bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 149: Echocardiographic Reporting and Subsequent Referral to a Pulmonary Hypertension Clinic
Authors: Andrus Bruce W , Sullivan Malachy J , Brown Randolph E , Welch Terrence D , Beaver Timothy A , Costa Salvator P
Published: June 2021

Introduction:
Pulmonary hypertension (PH) is a common and often ominous finding in the echocardiographic evaluation of patients with cardiopulmonary complaints. As with all diagnostic imaging, the report summary may influence future evaluation. Our aim was to explore the relationship between the echocardiographic reports of patients with PH and subsequent referral to a PH clinic.

Methods:
From the institutional database of a single academic medical center, we randomly selected 500 reports of patients with an estimated RVSP > 40 mm Hg between 2006 and 2014. Demographic and echocardiographic data were recorded prospectively. Referral to the only PH clinic in the region was determined by searching the electronic medical record. We used multivariable logistic regression to identify demographic and echocardiographic characteristics associated with referral.

Results:
The mean age of the population was 74 years and 54% (269 of 500) were women. The mean RVSP was 53 mm Hg. Pulmonary hypertension was mentioned in only 31% (153 of 500) of the report summaries and only 4.6% (23 of 500) of all patients were referred to the PH clinic. Referral was associated with younger age, indication for the echo, right atrial and right ventricular (RV) pressure, RV dilatation, and mention of PH in the summary. Mention of PH in the summary was the variable most strongly associated with referral (adjusted OR 4.6, 95% CI 1.5-14.2). Over the time period studied, there was no trend in the frequency of mentioning PH in the summary. The sonographer’s coding of PH as a preliminary finding was strongly associated with physician mention of PH in the summary, persisting after adjustment for RV systolic pressure, RV dilatation, and RV systolic function (adjusted OR 11.3, 95% CI 6.2-20.3).

Conclusion:
In this single institution study, PH was infrequently mentioned in the echo report summary of patients with an RVSP exceeding 40 mm Hg. Referral to the only PH clinic in the region was relatively rare but occurred more often following mention of PH in the summary. Explicitly stating the presence of pulmonary hypertension in the summary of patients with elevated RSVP may facilitate referral for comprehensive evaluation.
Abstract 157: Assessing Physician Knowledge Regarding Indications for a Primary Prevention Implantable Defibrillator and Potential Barriers for Referral
Authors: Bernier Rochelle C , Raj Satish R , Reyes Lucy , Sauve Michael , Sumner Glen L , Exner Derek V , Sandhu Roopinder K
Published: June 2021

Background:
Primary prevention implantable cardioverter defibrillators (ICD) are under-utilized despite multiple clinical trials that demonstrated reduced mortality and cost-effectiveness in patients at risk for sudden cardiac death. Our objectives were to determine physician knowledge about primary prevention ICD guidelines and to identify potential barriers impacting referral rates.

Methods:
The Cardiovascular Arrhythmia and Stroke Working Group from Alberta, Canada developed a web- based survey as part of a quality assurance initiative to aid in the design of a complex device care pathway. The survey consisted of five case scenarios regarding primary prevention ICD guidelines and a list of potential barriers for ICD referral. Through expert consensus, case scenarios were developed based on current device guidelines. The survey was administered to physicians encountering patients eligible for ICD therapy, including General Internists and Cardiologists with Alberta Medical Association membership and Cardiology residents.

Results:
The survey was completed by 109 of 799 (response rate =14%). Of those, 55% were General Internists, 32% were Cardiologists and 13% were Cardiology residents. The majority of physicians were male (62%) and practicing at a University Hospital (66%). Overall, 34% of participants answered all case scenarios correctly. A correct answer on all five case scenarios was demonstrated by 62.5% of Cardiologists, 61.5% of Cardiology residents and 16% of General Internists (p<0.0001). Figure 1 demonstrates significant differences regarding perceived barriers for ICD referral among physician groups (p<0.0001). There were also significant differences among physician age groups (p<0.0001), with younger physicians reporting more barriers. The most common barriers among all physician groups were cost- effectiveness (55%), concerns regarding knowledge of ICD guidelines (47%) and the risk of inappropriate shocks (41%).

Conclusion:
Knowledge of indications for a primary prevention ICD is poor and a recognized barrier among physicians who may refer patients for device therapy. Adequate knowledge translation of ICD guidelines is crucial in order to improve ICD utilization.
Abstract 163: Aortic Valve Replacement Confers a Survival Benefit in Patients With Severe Aortic Insufficiency With Depressed Left Ventricular Ejection Fraction
Authors: Fiedler Amy , Bhambhani Vijeta , Laikhter Elizabeth , Picard Michael , Sundt Thoralf , Wasfy Jason
Published: June 2021

Background:
Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AI) and left ventricular ejection fraction (LVEF) < 50%, severe left ventricular dysfunction (LVEF < 35%) is thought to confer very high surgical risk. The survival benefit associated with surgical intervention, however, is unknown. We evaluated long term outcomes of this patient population with and without surgical intervention.

Methods:
To capture patients who did and did not undergo AVR, we queried a single institutions echocardiography database to identify all patients with severe AR and LVEF < 35%. Manual chart review was performed to identify key demographic, clinical, and operative details. This retrospective cohort was then merged with institutional patient data. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for co-morbidities and age was then calculated using the weighted average of the individual survival curves.

Results:
Of 43 echocardiograms representing 41 unique patients, 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. After multivariate adjustment, end stage renal disease (HR = 17.633, p =0.0335) and peripheral arterial disease (HR = 6.050, p =0.0180) were associated with increased long term mortality. AVR was associated with decreased mortality (HR = 0.143, p =0.0490, see Figure 1). The mean survival for patients undergoing AVR was 6.3 years. The mean follow-up time was 6.58 years.

Conclusions:
Even after adjustment for clinical characteristics and patient age, AVR is associated with increased survival for patients with severe systolic dysfunction and severe aortic insufficiency. Although treatment selection bias cannot be completely eliminated with this retrospective cohort design, these results support performing surgery on this high-risk patient group.
Abstract 165: Total Intravenous Anesthesia as Compared to Volatile Anesthesia is Associated with Reduced Length of Stay After Transcatheter Aortic Valve Replacement: Results From Two-Year Program at Major Academic Medical Center
Authors: Goins Allie , Strassle Paula , Ramm Cassandra , Teeter Emily , Smeltz Alan , Caranansos Thomas , Vavalle John , Kolarczyk Lavinia
Published: June 2021

Background:
Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement in patients with severe, symptomatic aortic stenosis who are at least intermediate risk for surgery. As TAVR has evolved, more emphasis has been placed on reducing hospital length of stay (LOS) following the procedure. Therefore, we sought to identify whether changes in the general anesthetic technique, specifically using total intravenous anesthesia (TIVA) versus volatile anesthesia (VA), would lead to reductions in hospital LOS.

Methods:
A retrospective review was conducted of 67 consecutive patients at a single institution who underwent TAVR under general anesthesia (GA) with either TIVA or VA between November 2014 and July 2016. Hospital LOS, as well as patient demographics, intraoperative, and postoperative risk factors for prolonged hospital LOS were analyzed. Descriptive statistics were conducted using Fisher’s exact and Student’s t-test. Risk factors for LOS were assessed using unadjusted linear regression.

Results:
Data were analyzed from 67 TAVR patients with a mean age of 78 ± 9 years. The patient population was 43% female (29/67), 88% Caucasian (59/67), with a mean ± SD aortic valve gradient of 42 ± 17 mmHg with an ejection fraction of 53 ± 13 %. Of the 67 patients, 35 received TIVA (52%) and 32 received VA (48%). The majority of patients in both the TIVA and VA group underwent TAVR with a transfemoral approach (29/35, 83% vs. 24/32, 75%, p=0.55). Patients receiving TIVA had a shorter hospital LOS (3.7 ± 2.6 days vs. 5.9 ± 3.3 days, p=0.003) and shorter ICU LOS (1.5 ± 0.8 days vs. 2.7 ± 2.0 days, p=0.004) as compared to patients receiving VA. For every hour increase in anesthesia time, hospital LOS was increased by 0.92 days (p=0.02). Patients receiving GA with propofol infusion had a reduction in hospital LOS by 1.9 days (p=0.02) and a reduction in ICU LOS by 1 day (p=0.009) as compared to patients who received VA with desflurane.

Conclusions:
Reducing hospital LOS following TAVR is a complex and multifactorial problem. Our study suggests that anesthetic technique, the particular mix of drugs used for GA, and the time under GA all play a role in determining the hospital LOS. This finding can influence refinements in the techniques used to care for patients undergoing TAVR and may help us continue to reduce hospital LOS following TAVR.
Abstract 171: Improving Adherence to Antihypertensive Agents for Hypertensive Patient With Chronic Kidney Disease
Authors: Li Yunyun , Zeng Xianghong , Zeng Xiangji , Xie Jiangyuan
Published: June 2021

Background:
hypertension is a modifiable and very important risk factor in chronic renal disease (CKD), and medication adherence (MA) is critical in reaching the treatment goals. Improvement of MA for antihypertensive agents and its impact on blood pressure (BP) in CKD practice settings are not well studied.

Methods:
In a prospective, controlled open-label studies, the authors have evaluated the four year MA for antihypertensive agents on progress of renal disease and risk of development of cardiovascular disease in 546 hypertension patients with CKD from 2006 to 2014 with targeted nurse-physician intervention. Before randomization Outpatient BP measurements were averaged as high (>140/ 90 mm Hg) . Blood pressure ,serum creatinine(Cr) and potassium were monitored every 14 days in the period of follow-up by physician and healthcare nurse so that every patient is able to perforce self-monitoring BP at home and medication possession ratio(MPR) of target systolic blood pressure<130/80 mmHg is more than 90 % in observation groups. MA was calculated using medication possession ratio (MPR = actual treatment days/total possible treatment days). Good versus Poor MA (MPR ≥ 0.9 vs. <0.9) groups were compared for differences in outcome and laboratory variables.

Results:
By the end of four year,MPR in observation group is 94% and in other is 38%, mean blood pressure in good MA group was 126/76±9/7 mmHg and in control was 146/88±19/12 mmHg, Cr clearance increased from 51±2.0 to 64±3.0 ml/min (p<0.001)in the group of good MA group, By contrast, Cr clearance decreased significantly from 52±1.9 to 40±3.6 ml/min( P<0.001)in the controls. During this time, urine protein excretion decreased from 1.4±0.5 to 0.7±0.4g every 24 hours(P<0.0001) in the treatment group ,but urine protein excretion decreased slightly (from 1.3±0.4 to 1.2±0.6,P>0.05)in the controls. 20 patients had got ACS ,28 patients stroke,38 patients had got pneumonia, 11 patients renal dialysis and nine patient died (6 in SCD and 2 in heart failure and 1 in pneumonia) in controls ,but six patient had stroke ,11 pneumonia, 3 patient renal dialysis and four patients died (2 in SCD and 2 in non-cardio causes) in the treatment group, but incidence of hyperkalaemia was similar between two groups.

Conclusions:
Good MA is associated with a greater controlled hypertension, better protection of heart and kidney and may decrease mortality than the poor MA.
Abstract 174: The Longitudinal Effect of Medicaid Expansion on 30-Day Readmissions for Heart Failure and Acute Myocardial Infarction - Insights from Hospital Compare
Authors: Bhatt Ankeet S , Kim Azalea , Bleser William K , Saunders Robert , Eapen Zubin J
Published: June 2021

Background:
The emergency department (ED) is a primary access point for hospital admissions/ readmissions. Recent analyses have found that state-level Medicaid expansion is associated with higher ED volumes and longer ED length of stay (LOS). Increased ED congestion has been proposed to lead to higher readmission rates, though this has not been empirically evaluated. We examined the association of Medicaid expansion with readmission rates for AMI and HF specifically given that these readmissions are prevalent, publicly reported, and subject to financial penalties.

Methods:
We utilized the Hospital Compare database to construct a panel of US acute care hospitals offering ED services over three time intervals: 10/01/2012-09/30/2013, before any Medicaid expansion effective coverage dates (“Period 1”); 10/1/2013-9/30/2014 and 10/1/2014-9/30/2015, after Medicaid expansion effective coverage dates (“Periods 2 and 3”).

We used multivariate linear fixed-effects regression to evaluate the independent effect of Medicaid expansion on absolute unplanned 30-day case-mix adjusted readmission rates for AMI and HF. Fixed effects regression adjusts for time-invariant confounders by design and potential time-variant confounders were included as covariates, including year fixed effects to control for temporal variation. Standard errors were clustered on states. Sensitivity analysis was performed to evaluate the interaction between Medicaid expansion and ED LOS with respect to the primary outcome.

Results:
Our model examined 2,257 hospitals for AMI and 2,947 hospitals for HF. Overall, within-hospital 30-day unplanned readmission rates for AMI and HF decreased over the three defined periods. AMI readmission rates decreased by 1.37% (95% CI: -1.46% to -1.27%) from Period 1 to Period 3. HF readmission rates decreased by 1.07% (95% CI: -1.21% to -0.93%) from Period 1 to Period 3. All p-values were <0.001.

Medicaid expansion effective coverage dates did not affect within-hospital readmissions rates for AMI (ARR -0.09%; 95% CI: -0.22% to 0.04%; p-value 0.162) or HF (ARR -0.03%; 95% CI: -0.20 to 0.15%; p-value 0.770). A sensitivity analysis showed no interaction between Medicaid expansion and ED LOS with respect to the primary outcome (p value = 0.190 for AMI, p-value = 0.255 for HF).

Conclusion:
Among hospitals with publicly reported outcomes in the Hospital Compare database, readmission rates for AMI and HF decreased from 2012-2015. Medicaid expansion was not associated with significant within-hospital differences in 30-day readmission rates for AMI and HF. There was no interaction by ED LOS. Our results offer evidence to quell concerns that Medicaid expansion, by increasing ED LOS, may adversely impact unplanned readmission rates. Further studies are needed to evaluate factors affecting within-hospital readmission rates.
Abstract 175: Development of a National Dataset for Ambulatory Quality Improvement and Research: Insight From The Guideline Advantage
TM
Authors: Langabeer James R , Kahn Yosef , Bolles Michele , Vennum Katy , Kuban Katherine
Published: June 2021

Background:
Electronic Health Record (EHR) data provides a wealth of patient data valuable to providers, organizations, registries, and researchers. The Guideline Advantage™ (TGA) has been developed by the American Heart Association, American Cancer Society, and American Diabetes Association as a national ambulatory registry to cover primary and secondary prevention across multiple disease groups.

Methods:
The program leverages EHR data to populate a clinical registry and provide population health measurement and analytic tools to drive improvements in population health and support registry-based research. TGA uses a data extraction model without the restrictions and resource demands of traditional data abstraction or interface mechanisms typical of clinical registries. This model supports customization and flexibility in data alignment which allows for more accurate measurement and representation of the care being delivered. The web-based population health tool delivers a clear lens into clinical data from a population level to a patient level, simplifying data stewardship and improvement tracking. Through these methods, the program has grown to include 25,091,500 patient observations for 797,079 unique patients. 408 providers and their clinical teams have access to population health analytic tools, quality improvement support, and resources to drive improvements in the care they are delivering.

Discussion:
While there are several disease-specific registries in existence, there have not yet been integrated solutions that can expand across key chronic and acute conditions facing ambulatory patients. To obtain data across multiple conditions without a high resource burden, TGA is maintaining a data extract model that foregoes traditional barriers and resource burdens such as extensive query development, abstraction, or maintaining costly interfaces. The data extraction model affords the ability to obtain exponentially more data than abstraction models allowing the registry to cover multiple disease groups. This breadth of data improves the application of the registry in both the practice setting and research. With this data, practices are able to look across their entire population to identify high-risk or at-risk populations with a single condition or comorbid conditions and create cohorts of patients to target with quality improvement strategies. Providing clinicians and researchers a clear look into complete and longitudinal clinical data is critical to supporting quality improvement activities pivotal to success in value-based care models and the advancement of novel research in primary and secondary prevention.
Abstract 176: Door to Needle Targets in the Real World: A Dynamic Statistical Tool for Institutional Stroke Code Metrics
Authors: Andrew Benjamin Y , Ehrlich Matthew E , Stack Colleen M , Yang Julian P , Dodds Jodi A
Published: June 2021

Background:
The benefit of tissue plasminogen activator (tPA) in the treatment of acute ischemic stroke is time-dependent. AHA/ASA guidelines recommend a goal door-to-needle (DTN) time of 60 minutes or less. In practice, medically complicated patients can pose challenges leading to prolonged treatment times that skew institutional mean DTN values. We aimed to produce a simple statistical tool to calculate individualized DTN targets while accounting for outliers to help institutions achieve a mean DTN < 60 minutes.

Methods:
An IRB approved, single-center, retrospective analysis of consecutive acute stroke code case data from Duke University Hospital (Durham, NC) between January 2014 and July 2016 was conducted. We devised a formula (Figure 1) to calculate the goal DTN time (t
g
) necessary to achieve an overall mean DTN of < 60 minutes while adjusting for the frequency and magnitude of outliers. This formula was created as a modifiable tool using an individual institution’s outlier definition, current outlier frequency (f
m
), and outlier DTN average (t
m
) over a pre-defined time period. As proof of concept, the formula was tested using an outlier definition of ≥100 minutes. The formula was modeled using both real-world institutional data and a simulated sample of 200 patients.

Results:
In 1069 consecutive stroke codes, tPA was administered in 135 cases with mean DTN 68.2 minutes (range 15-205). Of these, 18 cases (13.3%) met our definition of outlier, with t
m
of 134 minutes. Using the developed formula with institutional data resulted in a target DTN of 48.6 minutes for non-outlier cases to achieve overall mean DTN < 60 minutes. Using the simulated dataset, our tool similarly calculated a goal DTN of 49 minutes.

Conclusions:
This simple statistical tool is a novel solution for generating an institution-specific goal DTN based on unique organizational data, experiences, and nuances in order to meet the recommended mean DTN. Additionally, these individualized goals may further motivate stroke teams to carry out more efficient clinical care rather than consistently aiming for DTN values < 60 minutes. The tool presented here is easily adaptable to future changes in recommended target goals and can be seamlessly incorporated into institution-wide systems planning.
Abstract 179: Short Length of Stay After Elective Transfemoral Transcatheter Aortic Valve Replacement is Not Associated With Increased Early or Late Readmission Risk
Authors: Sud Maneesh , Qui Feng , Austin Peter C , Ko Dennis T , Wood David , Czarnecki Andrew , Patel Vaidehi , Lee Douglas S , Wijeysundera Harindra C
Published: June 2021

Background:
Elderly patients undergoing transcatheter aortic valve replacement (TAVR) are at risk of hospital readmission post-procedure. It is not known if the index hospital length of stay, and specifically early discharge after TAVR is associated with an increased risk of readmission. We hypothesized a non-linear relationship whereby both short and long lengths of stay were associated with increased readmission risk.

Methods:
We performed a retrospective multi-center cohort analysis of patients undergoing elective transfemoral TAVR and surviving to discharge between Jan 2007 and March 2014. The exposure variable was hospital length of stay measured from the procedure date to the date of discharge and modeled as a continuous variable in a multivariable cause-specific Cox regression. Main outcome measures were 30-day and 1-year all-cause readmissions.

Results:
The study population consisted of 709 patients with a median length of stay of 6 days (interquartile range: 4-8 days). At 30-days and 1-year, 13.5% (n=96) and 44.0% (n=312) of patients were readmitted, respectively. Although length of stay was not associated with 30-day all-cause readmissions (p=0.92), there existed a significant association with 1-year readmission (p=0.01) after adjustment for baseline clinical variables. The association between length of stay and 1-year readmission was linear (p=0.55 for non-linearity) with no evidence supporting an increased readmission risk for shorter length of stays.

Conclusions:
Among elderly survivors of elective transfemoral TAVR, a short length of stay was not associated with an increased readmission risk within 30 days or 1 year. The 1-year readmission risk increased with longer length of stay.
Abstract 183: Safety and Utility Outcomes of Off-label Magnetic Resonance Imaging on Patients With Cardiovascular Implantable Electronic Devices
Authors: Strom Jordan B , Whelan Jill B , Zheng ShuangQi , Kramer Daniel B
Published: June 2021

Background:
Off-label magnetic resonance imaging (MRI) for patients with cardiac implantable electrical devices (CIEDs) has been limited due to concerns about safety and unclear diagnostic and prognostic utility.

Methods:
We evaluated all patients with CIEDs not FDA-approved as MRI-conditional who were referred to our clinical protocol for off-label imaging from June 2014 - October 2016. All referrals were screened by radiology and electrophysiology, with peri-MRI programming and monitoring performed by cardiology. Clinical and device characteristics were abstracted from electronic records. The primary safety outcome was the incidence of major adverse events (loss of pacing, inappropriate shock or anti-tachycardia pacing, need for system revision, or death). The primary clinical outcomes were (1) interpretability and (2) utility of MRI, with the latter graded independently by two reviewers according to whether the MRI changed management, prognosis, or guided intervention. Secondary safety outcomes included or minor adverse events (inappropriate pacing, arrhythmias, power on reset events, or discomfort at the generator site), and clinically significant changes in lead parameters or battery life both (1) immediately post-MRI and (2) at six months.

Results:
A total of 190 MRIs were performed on 123 patients (63.1% men, mean age 70±18.5 years, 37.0% ICDs, 21.8% pacemaker-dependent) predominantly for brain or spinal conditions (Figure). Nearly one quarter (22.7%) were performed for urgent or emergent indications. Major adverse events were rare: no deaths or system revisions; 1 patient with loss of pacing without clinical sequelae (overall rate, 0.5%). Nearly all (98.4%) studies were interpretable, while 74.9% were determined to change management based on pre-specified criteria. Minor adverse events were unusual (overall rate 1.6%): 2 reports of heating at the generator site; 1 patient with an atrial arrhythmia. No clinically significant changes were observed in device parameters acutely after MRI or at 6 months as compared with baseline across all patient and device categories.

Conclusions:
Off-label MRIs performed under a strict clinical protocol demonstrated reassuring safety outcomes while providing interpretable imaging that frequently influenced clinical care.
Abstract 186: Rates and Causes of Short Term Rehospitalization Across the Spectrum of Age and Insurance Types in the United States
Authors: Strom Jordan B , Kramer Daniel B , Wang Yun , Wasfy Jason H , Landon Bruce E , Yeh Robert W
Published: June 2021

Background:
Few studies have examined rates, characteristics, and costs of 30-day readmissions across the spectrum of age and insurance. In this setting, the relative impact of non-Medicare readmissions is unknown.

Methods:
Discharges of patients ≥18 hospitalized for any cause 1/1/13 - 11/30/13 at 2,006 hospitals in the Nationwide Readmissions Database (NRD), an 85% sample of hospital discharges from 21 states, were included. Results were stratified by age (18-44, 45-64, ≥65) and insurance (Medicare, Medicaid, private insurance, self-pay, and unknown). Outcomes included rates of 30-day readmission, index hospitalization diagnoses associated with readmission, and total direct costs of readmissions determined using hospital charges and the NRD Cost to Charge ratio. A hierarchical logistic regression model was used to examine the association between insurance and readmission risk, adjusting for age, admission source, and Elixhauser comorbidities, including a random effect for hospital. Dual eligible patients are classified according to primary insurance in the NRD.

Results:
Among 12,533,551 discharges, 1,818,093 (14.5%) resulted in readmission within 30 days. Medicaid insurance was associated with the highest adjusted odds ratio (AOR) for readmission both in those ≥65 years old (AOR 1.12, 95%CI 1.10-1.14; p <0.001), and 45-64 (AOR 1.67, 95% CI 1.66-1.69; p < 0.001), and Medicare in the 18-44 group (Medicare vs. private insurance: AOR 1.99, 95% CI 1.96-2.01; p <0.001). Discharges for psychiatric or substance abuse disorders, septicemia, and heart failure accounted for the largest numbers of readmissions, 5.0%, 4.7%, and 4.6% of total readmissions, with readmission rates of 24.0%, 17.9%, 22.9% respectively (
Table
). Total costs for readmissions were 50.7 billion USD, highest for Medicare (29.6 billion USD [58%]), with non-Medicare costs exceeding 21 billion USD (42%).

Conclusions:
Costs of non-Medicare readmissions are large. Medicaid patients have the highest odds of readmission in individuals older than age 44, commonly due to hospitalizations for psychiatric illness and substance abuse disorders. Medicaid patients represent a population at uniquely high risk for readmission.
Abstract 187: Sex-related Differences in Discharge Disposition for STEMI Care
Authors: Langabeer James R , Henry Timothy D , Fowler Raymond , Champagne-Langabeer Tiffany , Jacobs Alice
Published: June 2021

Background:
It is known that women with ST-elevation myocardial infarction (STEMI) have higher mortality in comparison to men. While the reasons for this sex-based difference are not completely understood, older age, higher prevalence of risk factors and co-morbid disease and longer time to reperfusion have been implicated. To determine whether the difference in outcomes persist even with an increase in the regional breadth of STEMI systems of care, we evaluated discharge disposition patterns and medications in a mature, multi-hospital cardiovascular network.

Methods and Results:
Data were drawn from a regional subset of the National Cardiovascular Data Registry for 33 hospitals in and around Dallas County, Texas from 2010 to 2015 (8,725 STEMI patients). We explored the difference between men and women in discharge dispositions (to home or other facility), to cardiac rehabilitation programs, to dietary counseling, as well as prescribed discharge medications. After multivariate controls for confounding factors including age, we found that men were 1.277 times more likely be discharged home than women (92% versus 86%), while women were more likely to be sent to an additional transitional care unit, nursing facility, or other facility. Women were also less likely to be offered dietary modification counseling (71% vs. 67%). Importantly, women were also much less likely to be prescribed Class I medications at discharge, including aspirin, beta blockers, statins, GP IIb/IIA and ACE inhibitors (all p<.001).

Conclusions:
Women treated for STEMI have notable differences in discharge dispositions patterns following percutaneous coronary intervention discharge. The post-discharge medications and services that women are prescribed needs to be carefully considered to reduce the significant differences in discharge disposition, although more research is needed in order to fully understand the impact of these differences.
Abstract 189: Income Level Disparities in Consumer Reported Domains of Healthcare Experience Among Those With Established Atherosclerotic Cardiovascular Disease in United States: Insights From Medical Expenditure Panel Survey 2010-2013
Authors: Okunrintemi Victor , Spatz Erica , Salami Joseph , Capua Paul D , Warraich Haider , Virani Salim , Blaha Michael , Blankstein Ron , Krumholz Harlan , Nasir Khurram , Ting Henry H , Dharmarajan Kumar
Published: June 2021

Background:
While it is well established that significant health outcome disparities exist across patients of varying socio-economic status (SES) with established atherosclerotic cardiovascular disease (ASCVD), disparities in patients’ healthcare experiences are not well investigated. We explore income level differences in four central tenets of patient-reported healthcare experience (access to care, provider communication, shared decision making and provider satisfaction) as measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, in a nationally representative adult US population with established ASCVD.

Methods:
The study population consisted of 8223 individuals (age ≥ 18 years) representing 21.6 million with established ASCVD (self-reported or ICD-9 diagnosis) reporting a usual source of care in the 2010-2013 pooled Medical Expenditure Panel Survey (MEPS) cohort. We assessed the responses for each item as: a) difficult access to care (always/almost difficult), b) ineffective communication and shared decision making (never/sometimes), and c) poor provider satisfaction (lowest quartile on a scale of 0-10). We examined the relationship between scores in the lowest quartile of each domain composite scores, derived using the weighted average response from each items scores, with patients’ SES, using the high-income group as reference.

Results:
Lower SES was consistently associated with greater perceived difficulties in access, poor provider-patient communication, less shared decision making, as well as lower provider satisfaction (Table). Participants classified as poor vs. high income were 47% (95% CI 1.17-1.83) more likely to report difficulty accessing care, 39% (95% CI 1.09-1.78) and 26% (95% CI 0.99-1.60) reported a higher likelihood of experiencing poor communication and shared decision making respectively, as well as a 66% (95% CI 1.31-2.11) higher likelihood of reporting lower provider satisfaction.

Conclusion:
Among patients with established ASCVD, significant SES disparities exist in all domains of patient reported healthcare experience quality of care metrics. Targeted policies focusing on improving communication, engagement and satisfaction are needed to enhance patient healthcare experience among high-risk vulnerable populations.
Abstract 192: Prompt Defibrillation and Epinephrine Treatment and Long-term Survival After In-hospital Cardiac Arrest
Authors: Patel Krishna K , Tang Yuanyuan , Khariton Yevgeniy , Curtis Lesley H , Spertus John A , Chan Paul S
Published: June 2021

Background:
Prior studies have reported higher in-hospital survival with prompt defibrillation and epinephrine treatment in patients presenting with in-hospital cardiac arrest (IHCA). Whether this survival benefit persists after discharge is unknown.

Methods:
We linked data from a national IHCA registry with Medicare files and identified 37,042 patients aged ≥ 65 years who presented with IHCA at 517 hospitals between 2000 and 2011. Patients with IHCA due to pulseless ventricular tachycardia (VT)/ventricular fibrillation (VF) were stratified by prompt (≤2 min) vs. delayed (>2 min) defibrillation, whereas patients with IHCA due to asystole/pulseless electrical activity (PEA) were stratified by prompt (≤ 5 min) vs. delayed (>5 min) epinephrine treatment. The associations between prompt treatment and long term survival for each rhythm type were assessed using hierarchical multivariable modified Poisson regression models after adjusting for patient and hospital characteristics.

Results:
Patients receiving prompt treatment were younger, more likely to arrest in intensive care unit and have shorter event durations. Of 8119 patients with an IHCA due to VT/VF, rate of survival to discharge were 39.3% (2247/5714) for those treated with prompt defibrillation and 24.1% (580/2405) with delayed defibrillation (p <0.001). Of 28,923 patients with an IHCA due to asystole/PEA, survival rates were 10.4% (2596/24925) with prompt epinephrine treatment and 8.1% (324/3998) with delayed treatment (p<0.001). Long-term survival from the time of IHCA to 1, 3, and 5 years of follow-up remained higher among those with prompt defibrillation for VT/VF (Table). In contrast, there was no long term survival benefit with prompt epinephrine treatment in patients with asystole/PEA.

Conclusions:
Prompt defibrillation for IHCA due to VT/VF was associated with a sustained long-term survival benefit, whereas prompt epinephrine treatment for IHCA due to asystole/PEA IHCA was not associated with long-term survival.
Abstract 200: Is Risk-standardized In-hospital Stroke Mortality an Adequate Proxy for Risk-standardized 30-day Stroke Mortality Data? Findings From the GWTG-Stroke Program
Authors: Reeves Mathew J , Fonarow Gregg C , Xu Haolin , Matsouaka Roland , Xian Ying , Saver Jeff , Schwamm Lee H , Smith Eric E
Published: June 2021

Background:
Hospital profiling is typically undertaken using risk standardized 30-day mortality but obtaining this data is complicated as it requires tracking patients post discharge. We undertook this analysis to determine if risk standardized in-hospital mortality could serve as an adequate proxy for risk standardized 30-day mortality data for the purposes of identifying outlier hospitals with high or low ischemic stroke mortality.

Methods:
Acute ischemic stroke cases entered into Get With The Guidelines (GWTG)-Stroke between 2003-2013 were linked to fee-for-service Medicare files. Hospitals with fewer than 25 cases were excluded. Risk-standardized mortality rates (RSMR) for both in-hospital and 30-day mortality were generated using a previously developed risk model, and the proportion of hospitals classified as statistical outliers (based on random effects models) were compared between the two. To assess the impact of stroke severity we conducted a sensitivity analysis limiting cases to those with NIHSS data.

Results:
A total of 535,332 ischemic stroke patients from 1494 GWTG-Stroke hospitals were included; mean age was 80 years, 59% were female, 19% were non-white, NIHSS (mean = 7.7) was recorded in 58%. Average in-hospital and 30-day mortality was 5.7% and 14.5%, respectively. At the hospital level, mean in-hospital RSMR and 30-day RSMR was 6.0% (SD 1.9) and 14.6% (SD 2.0), respectively, but the correlation between the two was only modest (r = 0.53). Overall agreement between the designation of outlier hospitals based on in-hospital and 30-day RSMRs was 78% (Table), but after correcting for chance agreement, concordance was quite modest (Kappa = 0.29). Findings based on models that included NIHSS were similar.

Conclusions:
When used to identify outlier hospitals with high or low ischemic stroke mortality the agreement between in-hospital mortality and 30-day mortality was only modest. Using in-hospital mortality data proved to be a poor proxy for 30-day mortality.
Abstract 206: Abstract submission for QCOR 2017
Authors: Kashani Mariam , Eliasson Arn , Fuller Claire , Walizer Elaine , Turner Ellen , Tschiltz Nancy , Grunewald Marilyn , Halsey Joy , Engler Renata , Villines Todd , Vernalis Marina
Published: June 2021

Background:
Although healthy lifestyle behaviors have been shown to significantly reduce cardiovascular disease (CVD), offsetting even genetic risk, most CVD programs focus solely on risk scores rather than calculating health improvement. We sought to validate a newly developed quantitative composite healthy lifestyle behavioral score, the Optimal Health Impact Factor (OHIF), which captures behavioral change by attainment of thresholds established by clinical guidelines.

Methods:
Patients in the Integrative Cardiac Health Project’s 12-month Registry, a prospective lifestyle change program for the prevention of CVD, underwent traditional risk assessment by a nurse practitioner. Additionally, at baseline and 12-months, OHIF scores were calculated using validated questionnaires in the following four domains: nutrition (Rate-Your-Plate), exercise (minutes of continuous exercise per week), stress (Perceived Stress Scale) and sleep (Pittsburgh Sleep Quality Index). Each domain has a gradient of three behavioral threshold scores (not at goal, red=1; almost to goal, amber=2; at goal, green=3) for a maximum of 12 possible OHIF points representing optimal health behaviors. All patients received motivational health coaching by a multidisciplinary team. Data were analyzed by t-tests, comparing measures at baseline and at 12-months.

Results:
Of 225 consecutive completers (48% men, age 56.8 ± 12.9 years, 145 White, 54 Black, 26 other, 61% at high risk by family history of CVD in first order relatives), 160 (71%) showed clinically and statistically significant improvements in the four behavioral domains and selected laboratory data.

Conclusions:
Improvements in healthy lifestyle behaviors captured by the OHIF score correlate significantly with improvements in critical CVD risk factors, even in a population with high genetic risk. The OHIF score emphasizes gradients of positive lifestyle behavior change for both patient and provider to facilitate development of an actionable behavioral health plan to reduce CVD. Clinicians who calculate a CVD risk score may also find clinical value in calculating a composite OHIF score as a single measurable outcome tool for tracking behavioral changes longitudinally.
Abstract 210: Improving the Use of Biomarkers in HF: Effect of Online CME
Authors: Spyropoulos Jelena , Hanley Kelly , Trupp Robin J
Published: June 2021

Introduction:
Biomarkers, including of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), are an important clinical tool for prognostic assessment and management of heart failure (HF). However, many clinicians have limited ability to appropriately use biomarkers in clinical practice.

Hypothesis:
A video-based, online medical education (CME) activity can improve competence and performance of cardiologists and emergency room (ER) physicians related to the use of biomarkers in the management of HF.

Methods:
An online CME activity was developed as a 25-minute roundtable discussion with 3 leading experts on the use of biomarkers in HF. The activity included a transcript of the discussion and a downloadable slide deck to highlight and reinforce key data. The effects of education were assessed using a linked pre-assessment/post-assessment study design. For all questions combined, the McNemar’s chi-square test was used to assess differences from pre- to post-assessment. P values are shown as a measure of significance; P values <.05 are statistically significant. Cohen’s d was used to calculate the effect size (> 0.8 are large, 0.8-0.4 are medium, and < 0.4 are small).

Results:
Comparison of individually linked pre-assessment question responses to the respective post-assessment question responses demonstrates statistically significant improvements for both cardiologists (N = 226;
P
<.05; d=1.549) and ER physicians (n=108; P<.05; d=1.731). Among cardiologists, 5% of participants answered all 4 assessment questions correctly pre-education vs 42% post-education, compared to 2% vs 45% for ER physicians. Significant improvements were observed pre- compared to post-education (all P<.05): • - A 52% relative improvement for cardiologists (61% vs 93%) and a 106% improvement (44% vs 90%) for ER physicians in knowledge of factors which reduce the diagnostic accuracy of BNP and NT-proBNP • - A 116% relative improvement for cardiologists (33% vs 71%) and a 192% improvement (23% vs 68%) for ER physicians in recognition of the additive value of other biomarkers such as ST2 to risk stratify patients • - A 155% relative improvement for cardiologists (24% vs 62%) and a 177% improvement (24% vs 67%) for ER physicians in knowledge of the effect of neprilysin inhibition on BNP and NT-proBNP values • - A 165% relative improvement for cardiologists (29% vs 76%) and a 139% improvement (29% vs 69%) for ER physicians in appropriate use of BNP vs NT-proBNP for patients treated with neprilysin inhibitors

Conclusion:
The significant improvements observed as a result of participation in this online CME intervention demonstrate that effective internet-based education can deliver content in the context of clinical practice to promote effective knowledge transfer and performance change.
Abstract 214: A Blood-based Precision Medicine Test Score is Additive in Determining a Patient’s Risk of Obstructive Coronary Artery Disease After Positive Myocardial Perfusion Imaging: Results From the PREDICT and COMPASS Studies
Authors: Lansky Alexandra , McPherson John , Chronos Nic , Schmitz Kari , Wingrove Jim , Monane Mark
Published: June 2021

Background:
Myocardial perfusion imaging (MPI) is the predominant diagnostic tool for evaluating outpatients with typical and atypical symptoms suggestive of obstructive coronary artery disease (CAD) and is commonly followed by invasive coronary angiography in patients with abnormal findings. Despite this paradigm, a significant proportion of patients do not need intervention, suggesting better diagnostic methods are needed to identify appropriate patients who would benefit from the risks, resource utilization, and healthcare costs incurred after a positive MPI. A previously validated, blood-based test incorporating age, sex and genomic expression score (ASGES) utilizing peripheral blood cell expression has demonstrated clinical validity in assessing the likelihood of obstructive CAD (≥50% luminal diameter stenosis by quantitative coronary angiography) early in the cardiac workup.

Objective:
The objective of this study is to evaluate if the utilization of the ASGES in conjunction with a positive MPI would assist in the determination of a patient’s risk of obstructive coronary artery disease.

Methods:
A total of 249 patients (mean age 58, 45% female) from 59 sites in the PREDICT (NCT00500617) and COMPASS (NCT01117506) studies were identified with a positive MPI study, defined as at least one reversible of fixed defect consistent with obstructive CAD and a subsequent invasive coronary angiography. ASGES scores were performed in all patients and were categorized into 3 groups based on score: low (1-15, 25%), mid-range (16-27, 43%) and high (28-40, 32%). Obstructive CAD rates defined by invasive coronary angiography were measured. The association between obstructive CAD and ASGES was evaluated using Cochran-Armitage trend test and area under the receiver-operating characteristics curve (AUC) analyses.

Results:
The rate of obstructive CAD among patients with a positive MPI was 35% (88/249). There was a net redistribution of risk based on ASGES testing in 52% (49/88) of these patients. The rate of obstructive CAD was 11% (7/63), 37% (39/106), and 53% (42/80) in the low, mid-range, and high score groups respectively (p<0.001). AUC for the ASGES use with a positive MPI was 0.704.

Conclusion:
The ASGES test, when used in patients after positive MPI, improved the diagnostic accuracy in the assessment of obstructive CAD. The use of this precision medicine test may help minimize unnecessary referral of low-intermediate risk patients as well as improve diagnostic yield among patients with abnormal MPI findings scheduled to undergo invasive coronary angiography.
Abstract 218: Expanding a Learning Collaborative Model in Chicago to Improve Door to Needle for Stroke Thrombolysis: Raising the Bar
Authors: Prabhakaran Shyam , Sednew Renee M , O’Neill Kathleen
Published: June 2021

Background:
There remains significant opportunities to reduce door-to-needle (DTN) times for stroke despite regional and national efforts. In Chicago, Quality Enhancement for the Speedy Thrombolysis for Stroke (QUESTS) was a one year learning collaborative (LC) which aimed to reduce DTN times at 15 Chicago Primary Stroke Centers. Identification of barriers and sharing of best practices resulted in achieving DTN < 60 minutes within the first quarter of the 2013 initiative and has sustained progress to date. Aligned with Target: Stroke goals, QUESTS 2.0, funded for the 2016 calendar year, invited 9 additional metropolitan Chicago area hospitals to collaborate and further reduce DTN times to a goal < 45 minutes in 50% of eligible patients.

Methods:
All 24 hospitals participate in the Get With The Guidelines (GWTG) Stroke registry and benchmark group to track DTN performance improvement in 2016. Hospitals implement American Heart Association’s Target Stroke program and share best practices uniquely implemented at sites to reduce DTN times. The LC included a quality and performance improvement leader, a stroke content expert, site visits and quarterly meetings and learning sessions, and reporting of experiences and data.

Results:
In 2015, the year prior to QUESTS 2.0, the proportion of patients treated with tPA within 45 minutes of hospital arrival increased from 21.6% in Q1 to 31.4% in Q2. During the 2016 funded year, this proportion changed from 31.6% in Q1 to 48.3% in Q2.

Conclusions:
Using a learning collaborative model to implement strategies to reduce DTN times among 24 Chicago area hospitals continues to impact times. Regional collaboration, data sharing, and best practice sharing should be a model for rapid and sustainable system-wide quality improvement.