bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 318: Caregiver Experiences with Decision Making in Destination Therapy Left Ventricular Assist Devices: A Qualitative Study
Authors: McIlvennan Colleen K , Jones Jacqueline , Allen Larry A , Lindenfeld JoAnn , Nowels Carolyn , Swetz Keith M , Matlock Daniel D
Published: March 2022

BACKGROUND:
Destination therapy left ventricular assist device (DT LVAD) is increasingly offered to patients with end-stage heart failure who are ineligible for heart transplantation. Implanting centers often require the identification of a dedicated caregiver prior to DT LVAD implantation; however, the caregiver experience surrounding this difficult decision is relatively unexplored.

METHODS:
Between October 2012 and July 2013, we conducted semi-structured, in-depth interviews of caregivers to understand their experiences with decision making for loved ones considering and living with DT LVADs. Data were analyzed using a mixed inductive and deductive approach.

RESULTS:
We interviewed 17 caregivers: 16 caregivers of patients who had received a DT LVAD and 1 caregiver of a patient who had declined a DT LVAD. At the time of the caregiver interview, 10 DT LVAD patients were living and 7 were deceased. The majority were women (n=16) of whom 12 were either spouses or widows of the patients. Median age of caregivers was 65 (range 35-79). Twelve caregivers reported spending more than 8 hours per week caring for their loved one, and 14 attended regular medical appointments. Throughout the interviews, caregivers reported that DT LVAD was a complex decision making process with many inherent tensions. The themes identified are broadly interpreted under three domains: 1) the stark decision context with tension between hopes and realities, “when we first started out¼we had hopes of a transplant¼but once the lung function was done, and the kidneys ¼there was pretty much nothing. There was no hope other than the LVAD”; 2) the challenging decision process and the tension between wanting their loved ones to live, “I said ‘Well, I'll tell you what. I didn't marry you to be a young widow” and wanting to respect their loved ones’ wishes, “My thoughts were this was his life and it was his choice”; and 3) the downstream decision outcome and the tension between gratitude, “I'm just thankful to have my dad here¼” and a feeling of burden, “I've never felt caregiver was my gift¼I tend to feel like I'm being imposed upon at times.”

CONCLUSIONS:
Despite the promise of significantly improved survival for some patients, DT LVAD has major implications for caregives as well as patients. Decision making surrounding DT LVAD requires education of both the patient and caregiver of potential stresses. Additionally, decision-making surrounding DT LVAD should seek to incorporate decision support for patients and caregivers. This should include a focus on caregiver burden and the tensions that caregivers may experience.
Abstract 322: Chronic Kidney Disease Does Not Impact Health Status Following Acute Myocardial Infarction
Authors: Navarro Mark A , Gosch Kensey L , Spertus John A , Rumsfeld John S , Ho P. Michael
Published: March 2022

Introduction:
Chronic kidney disease is strongly associated with mortality after acute myocardial infarction (AMI), however, its association with health status outcomes (symptoms, function and quality of life (QoL)) is unknown.

Methods:
Patients with AMI were enrolled between 2003 and 2008 in the TRIUMPH registry, a national, prospective, multi-center study of health status outcomes after AMI. Detailed interviews with the disease-specific Seattle Angina Questionnaire (SAQ) and generic Short Form-12 (SF-12) were attempted on all survivors at 1, 6 and 12 months following AMI admission. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation and based on the highest calculated eGFR recorded during the AMI hospitalization. Patients with CKD, based on an eGFR < 60 ml/min, were compared to those without CKD. Linear repeated measures models of SAQ angina frequency and QoL and SF-12 PCS and MCS scores were used to control for treatment site, baseline health status and known covariates to assess the independent association between CKD and health status after AMI.

Results:
Of 3592 3,617 patients, 3,041 (84%) had no CKD and 551 576 (16%) had CKD;, 7980% stage 3 (eGFR 30-59); 1312% stage 4 (eGFR 15-29); and 8% stage 5 (eGFR <15). Patients with CKD were older (67.5 vs. 587.8) and had more co-morbidities, including heart failure, CVA, and PVD. CKD patients were more likely to have 3-vessel CAD, left ventricular dysfunction and less likely to undergo revascularization during their hospitalization. CKD patients also also had a higher 1-year mortality (8.59% vs. 2.3%; p<0.0001). Among AMI survivors at 1 -year, patients with and without CKD had similar QoL 81.9 8 vs. 81.7 (adj. difference of 0.4624, [95% CI, -1.2646, ,2.181.95]), angina frequency 91.4 vs. 93.1 (adj. difference of 1.2327, [95% CI, -0.0605, ,2.589]), and mental health scores 52.7 vs. 51.9 (adj. difference of -0.0907, [95% CI, -0.90, 2,0.7475]). Physical functioning scores were low overall at 1-year and CKD patients had slightly lower scores, 38.0 4 vs. 44.4 ((adj. difference -1.6861, [95% CI, -2.562.49, -0.749]).

Conclusion:
Among AMI survivorspatients who survived to 1 year, CKD patients have similar quality of life and angina burden compared to those without CKD despite a higher burden of co-morbidities. While CKD patients had lower physical functioning scores, this difference was not clinically significant compared to patients without CKD. These findings suggest that among AMI patients surviving to 1 yearsurvivors, CKD patients can achieve similar health status outcomes compared to non-CKD patients.
Abstract 331: My Unlimited Health Potential: 6 Month Effect of Participation in a Worksite Lifestyle Intervention Program on Significant Weight Loss and Eligibility Criteria for Bariatric Surgery Among High Risk Individuals
Authors: Shaharyar Sameer , Roberson Lara , Aneni Ehimen , Rouseff Maribeth , Tran Thinh , Guzman Henry , Das Sankalp , Brown Doris , Santiago-Charles Joann , Ochoa Teresa , Mora Joseph , Castillo Beatriz , Veledar Emir , Feldman Theodore , Agatston Arthur , Post Janisse , Nasir Khurram
Published: March 2022

BACKGROUND:
Current recommendations support bariatric surgery among the morbidly obese as an option to mitigate future risk of cardiovascular disease, diabetes and hypertension. To date, there is little evidence on the effect of extensive lifestyle interventions among those high-risk individuals in reducing the need for such procedures.

METHODS:
The purpose of the present study is to examine the efficacy of an intensive lifestyle workplace intervention on significant body weight and cardiovascular disease risk factors across the spectrum of obesity. Changes in BMI are being measured from baseline to 6 months follow up, along with corresponding improvements in cardio-metabolic risk. In addition, the decrease in participants meeting criteria for bariatric surgery over the study period is examined. Bariatric surgery criteria were defined as BMI≥40 or BMI between 35 and 40 and at least one of the following co-morbidities: diabetes, hypertension, or high cholesterol. Short term results (at 9-12 weeks follow-up) of this study are being presented at AHA 2014 in March.

RESULTS:
The study population consisted of 152 individuals (49±10 years, 78% female) with BMI≥27 at baseline and complete data at 6 month follow-up. A total of 71 (47%) participants lost at least 10 % of their body weight. Additionally, 37% dropped an entire BMI category. Of note, 39%(16 of 41) who were classified as BMI>40 were in BMI 35-39 at follow-up, respectively 44%(14 of 32) of individuals in the BMI category 35-39 successfully moved to the BMI category 30-34 at 6 months follow-up. Forty-five participants (35% of total) initially met criteria for bariatric surgery. At 6 months of follow-up 40% (18 of 45, p<0.001) of these candidates no longer needed bariatric surgery.

CONCLUSIONS:
Worksites can be effective for achieving clinically important reductions in body weight and diminish the potential need for procedures among a small proportion of morbidly obese individuals. Many lifestyle interventions succeed in achieving short term reductions but are unable to sustain them over longer periods. Our program shows promising results at 6 months and continued follow up will allow us to determine whether workplace wellness interventions similar to ours are a viable and lasting alternative to bariatric surgery.
Abstract 345: High Risk Characteristics of Patients Returning Within 30 Days After PCI with Chest Discomfort
Authors: Wasfy Jason H , Strom Jordan B , Mauri Laura , Normand Sharon-Lise T , Kennedy Kevin F , Spertus John A , Yeh Robert W
Published: March 2022

Background:
To improve care coordination, Medicare is reporting 30-day readmissions after percutaneous coronary interventions (PCI) as a quality metric. Chest pain or other symptoms concerning for angina is the most common reason for early hospital readmission after PCI. To reduce hospital readmission in ways that improve value and ensure patient safety, clinicians need to understand which patients returning with symptoms are at high risk and merit admission.

Methods:
The Partners PCI Readmission Database is a database of 893 patients readmitted within 30 days of PCI that includes detailed information from chart review. Among patients readmitted for chest pain, or other symptoms concerning for angina, we evaluated patient characteristics associated with either myocardial infarction or repeat PCI during the readmission. Continuous variables were evaluated with t-tests and categorical variables with chi-squared tests. Variables with p < 0.3 on initial screen were included to create a logistic regression model, and a C-statistic was calculated.

Results:
Of these patients, 341 (38.1%) were readmitted for evaluation of chest pain or other symptoms concerning for angina, of which 65 (19.1%) required PCI or met criteria for myocardial infarction during the readmission (PCI/MI patients). Age, Caucasian race, hypertension, prior PCI (before the PCI during the index admission), diabetes, multivessel disease found on index catheterization, and drug-eluting stent found on index catheterization all were found to have p < 0.3 in bivariate comparisons and included in the model (Figure 1). The C-statistic of the model was 0.71.

Conclusions:
Among patients returning with chest pain or other anginal symptoms within 30 days after PCI, this model can be used to predict likelihood of having a myocardial infarction or requiring repeat PCI. The association of race with PCI/MI merits further investigation. This model may help physicians risk-stratify patients for readmission versus outpatient evaluation.
Abstract 346: Initial Results from a Cardiac Curbside Program
Authors: Wasfy Jason H , Rao Sandhya K , Isselbacher Eric M , Ferris Timothy G
Published: March 2022

Background:
Improving value in outpatient cardiology care is an important goal. Some clinical questions for cardiologists involve interpretation of imaging data, and do not require in-person evaluation by a cardiologist. Creating a formal mechanism to process these questions outside the traditional framework of an in-office consult might reduce cost, improve access, and enhance patient satisfaction.

Methods:
We offered referring doctors at the Massachusetts General Hospital the opportunity to request cardiac “curbside” consults, with a formal mechanism for the cardiologist to annotate the electronic medical record with recommendations. This pilot started on January 13. We tracked volume of referrals by week before and after the new option became available. We compared traditional gastroenterology consults (excluding screening colonoscopy requests) over the same time period as a control. The volume of consults for cardiology and gastroenterology before and after the intervention was compared with a Fisher exact test.

Results:
During the first two weeks of the pilot, 14 cardiac curbsides were requested. Of those, 1 was rejected by the cardiologist, and 1 eventually led to a traditional office visit. In a 15 week lead in period before the new mechanism, 2384 gastroenterology consults were requested and 1329 cardiology consults were requested. In the 2 weeks after the intervention, 359 gastroenterology consults were requested and 203 traditional cardiology consults were requested. In the 15 week lead in period, the ratio of traditional cardiology consults to gastroenterology consults was 0.557. After the intervention, the ratio of traditional cardiology consults to gastroenterology consults was 0.565 (p = 0.888).

Conclusions:
In the initial phase of a cardiac curbside pilot, demand for curbsides accounted for about one-tenth of total referral volume. The volume of traditional cardiology consults has not yet declined at this early stage. Such interventions have the potential to improve efficiency and value.
Abstract 350: The ‘Frequent Flyer’ Hypothesis and Increased Risk of Thirty Day Readmission after Percutaneous Coronary Intervention
Authors: Carlisle Adam J , Tibrewala Anjan , Novak Eric , Singh Jasvindar , Amin Amit P
Published: March 2022

Background:
Thirty day readmission (30DR) post PCI is both prevalent and significant. These readmissions are associated with increased costs of care. Previous studies have shown comorbidities, socio-demographics, and angiographic characteristics as risk factors for readmission post PCI. However, unique factors such as prior frequent admissions and specifically its interaction with anxiety or depression as risk factors for readmission after PCI have not been studied.

Methods:
We retrospectively analyzed 1,343 consecutive PCIs representing 1,256 patients from a single institution from February 1, 2012 to August 13, 2013. The primary outcome was 30DR post PCI. Secondary outcomes included 30DR for PCI, CABG, and acute systolic or diastolic heart failure. The independent variables were ‘number of prior admissions in the 12 months before PCI’ and history of ‘anxiety or depression’ based on an ICD9 diagnosis in the preceding 10 years. Negative binominal and logistic regression models were built to examine the association between ‘anxiety or depression’ diagnosis, number of prior admissions, and 30DR after adjusting for known covariates including: age, gender, admission status, prior CABG, CHF, chronic lung disease, peripheral artery disease, cardiogenic shock, renal function, and insurance.

Results:
Of the 1,343 PCIs, 30.6% were readmitted within 30 days. We observed a large prevalence of ‘anxiety or depression’ in patients undergoing PCI (439, 33%). The mean number of 30DR post PCI was higher at 0.55 for patients with anxiety or depression and 0.43 for patients without anxiety or depression (P=0.006). Prior admissions were a strong and independent risk factor for 30DR with OR 1.258 (95% CI 1.164 to 1.360, P<0.001). ‘Anxiety or depression’ was also an independent risk factor for 30DR with OR 1.384 (95% CI 1.056 to 1.814, P=0.019). Interestingly, patients with anxiety or depression did not have significantly different 30DR for PCI, CABG, acute systolic or diastolic CHF 0.093 (95% CI 0.068 to 0.128) vs. 0.087 (95% CI 0.070, 0.109) among patients without anxiety or depression (p=0.74).

Conclusion:
A prior history of frequent admissions and anxiety or depression diagnoses contribute significantly and independently towards 30DR post PCI, even after adjusting for traditional risk factors of readmissions. As such, they should be considered as important risk factors for post PCI readmission. Patients with diagnoses of anxiety or depression were not at increased risk of 30DR for cardiovascular events such as PCI, CABG or acute CHF. Future studies are needed to evaluate the role of treating anxiety and depression in patients at risk for frequent readmissions.
Abstract 352: Clinician Attitudes and Self-Reported Practices Regarding End of Life Care in Heart Failure
Authors: Dunlay Shannon M , Foxen Jilian L , Cole Terese , Feely Molly A , Loth Ann R , Strand Jacob J , Swetz Keith M , Wagner Jean A , Redfield Margaret M
Published: March 2022

Background:
Heart failure (HF) is a clinical syndrome with an overall poor prognosis, but the clinical trajectory is often unpredictable in individuals. There has been an impetus to promote iterative patient-provider discussions regarding preferences for end of life (EOL) care and advanced care planning. However, very little is known regarding provider preferences or their personal confidence addressing EOL care with their patients with HF. To address these gaps in knowledge, we surveyed clinicians at three practice sites in a large integrated health system.

Methods:
Physicians, nurse practitioners (NP), and physician assistants (PA) at Mayo Clinic (Rochester, Minnesota) and its surrounding health system were asked to participate in an electronic survey in October 2013. Clinicians surveyed included tertiary care HF specialists (Tertiary Care Cardiology), cardiologists and NP/PAs practicing in a community setting (Community Cardiology), and primary care clinicians (Primary Care).

Results:
A total of 95 clinicians completed the survey (52.5% response rate), including 50 physicians and 45 NP/PAs. Clinicians reported discussing prognosis and EOL wishes when their patient’s health status was worsening, but only 12% reported annual discussions as advocated by the American Heart Association. In total 52% of providers reported one or more reasons that they hesitate to discuss EOL care with their patients, including provider discomfort (11%), perception of patient (21%) or family (12%) unreadiness to have the discussion, fear of destroying hope (9%), or a lack of time (8%). Tertiary Care (63%) and Community Cardiology (58%) clinicians were more likely to attribute responsibility for having EOL discussions to the HF cardiologist, while 66% of Primary Care providers felt it was their responsibility. Tertiary and Community Cardiology clinicians were more likely to have referred patients to Palliative Medicine within the last year than Primary Care (89% vs. 21%, p<0.001). Overall, 30% of those surveyed reported low or very low confidence levels in initiating prognosis or EOL discussions, enrolling patients in hospice, or providing EOL care, with lower confidence among those with fewer years of clinical experience. The majority of clinicians expressed a high level of interest in further skills acquisition on these topics.

Conclusion:
There is tremendous variability in the way that clinicians view and approach advanced care discussions with their patients with HF; varying provider perception and lack of provider confidence may contribute. Despite this variability, most clinicians are interested in further development and skills acquisition. Addressing the learning needs of providers is an important next step toward enhancing the EOL care of patients with HF.
Abstract 378: A Needs Assessment Survey to Improve Utilization of Home Telehealth Services for Veterans at a VA Facility
Authors: Sahay Anju , Hextrum Anne , McElrath Mary , Heidenreich Paul
Published: March 2022

Objectives:
The US Department of Veterans Affairs (VA) has been a leader in the use of Home Telehealth (HT) to monitor the health status and promote self-care for Veterans. VA’s HT services use standardized Disease Management Protocols (DMP) and telehealth technologies to target care and case management to improve access to care, improving the health of veterans. With HT, the location of health care services shift to the homes of Veterans receiving routine care. Current technologies include in-home devices from six vendors that ask the patient several daily questions regarding symptoms and vital signs and return the answers to the medical record.

In collaboration with the HT program at the Palo Alto VA Health Care System (PA VAHCS), the VA’s Chronic Heart Failure (CHF) QUERI conducted a needs assessment survey with the PA VAHCS providers to help understand the provider’s view of HT and to understand any reasons for lack of enrollment.

Method:
A 9-item semi structured survey was developed and pilot-tested. The questions asked about use of HT program and referral of Veterans to HT program. The survey was sent to all providers at the PA VAHCS (n=198) and the response rate was 50% (n=89). Quantitative data analyses were conducted using descriptive statistics and chi-square tests.

Results:
The providers (respondents) were MD/DO (29.2%), RN (25.8%), LVN (21.3%), RNP (9.0%), pharmacists (7.9%), social workers (3.4%) and others (3.4%). Overall, 93% (n=83) of these providers knew about the available HT services. Among them, 57.8% reported that they refer Veterans more than 1-3 times a year to HT for heart failure (57.1%), diabetes (53.2%), hypertension (54.5%), COPD (31.0%) and depression (9.8%).

A majority of all providers (73%) wanted all Veterans interested in HT be referred directly (without requiring primary care provider approval) and most of them want HT to utilize standard order sets for managing aspects of chronic self-care for Veterans with heart failure (87.5%), diabetes (89.2%), hypertension (87.7%), COPD (88.0%) and depression (79.1%). Patient refusal (38.2%) and time/effort required by the primary care provider for reviewing HT notes (21.3%) were the significant barriers experienced in referring Veterans to HT for screening.

Conclusions:
Providers were aware of home telehealth though only about half chose to refer patients. Providing direct enrollment in home telehealth (e.g. through a survey of interested patients with heart failure) may decrease a provider barrier and improve enrollment.
Abstract 381: Femoral Artery Access Safety and Outcomes Across Multiple Specialties on a Novel Interventional Platform
Authors: Shih Michael J , Olstein Richard , Keigher Kiffon , Capalbo Sara , Snell Jeffrey
Published: March 2022

Background:
The Rush University Medical Center interventional platform is a novel hospital design concept created to facilitate multidisciplinary collaboration and centralize common resources in effort to improve safety and outcomes. Currently, there are no outcomes studies that evaluate the utility of an interventional platform. Multiple specialties on our platform utilize femoral artery access in a heterogeneous fashion. While complications are uncommon, they may affect morbidity, mortality, cost and length of hospital stay. We instituted a standardized femoral artery access workflow across the subspecialties on our interventional platform to evaluate techniques and outcomes.

Methods:
A prospective cohort of patients undergoing femoral artery access procedures on our interventional platform performed by interventional cardiology, electrophysiology, interventional radiology, and neurointerventional services was studied. Arterial access and hemostasis technique as well as periprocedural medications were at the operators’ discretion. Patients were evaluated for complications, including bleeding, thrombosis, pseudoaneurysm, and arteriovenous fistula formation.

Results:
Data was collected on 696 consecutive patients undergoing femoral artery access. Across subspecialties, there were significant differences in imaging modalities and adjunct tools used to obtain arterial access, frequency and types of closure device used, and intraprocedural medications. Notably, the neurointerventional service utilized adjunct modalities to achieve femoral artery access in significantly less cases compared to other specialties (16.8% vs. 65.7%; P<0.0002). Complications occurred in 5 procedures (0.72%), including 2 (0.45%) closure device and 3 (1.6%) manual compression cases; of the complications, 4 (2.1%) were neurointerventional procedures and 1 (0.29%) was a cardiology procedure.

Conclusions:
Institution of a standardized femoral artery access workflow on an interventional platform facilitated accurate monitoring of femoral artery access procedural techniques and complications across multiple specialties. Overall complication rates were similar to historical studies; however, varying practice patterns between subspecialties may have contributed to differing complication rates. Additional standardization of femoral artery access and hemostasis techniques across an interventional platform may further improve outcomes.
Abstract 383: Characteristics and Outcomes of Patients Undergoing Cardiac Catheterisation Procedures in US versus Australian Hospitals
Authors: Tavella Rosanna , Kennedy Kevin , Beltrame John F , Spertus John , Rumsfeld John
Published: March 2022

Introduction:
CathPCI Registry® is well established in providing assessment and benchmarking of patients undergoing catheterization and/or percutaneous coronary intervention (PCI). In 2011, the Coronary Angiogram Database of South Australia (CADOSA) was established as a quality assurance tool for cardiac interventions performed at all tertiary facilities in South Australia. CADOSA is compatible with the CathPCI Registry® with the use of common data elements and definitions, thereby allowing international comparisons.

Objective:
To compare Australian and United States (US) cardiac catheterization patients and practices using the unique infrastructure of CADOSA and CathPCI Registry®.

Methods:
Data collected for adult patients undergoing catheterization and/or PCI in 2012 was collated. Patients with cardiomyopathy and no symptoms or valvular heart disease were excluded.

Results:
In 2012, there were 1,415,326 cases in CathPCI Registry®, of which 46% were PCI. In contrast, CADOSA included 4,806 cases of which 29% were PCI. Prior revascularization was more frequent in CathPCI Registry® (prior PCI 32%, prior CABG 16%) compared to CADOSA (prior PCI 17%, prior CABG 8%). Acute coronary syndrome was the procedure indication for 63% of CathPCI Registry® cases and 55% of CADOSA, and 82% of CADOSA procedures had radial access sites compared to 45% in CathPCI Registry®. Table 1 summaries the PCI cases.

Conclusions:
In Australia, coronary angiography is frequently performed using radial approach, and PCI cases are often emergency reflecting the inclusion of tertiary referral centres. Elective PCI in the US is commonly preceded by SPECT. The potent antiplatelet inhibitors are also frequently administered during PCI. Whether the practice differences are related to significant differences in post procedure outcomes is unknown. This international comparison creates a broad perspective for cardiac health outcomes research and justifies further collaborative analyses.
Abstract 387: Utility of Glycated Hemoglobin for Assessment of Glucose Metabolism in Patients with ST segment elevation Myocardial Infarction
Authors: Aggarwal Bhuvnesh , Randhawa Mandeep S , Shah Gautam , Goel Sachin S , Ellis Stephen G , Lincoff A M , Menon Venu
Published: March 2022

Background:
The performance of glucose tolerance test (OGTT) in patients with STEMI results in the new recognition of diabetes mellitus (DM) in over 25% of subjects. However, due to presence of stress hyperglycemia and critical patient condition, diagnosis of DM using traditional tests (fasting glucose and OGTT) during initial hospital stay is challenging. The ADA definition now enables use of HbA1c for diagnosis of DM. We sought to evaluate the incidence and trends in newly diagnosed DM utilizing HbA1c in patients with STEMI.

Methods:
Consecutive patients (N=1,812) undergoing primary PCI for STEMI at the Cleveland Clinic between Jan 05-Dec 12 were included. Medical charts were queried to identify patients with an established history of DM. Admission HbA1c was used to identify patients with previously undiagnosed DM (HbA1c ≥ 6.5) and pre DM (HbA1c ≥ 5.7 and < 6.5).

Results:
Mean age was 60 years with 68% males. Overall, 428 patients (23.6%) had an established history of DM. Of the remainder, only 118 (8.5%) were diagnosed with DM while 593 patients (42.9%) had pre-DM based on admission HbA1c (Figure 1). There was no significant increase in mean body mass index (BMI) and incidence of DM over time (p=0.5).

Conclusions:
Utilization of admission HBA1c in patients with STEMI enables cardiologists to establish a new diagnosis of DM in a significant minority of subjects. Although convenient, HbA1c appears to under diagnose DM when compared to historical data with OGTT. Despite the increasing prevalence of obesity and DM in overall US population, we did not observe differences in mean BMI and prevalence of DM over time. The manifest cardiovascular consequences of DM may yet represent the exposed tip of the iceberg.
Abstract 4: Recognition of Newly-Diagnosed Diabetes Mellitus During an Acute Myocardial Infarction
Authors: Arnold Suzanne V , Stolker Joshua M , Lipska Kasia J , Li Yan , Spertus John A , McGuire Darren K , Inzucchi Silvio E , Goyal Abhinav , Maddox Thomas M , Lind Marcus , Shore Supriya , Kosiborod Mikhail
Published: March 2022

Background:
Diabetes mellitus (DM) is a common comorbidity in patients hospitalized with an acute myocardial infarction (AMI), and, in some cases, the AMI hospitalization represents the first opportunity to recognize and treat DM. We sought to understand both the prevalence of incident DM and its rate of recognition among AMI patients without DM diagnosis on admission.

Methods:
Patients in a 24-site U.S. AMI registry had A1C assessed at a core lab, which was blinded to clinicians. Patients could also have A1C drawn for clinical purposes. We defined DM based on A1C≥6.5% or, if A1C level was missing, based on ≥2 fasting glucose levels ≥126 mg/dL or ≥1 fasting glucose ≥126 mg/dL AND glucose at presentation ≥200 mg/dL. DM was considered recognized if the patient received DM education during the hospitalization or a DM medication at discharge. Multivariable, hierarchical logistic regression examined factors associated with recognition. Treatment with DM medications was evaluated at 6-months after discharge.

Results:
Among 2854 AMI patients without known DM on admission, 287 patients (10.1%) had core lab-diagnosed DM. Among these, 198 (69%) were not recognized by the treating physicians. Median A1C of unrecognized patients was 6.7%, range of 6.5-12.3%. If the treating physician checked an A1C during the AMI, this was associated with a 17-fold increased odds of recognition (95% CI 6.0-50.2). Furthermore, if the A1C was checked and was ≥7% (vs. <7%), this was also associated with 17-fold increased odds of DM recognition (95% CI 6.3-47.1). Six months after discharge, only 6.8% of those not recognized as having DM during hospitalization had been initiated on DM medications vs. 71% of those recognized during the AMI (p<0.001).

Discussion:
Among AMI patients without known DM, 1 in 10 have underlying DM. Recognition of this remains sub-optimal, with fewer than 1 in 3 patients receiving DM education or medications at discharge. The majority of unrecognized patients are not initiated on therapy during follow-up, emphasizing the importance of recognition during the AMI hospitalization. Furthermore, the strongest predictor of recognition was A1C assessment during hospitalization, highlighting an important opportunity to improve the recognition of DM and, possibly, long-term glycemic control in patients hospitalized with AMI.
Abstract 6: Early Telephone Follow-up Fails to Reduce Readmission Rates for CHF & AMI.
Authors: Lehman Elmer P , Granger Bradi B , Batten Hunter , Pura John , Lokhnygina Yuliya V , McCarver Catherine , Shah Bimal R
Published: March 2022

Background:
To reduce readmissions rates for patients admitted with acute myocardial infarction (AMI) or congestive heart failure (CHF), Duke University Hospital piloted a program in which patients were contacted by telephone within 72 hours of discharge and asked a set of structured questions believed to identify gaps in care to reduce the risk of readmission.

Methods:
A cohort of 838 patients admitted between December 2012 and May 2013 with a primary diagnosis of AMI (n=374) or CHF (n=464) were identified by DRG for prospective telephone follow-up and analyzed retrospectively. For primary outcome analysis, readmission rates were compared between two groups: one that received the telephone intervention and one that did not. If successfully contacted, patients were asked about filling and complying with their prescriptions, knowledge of their follow-up appointment, and understanding their discharge instructions. A secondary outcome analysis evaluated readmission rates among the telephone-eligible subgroup.

Results:
Patient characteristics among those contacted vs. not contacted did not differ substantially for either AMI or CHF discharges.

Among AMI patients, there was no association between contact attempt and readmission within 30 days (p = 0.719) or 90 days (p=0.803). This finding persisted after adjusting for the effect of age at hospitalization, disease group, race, gender, and payor (OR = 1.28, 95% CI = 0.61 - 2.68, p = 0.512 at 30 days; OR = 1.24, 95% CI = 0.65 - 2.37, p = 0.510 at 90 days).

Among CHF patients, there was no association between contact attempt and readmission within 30 days (p = 0.156) or 90 days (p=0.904). This finding persisted after adjusting for the effect of age at hospitalization, disease group, race, gender, and payor (OR = 0.67, 95% CI = 0.35 - 1.25, p = 0.207 at 30 days; OR = 0.94, 95% CI = 0.56 - 1.55, p = 0.797 at 90 days).

There was no association between telephone-eligible patients and readmission rates at 30 or 90 days for either condition. Among patients successfully contacted, there was no association between answers pertaining to post-discharge behavior and readmission rates for CHF or AMI.

Conclusions:
Early telephone follow-up targeting post-discharge behaviors was not observed to impact 30- or 90-day readmission rates for patients admitted to an academic medical center with CHF or AMI.
Abstract 7: Risk of Intracranial Hemorrhage Among Acute Ischemic Stroke Patients Receiving Prior Antiplatelet Therapy and Treated with Intravenous Tissue Plasminogen Activator
Authors: Xian Ying , Grau-Spulveda Maria , Schwamm Lee H , Bhatt Deepak L , Smith Eric E , Reeves Mathew J , Federspiel Jerome , Thomas Laine , Bettger Janet P , Laskowitz Daniel T , Hernandez Adrian F , Fonarow Gregg C , Peterson Eric D
Published: March 2022

Background:
Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic stroke. However, patients receiving long-term antiplatelet therapy may face an increased risk of symptomatic intracranial hemorrhage (sICH) when treated with tPA. While current guidelines allow use of tPA in patients on antiplatelet therapy, there are limited data on the safety of tPA in this population.

Methods:
Data from 51,922 ischemic stroke patients treated with tPA within 4.5 hours of symptom onset from 1,401 Get With The Guidelines-Stroke hospitals between January 2009 and June 2013 were analyzed. Multivariate logistic regression model with generalized estimating equations approach was performed to evaluate the association of preadmission antiplatelet therapy on sICH risk.

Results:
Of tPA treated patients 23,232 (45%) were receiving antiplatelet medicine prior to admission. Patients on prior antiplatelet therapy were older (median 76 vs. 68 years, p<.001), had more comorbid illness (CAD/prior MI, prior stroke/TIA, atrial fibrillation, diabetes, dyslipidemia, hypertension and heart failure, all p <.001) but had similar stroke severity (median National Institutes of Health Stroke Scale [NIHSS] 10 vs. 10, p=0.07). Crude rates of sICH were higher in those on prior antiplatelet therapy 5.32% vs. 4.03% (unadjusted OR 1.31, 95% CI 1.20-1.43). Multivariate analysis revealed that prior antiplatelet therapy was an independent predictor of sICH (adjusted OR 1.17, 95% CI 1.06-1.29; adjusted sICH rates 4.93% vs. 4.26%), serious systemic hemorrhage or any tPA complications. These findings were consistent in subgroup analysis of 0-3 hour treatment window. However, there were no significant differences between two groups in mortality, discharge to skilled nursing facility or hospice. In contrast, antiplatelet therapy was associated with favorable ambulatory status at discharge after risk adjustment (
Table
).

Conclusion:
This study represents the largest clinical experience of the safety of thrombolysis in patients on prior antiplatelet therapy. Despite a higher incidence of sICH, the absolute excess risk appears small (0.67%). These findings support current guideline recommendations regarding use of intravenous tPA in patients on antiplatelet therapy with careful weighing of potential risk and benefit.
Abstract 125: Improving ECG Services at a Children’s Hospital: Implementation of a Digital ECG System
Authors: Osei Frank A , Gates Gregory J , Choi Steven J , Hsu Daphne T , Pass Robert H , Ceresnak Scott R
Published: March 2022

Background:
Pediatric ECGs and ECG interpretation were all paper-based until 2012 at our Children’s Hospital. There were significant delay between the time when the ECGs were performed and when they were officially interpreted by a cardiologist for the formal the medical records. To better understand the factors contributing to the delay or failure to complete an ECG report, we created a Fishbone (Ishikawa) Diagram to help facilitate a solution. (See Diagram 1 below). We hypothesized that the introduction of a completely digital ECG system would increase the volume of ECGs interpreted and improve the capture and billing of ECG services.

Diagram 1-Fishbone diagram of factors affecting ECG flow

Methods:
As part of a hospital wide quality improvement initiative, a digital ECG service (Muse®, GE) was implemented at the Children’s Hospital at Montefiore in June 2012. The total volume of ECGs performed in the first 6 months of the digital ECG era (Post-Digital, June 2012 - Dec 2012) was compared to 18 months of the pre-digital era (Pre-Digital, Jan 2011 - May 2012). In addition, billing times were compared in the Pre-Digital and Post-Digital eras and an assessment of workflow were performed. Pre-Digital and Post-Digital data were compared via t-tests. (Diagram 2 illustrates the ECG workflow in both eras)

Diagram 2-ECG workflow in the Pre Digital vrs Digital Eras

Results:
Table 1

Conclusion:
Implementation of a digital ECG system increased the volume of ECGs interpreted and reported at a children’s Hospital.
Abstract 13: Costs of Early Readmission After Percutaneous Coronary Intervention
Authors: Amin Amit P , Burns Sara , Novak Eric , Crimmins-Reda Patricia , Singh Jasvindar
Published: March 2022

Introduction:
Early readmission within 30 days (30DR) after percutaneous coronary intervention (PCI) is thought to contribute towards greater healthcare costs. However, no study has examined the exact cost of 30 day readmission after PCI from a hospital’s perspective.

Methods:
We used the national State Inpatient Databases (SID) which is a part of the Healthcare Cost and Utilization Project (HCUP) from 8 states with long term follow-up to identify the hospital costs through 30 days after PCI. Cost from the hospitals’ perspectives was obtained using published hospital-specific cost to charge ratios. Costs were trimmed to exclude extreme outliers and inflated to 2014 US dollars using the medical consumer price index. Costs through 30 days after index PCI were compared among those who were and were not readmitted within 30 days. A multivariable linear regression cost model was developed to identify the incremental and independent costs of 30DR when adjusted for baseline socio-demographics, clinical characteristics and comorbidities.

Results:
Of the 539,045 patients undergoing PCI included in the SID from 8 states, readmission within 30 days occurred in 14.7%. Costs of hospitalization through 30 days of index PCI were higher for those readmitted within 30 days ($40,869) vs. those not readmitted ($21,983), P<0.001. These higher costs were contributed by a higher index PCI hospitalization costs of $25,943 for patients readmitted within 30 days vs. $21,983 for those not readmitted, P<0.001 as well as costs of subsequent readmission hospitalization within 30 days ($14,926). When adjusted for baseline socio-demographics, clinical characteristics and comorbidities, 30DR incrementally cost $1,384 (95% CI $1,254 to $1,513, P<0.001).

Conclusions:
This study, to the best of our knowledge, is the first study to examine the cost of early readmission within 30 days of PCI. Readmissions within 30 days of PCI are expensive and contribute towards excessive healthcare costs. This study further supports systematic efforts to reduce 30DR after PCI.
Abstract 134: Unmet Need in Hyperlipidemia
Authors: Ton Thanh , Campinha-Bacote Avrita , Yurgin Nicole , Stevens Warren
Published: March 2022

Background:
Cardiovascular disease (CVD) remains the largest driver of mortality worldwide, with an annual global estimate of 20 million deaths by 2030. Lipid lowering therapies (LLT) including statins have become a mainstay of treatment for those at risk for CVD. Similarly, for approximately 20 years, treatment for those with atherosclerotic disease (ASVCD) has mainly involved the use of LLTs to lower levels of low density lipoprotein (LDL-C). Despite the widespread use of LLTs, it remains unclear whether greater intervention is required to reduce LDL-C to safe levels among those at high risk.

Objectives:
We examined the utilization patterns of LLTs between 2003-2012, and the proportion of LLT users with LDL<70 mg/dL among those in the 4 statin benefit groups defined by the American College of Cardiology and the American Heart Association (ACC/AHA).

Methods:
We used data from NHANES between 2003-2012 to assess trends in LLTs use and percent of users with LDL-C<70 mg/dL among adults ≥18 years old in the US population who met the criteria for the 4 statin benefits groups. We calculated frequencies, means, and percents that were weighted to obtain population estimates. We conducted linear trend tests to assess whether changes in estimates were statistically significant over time.

Results:
The number of adults ≥18 years old in the US who belonged to the 4 statin benefit groups increased from 57,260,635 (26.7%) in 2003-2004 to 64,479,875 (27.9%) in 2011-2012. The percent of adults in these 4 statin benefit groups who used LLTs increased from 30.8% to 47.1% (p<0.001) between 2003-2012. Among LLT users, the percent with LDL-C<70 mg/dL increased from 11.0% in 2003-2004 to 21.9% in 2011-2012 (p<0.001). In 2011-2012, the percent of LLT users with LDL-C <70 mg/dL in the 4 statin benefit groups ranged from 0% to 46%. Among people at highest risk (with ASCVD), 72.9% used LLTs in 2011-2012, and only 20% of these users had LDL-C<70 mg/dL.

Conclusions:
Despite an increase in the number of people considered at high risk by the ACC/AHA guidelines and the significant rise in LLT use between 2003-2012, the majority of LLT users have LDL-C levels over 70 mg/dL. Given the recent evidence that lower LDL-C levels confer the greatest decreases in risk of cardiac events, a significant unmet need exists for greater intervention in order to effectively decrease LDL-C to safe levels in the US adult population.
Abstract 138: Adoption of U.S. Preventive Services Task Force Recommendations in Primary Care
Authors: Axiyan Maihemuti , Kaveti Punita , Nchang Taka , Patel Nirav , Khurana Saurabh , Menon Vivek , Ampanattu Sherrin Daniel , Okeiyi Benson , Onwuanyi Anekwe
Published: March 2022

Background:
The U.S. Preventive Services Task Force (USPSTF) recommendations for cardiovascular disease(CVD) includes aspirin for primary prevention and abdominal aortic aneurysms (AAA)screening . USPSTF recommends that men ages 45 to 79 years and women ages 55 to 79 years should be prescribed aspirin to prevent cardiovascular events. USPSTF also recommends one-time screening for AAA with ultrasonography in men ages 65 to 75 years who have ever smoked.We sought to evaluate the adoption of aspirin use and AAA screening per USPSTF recommendations in a primary care setting at an urban academic teaching hospital.

Methods and Results:
We obtained data for aspirin use and AAA screening by chart review of patients seen in primary care continuity clinic by internal medicine resident physicians in their first and second year of training, between August - October, 2014. A total of 626 charts were reviewed to identify patient who needs primary prevention per USPSTF (men 45 -79 years and women 55- 79 years of age). This resulted in a study population of 388 patients which comprised of 219 men and 169 women. Comorbid conditions in this patient population included hypertension (69.3%), diabetes mellitus (28.10%), dyslipidemia (39%), smoking (37.9%) and obesity. Only 150 (38.7%) of the 388 patients were appropriately placed on aspirin per USPSTF recommendations. Moreover only 13% of patients were appropriately screened for AAA (Table 1).

Conclusion:
Adoption of USPSTF recommendations for aspirin use for primary prevention of CVD and AAA screening is under implemented even in an academic teaching environment. Our results indicate that there is an urgent need for implementation strategies to improve the adoption of these recommendations.

Table 1: Patient characteristics and screening percentage
Abstract 139: Building Sustainability: Creating Structure for Improved Heart Failure Patient Outcomes
Authors: Thompson Christine M , Kell Charlene , Bingham Angela , DiBiase Aria , Banerjee Dipanjan
Published: March 2022

Background:
As heart failure (HF) prevalence continues to climb, patient re-hospitalizations challenge collective healthcare resources across the US. Many centers have implemented care transition strategies to reduce 30-day readmissions, but impacting 90-day readmissions and sustaining those positive outcomes remain daunting.

Aim:
Create and implement a programmatic structure to embed a care transitions approach to HF patient care at a tertiary care medical center, sustaining reduced patient readmissions and improving the patient care experience.

Methods:
To effect change in our evidence-based HF care processes, we adopted a multidisciplinary team approach to develop, implement and monitor patient care processes. Post-discharge phone calls to patients proved a particularly impactful intervention. Weekly internal meetings and monthly meetings with patient and community partner participation were implemented, in addition to ongoing, multimodal communication to the frontline care team to share strategies and outcomes data. Actively engaging patients in care improvement efforts is critical to understanding and meeting their needs and inpatient interviews with empathy mapping was used. Patients participated in medication safety workshops and provided feedback on educational tools that were developed. EMR-embedded tools were created to guide workflows and facilitate analytics (outcomes/balancing measures, process measures, automated risk assessment). Routine team review of post-discharge coding, individual patient readmissions and evaluating program impact on care delivery costs were instituted.

Results:
12 months of data both pre- and post- program implementation, all-cause 90-day readmissions declined by 23% from baseline 31% (160 of 524) to 24% (78 of 327). HF patient subjective reporting of feeling prepared to manage self-care post discharge improved by 6%, while understanding of medications improved by 5%.

Conclusion:
Impacting HF readmissions remains challenging. In executing healthcare quality improvement initiatives, implementing programmatic structure in addition to interventions is essential to sustain positive results with manageable resources. Involving the multidisciplinary team, developing community partnerships and engaging patients are key.