) of patients discontinued warfarin therapy at least once and the overall sample had a mean of 1.87 warfarin treatment periods during a mean of 668 days follow-up. Approximately 1186 patients (7%) had a stroke or TIA at any site of service during follow-up. Risk of stroke significantly increased during warfarin discontinuation periods compared with therapy periods (HR 1.60; 95%CI 1.35-1.90; P<.0001). Stroke risk was significantly increased for patients with baseline CHADS2 score ≥2 (HR 2.69; 95%CI 1.44-5.03; P=.002), HAS-BLED score ≥3 (HR 1.46; 95%CI 1.05-2.05; P=.027), or who had a bleeding (HR 1.29; 95%CI 1.06-1.57; P=.013) or stroke event (HR 3.04; 95%CI 2.47-3.75; P<.0001) in the prior treatment period.

Conclusions
In the real world, over half of patients on anticoagulation therapy had treatment gaps or permanently discontinued therapy. These usage patterns, as well as prior bleeding, were associated with increased stroke risk.
Abstract 182: Shared Decision-Making Results in Knowledge Transfer Across Diverse Patient Subgroups: An Encounter-Level Meta-Analysis of Decision Aid Trials
Authors: Coylewright Megan , Branda Megan E , Shah Nilay D , Hess Erik P , LeBlanc Annie , Montori Victor , Ting Henry
Published: July 2021

Background:
Shared decision-making with decision aids (DA) improves patient knowledge and reduces decisional conflict. The extent to which they do so across sociodemographic subgroups remains unknown.

Methods:
An encounter-level meta-analysis of five DA randomized trials examined the impact of sociodemographic variables on knowledge transfer and decisional conflict using a generalized linear model stratified by study and adjusted by treatment arm.

Results:
We analyzed 595 patient-clinician encounters. Significantly higher knowledge transfer with DA occurred in nearly all patient subgroups when compared to usual care (UC). Patients with more formal education tended to have greater knowledge transfer with UC; this was diminished with DA. There was a trend towards improved decisional conflict in all subgroups with the use of DA; overall decisional conflict was low. (see Table)

Conclusion:
The use of DA compared to UC significantly increases knowledge transfer across diverse subgroups and there is a tendency towards reduced decisional conflict. Differences at baseline, such as knowledge transfer across educational strata, may be mitigated with use of DA. In conclusion, DA are found to be effective across patient subgroups and may represent a novel strategy to lessen disparities.
Abstract 188: Blood Pressure Control in Veterans following Percutaneous Coronary Intervention
Authors: Challa Karthik , Ladani Amit , McGraw Sloane , Shivaraju Anupama , Shroff Adhir
Published: July 2021

Background:
As per the US Joint National Committee VII (JNC-7) recommendations, patients with known underlying CAD and percutaneous coronary intervention (PCI) should have goal blood pressures of systolic <130 and diastolic <80. In addition to lifestyle modification, these goals can be attained by use of multiple classes of drugs including beta-blockers (BB), angiotensin agonists (ACE-I/ARB), calcium channel blockers (CCB), diuretics and nitrates.

Methods:
We conducted a retrospective cohort study in 935 consecutive patients undergoing PCI between September 2004 and January 2011 at the Jesse Brown Veterans Administration Hospital in Chicago, IL. Blood pressure (BP) measurements and antihypertensive medications pre and post PCI at 6-month follow-up were documented.

Results:
Over the 6-month follow-up period, mean systolic blood pressure (SBP) decreased from 134 to 129 mmHg (p < 0.0001) and mean diastolic blood pressure (DBP) decreased from 73 to 70mmHg (p < 0.0001). As per JNC-7 guidelines, the percent of patients who reached SBP goals increased from 43 to 52% (403 to 485 of 935) and with DBP goals rose from 70 to 76% (655 to 706 of 935). At 6-month follow-up, there was a statistically significant increase in the utilization of beta-blockers, ACE-I/ARBs, and nitrates. (TABLE)

Conclusions:
In this group of patients undergoing PCI, both systolic and diastolic blood pressure improved with more patients achieving JNC-7 targets. There was a significant increase in utilization in evidence-based medication.
Abstract 206: Projected Estimates of Prevalence and Annual Growth Rate of Atrial Fibrillation in the United States from a Dynamic Age-Period Progression Model
Authors: Colilla Susan , Crow Ann , Simon Teresa , Singer Daniel E , Petkun William , Liu Xianchen
Published: July 2021

Background:
Estimates from epidemiologic studies projecting the prevalence of atrial fibrillation (AF) in the US have varied widely in the literature, ranging from 2.7 million cases to 6.1 million cases for 2010. While the prevalence of AF is increasing due to an aging population, the extended survival of the elderly population and increases in other AF risk factors in the US population have not been factored into the current published AF prevalence projections. The large range of prevalence estimates for AF may be due to several factors, including study design, time period when study participants were ascertained, increases in AF over time, changes in AF diagnostic tools, and aging demographics.

Methods:
In an effort to quantify the population size for AF, a yearly annual incidence rate was estimated over a 7-year period (2002-2009) using data from a large US health insurance claims database (i3, n=45,871). Prevalence estimates were modeled for each year based on US population age and gender distribution and mortality rates. The US AF prevalence was computed (upweighted to age-standardized US census data) in a dynamic age-period cohort progression (Markov chain) model, which back-tracked prevalence to 1990 from incidence rates and projected trends forward to 2020.

Results:
The number of prevalent chronic plus current year incident cases of AF for 2010 was estimated at 5.2 million cases and was projected to increase to 8.4 million by 2020 (Figure). The estimated AF incidence was projected to double from approximately 200 cases/100,000 in 2010 to over 450 cases/100,000 in 2020, equating to an annual growth rate of 4.7%.

Conclusion:
These estimates, derived from the largest longitudinal study sample reported thus far, with a dynamic age-period cohort progression model, suggest that the diagnosed AF population in the US in 2010 was approximately 5.2 million cases, which falls within the wide range previously reported in the literature and may represent a more precise estimate.
Abstract 212: Control of Diabetes And Cardiovascular Biomarkers
Authors: Kaur Ramanjit , Mewada Abhishek , Veeranna Vikas , Zalawadiya Sandip , Ramesh Krithi , Panaich Sidakpal , Afonso Luis
Published: July 2021

Background
Diabetes mellitus (DM) is a major cause of overall mortality even with optimal control. We sought to explore the association of novel biomarkers with mortality in a nationally representative cohort of adults based on DM status and control.

Methods
Adults (aged >20 years) in the
National Health and Nutrition Examination Survey
(
NHANES
) 1999-2008 we subdivided into four groups: no DM, Controlled DM, Uncontrolled DM and Evidence of DM but no formal diagnosis. Cox-proportional hazard analysis was performed to determine the association between novel biomarkers and mortality across the subgroups.

Results
Red cell distribution width (RDW) and homocysteine remained significant predictors of mortality beyond traditional risk factors (for age, sex, race, body mass index, hypertension, dyslipidemia, smoking and additionally for hemoglobin, mean corpuscular volume and nutritional factor deficiencies) across all the DM subgroups in comparison to the other biomarkers. (Table 1).

Conclusion
RDW and homocysteine predict mortality irrespective of the diabetes status. These may be the potential targets for future research to ascertain the exact pathophysiologic mechanism.
Abstract 224: Gender Differences in Quality of Life and Psychological Responses among Implantable Cardioverter-Defibrillator Patients in Japanese Population
Authors: Rahmawati Anita , Sawatari Hiroyuki , Tsuchihashi-Makaya Miyuki , Ohtsuka Yuko , Miyazono Mami , Hashiguchi Noboku , Sakurada Harumizu , Takemoto Masao , Nakai Sei , Mukai Yasushi , Inoue Syujiro , Chishaki Hiroaki , Suyama-Chishaki Akiko
Published: July 2021

BACKGROUND:
Implantable cardioverter-defibrillator (ICD) has improved prognosis of patients with fatal arrhythmias and ICD implantation has increased. However, there have been known ICD-related psychological problems and impaired quality of life (QOL). There are still limited studies about gender differences in the response to ICD therapy in Japanese population. This paper compared female and male ICD patients on health-related QOL and psychological factors. The aim of the current study were to examine whether women are at a greater risk of poorer QOL and psychological disturbance.

METHODS:
We studied consecutive ICD patients (n=179, males: 145, females: 34, mean age: 61±16) with Short Form-8 Health Survey (SF-8), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and Impact of Event Scale-Revised (IESR). One-way multivariate analysis of variance (MANOVA) was performed to examine the relationship between gender and health-related QOL and psychological factors.

RESULTS:
Women were younger (53.5±19.3 vs 62.2±14.5, P < 0.05) and less likely to be smoker compared to men (8.8% vs 45.5%, P < 0.001). Women were less likely to have ischemic heart disease (17.6% vs 37.2%, P< 0.05). Majority of patients (62%) had a secondary indication for ICD. MANOVA showed women to have impaired QOL on role physical functioning (P <0.05) and bodily pain (P < 0.05) subscales of the SF-8. When adjusting for older age, female gender was associated with impaired QOL on the physical functioning, role physical functioning, bodily pain, and social functioning subscales. Ischemic etiology was not associated with any of the quality of life subscales. Overall of QOL, women have worse physical component summary (PCS) score (44.3±8.8 vs 48.7±9, P <0.05), but no significant differences in mental component summary (MCS) score. Women have greater BDI score than men (9.3±9.2 vs 5.8±7.4, P <0.05). There were no differences in anxiety-state and anxiety-trait between women and men, as well as IESR score.

CONCLUSION:
In Japanese population, women and men did not differ on mean QOL score, except for women reporting poorer quality of life on two subscales, role physical functioning and bodily pain. In terms of QOL thoroughly, PCS was worse in women than men. There was high tendency of depression in women than men. These gender difference were similar to that of foreign country. Based on the finding in gender differences, it can be consideration to manage those potential decline of quality of life and psychological problems in ICD patients.
Abstract 245: Cause specific Cardiovascular Risk Associated with use of Non Steroidal Anti-Inflammatory Drugs among Patients with Prior Myocardial Infarction - a Nationwide Cohort Study.
Authors: Schjerning Olsen Anne-Marie , Fosbøl Emil L , Lindhardsen Jesper , Andersson Charlotte , Folke Fredrik , Køber Lars , Torp-Pedersen Christian , Gislason Gunnar H
Published: July 2021

Background:
Non steroidal anti-inflammatory drugs(NSAIDs) utilization has been associated with worsened outcomes among patients with established cardiovascular disease.We analyzed the cause-specific cardiovascular risk associated with use of NSAIDs in a nationwide cohort of patients with prior myocardial infarction (MI).

Methods:
By individual-level linkage of nationwide registries of hospitalizations and drug dispenses from pharmacies in Denmark, patients aged >30 years admitted with first-time MI during 1997-2009 and their subsequent NSAID use were identified. The risk of cardiovascular death, a composite of coronary death or nonfatal MI, and fatal or nonfatal stroke with NSAID use was analyzed by adjusted Cox proportional hazard models.

Results:
Of 97,698 patients included (mean age 69 years (SD 13.0), 63.0% men),44.0% received NSAIDs during follow-up. Relative to no NSAID use, overall NSAID was associated with an increased risk of cardiovascular death (hazard ratio [HR] 1.52 95% confidence interval [CI] 1.34-1.73). In particular, use of the nonselective NSAID diclofenac and the selective cyclooxygenase-2 (COX-2) inhibitor rofecoxib was associated with increased risk of cardiovascular death (HR 2.05 95% confidence interval CI 1.88-2.23) and HR 1.74(CI.1.53-1.98), respectively) with a dose dependent increase in risk. Use of ibuprofen was associated with increased risk of fatal/nonfatal stroke (HR 1.27(CI. 1.14-1.41)).Naproxen was associated with the lowest risk of all outcomes, although higher than no NSAID use.

Conclusion:
The cause specific cardiovascular risks associated with the use of individual NSAIDs found to differ and in particular rofecoxib and diclofenac were associated with increased cardiovascular morbidity and mortality. These results further support caution in use of NSAIDs in patients with prior MI.
Abstract 251: Clinical Symptoms and Angiographic Findings of Patients Undergoing Percutaneous Coronary Intervention without Prior Stress Testing: Insights from the NCDR
Authors: Abdallah Mouin , Spertus John , Mercado Nestor , Nallamothu Brahmajee , Kennedy Kevin , Arnold Suzanne , Chan Paul
Published: July 2021

Background:
Many patients undergoing elective percutaneous coronary intervention (PCI) do not have prior stress testing. It is unknown if these patients have more severe angina or obstructive coronary artery disease (CAD), whereby proceeding directly to PCI would represent sound clinical judgment and efficient use of resources.

Methods:
We identified elective PCIs performed between 1/1/09 - 3/31/11 in the NCDR CathPCI Registry
®
and assessed for differences in angina (CCS class) and severity of CAD in those with and without pre-procedural stress testing. To further understand whether proceeding to PCI without prior stress testing could be justified because of a high pre-test probability for obstructive CAD (e.g., >70% stenosis in an epicardial coronary artery), we evaluated cardiac catheterizations performed within the registry during the same period to assess the diagnostic yield of obstructive CAD in patients with and without prior stress testing.

Results:
Of 246,629 elective PCIs, 89,084 (36.1%) were performed without prior stress testing. A substantial proportion of both groups undergoing PCI were asymptomatic (no stress test group: 28.9% vs. stress test group: 30.7%), with only a modest difference in the frequency of CCS class III/IV angina (16.2% vs. 11.9%; Table). No meaningful differences in the frequency of proximal LAD (29.7 % vs. 29.9%), left main (5.6% vs. 7.2%) or 3-vessel coronary artery disease (21.1% vs. 19.5%) were observed in the 2 PCI groups. Moreover, the diagnostic yield for obstructive CAD on cardiac catheterization for patients without prior stress testing (n=462,611) was 35.4%, as compared with 58.0%, 38.8%, and 24.1% for those with severe, moderate, and mild ischemia, on pre-procedural stress testing.

Conclusion:
For elective PCI, the current practice of proceeding to coronary angiography and PCI without prior stress testing does not identify higher risk coronary anatomy or more symptomatic patients and may not improve diagnostic yield.
Abstract 252: In-hospital and Discharge quality of pharmacological care among Acute Myocardial Infarction patients in Northern Italy.
Authors: Veronesi Giovanni , Borsani Andrea , Marzegalli Maurizio , Merlino Luca , Cesana Giancarlo , Ferrario Marco M
Published: July 2021

Aim
. We aim to evaluate the adherence to ACC/AHA guidelines for secondary prevention in a representative population of 35-79 years old living in Northern Italy, in 2007-2008.

Methods
. The study population comprises the 35-79 years old residents in the Varese Province. From the regional Hospital Discharge Record database we identified n=1917 hospitalizations with a main discharge code ICD-IX 410.xx occurring in the 17 surveyed hospitals. Clinical information was available for n=1908 events; according to the ACC/AHA 2008 performance measures, data collection included ASA administration at arrival, in-hospital assessment of left ventricular systolic function and LDL-cholesterol, prescription of ASA, beta-blockers and statin at discharge, as well as smoking cessation advice. Data on documented contraindications were also carefully collected. N=87 non acute events were excluded, leaving a final number of n=1821 records. The main performance measure is the proportion of patients treated according to guidelines among those without documented contraindications (eligible patients). We further considered a sex- and age at admission-adjusted analysis, by means of a logistic model.

Results
. Mean age at admission was 64.6±10.5 years, 72.8% were men. Data availability was above 90% for all the indicators. Almost 95% of patients received ASA at arrival; 91% had evaluation of left ventricular systolic function, and 69% had an evaluation of LDL-cholesterol during the hospitalization. ASA, beta-blockers and statin at discharge were prescribed to 94.9%; 74.3%; and 91.0% of eligible patients, respectively. Smoking cessation advice in clinical records was present in 1 smoker out of 4. Women were less likely to receive a prescription for beta-blockers, and the elderly (75-79 years old) less likely to have prescription for ASA and beta-blockers at discharge.

Conclusions
. Overall, a high proportion of eligible patients receives the recommended drug prescription at discharge; however, gender- and age-related disparities in secondary prevention care are present. A less than expected proportion of eligible patients had in-hospital LDL assessment, reducing the number of eligible patients for statin prescription.
Abstract 294: Post-Discharge Phone Calls: Efficient Opportunity to Assess and Improve Patient Adherence to Care Plan
Authors: Jackson E B , Trisdale Sherri , Byrd Jeannie , Devers Cathy , Schafer Kim , Stroud Mary , Dixon Stephanie , Ott Linda , Cunningham Brittany L , Steaban Robin , Fong Pete
Published: July 2021

Background:
Transitioning from hospital to home is a common failure point in care delivery and patient adherence to a plan of care. Our post-discharge phone calls helped identify gaps (especially related to medications) and assign accountability for addressing issues.

Method:
We reached more than 200 patients with Acute Coronary Syndrome and Congestive Heart Failure by phone 24-48 hours after discharge between 8/2011 - 1/2012. We tested two operating models: hospital nurse with knowledge of admission (n=200) vs. clinic nurse with ongoing responsibility for managing patient (n=10 and ongoing). Callers used a standardized script and documentation form with “teach-back” methodology.

Outcomes (Figure):
Medications issues (65%, 107 of 165) included errors in discharge meds lists that contributed to patient misunderstandings and lack of adherence. Most (63%, 89 of 142) patients left the hospital without a scheduled follow-up appointment (revealing systematic improvement need). Callers provided teaching and reinforcement and triaged issues, avoiding at least 3 - 4 probable readmissions. Comparing two delivery models (hospital vs. clinic nurse) yielded notable differences. For both groups, calls took ∼15+ minutes (min=6, max=48). However, prep time, documentation and follow-up were significantly longer for hospital nurses (35 mins) than clinic nurses (15 mins). The hospital nurse spent more time “mining” records to understand each patient story; clinic nurses could prioritize calls and personalize content based on prior relationships with patients. Issues were quickly handled by clinic nurses in face-to-face provider interactions, whereas the hospital nurse frequently became mired in lengthy back-and-forth clinical communication.

Conclusion:
Analysis of post-discharge phone calls shows that some patients (new diagnoses, complicated medications regimen) may particularly benefit; however, the call represented a valuable reinforcement opportunity for
all
patients we reached. Optimally efficient, effective calls require: 1) Reliable patient contact information; 2) Clear record of plan of care, including accurate medications list; 3) Follow-up appointments scheduled; 4) Caller expertise with diagnoses; and 5) Caller prior relationship with the patient. Going forward, our team will continue to test clinic-based post-discharge phone calls, evaluating several key metrics including ability of patients to successfully articulate their medications and follow-up plans, % of patients who attend their follow-up appointments, readmission rates, et al.
Abstract 300: Race/Ethnicity Is Not Associated with Longer Door to Balloon Time or Increased Mortality in Patients Undergoing Primary PCI for STEMI: Findings from AHA-GWTG
Authors: Cavender Matthew A , Rassi Andrew N , Fonarow Gregg C , Cannon Christopher P , Peacock Frank , Laskey Warren , Hernandez Adrian F , Peterson Eric D , Cox Margueritte , Schwamm Lee H , Bhatt Deepak K
Published: July 2021

Introduction:
In patients with ST-Elevation Myocardial Infarction (STEMI) treated with PCI, door to balloon time (DTB) of ≤ 90 minutes is associated with improved outcomes. We sought to compare DTB between patients of different race/ethnicity undergoing primary PCI in Get With The Guidelines (GWTG) hospitals.

Methods:
We analyzed the GWTG registry to identify patients treated with primary PCI for STEMI within 24 hours of presentation between 2005-2009. Patients treated with fibrinolytics, transferred to the hospital for PCI, or those missing DTB were excluded. Baseline demographics, median DTB, proportion of patients with DTB ≤ 90 minutes, and in-hospital mortality were compared between groups: White, African American, Hispanic.

Results:
Of the 7824 patients, 85% were White (n=6666), 8% were African American (n=607) and 7% were Hispanic (n=551). When compared with Whites and Hispanics, African American were younger but had higher rates of smoking, hypertension, renal disease, prior myocardial infarction, heart failure, or stroke. The Hispanic group had a higher proportion of patients with diabetes, hyperlipidemia, and no insurance. Median DTB times and the proportion of patients treated ≤ 90 minutes were similar between the three groups (Figure). In-hospital mortality was similar in the groups: white (3.8%), African American (3.0%), and Hispanic (3.8%); p=0.62.

Conclusion:
Within the context of a national quality improvement initiative, race/ethnicity was not associated with either DTB or in-hospital mortality among STEMI patients undergoing PCI. This suggests that programs such as GWTG may reduce race/ethnicity based disparities in the care of patients with STEMI.
Abstract 311: Statewide Hospital Performance on Total Lives Saved during Coronary Revascularization Procedures among Medicare Beneficiaries in Fiscal Year 2010
Authors: Kugelmass Aaron D , Brown Phillip P , Reynolds Matthew R , Cohen David J , Culler Steven D , Simon April W
Published: July 2021

Background:
This study calculates and reports total lives saved for each of the 50 states in the US among Medicare beneficiaries (MB) undergoing any coronary revascularization procedure (CRP) performed during 2010.

Methods:
This retrospective study examined the fiscal year 2010 Medicare Provider Analysis and Review (MedPar) Files to identify 319,423 MB undergoing a CRP; either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) during the study period. Separate risk-adjusted mortality models were estimated for each procedure. Next, total lives saved compared to the national average mortality rate was calculated for each of the 718 hospitals performing 52 (one/week) or more of each type of revascularization procedure. Finally, statewide total lives saved were calculated by summing the number of lives saved/lives lost for both revascularization procedures in all hospitals in that state. States were then ranked by the total number of lives saved and this study reports on the ten best and worst states.

Results:
The table reports statewide total number of lives saved/lost, number of hospitals, and the percent of all hospitals in the state that either saved or lost lives on both CRPs for the 10 best and 10 worst states. For the 10 best states, total lives saved ranges from 71.8 to 8.6. Among the 257 hospitals in these 10 states only 17.1% of the hospitals lost lives in both procedures while 42.8% saved lives (above average) in both procedures. For the 10 worst states, total lives lost ranges from 64.1 to 10. Among the 155 hospitals in these 10 states only 16.1% of the hospitals saved lives in both procedures while 40.7% lost lives (below average) in both procedures.

Conclusions:
The study shows that in three of the 10 best states more than half of the hospitals in those states had adjusted survival rates above the national average. On the other hand, 4 of the 10 worst performing states do not have any hospitals that save lives in both CRPs.
Abstract 325: Readmission among Hospitalized Patients with Non-Valvular Atrial Fibrillation
Authors: Smoyer-Tomic Karen E , Siu Kimberly , Johnson Barbara , Walker David R , Sander Stephen , Song Xue , Amin Alpesh
Published: July 2021

Background:
An important goal of healthcare reform is reducing the need for hospital readmissions. This study examined readmission rates, reasons for readmissions, and risk factors associated with readmissions in non-valvular atrial fibrillation (NVAF) patients, which may facilitate identification of potential gaps in care.

Methods:
Patients with AF hospitalizations in any diagnostic position in 2004-2009 were extracted from a large, national commercial and Medicare supplemental administrative claims database. Patients with valvular or transient causes of AF, under the age of 18 years, pregnant, or dead at discharge were excluded from the study. All patients had at least 30 days follow up from the index hospitalization discharge date. Readmission rate within 30 days of discharge date was calculated. Reasons for readmission were reported by ICD-9 diagnosis codes in the primary position. ICD-9 diagnosis codes were grouped into common acute conditions (e.g., ischemic heart disease, cerebrovascular disease) and reported. Logistic regression analyses were conducted to identify risk factors for readmission, controlling for patients’ demographic and clinical characteristics.

Results:
A total of 6439 patients met the study criteria. The overall 30-day readmission rate was 18.0%. Readmission rates for patients with AF as primary or secondary diagnosis in index admissions were 11.8% and 20.3%, respectively (p<0.001). Readmissions on average occurred 9.7 (SD 9.0) days from index admission discharge, with a mean readmission length of stay (LOS) of 7.4 (SD 8.0) days. The 4 most common grouped diagnoses for readmissions were AF (ICD-9 code 427.31, 10.2% of all readmissions), ischemic heart disease (IHD; 410.xx - 414.xx, 7.2%), heart failure (HF; 428.xx, 7.1%), and cerebrovascular disease (CVD; 430.xx - 438.xx, 6.0%). Longer LOS in the index admission, higher Charlson comorbidity index, and emergency room admission for the index admission all significantly increased the likelihood of having a readmission (p<0.001 in all cases). Patients discharged to home from index admission, patients with AF as primary diagnosis in index admissions, and patients living in the South region were less likely to be readmitted (p<0.01 in all cases).

Conclusions:
Almost one fifth of patients with NVAF were readmitted within 30 days of discharge. AF, IHD, HF, and CVD were the most common reasons for readmission. Identification of risk factors for readmission may assist healthcare providers in targeting good clinical practice aimed at improving quality of care and reducing the need for readmissions.
Abstract 40: Hospital Variation in Premature Clopidogrel Discontinuation following Drug Eluting Stent Placement and Adverse Cardiovascular Outcomes from the VA Clinical Assessment, Reporting, and Tracking System for Cath Labs (CART-CL)
Authors: Vigen Rebecca , Maddox Thomas M , O'Donnell Colin , Bhatt Deepak L , Tsai Thomas T , Rumsfeld John S , Ho P M
Published: July 2021

Background:
Clopidogrel is recommended for 1 year following drug eluting stent (DES) placement and premature discontinuation has been associated with adverse outcomes. The extent of variation in premature discontinuation across hospitals within an integrated healthcare system is unknown. Accordingly, we assessed variation in premature clopidogrel discontinuation across all VA PCI sites and whether there was an association between hospitals with higher rates of premature discontinuation and adverse outcomes.

Methods:
We used the VA CART-CL registry which includes all PCIs with drug eluting stents performed between 10/01/08 and 09/30/09 at 55 VA cath labs that used CART. We evaluated the frequency of patients who prematurely discontinue clopidogrel at 6 and 9 months using pharmacy refill data. Multivariable regression assessed the association between premature discontinuation and all-cause mortality and/or myocardial infarction (MI). We then grouped sites into quartiles of premature discontinuation and evaluated the association between hospital level premature discontinuation and adverse outcomes.

Results:
Of the 7,022 patients who received a DES, 6.3% discontinued by 6 months, and 10.2% by 9 months. After risk adjustment, patients who discontinued clopidogrel prematurely had increased risk of adverse events with HR of 5.42 at 6 months (95% CI 4.22 – 6.99), and 6.24 at 9 months (95% CI 4.98 – 7.83). There was a significant trend in the unadjusted rates within quartiles toward increased risk of adverse outcomes among hospitals with greater rates of patients who discontinue prematurely by 6 months (p < 0.01 for trend, OR 1.65 CI 1.07 – 2.62 for comparison between quartile 1 and 4).

Conclusion:
Premature discontinuation of clopidogrel is associated with adverse outcomes among patients who receive drug eluting stents. Hospitals with higher rates of premature discontinuation of clopidogrel have higher rates of adverse outcomes. Hospital-level interventions to reduce early discontinuation of clopidogrel therapy have the potential to improve outcomes of patients who receive a DES.
Abstract 42: Differences in Presentation, Process, and Outcomes of Aortic Valve Surgery for Women versus Men
Authors: Gelb Daniel J , Likosky Donald S , Quinn Reed D , DiScipio Anthony W , Surgenor Stephen D , Leavitt Bruce J , Baribeau Yvon R , Sardella Gerald L , Russo Louis , Sisto Donato , Hernandez Felix , Malenka David J ,   The Northern New England Cardiovascular Disease Study Group
Published: July 2021

BACKGROUND:
There is a rich literature on differences in process and outcomes for women versus men undergoing coronary revascularization. Much less is known about gender differences for patients undergoing valve replacement surgery.

HYPOTHESIS:
Extrapolating from revascularization, women undergoing aortic valve replacement (AVR) for aortic stenosis would have greater severity of illness, more comorbidities and worse outcomes than men.

METHODS:
From our Northern New England Cardiac Surgery Registry we identified 4133 patients who underwent AVR for severe stenosis (area <1.0 cm2) between 1/1/2000-12/31/2010; 2144 isolated AVRs and 1969 AVR+CABG. We compared severity of illness, comorbidities, the process of care, and in-hospital outcomes for women versus men, stratifying by concomitant CABG, using standard statistical techniques.

RESULTS:
Women comprised 47.9% of AVRs and 36.4% of AVR+CABGs. In the AVR population women were older, smaller, had more symptoms of heart failure but had less renal and coronary disease. They had shorter pump runs despite being more likely to receive blood products. Outcomes were similar to those in men including mortality (3.5% v 2.2% women v men; adjusted OR 1.32, 95%CI 0.71-2.44). In the AVR+CABG population women were older, smaller, and had more hypertension but less vascular disease and multivessel coronary disease. Again, pump runs were shorter but the use of blood products was greater. Mortality was higher for women than men (7.5% women v 3.8% men; adjusted OR 2.12, 95%CI 1.32-3.43) with no difference in other outcomes.

CONCLUSION:
In-hospital outcomes for women undergoing isolated AVR are comparable to those in men. However, as with isolated CABG, AVR+CABG is associated with higher mortality for women than for men. Why this is true remains to be determined.
Abstract 47: Adherence to Antihypertensive Medications is Associated with Fewer Cardiovascular Related Hospitalizations and ED Visits in Patients 65 and Older
Authors: Pittman Donald G , Tao Zhuliang , Eisenberg Edward S , Pendergrass Merri
Published: July 2021

Objective
To examine the relationship between Antihypertensive Medication (AHM) adherence and subsequent cardiovascular related hospitalizations (CVH) and emergency department visits (CVED) in patients 65+ years of age.

Methods
A retrospective cohort study of patients 65+ years of age receiving AHM therapy was performed. Patients had deidentified data on medical and pharmacy claims in the Medco Health Solutions, Inc. integrated warehouse, and were continuously enrolled in coverage from January 2009 through June 2011. Medication adherence was assessed by proportion of days covered (PDC) over 1 year, and risk of CVH and CVED over the subsequent year. Patients were segmented into three adherence cohorts based on PDC: 80 to 100% (adherent), 60 to 79% and <60%. Risk of CVH and CVED visits was determined by medical claims during the subsequent 12 months.

Results
Among the 316,108 total eligible adults, mean age was 74.9 +/-6.1 years; 57.5% were women, 82.4% were hypertensive, 28.3% had coronary artery disease (CAD), 14.1% had stroke, 9.6% had heart failure (HF) and 32.5% had diabetes. A subset that included only Medicare Part D (Med-D) plan participants (n=26,248, mean age 74.3 +/-5.8 years) had a greater percentage of women and comorbidities vs. the non-Med-D patients (n=298,860, mean age 75.0 +/-6.1 years). Comorbidity differences between the Med-D vs. non-Med-D groups were: Women 64.5% vs. 56.8%; hypertension 93.6% vs. 81.4%; CAD 34.8% vs.27.7%; stroke 16.0% vs. 13.9.%; HF 15.4% vs. 9.0%; and diabetes 54.9% vs. 30.5%, p<0.0001 for all groups. Overall, mean PDC was 91% (+/-15%) and was lower in the Med-D group at 89% (+/-17%) vs. non-Med-D group at 91% (+/-14%). The majority, 271,002 (85.7%) had PDC ≥80%; 26,973 (8.5%) had PDC of 60-79% and 18,133 (5.7%) had PDC of <60%. After adjustment for age, sex, comorbidities, year 1 hospitalizations and ED visits, and total medications, the overall risk of CVH was significantly greater with PDC 60-79% (OR 1.23; CI 1.19-1.28) and PDC <60% (OR 1.31; CI 1.25-1.37), p<0.0001 vs. PDC ≥80%. The risk of CVED was increased with PDC 60-79% (OR 1.18; CI 1.12-1.24) and PDC <60% (OR 1.29; CI 1.22-1.37), p<0.0001 vs. PDC ≥80%. Patients covered by Med-D plans with PDC < 60% had the greatest risk of CVH (OR 1.42; CI 1.26-1.59) and CVED (OR 1.49 CI 1.32-1.68).

Conclusions
For patients 65+ years of age, one in seven was nonadherent to AHM medications. Adherence to AHM was associated with an inverse risk of CVH and CVED. The risk of increased CVH and CVED was even more pronounced in Med-D plan participants with the poorest nonadherence.
Abstract 53: Development of Standardized Approach in Symptomatic Carotid Stenosis for Early Intervention
Authors: De Rango Paola , Lenti Massimo , Caso Valeria , Cieri Enrico , Simonte Gioele , Giordano Giuseppe , Verzini Fabio
Published: July 2021

Background:
Despite current guidelines recommend performing carotid endarterectomy (CEA) within the first 7-14 days from symptoms onset, this is not the routine approach for symptomatic carotid stenosis in most countries because of logistic difficulties and concerns regarding perioperative risk of “urgent CEA”. The aim of this study was to implement a multi-service in-hospital protocol to standardize the approach and reduce recurrence risk in acute symptomatic carotid stenosis without radical logistic reorganizations.

Methods:
All patients referred to the Emergency Room (ER) for acute cerebrovascular events will be seen within 24hours by the neurovascular specialist on call who rapidly triages patients (ABCD2 score), starts optimum medical therapy and performs carotid duplex ultrasound in the ER where immediate cerebral imaging will be also done by the neuroradiologist on call. Patients with 50-99% stenosis are discussed with the vascular surgeon on call and treatment decided (CEA vs stenting vs medical therapy) according to patients’ comorbidities, neurological status and carotid plaque morphology. Decision for intervention implies immediate transferal to the Vascular Surgery Unit where treatment is guaranteed within 2-48 hours in a hybrid operating room. The neurovascular specialist follows all postoperative courses (eventual transferal to Stroke Unit can be decided).

Results:
Before the application of the standardized protocol, over 2002 consecutive carotid interventions, 684 were performed for symptomatic stenosis with perioperative stroke/death risk of 3.5%, similar in Stenting and CEA. The stroke risk at 5 years after the procedure was 8.7% after CEA vs. 4.9% after stenting (p =0.7). However, there was extreme variability in symptoms-to-treatment delay.

Conclusion:
Multidisciplinary team collaboration among traditional 24h availability local services would standardize the approach to carotid stenosis in symptomatic patients without substantially changes in hospital services and relevant logistic reorganization. The efficacy of stenting in early treatment will be verified. Increased prevalence of symptomatic interventions and improved stroke prevention rates are expected with the new protocol.