bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 134: Hospital-Level Variability in the Use of Anticoagulant Strategies in a Real-World Population of Patients with Acute Myocardial Infarction
Authors: Arnold Suzanne V , Spertus John A , Alexander Karen P , Bach Richard G , Wang Tracy Y , Krumholz Harlan M , Li Yan , Jones Philip G , Kosiborod Mikhail
Published: March 2022

Background:
Anti-coagulants (AC) are a key treatment for reducing morbidity and mortality during an acute myocardial infarction (AMI). Each AC agent has risks and benefits and may be optimal in certain patient subgroups, but the extent to which the choice of AC therapy is dependent on the hospital site, as opposed to patient characteristics alone, is unknown.

Methods:
We examined the use of unfractionated heparin (UFH), low-molecular weight heparin (LMWH), and bivalirudin within the first 24 hours of hospitalization for AMI among patients from 24 US hospitals (83% academic; mean #beds=598 [range 66-1000]; all with PCI capability) in the TRIUMPH registry from 4/05-12/08. Only patients who underwent coronary angiography during hospitalization and were treated with an AC were included in the analyses. Hierarchical multinomial regression was used to examine the predicted probabilities of receiving UFH, LMWH, or bivalirudin across the 24 sites, adjusting for patient characteristics (including estimated risk of bleeding). Site level variation was further explored with a median odds ratio (MOR), which estimates the average difference in odds ratios of 2 hypothetically identical patients treated at 2 random sites within TRIUMPH, using UFH as the reference treatment.

Results:
Of the 3682 AMI patients (47% STEMI/53% NSTEMI) who underwent angiography and were treated with an AC, 77.1% were treated with UFH during the first 24 hours of their AMI, 18.2% with LMWH, and 4.8% with bivalirudin. The predicted probabilities of AC use by site for a hypothetically identical patient ranged across hospitals from 45-98% for UFH, 1-51% for LMWH, and 1-11% for bivalirudin (Figure). The MORs (95% CI) were 2.97 (95% CI 2.25-5.21) for LMWH vs. UFH and 2.52 (95% CI 1.92-4.80) for bivalirudin vs. UFH, indicating substantial variability of the use of different ACs across hospitals even after accounting for patient-level differences.

Conclusion:
In a large, multicenter AMI registry, we found that the use of different AC strategies is highly dependent on the site to which a patient presents, even after accounting for differences in patients’ presenting characteristics and treatment strategies.
Abstract 136: Non-Adherence to Anticoagulant Therapy Among Employed and Unemployed Patients With Venous Thromboembolism
Authors: Vanderpoel Julie , Bookhart Brahim , Gross Hillary J
Published: March 2022

Objective:
To identify self-reported non-adherence to anticoagulant therapy among patients with venous thromboembolism (VTE) and determine whether non-adherence differs among these patients based on employment status.

Methods:
This study was conducted using the 2010 wave of the National Health and Wellness Survey (NHWS). The NHWS is a self-administered, Internet-based questionnaire from a nationwide sample of adults (N=75,000). Only patients with a diagnosis of VTE (defined as a self-reported diagnosis of deep vein thrombosis [DVT] or pulmonary embolism [PE]) and receiving medication for VTE were included in the analysis. Patients completed the 4-item Morisky Medication Adherence Scale (MMAS), tailored specifically to VTE medications. Complete adherence was defined as a score of 0 on the MMAS, while non-adherence was defined as a score of 1 through 4. Based on this definition, the proportion of patients reporting non-adherence was determined. Non-adherence was determined separately for patients with DVT and those with PE. Patients’ employment status was collected from the NHWS. Bivariate differences for non-adherence between the employed and unemployed patient groups were assessed using Chi-squared tests.

Findings:
A total of 261 patients with DVT and 129 patients with PE were included in the analysis. Among these patients, 28% (n=72) of those with DVT and 29% (n=37) of those with PE reported being non-adherent to their medication regimens. Of the patients with DVT, 39% (n=102) were employed; of those with PE, 37% (n=48) were employed. Employed patients were more likely to be non-adherent than their unemployed counterparts. Specifically, 36% (n=37) of the employed DVT patients reported being non-adherent, versus 22% (n=35) of the unemployed DVT patients (
P
<0.05). Similarly, 40% (n=19) of the employed PE patients reported non-adherence, versus 22% (n=18) of the unemployed PE patients (
P
<0.05). The most commonly reported reason for non-adherence among both DVT and PE patients, regardless of employment status, was forgetting to take their medication.

Conclusions:
Among patients with VTE, self-reported non-adherence to anticoagulant therapy is higher among those who are employed, indicating that adherence may be a greater challenge for them. Therefore, selecting less burdensome VTE treatment options may be of particular importance among patients with VTE who are employed.
Abstract 140: Effectiveness Of Dronedarone Among US Patients With Atrial Fibrillation/Flutter In The Real-World Setting
Authors: Kim Michael H , Lin Jay , Jhaveri Mehul , Koren Andrew
Published: March 2022

Introduction:
In the ATHENA trial, dronedarone reduced the rate of first cardiovascular (CV) hospitalization by 26% in patients with paroxysmal or persistent atrial fibrillation/flutter (AF/AFL). This analysis quantifies the impact of dronedarone on hospitalization events and healthcare costs among AF/AFL patients in real-world practice.

Methods:
This retrospective cohort study identified patients aged ≥18 years with ≥2 concurrent
de novo
pharmacy claims for dronedarone (≥180 days’ total supply) from the MarketScan database (June 2009[[Unable to Display Character: ‒]]March 2011). Patients had to have an AF/AFL diagnosis (ICD-9-CM codes 427.31/427.32) and no heart failure-related hospitalization during the 12-month period before the initial (index) dronedarone claim, and continuous pre-index (≥12 months) and post-index (≥6 months) insurance coverage. Patients were followed until (the earlier of) end of dronedarone supply or health insurance disenrollment. Annualized hospital and emergency room (ER) admissions/visits (all-cause, CV- and AF-related) and healthcare costs were compared between baseline and follow-up.

Results:
In total, 5,656 patients (mean age 68.3 years; 62% male; mean Charlson Comorbidity Index 1.50) were treated with dronedarone and were followed for (mean ± SD) 11.9 ± 4.7 months. Mean numbers of annualized all-cause, CV-related, and AF-related hospitalizations and ER visits were reduced (
P
<0.0001) after dronedarone initiation (Table). All-cause hospital and ER costs declined (28% and 26%, respectively) after dronedarone initiation; this was offset by increases in total outpatient and prescription costs (14% and 79%, respectively) (Table). Overall, total (inpatient, outpatient, and prescription) costs increased marginally (8%) after dronedarone initiation (mean $25,650
vs
$23,815 per patient-year,
P
<0.01). Patients switching to dronedarone from other antiarrhythmic drugs (n=2,080) showed similar reductions in hospital and ER events and costs; for this cohort, total healthcare costs were minimally affected by dronedarone initiation [mean $26,248 (baseline)
vs
$26,928 (follow-up) per patient-year,
P
=0.51].

Conclusions:
Dronedarone use in real-world practice results in substantial reductions in hospital admissions and variable overall costs in first- and second-line treatment of AF/AFL.
Abstract 153: Impact Of The Enhance Trial On The Use Of Ezetimibe In The Us And Canada
Authors: Lu Lingyun , Krumholz Harlan , Tu Jack , Ross Joseph , Ko Dennis , Jackevicius Cynthia
Published: March 2022

Background:
Clinical evidence, particularly landmark trials, may impact physicians’ prescribing patterns and medication use. Drug policies and marketing may also impact medication use. We examined trends in the use of ezetimibe before and after the reporting of the landmark ENHANCE trial in the United States compared with Canada.

Methods:
We conducted a population-based, retrospective, time-series analysis using the data collected by IMS Health in the United States and Compuscript in Canada from January 1, 2002 to December 31, 2009. The main outcome measures were monthly number of prescriptions for ezetimibe-containing products before and after the ENHANCE trial. The ENHANCE trial, which was released in mid-January 2008, represented the intervention event.

Results:
The monthly number of prescriptions for ezetimibe rose from 6 to 1082 per 100,000 population in the United States from November 2002 to January 2008, then started declining to 572 per 100,000 population by December 2009 after the release of the ENHANCE trial. However, the monthly number of prescriptions for ezetimibe has been consistently rising from 2 to 495 per 100,000 population in Canada from June 2003 to December 2009. The autoregressive time series analysis showed that the release of the ENHANCE trial significantly decreased the use of ezetimibe in the United States (p=0.0005) but not in Canada (p=0.2382).

Conclusions:
Distinct patterns of use of ezetimibe emerged in the United States and Canada from 2002 to 2009. The ENHANCE trial has significantly decreased the use of ezetimibe in the United States but not in Canada. Factors other than available evidence appear to be influencing ezetimibe use in Canada.
Abstract 157: The Relationship between Readmission Cost and Total Cost Over Time for Heart Failure
Authors: Burke Joseph M , Weeks William B , Westrich James L , Savitz Lucy A , Dunlay Shannon M , Wennberg David E , Havranek Edward P
Published: March 2022

Background:
The dominant healthcare payment model in the US, fee-for-service, provides incentives to deliver costlier care for heart failure and disincentives to deliver higher quality care. One proposed method to align cost and quality incentives is to impose financial penalties on providers when patients are readmitted within 30 days after a heart failure hospitalization. We hypothesized that this strategy might not lower overall costs, because lower readmission costs might be offset by higher non-readmission post-acute care costs.

Methods:
We studied cost to Medicare from 2008-09 for all heart failure hospitalizations (MS-DRG 291, 292, or 293) in the 15 healthcare delivery systems participating in the High Value Health Collaborative. We categorized costs for the 30, 90, and 180 days after the day of admission for first heart failure hospitalization in the study period into acute care costs (inpatient care, outpatient facility costs with 3 day look back window, part B professional fees), inpatient readmission cost, and non-readmission post-acute care costs (outpatient facility fee, sub-acute rehab, inpatient rehab, long term care, home health care, part B professional fees).

Results:
Using the most common MS DRG (DRG 292) as an example, across the 15 healthcare systems, we found wide variation in median total costs for the 30- ($6487-$11565), 90- ($8049-$18918), and 180- ($9844-$24752) day time frames. For the 30-day time frame, readmission costs ($700 - $2684) and non-readmission post-acute care costs ($477 - $6398) also showed wide variation. The Figure is a plot of these two costs, with bubbles sized to reflect the number of cases for the hospital system (30-day time frame); results were comparable for 90 and 180 days. Contrary to our hypothesis, we found no inverse relationship between readmission costs and non-readmission post-acute care costs. These data do not account for possible differences in case mix and in geographic differences in labor and facility costs.

Conclusions:
Non-readmission post-acute costs for heart failure are unrelated to readmission costs but were greater than readmission costs in a number of healthcare deliver systems, raising questions about the overall value to the healthcare systems of an exclusive focus on readmission as a strategy for reducing the costs of heart failure.
Abstract 159: Achieving STEMI Revascularization Goals with an Inter-Hospital Transfer System
Authors: Lawson William E , Wilbert Lisa , Pulipati Bhargava , Gruberg Luis , Mani Anil , Jeremias Allen , Chernilas Joseph
Published: March 2022

Background:
Primary PCI has been recognized as the procedure of choice for STEMI revascularization when performed in a timely manner. Developing an effective system to allow immediate transfers from non-PCI capable community hospitals to a PCI capable center requires continued collaborative effort to achieve and maintain. Stony Brook University Hospital (UH) is the sole tertiary care hospital in Suffolk county (population of 1.5 million; area over 900 square miles). Particularly challenging for effective revascularization is the lack of a triage strategy permitting direct transfer to PCI capable hospitals and the system of multiple voluntary EMS providers. Post C Port trials, additional sites capable of performing PCI have opened, but for much of the county UH remains the center of choice. For hospitals with a transport time of over 45 minutes lytic therapy is typically advised as the primary reperfusion strategy. We report our efforts at improving D2B times to achieve a first medical contact (FMC) to device time of < 120 minutes for our most challenging referral hospital (20 miles away with a one way travel time of 25-40 minutes).

Methods:
The 2011 FMC -to balloon (2B) time of transfers was compared to the FMC-2B median times in 2012 after a series of system based changes were initiated. Efforts focused on early performance and interpretation of an ECG in appropriate patients, immediate transport to UH for revascularization, activation of the UH cath lab simultaneous with transport.

Results:
FMC-2B times improved from a median time of 145.0 minutes in 2011 to 118.5 minutes in 2012. With the early activation of the UH cath lab the SB D2B time was consistently < 30 minutes, allowing up to 90 minutes for the identification and transfer of the STEMI patient. Transport time remained the greatest variable and caused the most outliers, while improvement opportunities in performance of ECG, ECG interpretation and team activation were also identified. Immediate feedback and monthly review of cases facilitated process improvement.

Conclusions:
Improving FMC-D2B times in a system with referring non-PCI capable hospitals is challenging and requires efforts to establish protocols aimed at promoting a regional system of STEMI care. Assigning interval responsibility, shared participation in identifying opportunities for improvement, immediate feedback, periodic review by all team participants can effectively move the process forward.
Abstract 160: Presence of Anti-Viral and Anti-Parasitic Antibodies and Cardiovascular Mortality: Insights From NHANES III
Authors: Grover Peeyush , Shah Neeraj , Patel Nileshkumar J , Chothani Ankit , Mehta Kathan , Deshmukh Abhishek , Rathod Ankit , Savani Ghanshyam , Singh Vikas , Gupta Sandeepkumar J , Badheka Apurva O , De Marchena Eduardo , Cohen Mauricio G
Published: March 2022

Background:
Prior studies analyzing the effect of infection and cardiovascular events have met with contradictory results. We investigated whether infectious burden increases cardiovascular mortality in a cross sectional US population.

Methods:
The public dataset of the National Health and Nutrition Examination Survey III (NHANES III) between the years 1988-1994 was used for the analysis. We included patients >18 years with data on positive antibodies against Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis E, Herpes simplex virus 1 and 2, Toxoplasma, Varicella, Cytomegalovirus (CMV), Human herpes virus -8 and Toxocara (n= 7,876). These infections were combined to create a total infection burden variable. This variable was split into quartiles. The primary outcome was cardiovascular (CV) mortality. Traditional cardiac risk factors along with C-reactive protein (CRP) and social class (insurance, income and education level) were adjusted for in the multivariable analysis.

Results:
431 (5.5%) of cardiovascular deaths were reported with a mean follow up of 14.5 years. On a univariable analysis only positive toxoplasma antibody (HR, 95% CI, p-value) were predictive of CV mortality (1.18.,1.03-1.36, 0.02). Independent predictors of CV mortality in the multivariable model were age, female gender, CRP titers, hypertension, smoking, and diabetes. Social class (insurance, income and education level) and total infection burden, quartiles 2 (p = 0.1), 3 (p = 0.4) and 4 (p = 0.1) were not predictive of CV mortality when keeping quartile 1 as the referent.

Conclusion:
Our observational study in a large database suggests that presence of antibodies against certain viral and parasitic infections is not associated with increased cardiovascular mortality in a nationally representative cohort.
Abstract 164: Temporal Trends in Dimensions at Diagnosis, Treatment, Rate of Progression, and Outcomes in Patients with Thoracic Aortic Aneurysms
Authors: Ojha Chandra , Bulibek Batyrjan , Heinecke Carl , Britton Lewis , Torosoff Mikhail
Published: March 2022

Background:
We investigated contemporary trends in aneurysm dimensions at the time of diagnosis and long-term outcomes in patients with thoracic aortic aneurysms.

Material and Methods:
Medical records of 116 consecutive patients enrolled in the Aortic Aneurysm clinic at a single tertiary medical center were reviewed. Patients with aortic dissection were excluded. Patients were divided into groups 1 (n=25, diagnosed before 2005), 2 (n=69, diagnosed between 2006-2010), and 3 (n=22, diagnosed after 2011). Long-term outcomes were determined using Social Security Death Index. ANOVA and chi-square tests were employed.

Results:
There were no significant differences in age, gender, hypertension, and the size of aortic aneurysm at the time of diagnosis (Table). There was a trend towards increased prevalence of diabetes, chronic kidney or coronary artery disease during recent years (Table). This, however, was not associated with increased utilization of beta-blockers and/or differences in the rate of aneurysm expansion (average rate of 0.252+/-0.263 cm/year; see Table for per group values). Outcome data was skewed towards patients diagnosed earlier, with significantly longer follow-up duration (p<0.001, Table). However, we have observed a trend towards higher mortality in patients diagnosed during recent years (p=0.072, Table).

Conclusions:
Our data suggests a contemporary trend towards increased co-morbidities and reduced longevity in patients with thoracic aortic aneurysms despite stable rate of aneurysm progression. This suggests a need for a more vigilant and aggressive risk factor modification and medical management in this vulnerable patient population.
Abstract 181: Relationship Between 30-Day Readmission and 30-Day Mortality for Heart Failure and Acute Myocardial Infarction.
Authors: Heidenreich Paul , Sahay Anju , Massie Barry
Published: March 2022

Background:
Mortality and readmission at 30 days following admission for heart failure (HF) and acute myocardial infarction (AMI) are publically reported. It is unclear if these are influenced by similar (correlated) or different care processes (not correlated).

Methods:
We used publically available data from Hospital Compare of the Center for Medicare and Medicaid Services that includes hospital specific 30-day mortality and 30-day all-cause readmission rates adjusted for patient characteristics for US hospitals from 2010-2011. In multivariate analyses of 30-day outcome we included hospital level rates of the HF and AMI rates of process of care reported on Hospital Compare, hospital type (critical access vs. other) and used backward selection to determine those characteristics associated with outcome (p<0.05). All analyses were weighted for the number of discharges per facility.

Results:
There was a slight negative correlation (r= -0.17, p< 0.0001) for HF (hospitals with lower mortality had more readmissions, N=3990) and no correlation (r= 0.01, p=0.52) for AMI (N=2434, Figure). 30-day mortality for HF was correlated with 30-day mortality for AMI (r=0.37, p<0.0001), and a stronger correlation (r=0.50, p<0.0001) was observed for readmission (HF vs. AMI). In multivariate analysis, hospitals with a higher HF readmission rate were more likely to have a lower HF mortality rate, be a non-critical access hospital, have more documentation of discharge instructions and less documentation of ejection fraction. A higher HF mortality rate was associated with a higher HF readmission rate, less documentation of ejection fraction and hospitalization at a critical access hospital. A higher AMI readmission rate was associated with less aspirin use on arrival and longer door to balloon times. A lower AMI mortality rate was associated with more beta-blocker use and rapid door to balloon time.

Conclusion:
There is a slight inverse correlation for 30-day readmission and 30-day mortality following an admission for HF but not for AMI. Associations of recommended processes of care with less readmission were limited but consistent for AMI. Disparate associations were noted for HF readmission and processes of care.
Abstract 186: Understanding Readmissions at Minority-Serving Hospitals
Authors: Joynt Karen E , Winn Laura , Epstein Arnold M , Jha Ashish K , Weissman Joel
Published: March 2022

Objective:
The Affordable Care Act requires that the Centers for Medicare and Medicaid Services (CMS) reduce payments to hospitals with high readmission rates starting in 2013. Minority-serving institutions have higher rates of readmissions, and are therefore likely to be financially penalized as a result of this policy. Our objective was to better understand the characteristics, settings, and strategies that differentiate strong and poor performing minority-serving hospitals.

Methods:
We conducted case studies at six U.S. hospitals with a patient population over 50% black, choosing sites based on either strong or poor performance on readmissions in 2008-2009. Chief Medical Officers, Chief Executive Officers, Chief Quality Officers, Case Managers, and other key staff at each site each participated in hour-long semi-structured interviews where questions about hospital and patient characteristics, priorities, strategies to reduce readmissions, and general impressions about CMS’s policies were asked. Detailed notes were collected and supplemented by a review of audio tapes. Themes and intensity of comments were coded and prepared as a matrix.

Results:
Nearly all of the case study respondents felt that the readmission rate was an important quality metric for CMS to assess, and most respondents felt their hospitals could do better to reduce readmissions. However, few respondents knew if they were going to be penalized by CMS. The majority of respondents reported implementing new programs or procedures to try to reduce readmissions regardless of whether they were going to be penalized. Hospitals that had a low proportion of self-pay patients, high occupancy rates, and high margins had more programmatic efforts around reducing readmissions and improving transitions of care. Some strategies employed were the implementation of call centers, focused attention on discharge planning, and availability of local external resources to support program staff. Nevertheless, nearly all respondents felt that they were unable to reduce readmission rates to the level they wished because of patient and community factors, including difficulties with paying for and managing medications, literacy, housing stability, and income. Respondents also identified significant challenges in terms of infrastructure, including inadequate staffing and expertise in this area to implement potentially beneficial programs.

Conclusions:
Minority-serving hospitals in our case studies faced substantial challenges to reducing readmissions, including their own financial health as well as community and patient-level factors. Better understanding the strategies and approaches that work in resource-poor settings, or accounting for the poverty of the underlying patient population, are two potential strategies for ensuring that CMS’s readmissions policies do not inadvertently worsen disparities.
Abstract 194: Assessing The Impact Of Financial Incentives On The Quality Of Diabetes Care; An Observational Study Of Primary Care Diabetes Initiatives In Ireland.
Authors: Mc Hugh Sheena M , Marsden Paul , Brennan Carmel , Murphy Katie , Joe Moran , Harkins Velma , Perry Ivan J
Published: March 2022

Aim:
The aim of this study was to examine the association between financial incentives and the quality of structured type 2 diabetes management in three primary care-led initiatives in Ireland.

Methods:
A purposive sample of 3 primary care diabetes initiatives in the Republic of Ireland, were involved in this study. Routine audit data, collected between 2007 and 2009, on 3010 adult patients with Type 2 diabetes across 63 general practices, were analysed. All practices provided structured care to patients with diabetes which involved continuing professional education, maintaining practice registers and engaging in regular audit and feedback. Chi-squared tests were used to examine associations between the presence of financial incentives and the recording of processes of care. Independent t-tests were conducted to examine differences between the groups in terms of intermediate outcomes. Bonferonni adjustment was used to correct for multiple comparisons.

Results:
There were significant differences between practices receiving a financial incentive for participation in a structured care initiative (n=2004), and practices which did not receive financial remuneration (n=1006). While recording of clinical processes of care was high in both groups, recording was significantly higher among practices in receipt of a financial incentive (p=0.000). The level of retinopathy screening and foot assessment received by patients was higher in practices which did not receive financial recompense. However, there was a substantial proportion of missing data for these outcomes in the non-incentivised practices. Over one third of cases had no information on retinopathy screening recorded (35%, 353/1004) and almost two thirds were missing information on the receipt of foot assessment (65%, 651/1004). There was less than 5% missing data for these variables among incentivised practices. Patients in practices receiving a financial incentive had a significantly lower HbA1c value (6.9%) compared to practices not receiving an incentive (7.3%) (p=0.000). There was also a significant difference between the groups in terms of total cholesterol (p=0.000) and diastolic blood pressure (p=0.001). There was no significant difference between the groups in terms of LDL cholesterol (p=0.66), HDL cholesterol levels (p=0.7) or BMI levels (p=0.06).

Conclusions:
This study demonstrates an association between financial remuneration for diabetes management and the quality of care provided to people with diabetes. The results are important given the lack of routine data on the quality of care in Ireland and timely in light of proposed reforms to improve the quality of diabetes care in Ireland, including plans to introduce a national model of integrated care and targeted remuneration for chronic disease management.
Abstract 199: Renin-angiotensin-aldosterone System Polymorphisms-based Risk Score In Resistant Arterial Hypertension And Adverse Cardiovascular Events: The Genhart-rio SubStudy
Authors: Benchimol-Barbosa Paulo R , Cordovil Ivan , Campos Priscilla S , Tura Bernardo R , Barbosa-Filho José
Published: March 2022

Introduction:
Renin-angiotensin-aldosterone system (RAAS) determines arterial pressure fluctuation. Resistant arterial hypertension (RAH) has increased risk for end organ damage. The aim of this study was to prospectively investigate, in subjects with RAH in a South American city: 1) Adverse cardiovascular events defined as fatal and non-fatal stroke or acute myocardial infarction (AMI); and 2) the association between RAAS polymorphisms and adverse cardiovascular events.

Methods:
Two hundred and twelve subjects under investigation for RAH were admitted. All subjects received standard drug therapy aiming at achieving <140/90mmHg, and were re-evaluated four weeks later, including 24h ambulatory arterial pressure monitoring. Subjects with secondary causes of RAH were excluded. Eighty eight subjects (age 57±10 y.o, 58 women) underwent genotyping to RAAS polymorphisms: renin (G1051A), angiotensinogen (M235T), angiotensin II type 1 receptor (A1166C) and aldosterone synthase (C344T). In this group, 65% were found RAH and 35% pseudo-RAH. Subjects were actively followed at scheduled clinical visits and phone contact. During follow-up, a composite of fatal and nonfatal stroke and/or AMI was assessed. A genetic score (GEN) based on allele risk was composed for each polymorphism (zero [low risk homozygosis], 1 [heterozygosis] to 2 [high risk homozygosis]), and summed up. Cox proportional-hazard model assessed both RAH and RAAS polymorphisms hazards for adverse events. (α<0.05)

Results:
During a median follow-up of 26 years, 40 subjects reached composite endpoint (median 22 years of follow-up). Hardy-Weinberg equilibrium was observed in all polymorphism. Optimal cutoff for GEN was >3 (AUC=0.66; p=0.006). In Cox proportional-hazard model, RAH and GEN>3 were independently associated with composite endpoint (RAH Hazard ratio [HR] 2.3; 95%CI [1.1-5.0]; p=0.027; and GEN>3 HR 3.4; 95%CI [1.2-9.6]; p=0.020). No significant differences according to age, gender, hypertension time were found.

Conclusion:
RAH determines an increased risk for a composite of stroke and AMI. A RAAS stratified genetic score identifies hypertensive subjects at increased risk for adverse cardiovascular events. (
NCT01173029
)
Abstract 2: The Changing Face of Cardiac Surgery: Frailty, Age, and Adverse Outcomes Create a Mandate for Shared Decision Making
Authors: Gainer Ryan , Buth Karen , David Jennie , Garson Rose , Mufti Hani , Hirsch Greg
Published: March 2022

OBJECTIVES
The literature shows that comprehension of risks, benefits, and alternatives of treatment options is poor among patients referred for cardiac interventions. We have previously demonstrated that frail, elderly patients undergoing cardiac surgery require complex procedures and are at markedly increased risk of postoperative death and prolonged institutional care. An effective informed consent process is critical in this population. We sought to determine the proportion of frail, elderly patients referred for cardiac surgery over time and their associated outcomes.

METHODS
Patient demographics and utilization rates from 2001 to 2010 were examined at a single cardiac surgery center. Patients were stratified by age (≤70, 71-79, 80+) and frailty (defined as any loss of independence in activities of daily living (Katz Index), ambulation, or a documented history of dementia; frailty data available since 2006). We examined case complexity (CABG, Valve, combined CABG+Valve) and in-hospital outcomes: major adverse cardiac events (MACE, defined as one or more of mortality, stroke, infection or renal failure), as well as ICU stay >7 days, and discharge (DC) to an institution.

RESULTS
In the past decade the proportion of patients 80+ has increased from 7% (75/1005) to 13% (105/824) while the proportion <70 has decreased from 63% (632/1005) to 57% (466/824) (p<0.0005). Isolated CABG surgery declined from (79% (789/1005) to 60% (497/824) while CABG+Valve cases increased from 9% (91/1005) to 12% (104/824) (p<0.05). CABG+Valve surgery was performed on 26% (228/893) of patients 80+ vs. 6% (348/5614) of patients <70 (p<0.0005). In the past five years the proportion of frail patients referred for surgery has increased from 3.8% (33/871) to 9.3% (77/824). Adverse outcomes were significantly higher for frail patients (p<0.0001) as shown in figure 1, as well as for older patients (p<0.0001).

CONCLUSIONS
We have identified increasing rates of elderly and frail patients with high-risk profiles referred for cardiac surgery. These patients experience higher rates of mortality and prolonged institutional care. We suggest this vulnerable patient population may benefit from the institution of a formalized shared decision making process to effectively communicate risks, benefits and alternatives to the planned procedure.
Abstract 20: Socioeconomic Status and Hospital Variation in 30-Day AMI Episode-of-Care Payments
Authors: Spivack Steven B , Ott Lesli S , Kim Nancy , Xu Xiao , Han Lein , Krumholz Harlan M , Liu Alex , Volpe Mark , Bernheim Susannah M
Published: March 2022

Objective:
We examined how payments for a 30-day episode-of-care following AMI differ for hospitals with higher and lower proportions of dual-eligible AMI patients.

Background:
With the implementation of bundled payment programs, an increasing number of providers are being reimbursed for episodes-of-care as opposed to fee-for-service. Providers may have concerns about how their patient mix impacts this change in reimbursement. For example, low SES patients may require greater healthcare resources due to higher disease burden or lack of social support thereby increasing the costs of care for an episode.

Methods:
We performed a national hospital-level study of Medicare fee-for-service beneficiaries 65 or older hospitalized with AMI (principal discharge diagnosis of ICD-9 codes 410.xx excluding 410.x2) in 2008. To create comparable 30-day episode-of-care payments across hospitals, we standardized payments by removing or averaging Medicare-specific geographic and policy payment adjustments associated with each care setting. For each hospital, we calculated a risk-standardized payment (RSP) using hierarchical generalized linear models. We risk-adjusted payments for patient age, history of cardiac procedures, and select comorbidities in the 12 months prior to and including the index admission. We limited our analyses to hospitals with 25 or more AMI index admissions and compared RSPs for hospitals with the highest (>30%) and lowest (
<
10%) proportion of dual-eligible AMI patients. We also compared the proportion of unadjusted payments attributed to index and post-acute care for these two groups. Data were analyzed using two-sample t-tests (alpha=0.05).

Results:
Our final sample included 1,864 hospitals. 268 had >30% dual-eligible AMI patients and 531 had
<
10%. Hospitals with the highest proportion of dual-eligible patients had a significantly lower (p < 0.0001) RSP (mean = $19,962) than hospitals with the smallest proportion of dual-eligible patients (mean RSP = $20,455). In addition, hospitals with the highest proportion of dual-eligible patients spent a significantly lower (p < 0.0001) proportion of their overall payments during the index admission (mean = 74.5%) than hospitals with the lowest proportion of dual-eligible patients (mean = 77.4%).

Conclusions:
As a group, hospitals that cared for the highest proportion of dual-eligible patients had a lower RSP for a 30-day episode-of-care for AMI, spent a lower proportion of 30-day episode-of-care payments during the index admission, but a higher proportion during post-acute care. Given current practice patterns, this finding may suggest that bundled payments for AMI episodes-of-care generally would not penalize hospitals that provide for high proportions of low SES patients.
Abstract 220: Cost-effectiveness of CABG vs PCI for Treatment of Multivessel Coronary Disease among Diabetes Patients---A Secondary Analysis from ASCERT
Authors: Zhang Zugui , Kolm Paul , Jurkovitz Claudine , Edwards Fred , Grau-Sepulveda Maria , Ponirakis Angelo , McKay Charles , Shahian David M , Grover Frederick L , Mayer John E , Shaw Richard , O’Brien Sean M , Weintraub William S
Published: March 2022

Background:
The ASCERT--American College of Cardiology Foundation (ACCF) - Society of Thoracic Surgeons (STS) Database Collaboration on the Comparative Effectiveness of Revascularization Strategies study - has demonstrated that coronary artery bypass graft (CABG) surgery was associated with reduced mortality compared to percutaneous coronary intervention (PCI) at 4 years. In this study, we examined the cost-effectiveness of CABG versus PCI for treatment of multivessel coronary disease patients among diabetes patients.

Methods:
Diabetes Patients age ≥65 years with stable 2 and 3-vessel disease undergoing revascularization from 2004 through 2008 were evaluated. CABG patients with diabetes were selected from the STS National Database and the PCI patient population from The ACCF National Cardiovascular Data Registry. Costs were assessed at index, study period from years 2004 to 2008 by Diagnosis Related Group for hospitalizations. The average Medicare participant per capita expenditure in 2004 was used to estimate cost beyond the study period. Effectiveness during the study period was measured via mortality rate. Costs and effectiveness were adjusted using propensity scores and inverse probability weighting to reduce treatment selection bias. The incremental cost-effectiveness ratio (ICER) was expressed as cost per LYG.

Results:
Among diabetes patients (24,508 of 86,244 in CABG group and 25,481 of 103,549 in PCI group) at least 65 years old with two or three vessel coronary artery disease, costs were higher for CABG by $11,013 (95% CI: $10,930 to $11,136) during the index hospitalization. Over the period from 2004 through 2008 , average total costs were $28,413 for CABG versus $20,268 for PCI, a difference of $8,145 (95% CI: $7,918 to $8,373); patients undergoing CABG gained an average of 0.1524 life-years relative to PCI; the ICER of CABG, compared to PCI, was $53,500 per LYG, with 18%, 42%, 78%, and 88% of bootstrap-derived estimates <$25,000/LYG , <$50,000/LYG , <$75,000/LYG , and <$100,000/LYG, respectively.

Conclusions:
This study shows that over a period of 4 years or longer, CABG is associated with better outcomes but at higher cost than PCI in patients with diabetes.
Abstract 226: Impact of Gastrointestinal Disorders among Nonvalvular Atrial Fibrillation Patients on Healthcare Resource Usage and Costs
Authors: Kim Michael H , Makenbaeva Dinara , Bell Kelly F , Wiederkehr Daniel , Lin Jay , Graham John
Published: March 2022

Objective:
This study evaluated the incremental healthcare burden associated with GI disorders among nonvalvular atrial fibrillation (NVAF) patients.

Methods:
NVAF patients ≥18 years of age with continuous medical and prescription coverage were identified (1/1/2007-12/31/2009) from the
MarketScan
® Commercial and Medicare Research Databases. Patients with at least 1 inpatient or 2 outpatient GI diagnoses within 12 months following any NVAF diagnosis were grouped into the GI cohort, with patients without any GI diagnosis during the entire study period grouped into the non-GI cohort. The date of first GI diagnosis after NVAF diagnosis and a random date within 12 months after NVAF diagnosis date were selected as the index dates for GI and non-GI patients, respectively. Baseline and follow-up periods were each 12 months. Of the overall cohorts, patients were matched (1:1) by key patient characteristics. The GI cohort was further categorized as having a prior history of GI disorders (chronic) or no GI disorders (non-chronic) during the baseline period. Healthcare usage and costs were evaluated and compared during the follow-up period for the matched cohorts.

Results:
Among NVAF patients 38% were diagnosed with GI disorders, of which 52% had no baseline history of GI disorders. Patient characteristics, including age (non-GI: 71.16 vs. GI: 74.1 years), gender (male: 60.22% vs. 51.9%), Charlson Comorbidity Index (1.34 vs. 2.35) and CHADS
2
score (1.45 vs. 1.76) significantly differed among cohorts. When patients were matched for key patient characteristics including comorbidity, NVAF patients with a GI disorder used healthcare resources (inpatient, outpatient and pharmacy) to a much greater extent than those who did not have a GI disorder, which was reflected in their significantly higher healthcare costs (Table). These results were independent of a prior history of GI disorders in the baseline period. NVAF patients with chronic GI disorders were the least likely to have used warfarin in the follow-up period (non-GI: 59.8%, no history of GI: 53.4%, chronic GI: 48.5%, p<0.001).

Conclusions:
Greater than a third of NVAF patients have a GI disorder, which is associated with much greater healthcare resource utilization. Warfarin usage appears to be lower among NVAF patients with GI disorders, although further study is needed.
Abstract 232: Parenteral Antihypertensive Use on the First Day of Hospitalization after Acute Ischemic Stroke: A US Population Study
Authors: Wang Yamei , McDonough Erin , Adeoye Opeolu , LaPensee Kenneth , Crothers Tracy C , Kleindorfer Dawn
Published: March 2022

Introduction:
Elevated blood pressure (BP) is associated with increased risk of neurologic decline and poor outcome in acute ischemic stroke (AIS). The American Stroke Association (ASA) recommends antihypertensive (AH) therapy if BP is >220/120 mmHg, with a goal of 15-25% reduction in the first 24 hours. In thrombolytic candidates, BP should be maintained ≤185/110 mmHg for 24 hours after rt-PA. Labetalol and nicardipine are the recommended parenteral (IV) agents. We sought to characterize the use of IV AHs in the first 24 hours after AIS admission, stratified by treatment with rt-PA.

Methods:
This analysis utilized the Premier database, a representative sampling of US hospitals that includes approximately 20% of hospital discharges with pharmacy data, years 2006-2011. Patients with primary or admitting diagnosis of AIS (ICD-9 codes 433.x1, 434.x1, and 436) were included. Patients with age<18 or unknown gender were excluded. Pharmacy records were queried for IV AH and thrombolytic medication use (alteplase, 50 or 100mg vials).

Results:
There were 413,110 AIS patient discharges included in the analysis, with 64.3% white, 53.0% female, median age of 73 (range 18-89), and 2.8% receiving rt-PA. Of these, 62,438 (16.3%) received IV AH medications on Day 1. The most common AHs used were labetalol (47.1%), metoprolol (17.5%), hydralazine (16.1%), enalapril (12.9%), and diltiazem (11.7%). Nicardipine was used less frequently (11.8%). Patients treated with rt-PA were more likely to receive AHs than patients not treated (40.9 vs 15.6%, p<0.001). The rate of AH use increased from 14.5% in 2006 to 17.1% in 2011 (p<0.001); this rate increase was seen in non-rt-PA patients (14.1 to 16.2%, p<0.001), but not in rt-PA patients (figure).

Conclusion:
Approximately 16% of AIS patients receive IV AH medication in the first 24 hours of admission in the US. The rate of early AH treatment has increased over time both overall and among those who did not receive rt-PA. Whether this is due to increasingly aggressive BP treatment by physicians or higher BP on admission among AIS patients is unclear. Contrary to recommendations, nicardipine was used infrequently. More evidence is required to justify specific AH agents for BP treatment in AIS.
Abstract 238: Utilization and Safety of a Heparin Nomogram in Treating Thrombotic Comorbidities in Stroke Patients
Authors: Grantz Matthew R , Proctor Pamela , Skalabrin Elaine , Pendleton Robert C , Majersik Jennifer J
Published: March 2022

INTRODUCTION:
AHA guidelines discourage anticoagulation in acute ischemic stroke (AIS) patients to prevent stroke recurrence. However, some AIS patients have concurrent thrombotic states, such as DVT/PE, that require anticoagulation to prevent further morbidity. Little is published on the safety and efficacy of heparin titration nomograms used for thrombotic comorbidities in stroke patients. Our aim was to assess the utilization and safety of a heparin stroke infusion nomogram at a single, tertiary, academic hospital.

METHODS:
The heparin stroke nomogram contains no heparin bolus, a goal aPTT of 60-85, and stable “steady state” dose with 2 consecutive aPTT values at goal. Patients were identified via a retrospective, computerized order entry review for the heparin nomogram. Exclusion criteria were: baseline aPTT > 50s, a hypercoagulable state, and short usage (< 24 hrs) or interrupted nomogram prior to 2 consecutive “goal” aPTT values. Demographic data and aPTTs were determined from the prospectively-populated enterprise data warehouse. The aPTTs were divided into 6 hr time bins from initiation. Indication and outcomes were determined by source document review by a stroke neurologist.

RESULTS:
From 1/2010 - 6/2011, a heparin nomogram for any indication was initiated in 2,016 patients with 144 (7%) of these utilizing the “stroke” heparin nomogram, The nomogram was ordered by neurology (72%, n=103 ), neurosurgery (8%, n=11), other surgical specialties (9%, n=13), internal medicine (7%, n=10), and other (5%, n=7). After excluding those as above, the “stroke” heparin nomogram was used in 86 patients (40% female; mean 55 yrs SD 17), 74 with AIS, 2 with ICH, 1 with SAH, 2 with craniectomy, and 3 other. The indication for heparin included large artery near total occlusion (30%, n=26), cardiac thrombus (suspected (26%, n=22) or visualized (9%, n=8)), cerebral sinus venous thrombosis (10%, n=9), DVT/PE (5%, n=4), artery dissection (17%, n=15), and other (7%, n=6).

Percent of “at-goal” aPTTs by 6 hr time bins were: 6-12 hrs: 24% (n=21/86); 12-18 hrs: 36% (n=31/ 86); 18-24 hrs: 48% (n=40/84); 24-48 hrs: 55% (n=42/77); 48+ hrs: 65% (n=29/45). At the 42-48 hrs time point, 4% of patients had aPTT>150.

There were 4 non-bleeding related deaths. Repeat AIS occurred in 3 patients of the 74 patients with primary AIS. Asymptomatic ICH occurred in 1 patient with primary AIS; symptomatic hemorrhage occurred in 2 patients (epistaxis, GI). Discharge anticoagulation was prescribed in 56 patients (65%). Ninety day readmission occurred in 15% of patients (n=13), 5 for bleeding.

CONCLUSION:
The heparin stroke nomogram appears safe in that it does not increase risk of ICH. However, therapeutic aPTTs are not reached quickly with less than half of patients therapeutic at 24 hours, nor are they maintained at steady state. This nomogram could be too conservative in cases where clinical situation requires rapid anticoagulation.