bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 373: Participation Rates, Process Monitoring, and Quality Improvement Among United States Cardiac Rehabilitation Programs: A National Survey
Authors: Pack Quinn R , Squires Ray W , Lopez-Jimenez Francisco , Lichtman Steven W , Rodriguez-Escudero Juan P , Lindenauer Peter K , Thomas Randal J
Published: July 2021

Background:
Cardiac Rehabilitation (CR) is an effective but highly underutilized treatment for heart disease. Prior studies have demonstrated that the use of strategies such as systematic referral (as part of an order set that does not depend on physician initiative or memory, usually with an opt-out option), liaison facilitated referral (a specific staff member who discusses the program, encourages attendance, and facilitates referral), an early appointment (< 2 weeks), and telephone appointment reminder calls can all improved enrollment rates. However, it is unclear how frequently these strategies are utilized across the United States, how often CR programs monitor their participation rates, and how often quality improvement (QI) projects designed to improve participation rates are performed.

Methods:
We surveyed all CR program directors in the American Association of Cardiovascular and Pulmonary Rehabilitation’s (AACVPR) database. We assessed basic program features, use of systematic referral, liaison facilitated referral, early appointments, and telephone reminder calls and QI projects. We also assessed self-reported referral, enrollment, and completion rates.

Results:
Response rate was 36% (290/812). Non-response bias analysis showed reasonable survey representativeness. Over the past 5 years, 49% of programs measured hospital referral, 21% office/clinic referral, 71% program enrollment, and 74% program completion rates. Self-reported rates (interquartile range) were 68 [32 to 90]% for hospital referral, 35 [15 to 60]% for office/clinic referral, 70[46 to 80]% for program enrollment, and 75[62 to 82]% for program completion. Programs reported utilizing a hospital-based systematic referral, liaison facilitated referral, or inpatient CR program 64%, 68%, and 60% of the time, respectively. Early appointments (< 2 weeks) were utilized by 35% and consistent phone call appointment reminders were utilized by 50%. Over the past 5 years, the percent or programs performing QI projects were 62% for hospital referral, 42% for clinic referral, 60% for program enrollment, and 57% for program completion. Measurement of participation rates was highly correlated with performing QI projects (p < 0.0001.)

Conclusions:
Although programs are aware of participation rate gaps, the monitoring of participation rates is suboptimal, quality improvement initiatives are infrequent, and proven strategies for increasing patient participation are inconsistently utilized. Awareness in outpatient clinical settings is particularly low. These issues likely contribute to the national CR participation gap and may prove to be useful targets for national QI initiatives.
Abstract 375: Influence Of Intensification Of Pharmacology Therapy In Preventing Hospital Readmissions
Authors: Prasad Hari , Kulkarni Abhishek , Singh Maninder , Stapleton Dwight
Published: July 2021

Background:
A Gap remains between evidence-based guidelines in the treatment of heart failure and current pharmacologic and device therapy. Current performance measures for Heart Failure are designed to assess medication prescription but fail to address the need to achieve optimal pharmacology dosing.

Methods:
We examined 405 patients’ charts who were admitted with a diagnosis of acute systolic heart failure or acute on chronic systolic heart failure with a left ventricular ejection fraction ≤ 40%. Twenty-one data elements related to heart failure were abstracted based on Seattle Heart Failure Model.

Results:
The mean age of the population examined was 77 ± 9 years. The cohort was comprised of 72 % males, mean weight 89 ± 22.5kg, with NYHA class 2.4 ± 0.6 symptoms. Ischemic etiology was identified in 86% with a mean left ventricular EF of 29.8 ± 9 %. The one year all-cause mortality rate was 19.5 %, reflecting an advanced heart failure population. There were 97 (23.9%) patients who were not readmitted in 1 year and were considered as optimal medical therapy. The readmission group was compared against this group (Tables). Up titration of medication or addition happened only in 27 % of patients. In 61.5 % of patients there were no dose adjustments made in follow up visits. There was statistically significant difference (P < 0.05) between both the groups in terms of pharmacology and device therapy.

Conclusion:
Up titration of heart failure medications to guideline recommended therapeutic doses reduces heart failure readmissions.
Abstract 380: Gender Differences in Glucose Metabolism Profile in Patients with ST Segment Elevation Myocardial Infarction
Authors: Shah Gautam V , Aggarwal Bhuvnesh , Randhawa Mandeep , Goel Sachin S , Lincoff A. Micheal , Ellis Stephen G , Menon Venu
Published: July 2021

Background:
Presence of insulin resistance has been known to be a strong independent risk factor for coronary artery disease. However, there is limited data on gender differences in metabolic profile of patients that present with an acute ST segment elevation myocardial infarction (STEMI).

Methods:
All patients (N = 1,652) who underwent primary PCI for STEMI at the Cleveland Clinic Foundation between January 2005 to December 2012 were included. Insulin Resistance (IR) was defined as presence of diabetes mellitus (DM) or pre-DM. Further DM was identified if there was a known history of DM or hypoglycaemic therapy or if admission glycated hemoglobin (HbA1c) was ≥ 6.5 and pre-DM was defined for admission HbA1c ≥ 5.7 and < 6.5. Lastly, prevalence of IR in women was compared with similarly aged men presenting with STEMI at our institution.

Results:
IR was identified in 70% (n= 1,163/1,652) and DM in 30% (n = 487/1,652) of patients presenting with STEMI. Prevalence of IR was significantly higher in post menopausal women (age > 50 years) when compared with similarly aged men (79%; 344/435 vs. 69%; 603/871; p <0.0001) with majority of the difference contributed by difference in incidence of DM (38%; 163/435 in females vs 29%; 257/871 in males; p<0.0001; Figure 1).

Conclusions:
Our results indicate that prevalence of IR including diabetes mellitus may be higher in women as compared to similarly aged men who present with STEMI and the difference increases with increasing age. We also noted that Pre-DM contributes significantly to the high prevalence of IR in subjects with STEMI irrespective of gender. Larger studies are required to assess the impact of Pre-DM on adverse cardiovascular events in men as well as women.
Abstract 382: Risk Prediction Algorithm Accurately Identifies Patients at High Risk for 30-Day Readmission after Percutaneous Coronary Intervention
Authors: Strauss Craig E , Porten Brandon R , Mueller Denise L , Garberich Ross F , Chavez Ivan J , Poulose Anil K , Haupt Jason A , Baran Kenneth W , Chambers Jeffrey W , Henry Timothy D
Published: July 2021

Background:
Approximately 15% of Medicare patients who undergo percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days of discharge. A risk prediction algorithm which accurately identifies PCI patients’ risk for readmission may provide an opportunity to implement strategies to optimize care transitions to reduce inpatient readmissions and hospitalization costs in higher risk patients.

Methods:
We retrospectively applied a published validated 30-day readmission risk prediction algorithm to all PCI cases across three high volume centers within a single health care system between July 1, 2009 and September 30, 2013. Readmission risk scores were calculated and cases were grouped by low- (<6), intermediate- (6-10) and high-risk (≥11). Inpatient readmissions were compared between groups. Based on 4.25-year historical data and mean total variable costs per inpatient readmission, we assessed the impact of reducing the readmission rate by 50% in high-risk patients and 30% in intermediate-risk patients on readmissions per year and annual total variable costs.

Results:
Among 13,494 PCI cases, 1,237 (9.2%) were high-, 5,846 (43.3%) were intermediate- and 6,411 (47.5%) were low-risk. High-, intermediate- and low-risk groups had significantly different overall readmission rates (19.8% vs. 10.5% vs. 5.4%; p<0.001) (Figure). On average, there were 283 readmissions per year, and the mean total variable costs were $6,530 per inpatient readmission. Reducing readmissions by 50% in high-risk patients and 30% in intermediate-risk patients would reduce 72 inpatient readmissions per year and result in total variable costs savings of $470,160 annually.

Conclusions:
A risk prediction algorithm accurately identifies PCI patients at highest risk for hospital readmission. This tool may enable providers to implement targeted strategies to reduce 30-day readmissions and hospital costs through transition care conferences, registered nurse telephone contact, early clinical follow-up and care management.
Abstract 5: Another Inconvenient Truth: The Pernicious Effects of Hospital Case Volumes on the Accuracy of Hospital Report Cards
Authors: Reeves Mathew J , Austin Peter C
Published: July 2021

Background:
Hospital report cards are published with increasing frequency, but their accuracy is controversial, especially when case volumes are small. Our objective was to determine the relationship between hospital case volumes and the accuracy of hospital report cards using simulation studies.

Methods:
Monte Carlo simulations were used in a setting such that the true hospital rankings were known with certainty and perfect risk-adjustment was possible. Parameters used to generate simulated datasets were obtained from analyses of 31,000 hospitalized AMI patients in Ontario. We varied the number of patients per hospital from 100 to 2000 in increments of 100. For each scenario we simulated 500 datasets and determined the correlation between the true hospital ranking (determined by hospital-specific random effects) and the observed ranking (determined by observed vs. expected (O-E) or predicted vs. expected (P-E) ratios). Baseline simulations used the observed 30-day AMI mortality of 11%. In sensitivity analysis we explored the impact of using a lower event rate (2% mortality) commonly associated with cardiovascular procedures.

Results:
Provider volume had a strong effect on the accuracy of hospital report cards. When the event rate was high (11%), provider volume had to exceed 500 before the correlation between known and observed rankings exceeded 80%, and for hospitals with 200 or fewer cases the correlation was <60% (Figure). When the event rate was low (2%), provider volume had to exceed 1200 before the correlation exceeded 80%, and for hospitals with 200 or fewer cases the correlation was <40%.

Conclusions:
These results highlight the substantial amount of error that occurs when profiling hospitals even in the environment of perfect risk adjustment. These random errors increase with decreasing hospital volume and decreasing event rates. Hospital report cards display acceptable levels of accuracy only when provider volumes exceed those seen in many hospitals.
Abstract 101: Gender Has Differential Effects on Non-Hemorrhagic Stroke Outcomes
Authors: Pieper Justin , Ashamalla Michael , Sedhom Daniel , Yager Neil , Ghate Ketan , Nguyen Veronica , Shkolnik Boris , Torosoff Mikhail
Published: July 2021

Background:
We sought to examine the relationship between gender, age, co-morbidities, and outcomes in patients with non-hemorrhagic stroke.

Materials and methods:
Retrospective chart review was performed on 517 consecutive non-hemorrhagic stroke patients (48% women, 20% with diabetes, 26.8% with CAD, 38% with dyslipidemia, 62.2% with HTN, 4.2% with peripheral vascular disease, 4.7% with renal insufficiency) treated at a single academic medical center.

Results:
Younger patients were more likely to be men (age<50 55%, 51-60 58.3%, 61-70 59.6%; p<0.05) while older patients were likely to be women (age 71-80 54.9%, >80 56.6; p<0.05). Accordingly, the subsequent analysis stratified the cohort into two groups, <70 and >70 years old.

Regardless of age, men had a higher prevalence of CAD (age <70, 25.2% vs 18.8% in women, and age >70, 43.7% vs. 23.1% in women; p<0.05) and dyslipidemia (age <70, 43.4% vs 32.5% in women and age >70, 44.8% vs. 30.6% in women; p=.05). There were no significant gender based differences in BMI, prevalence of diabetes, hypertension, peripheral vascular disease, or chronic renal insufficiency.

The mean follow up duration was 47.3+/-0.9 months. Gender did not affect mortality in patients younger than 70 years old (15.5% men vs. 15.6% women.) However in patients of age >70 mortality was significantly increased in men (50.5% in men vs. 41.7% in women; chi-squared p<0.001, log-rank p<0.0001, Figure). In logistic regression analysis, when compared to women younger than 70 years old, men of the same age had similar mortality (HR 1.0; 95%CI 0.5-1.9, p=0.980); while age greater than 70 conferred 4-5 fold increased risk of mortality (HR 3.9; 95%CI 2.1-7.0, p<0.0001 in women, and HR 5.5; 95%CI 3.0-10.3, p<0.0001 in men). When gender and age were accounted for, history of coronary artery disease and/or dyslipidemia did not affect the outcomes.

Conclusion:
Men with non-hemorrhagic stroke were more likely to have dyslipidemia and history of coronary artery disease. This, however, did not translate into increased mortality in younger men.

Gender appears to have a differential effect on non-hemorrhagic stroke outcomes which warrants future investigation.
Abstract 108: Racial and Ethnic Disparities in Heart Failure Readmissions and Mortality in a Large Municipal Healthcare System
Authors: Durstenfeld Matthew S , Park Hannah , Katz Stuart D , Blecker Saul B
Published: July 2021

Background:
Hispanic and black patients with heart failure have been shown to have higher risk of readmission but lower risk of post-discharge mortality than white patients. To determine whether disparities exist among patients with similar access to care, we examined outcomes after heart failure hospitalization within a large municipal healthcare system.

Methods:
This retrospective cohort study included adults hospitalized with a principal diagnosis of heart failure at the 11 hospitals in The New York City Health and Hospitals Corporation in 2007-2010. Clinical data from electronic health records were linked to New York State hospital registry and vital statistics data. The primary exposure was hospital-reported ethnicity/race, which was categorized as Hispanic, non-Hispanic black, and non-Hispanic white; patients of other and unknown races were excluded. Outcomes were 30 and 90-day readmission and 30-day and one-year mortality. Logistic regression models were used to test for association between ethnicity/race and outcomes with adjustment for demographics, comorbidities, lab results, and vital signs.

Results:
Among 9,059 hospitalizations for heart failure (mean age 67±15 years), 2,629 (29%) were for Hispanic patients, 4,785 (53%) were for black patients, and 1,645 (18%) were for white patients. Of these patients, 3,248 (36%) had Medicare, 2,512 (28%) had Medicaid, and 1,489 (16%) had no insurance.

The one-year mortality rate was 24% (625 of 2,629) for Hispanics, 20% (964 of 4,785) for blacks, and 33% (541 of 1,645) for whites. Even after risk-adjustment, Hispanics and blacks had lower one-year mortality than whites, with adjusted odds ratios (aORs) of 0.78 (95% CI 0.67-0.91) and 0.78 (95% CI 0.68-0.90). Hispanics, but not blacks, had lower 30-day mortality compared to whites with aORs of 0.68 (95% CI 0.48-0.97) and 0.76 (95% CI 0.55-1.06).

Hispanics had higher rates of 30-day readmission than whites (aOR 1.25; 95% CI 1.09-1.44), but there was no difference between blacks and whites, (aOR 0.99; 95% CI 0.87-1.13). At 90 days, both Hispanics and blacks were more likely to be readmitted than whites with aORs of 1.39 (95% CI 1.22-1.59) and 1.13 (95% CI 1.00-1.29), respectively.

Conclusions:
Racial and ethnic disparities in outcomes after heart failure hospitalization comparable to prior reports were present within a large municipal healthcare system. Although outcomes were similar for black and white patients for 30 days post-discharge, during longer-term follow-up, black patients had higher readmission rates and lower mortality rates than white patients. Hispanic patients had higher readmission rates and lower mortality rates compared to white patients during all intervals studied. Further research is needed to identify causes for these disparities.
Abstract 11: Compliance With Risk Factor Optimization and Medical Therapy in Patients With Peripheral Vascular Disease (Peripheral Artery and Ischemic Cerebrovascular Disease) Compared to Ischemic Heart Disease.
Authors: Hira Ravi S , Pokharel Yashashwi , Cowart Jennifer , Akeroyd Julia M , Ramsey David , Nambi Vijay , Jneid Hani , Deswal Anita , Denktas Ali , Ballantyne Christie M , Petersen Laura A , Virani Salim S
Published: July 2021

Background:
Cardiovascular disease (CVD) is a systemic process with patients developing atherosclerosis in multiple vascular beds including ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD) and peripheral artery disease (PAD). PAD and ICVD are associated with increased risk of subsequent myocardial infarction, stroke and death. Medical management and risk factor optimization are recommended for all patients with CVD. Compliance with measures in patients with ICVD and PAD compared to IHD is not known.

Methods:
In a large national cohort, we identified 1,242,015 patients with cardiovascular disease (CVD) receiving care in 130 Veterans Affairs facilities between 10/1/2013 and 9/30/2014. CVD was defined as the presence of IHD, PAD, or ICVD. We assessed the frequency of compliance with performance measures in patients with IHD (with or without concomitant PAD or ICVD), PAD only, ICVD only, and PAD+ICVD groups. We compared compliance with hypertension control (BP <140/90 mmHg), diabetes control (HbA1C<7.0% among diabetics), and the use of statin therapy between IHD and PAD, ICVD, or PAD+ICVD groups. A composite of all 3 measures (BP control, statin use, HbA1C <7% among diabetics) termed optimal medical therapy (OMT) was also compared between groups. Multivariate logistic regression was performed with IHD group as the referent category.

Results (Table):
IHD patients comprised 989,380 (79.7%), PAD only 70,404 (5.7%), ICVD only 163,730 (13.2%) and PAD + ICVD 18,501 (1.5%) of the cohort. Compliance with most measures (hypertension control, statin use) as well as OMT was lower for PAD or ICVD patients compared with IHD patients with minimal differences between IHD and PAD +CVD group. Overall, only 32.3%-41.8% received OMT (i.e. met the composite measure).

Conclusions:
Compliance with OMT was low in all patients. Patients with PAD or ICVD were less likely to receive OMT compared with IHD. Our results suggest potential for improvement in OMT for all CVD patients especially those with PAD and ICVD.
Abstract 113: Predicting Short and Medium Term Hospital Readmission Following Heart Valve Surgery
Authors: Pack Quinn R , Priya Aruna , Lagu Tara , Pekow Penelope S , Kent David M , Lindenauer Peter K
Published: July 2021

Background:
Although models exist for predicting hospital readmission following coronary artery bypass surgery, no similar models exist for predicting hospital readmission following heart valve surgery (HVS). Given Medicare’s financial penalties for 30-day hospital readmission and the ongoing implementation of 90-day bundled payments for cardiac surgical procedures, we developed a clinical predictive model to estimate both short and medium-term readmission for patients with HVS.

Methods:
Utilizing a geographically and structurally diverse sample of US hospitals (Premier Inpatient Database), we examined patient characteristics, hospital characteristics, and treatment factors predictive of short and medium term hospital readmission following HVS. The study period was from January 2007 to June 2011. A generalized estimating equation model accounted for clustering within hospitals. We set aside a random 20% of hospitals during model derivation for later use as an internal validation cohort.

Results:
At 219 hospitals, we identified 38,532 patients with HVS (73 years old, 56% male, 71% non-Hispanic White, with 61% aortic valve, 29% mitral valve, and 10% combination valve surgery.) A total of 3084 (8%) and 4943 (12.9%) patients were readmitted within 1 month and 3 months, respectively, with the most common reasons for readmission being heart failure, atrial fibrillation, and pleural/pericardial effusions. Among the >60 factors examined, 18 independent factors were retained in the final model for predicting 3-month readmission (see table.) The strongest predictors of 3-month readmission were type of valve surgery, urgency of hospital admission, hospital length of stay, and discharge disposition. The final model had fair discrimination (C-statistic 0.667, p < 0.001) and good calibration (predicted vs. observed differences of <1-2% across all deciles of predicted readmission risk.)

Conclusions:
We described key factors that predict 3-month hospital readmission following HVS. This model should enable clinicians to identify individuals with HVS who are at increased risk of hospital readmission and who are most likely to benefit from improved coordination of post-discharge care and follow-up.
Abstract 129: My Unlimited Potential: Multidimensional Workplace Life Style Modification Program Associated With Reduction in Cardiovascular Disease Risk Among Employees With Type 2 Diabetes
Authors: Das Sankalp , Rouseff Maribeth , Guzman Henry , Tran Thinh , Brown Doris , Santiago-Charles Joann , Ochoa Teresa , Mora Joseph , Gilliam Cynthia , Lehn Virginia , Ruiz Angelica , Aneni Ehimen , Ogunmoroti Oluseye , Roberson Lara , Veledar Emir , Post Janisse , Nasir Khurram
Published: July 2021

Background:
Diabetes mellitus is one of the leading conditions resulting in high health costs and lost productivity. In recent year there is a growing interest for managing these chronic conditions through engagement of workplace wellness programs. In this study we examined the short and long term effects of an ongoing multicomponent lifestyle intervention improvement program (My Unlimited Potential (MyUP), among employees of Baptist Health South Florida (BHSF), a large not-for-profit health care system.

Method:
The present analysis focuses on the efficacy of an intensive lifestyle workplace intervention among individuals presenting with diabetes mellitus. The intervention provided tools to improve physical activity, stress and dietary habits. A multi-disciplinary team made up of an advanced nurse practitioner (ARNP), registered dietician (RD), exercise physiologist (EP), certified diabetic educator (CDE), and registered nurse (RN) met with participants to provide one-on-one counseling and training.

Results:
The current study assessed 33 (58 years +/- 8.8, 67% female) employees with diabetes mellitus enrolled in the MyUp wellness program who completed baseline, 12-weeks, 6 months and 1 year assessments. Significant short and long term improvements in cardio-metabolic risk factors were observed (Table1). Positive change in distribution of cardiovascular risk factors was noticed at 3, 6 and 12 months (Fig1). Conclusion: These results suggest that a multi component workplace lifestyle modification program results in both short and long term improvement in cardiovascular disease risk among employees with diabetes mellitus. Further large studies are needed to confirm our study findings.
Abstract 131: Shared Medical Appointments for Heart Failure Patients Improve Cardiac Health Status
Authors: Dev Sandesh , Williams Kathryn E , Hatseras Helen M , Weyer Matthew , Hepfinger Sona S , Biehl-Judge Nancy Y , Wu Wen-Chih
Published: July 2021

Objective:
Heart Failure Shared Medical Appointments (HF SMAs) are group visits in which several HF patients are treated by a clinician(s) at the same time. This intervention is a system redesign that addresses growing health system and patient care burdens in chronic HF management. Group visits have been associated with greater adherence to select HF medications and hospitalization-free survival during the intervention. However, there is little data on patient-reported outcomes such as HF-specific health status, an important outcome that quantifies the impact of the patient’s HF on his or her life. The objective of this pilot study is to determine whether HF SMA is associated with a change in HF-specific health status. The short version Kansas City Cardiomyopathy Questionnaire (KCCQ-12) measures HF-specific health status, including symptoms, physical and social function, and quality of life.

Methods:
We retrospectively collected patient characteristics by review of medical records for all patients in a VA hospital that completed the full HF SMA intervention (4 visits across 8 weeks). Each patient completed the KCCQ-12 at the beginning of each clinic visit. The primary outcome was change in KCCQ Summary Score(range 0 to 100; higher scores indicate better health status; 5 points is a clinically meaningful change). The secondary outcome was change in KCCQ subscales.

Results:
Twenty-eight patients (median age 64, median LVEF 35%) completed all four HF SMA visits. The mean KCCQ at baseline was 51. From pre- to post-SMA, the average change in KCCQ-12 Summary Score was +8 (p=0.001). The Quality of Life Subscale was associated with the greatest change (average change,+15, p=0.0003), followed by Symptom Scale (average change +10, p=0.002). There was no significant change in Social Limitation (average change +6, p=0.08) or Physical Function (average change +2, p=0.48).

Conclusions:
Preliminary findings suggest that a novel group intervention in patients with HF is associated with mild to moderate clinically significant changes in HF-specific health status. Further, HF SMA appears to specifically improve quality of life and symptoms more than physical function. Future clinical trials will be required to determine how these improvements compare to usual care.
Abstract 144: Cost of Cardiovascular Disease Episodes among Patients with Hypertension
Authors: Arrieta Alejandro , Qiao Nan , Woods John R , Jay Stephen J , Veledar Emir , Nasir Khurran
Published: July 2021

Background:
Because of its high prevalence and direct contribution to cardiovascular diseases (CVD), hypertension is among the most expensive components of CVD, representing nearly 50% of the total direct medical cost of CVD in the U.S. Yet, little is known about the per-patient cost of CVD episodes among hypertensives.

Methods:
This study used insurance claims data from over 16,000 individuals diagnosed with hypertension and enrolled in a private health insurance plan between 2008 and 2010. About one million medical and pharmacy insurance claims generated by these hypertensive patients were extracted for the analysis. Six CVD were included in the study: Myocardial infarction (MI), unstable angina (UA), stable angina (SA), transient ischemic attack (TIA), stroke, and congestive heart failure (CHF). Direct medical costs (ambulatory, emergency, hospital visits and medications) for each CVD were obtained on a weekly basis over 26 weeks before and after a recorded CVD episode. Per-patient direct medical costs were estimated by taking a before-after difference in cost, corrected by censoring due to deaths and insurance plan exits. Average costs were segmented by age groups (40-64 and 65 or over). Costs were adjusted to 2010 U.S. dollars.

Results:
The most expensive CVD episode among hypertensives was UA ($17,704; 95%CI $11,632-22,644), followed by MI ($13,480; 95%CI $8,328-18,752), stroke ($13,223; 95%CI $8,080-17,556), CHF ($12,462; 95%CI $9,734-15,335), SA ($6,991; 95%CI $4,178-9,947), and TIA ($5,787; 95%CI $2,671-9,670). CVD costs converged to pre-event cost levels within the next 4 to 14 months after the recorded CVD episode. Some CVD costs (CHF, UA, MI) rose 1 to 3 weeks before the recorded event, while others (stroke, TIA, SA) clearly started during the week of the recorded event (see Figure 1 comparing CHF and stroke). For the former, pre-event costs explained up to 30% of total costs.

Conclusions:
Cost estimates of CVD episodes among hypertensive patients are consistent with results from the scarce literature in this area. Moreover, our study finds evidence of increased medical resource utilization weeks before the recording of the CVD episode. Omitting these pre-event costs leads to an underestimate of the true costs of CVD.
Abstract 155: The Impact of Body Mass Index and Gender on Patient Survival After Therapeutic Hypothermia Following Resuscitation
Authors: Breathett Khadijah , Mehta Oza Nishaki , Yildiz Vedat , Ziegler Ryan , Abel Erik , Husa Ruchika
Published: July 2021

Background:
Therapeutic hypothermia has been established to improve survival in patients following cardiac arrest; yet the impact of body mass index (BMI) and gender on survival post hypothermia is lesser known. Given the obesity paradox in heart failure and the gender differences in cardiovascular outcomes, we hypothesized that men and higher BMI patients would have better survival post therapeutic hypothermia than women and lower BMI patients.

Methods:
We retrospectively evaluated 183 patients who underwent therapeutic hypothermia following resuscitation at our two large academic centers from 1/2012 to 9/2014. Logistic regression analysis was used to assess for survival based upon BMI, gender, and comorbidities.

Results:
The average BMI was 30.5 (standard deviation 9.7 kg/m2). There were 67% men (n=122). Therapeutic hypothermia was performed in 75% patients (n=138) for cardiac arrest, while the rest were cooled for neurologic indications. Mortality post therapeutic hypothermia was 60% (n=110). There was a significantly higher mortality for patients with BMI >30kg/m2 compared to BMI ≤30kg/m2 [Odds Ratio OR 1.94 (95% Confidence Intervals CI 1.04, 3.62), p=0.034]. There was no difference in mortality based upon gender [OR 1.57 (95% CI 0.8, 2.9), p= 0.166] or other comorbidities.

Conclusions:
BMI >30kg/m2 was a significant risk factor for mortality post therapeutic hypothermia protocol, while gender was not a factor. Larger studies will be needed to validate these findings.
Abstract 182: Radiofrequency Ablation for Atrial Fibrillation: Trends in Patients, Clinical Outcomes, and Resources Among Medicare Beneficiaries from Fiscal Year 2010 to Fiscal Year 2013.
Authors: Reynolds Matthew R , Kugelmass Aaron D , Cohen David J , Brown Phillip P , Simon April W , Culler Steven D
Published: July 2021

Introduction:
The objective of this analysis was to report four year trends among Medicare beneficiaries (MB) undergoing Radiofrequency Ablation (RFA) to treat Atrial Fibrillation (AF).

Methods:
This retrospective study examined both the Medicare Provider Analysis and Review Files and the Medicare Outpatient File to identify all MB undergoing RFA with a diagnosis of AF. The study population consists of 50,522 MBs. Exclusion criteria included a diagnosis of atrial flutter, Wolff-Parkinson-White syndrome, nonparoxysmal AV nodal tachycardia, prior pacer or ICD, the implantation of a pacer or ICD, or an open ablation during the hospitalization. ICD-9, CPT and APC coding was utilized to identify patients, exclusion criteria, as well as clinical outcomes.

Findings:
The number of RFA procedures for AF increased rapidly from 9,810 in FY2010 to 15,677 in FY2013 (CAGR of 16.9%). The proportion of MBs treated in a non-admission setting increased from 48.7% to 61.1%. Overall, the proportion of MB experiencing any complication declined annually from 5.95% to 4.12% and the mortality rate fell from 0.25% to 0.08%. The table indicates that all study complication rates were lower in FY_2013 than in FY_2010. Among inpatient MB average length-of-stay declined from 2.87 days to 2.35 days. The average per-procedure costs increased from $17,628 to $21,388 during the study period.

Conclusions:
From FY2010 to FY2013, the volume of AF ablations performed in MB rose rapidly, while major safety outcomes concurrently improved.
Abstract 19: Using the Heckman Selection Model to Assess Selection Bias in Ischemic Stroke Patients with Documented NIHSS
Authors: Thompson Michael P , Luo Zhehui , Gardiner Joseph , Burke James F , Reeves Mathew J
Published: July 2021

Objective:
Complete documentation in large scale datasets such as administrative data or disease registries is often difficult. Given that the subset of patients with complete data documentation are most likely not a random sample of patients, selection bias threatens the validity of results if a complete case analysis is used. To demonstrate, we will assess the presence and magnitude of selection bias in ischemic stroke patients with documented National Institute of Health Stroke Scale (NIHSS) [[Unable to Display Character: –]] which is often incomplete [[Unable to Display Character: –]] using the Heckman Selection Model.

Methods:
Patient level variables including demographics, comorbidities, clinical EMS and admission variables, and medical history/comorbidities were obtained from 10,717 ischemic stroke patients aged 65 and older in the Michigan Stroke Registry in 2009-2012. The Heckman Selection Model assesses the presence and magnitude of selection bias by estimating a correlation coefficient between error components of a linear regression model predicting patient NIHSS score [[Unable to Display Character: –]] the outcome model [[Unable to Display Character: –]] and a binary probit model predicting NIHSS documentation [[Unable to Display Character: –]] the selection model [[Unable to Display Character: –]] conditional on patient and hospital predictors. The outcome model predicting NIHSS score was specified using a backward selection process with stepwise deletion of non-significant predictors. The selection model included all variables in the outcome model, plus additional significant predictors of NIHHS documentation. Quasi-maximum likelihood estimation was used to produce robust standard errors. All analyses were done using PROC QLIM procedure in SAS.

Results:
7,956 cases (74.2%) of cases had NIHSS documented. Significant predictors in the outcome and selection models are shown in the Table. The Heckman Selection Model found a statistically significant but modest correlation coefficient of
ρ
=0.1089 (SE=0.0119, p<0.0001). The positive correlation indicates that NIHSS was more likely to be documented in patients with higher NIHSS scores, i.e., more severe strokes.

Conclusions:
We found statistically significant albeit weak selection bias in the documentation of NIHSS in stroke patients. The Heckman Selection Model is a novel method that can be used to assess the presence and magnitude of selection bias when missing data is common.
Abstract 2: Life Expectancy and Years of Life Lost by Patients Admitted to High and Low Performing Hospitals
Authors: Bucholz Emily M , Butala Neel M , Normand Sharon-Lise T , Krumholz Harlan M
Published: July 2021

Background:
Thirty-day risk standardized mortality rates (RSMRs) after acute myocardial infarction (AMI) are commonly used to evaluate and compare hospital performance. Patients with AMI admitted to high-performing hospitals have improved short-term mortality; however, the extent to which this early survival benefit reflects long-term survival and leads to life-time survival gains is unknown.

Methods:
We analyzed data from the Cooperative Cardiovascular Project, a study of Medicare beneficiaries hospitalized for AMI with 17 years of follow-up, to compare life expectancy in patients admitted to hospitals with low and high 30-day RSMRs (calculated using previously validated methods and categorized into deciles). Cox proportional hazards regression was used to calculate life expectancy for patients in each decile. Years of life lost (YLL) per 1000 patients treated were calculated to quantify differences in life expectancy across hospital deciles.

Results:
Our study sample included 119,735 patients with AMI admitted to 1,824 hospitals. Survival curves for patients in each decile separated within the first 30 days and remained parallel over 17 years of follow-up. Life expectancy estimates declined as RSMR decile increased. Patients admitted to hospitals in the lowest RSMR decile lived, on average, 6.44 (standard error (SE) 0.06) years after AMI, whereas patients in the highest RSMR decile lived 5.54 (SE 0.06) years. For every 1000 patients treated at low-performing hospitals (highest decile), 898 (SE 162) years of life were lost relative to patients treated at high-performing hospitals (lowest decile). These differences persisted after adjustment for patient characteristics and treatment. Patients in low-performing hospitals lost 1124 (SE 123) years per 1000 patients treated compared with patients in high-performing hospitals (Figure). When 30-day survivors were examined separately, there was no difference in unadjusted or adjusted life expectancy across hospital deciles.

Conclusions:
Patients admitted to high-performing hospitals live longer after AMI than patients in low-performing hospitals. This survival benefit occurred in the first 30-days and persisted over the long-term, resulting in meaningful gains in life expectancy for patients admitted to high-performing hospitals.
Abstract 20: Patient Characteristics and Outcomes among Early-Arriving Acute Stroke Patients for Whom Alteplase Was Dispensed but Not Administered
Authors: Siddiqui Khawja A , Ali Syed F , Anderson Christopher D , Rost Natalia , Schwamm Lee H
Published: July 2021

Introduction:
Best practice recommendations such as the AHA Target Stroke campaign suggest that IV tPA be dispensed as early as possible prior to final clinical decision when evaluating stroke patients at high likelihood of tPA eligibility. This practice may reduce door to needle times. We sought to determine the patient characteristics, outcomes and reasons for non-treatment among this selected group of individuals presenting to our stroke service.

Methods:
During the period of April 2007 till June 2014, 4170 patients presented to our hospital with acute Ischemic stroke, and 1152/4180 (28%) presented within 4 hours of last seen well (LKW). Using our hospital’s GWTG database and pharmacy logs, we identified all tPA treated cases as well as those in whom tPA was dispensed but not given. Categorical variables were compared using chi- square test and continuous variables were compared using Student t-test and Wilcoxon rank sum test.

Results:
Of 382 patients for whom tPA was dispensed, 239 (62.6%) ultimately received tPA. Compared to tPA treated patients, the 143 untreated patients in this cohort were more likely to have a history of previous stroke, present with weakness or language disturbance, and had a lower median NIHSS (Table). Untreated patients were more likely to be transferred from another hospital than to present directly from the scene, had a shorter median time from ED arrival to tPA dispensed, were less likely to undergo intra-arterial thrombolysis but had similar rates of home discharge and mortality. The most common reasons for non-treatment were mild symptoms (28%), rapid improvement (15%) and arriving after “drip and ship” (8%). In multivariate analysis, only lower NIHSS [aOR 0.93 per point (0.90, 0.97), p<0.001] and arrival via emergency medical services from scene [aOR 0.40 (0.24, 0.66), p <0.001] were independently associated with non-treatment.

Conclusion:
Delays in tPA initiation are common, and reduce health outcomes after thrombolysis. In our study, early dispensing of tPA prior to the final eligibility assessment produced an overall rate of tPA treatment of >60%. This conversion rate suggests that early tPA dispensing in high likelihood candidates is appropriate and supports the use of this strategy. Reasons for non-treatment were similar to those in unselected patients.
Abstract 214: Determinants of Cardiac Rehabilitation Referral Following Acute Myocardial Infarction In Australia
Authors: Tavella Rosanna , Arstall Margaret , Worthley Matthew , Chew Derek , Zeitz Christopher , Beltrame John
Published: July 2021

Background:
Despite the known benefits of cardiac rehabilitation (CR) and widespread endorsement of its use, CR is vastly underutilised, with less than 30% of eligible patients participating in a CR program after a cardiac event. The current study assessed the factors independently associated with referral to CR following acute myocardial infarction (AMI).

Methods:
The CR referral rate and factors associated with referral were assessed among all consecutive patients undergoing coronary angiography for AMI and surviving to hospital discharge, attending South Australian public hospitals from January 2012 [[Unable to Display Character: –]] December 2013. Data was maintained by the Coronary Angiogram Database of South Australia (CADOSA), a comprehensive registry compatible with the NCDR

®

CathPCI

®

Registry.

Results:
Among 3,212 patients undergoing angiography for AMI, CR referral occurred in 1,530 patients (48%). Compared to patients without CR referral, these patients were younger (62±13 vs. 64±14, p<0.01) and less likely to be female (25% vs. 34%, p<0.01). Following age-adjusted analysis, the cardiovascular risk factors were similar between CR referral and non-CR referral patients including: diabetes (29% vs. 30%, p>0.5), hypertension (61% vs. 64%, p>0.5), and dyslipidaemia (59% vs. 60%, p>0.5), but CR referral patients were more likely to be active smokers (40% vs. 33%, p<0.01). CR referral patients were less likely to have additional comorbidities including current dialysis (0.9% vs. 2.2%, p<0.01) and cerebrovascular disease (6.0% vs. 8.8%, p<0.01). In multivariable analyses, factors associated with increased CR referral were (c statistic 0.68): presentation with ST-elevation MI (STEMI) (1.4, 1.2-1.7, p<0.01), undergoing percutaneous coronary intervention (PCI) following angiography (1.6, 1.4-1.9, p<0.01) and younger age (1.0, 0.98-1.0, p<0.01). Prior CABG (0.6, 0.5-0.8, p<0.01) and absence of significant coronary artery disease, defined by stenosis <50%, (0.2, 0.1-0.3, p<0.01) were associated with decreased referral. Lastly, secondary prevention therapies were more often prescribed at discharge in patients with CR referral compared to patients without referral including: aspirin (93% vs. 82%, p<0.01), beta-blockers (64% vs. 61%, p<0.05), statin (92% vs. 78%, p<0.01), and ACE-inhibitor/angiotensin receptor blocker (84% vs. 74%, p<0.01).

Conclusion:
This study highlights a significant disparity in cardiovascular care with approximately half of AMI patients not referred to CR, despite it being a key performance measure. STEMI presentation, younger age and undergoing PCI are associated with increased referral. Alarmingly, AMI patients not referred to CR are also less likely to receive other guideline-based therapies. Increased physician awareness about the benefits of CR is required and initiatives to overcome barriers to referral may improve the delivery of evidence-based care.
Abstract 219: Cardiac Stress Testing Does Not Improve Patient Selection or Outcomes Among Patients Undergoing Abdominal Aortic Aneurysm Repair
Authors: Brooke Benjamin S , Sarfati Mark R , Zhang Yingying , Zhang Yue , Presson Angela P , Kraiss Larry W
Published: July 2021

Objectives:
Cardiac stress testing (CST) is commonly used to help determine whether patients with abdominal aortic aneurysms (AAA) are candidates for an open vs. endovascular repair, although it is unknown whether use of CST achieves its goal of optimizing patient selection and postoperative outcomes. This study was designed to examine whether utilization of CST reduces adverse cardiac events and improves survival following AAA repair.

Methods:
We retrospectively identified 3,635 patients in the Vascular Quality Initiative (VQI) database (2010- 2012) with an AAA ≥ 5.0cm who were candidates for open or endovascular AAA repair. The Vascular Study Group Cardiac Risk Index (VSG-CRI) was used to stratify patient risk. We applied generalized estimating equations with inverse probability weighting to adjust for patient factors and hospital level CST utilization to evaluate the effect of CST on composite of 30-day major adverse cardiac events or mortality (MACE-M) following AAA repair. Analyses were restricted to hospitals with 20% to 80% CST utilization to facilitate adjustment of the utilization rate.

Results:
CST was utilized in 1627 (45%) patients during AAA workup, including 451 of 794 (57%) patients selected for open repair and 1176 of 2841 (41%) selected for endovascular repair. After inverse probability weighting, the use of CST was not associated with the probability of patients receiving open vs. endovascular repair (OR: 1.00; 95%CI: 0.77-1.32). As compared to patients without CST during AAA workup, adjusted analyses revealed that CST utilization was not associated with improved MACE or mortality outcomes following AAA repair. Among patients receiving CST, an abnormal CST was not significantly associated with selection of open vs. endovascular repair or with postoperative outcomes after adjustment for the VSG-CRI score. Similar results were found for patients with either low or high VSG-CRI scores.

Conclusions:
Utilization of CST during workup for AAA is not associated with selection of repair procedure and improved postoperative outcomes. Our results suggest that CST adds no value beyond known clinical risk factors in selecting patients for open or endovascular repair or in predicting post-operative events.