bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 141: Trends in Left Ventricle Assist Device Use, Outcomes and Costs among Medicare Beneficiaries, 1999 to 2008.
Authors: Lampropulos Julianna F , Wang Yun , Desai Mayur , Kim Nancy , Barreto-Filho Jose A , Krumholz Harlan M
Published: July 2021

Background:
Over the last decade, left ventricle assist device (LVAD) technology has improved substantially, resulting in smaller devices requiring less invasive procedures, which has broadened its clinical indications to frail populations. During this time of technological advancement, we examined trends in use, mortality, and associated costs of LVADs among Medicare beneficiaries.

Methods:
Inpatient Medicare standard analytic files were used to identify 100% of fee-for-service (FFS) patients aged ≥65 years that received LVAD (ICD-9-CM codes 37.60, 37.62, 37.65, 37.66 and 37.68) from 1999 to 2008. We constructed a denominator file from Medicare administrative data to report operative rates per 1,000,000 beneficiary-years. Length of stay, hospital mortality, thirty-day and one-year mortality were ascertained through corresponding vital status files. Costs were defined as hospital payments made by Medicare.

Results:
Among Medicare FFS patients, the overall LVAD procedure rate increased from 13.8 per million beneficiary-years (365 procedures) in 1999 to 19.8 per million beneficiary-years (548 procedures) in 2008, a relative increase of 44 %. In addition, between 1999 and 2008 overall length of stay increased from 19.1 days to 23.8 days; hospital mortality decreased from 42.5% to 33.4%, 30-day mortality decreased from 38.9% to 30.7% and one-year mortality decreased from 54% to 47.1%. Total CMS payments for the hospitalizations in which LVADs were placed increased from $20,188,880 ($55,312/patient) in 1999 to $71,050,392 ($129,654/patient) in 2008. Over the study period, LVAD use increased in all age groups, most strikingly among the ≥75 years old, in whom incidence increased from 151 procedures in 1999 to 192 procedures in 2008, representing 35% of the LVAD implantation in the Medicare population in 2008.

Conclusions:
From 1999 to 2008, LVAD use increased substantially with a decrease in hospital, 30-day and one-year mortality.
Abstract 148: The Timing of 30-Day Readmissions after Hospitalization for Heart Failure and Acute Myocardial Infarction
Authors: Dharmarajan Kumar , Hsieh Fu-Chi , Lin Zhenqiu , Ross Joseph S , Kim Nancy , Barreto-Filho Jose , Bueno Hector , Bernheim Susannah , Drye Elizabeth E , Krumholz Harlan M
Published: July 2021

Background:
Readmissions are frequent and costly outcomes in patients hospitalized for heart failure (HF) and acute myocardial infarction (AMI). Knowledge of the exact timing of 30-day readmissions after hospitalization for HF and AMI can help identify time periods during which patients are at the highest readmission risk and guide the development of interventions designed to prevent early readmissions.

Methods:
Using Medicare Standard Analytic and Denominator files, we identified all HF and AMI hospitalizations in 2007-2009. We excluded hospitalizations for patients aged<65, transferred out, discharged against medical advice, or with an inpatient death. For both HF and AMI cohorts, we identified all readmissions to short-stay acute care hospitals due to any cause occurring within 30 days of hospital discharge except for planned coronary revascularization. Our primary outcome was the number of observed readmissions occurring during each day (0-30) after discharge. We also calculated the cumulative number of observed readmissions occurring during the 1
st
3 days, 1
st
week, and 1
st
15 days after discharge. We used a one-tailed two-proportion z test to evaluate if the proportion of readmissions during the 1
st
3 days, 1
st
week, and 1
st
15 days was higher than what would be expected had readmissions occurred at an equal rate during the 30 days (alpha=0.05).

Results:
We identified 329,308 readmissions within 30 days after 1,330,157 hospitalizations for HF (4,633 hospitals) and 108,992 readmissions within 30 days after 548,834 hospitalizations for AMI (3,895 hospitals). Readmission frequency by day is described for both HF and AMI in the accompanying figure. Following hospitalization for HF, 13.4% of 30-day readmissions occur during the 1
st
3 days after discharge, 31.7% occur during the 1
st
week, and 61.0% occur during the 1
st
15 days. Following hospitalization for AMI, 19.1% of 30-day readmissions occur during the 1
st
3 days after discharge, 40.1% occur during the 1
st
week, and 67.6% occur during the 1
st
15 days. For both HF and AMI cohorts, readmissions after 3, 7, and 15 days were higher than what would be predicted had readmission rates remained constant (p<0.0001 for all).

Conclusion:
For patients hospitalized with HF and AMI, a disproportionately high percentage of 30-day readmissions occur soon after discharge. Interventions designed to reduce hospital readmissions may therefore generate substantive benefits when applied to the time period shortly after hospitalization.
Abstract 15: Comparative Effectiveness of Coronary Angioplasty and Bypass Surgery Among Medicare Beneficiaries
Authors: Hlatky Mark , Boothroyd Derek , Baker Laurence , Shilane David , Go Alan S
Published: July 2021

Introduction.
The outcomes of CABG and PCI for the treatment of patients with multivessel CAD have been compared in several randomized trials (RCTs). A pooled analysis of 10 RCTs showed that diabetes and age significantly modified the effect of CABG on mortality. It is uncertain whether in routine practice the effect of CABG on mortality is modified by clinical characteristics.

Hypothesis.
The comparative effectiveness of CABG vs. PCI on mortality is modified by baseline clinical factors.

Methods.
We identified Medicare beneficiaries 66 and older with Parts A and B coverage who received either multivessel CABG or multivessel PCI between 1992 and 2008. We developed a propensity score for CABG vs. PCI treatment, and matched patients from the same year with diabetes, and age with one year on propensity score within 0.01. Mortality over five years was assessed in the matched patients with Cox models and treatment-by-covariate interactions were tested.

Results.
We matched 105,612 patients, with an average age of 75 years, 42% female, 92% white, and 33% with diabetes. Five-year survival was 74.7% after CABG, 71.8% after PCI, with an overall CABG:PCI adjusted hazard ratio (HR) of 0.90. (95% confidence limits, 0.88-0.93). There was a significantly greater reduction of mortality by CABG for patients (Figure) with male sex (HR 0.88 vs. 0.94, interaction p=0.009), diabetes (HR 0.87 vs. 0.93, p=0.02), tobacco use (HR 0.82 vs. 0.92, p=0.0004), heart failure (HR 0.86 vs. 0.92, p=0.03), and procedures performed prior to 2004 (HR 0.88 vs. 0.94, p=0.008). The interaction of age with treatment was not signficaint, but all patients were aged 66 years or greater. Results were consistent whether examined as hazard ratios, differences in five-year survival, or life-years added.

Conclusion.
The comparative effectiveness of CABG and PCI on mortality varies significantly according to baseline clinical factors.
Abstract 151: Report and Analysis of Risk Factors Associated With Heart Disease of Lower Income Populations Within New York City
Authors: Keller Norma , McWhir Gregory J
Published: July 2021

Background
Heart disease has been and continues to be the number one cause of death in New York City and New York State. In 2009, an estimated 19,715 deaths were associated with heart disease in New York City alone. Health awareness has played a key role in the steady decline of this number. NYU Langone Medical Center has been receiving funding from a grant to support free health fairs that have provided basic testing to any individual willing to enroll since 2008. To date, nearly a hundred of these fairs have been conducted across New York City in places of worship, community centers, and Bellevue Hospital Center.

Methods
Health fairs were conducted over a four-year period targeting lower income communities in the New York City Metro area. The target population included any individual over the age of 18. When consented, they provided their demographics and filled a questionnaire. The patient then received a finger prick to examine blood glucose, total cholesterol, LDL, HDL, and triglyceride levels, along with their blood pressure. After receiving the results on-site, the patients were counseled by a qualified individual, often a NP or physician, and given an interpretation of their results accompanied with lifestyle advice and clinic referrals. The data from the fairs was compiled onto an online Electronic Data Capture system.

Results
A total of 4366 subjects were enrolled with a median age of 45. Analysis of the data showed significant numbers associated with risk factors of heart disease. 40.1% (1687 of 4204) of all subjects showed a total cholesterol level greater than or equal to 200 mg/dL with the highest risk group being African-Americans at 68.4% (661 of 966). A family history of coronary disease or sudden death before age 55 was noted by 23.33% (923 of 3966) of subjects. 24.07% (1051 of 4366) of the patients were referred to their primary care provider or Bellevue Hospital's clinic because of abnormal test results at the health fair.

Conclusion
The data values obtained provide a general outlook of the health within lower income communities in New York City. A significant portion of the enrolled subjects met at least one risk factor associated with heart disease. Many factors can be attributed to these statistics including lifestyle, genetics, and access to healthcare. These free health fairs have made dramatic impact in local communities by providing access to simple yet important tests.
Abstract 2: Cost of Care for Heart Failure Patients Varies Substantially Among Hospitals Even When Controlling for Procedure Use
Authors: Chen Serene I , Strait Kelly M , Dharmarajan Kumar , Li Shu-Xia , Kim Nancy , Safavi Kyan , Lagu Tara , Krumholz Harlan M
Published: July 2021

Background:
Little is known about cost variation among heart failure (HF) patients across hospitals when controlling for invasive cardiovascular percutaneous and surgical procedures.

Methods:
We identified all adult HF hospitalizations in 2009-10 Premier, Inc. hospitals with >25 HF hospitalizations. Hospitals were divided into 3 groups by their percent of HF patients receiving invasive percutaneous or surgical procedures: none (0%), moderate (0-10%), and high (>10%) (see figure). The 10% mark was the median across hospitals. For each of the three groups, the median hospitalization cost was calculated for all non-procedural admissions in standard dollar costs (figure). Standard cost assigns each billed item its median cost across all hospitals. The Kruskal-Wallis test was used to assess cost, length of stay, and outcome differences among the 3 groups (p≤0.05). Frequencies of billing categories (e.g. pharmacy, lab, central supply) were calculated and compared across the 3 groups.

Results:
Median standard dollar costs among non-procedural HF hospitalizations were $5104 (IQR=$3421, $7968), $6108 ($4001, $9934) and $6585 ($4181, $11218) for hospitals with no, moderate and high procedure use, respectively (figure). Respective median lengths of stay were 3, 4, and 4 days, and risk-adjusted mortality was 4.8%, 4.9% and 4.7% (figure). Cost analysis by resource categories showed that the proportion of items billed did not appear to differ by hospital group.

Conclusion:
The cost of HF hospitalization is higher in more procedure-intense hospitals even among patients who do not receive invasive procedures. Length of stay may contribute to these differences. Despite higher costs, high procedure hospitals do not have materially improved risk-adjusted mortality rates.
Abstract 205: An Integrated Computer Decision Support Tool is Associated with Increased Frequency of Global Cardiovascular Risk Assessment
Authors: Brown Brian J , Tattersall Matthew , Li Zhanhai , Keevil Jon
Published: July 2021

Introduction:
Current guidelines recommend assessing global cardiovascular risk in all asymptomatic adults requiring primary prevention of coronary heart disease. Yet, physicians infrequently calculate risk, in part because use of global risk scores can be cumbersome.

Hypothesis:
We hypothesized that an auto populating Computer Decision Support Tool (CDST), providing point of care calculation of global cardiovascular risk, would improve clinical documentation of global risk.

Methods:
The HealthDecision CDST was launched on 02/01/2010 within the local electronic health record (EMR) at the University of Wisconsin Hospital and Clinics. Using a pre-post, matched case-controlled design, data was collected on all adult patients of 6 primary care physicians (PCP) for whom the CDST was used after EMR integration (2/1/2010-3/11/2011) and who also had a visit with the same PCP prior to CDST availability (1/1/2009-11/31/2010). Univariate and bivariate analyses of the cases identified the Framingham risk score (FRS) as a significant factor affecting change in risk documentation (p=0.0074). Control subjects with visits in the same time frames were individually matched 1:1 on PCP, age, gender, and FRS. Differences in pre-post risk documentation rates among cases and controls were analyzed using the McNemar’s test, while differences in risk documentation rates for matched cases and controls and differences among physicians were analyzed using the Fisher’s Exact test.

Results:
There were 61 patients for whom the CDST was used and had visits with the same PCP within the pre and post study periods. Clinic note documentation of the global risk score in patients for whom the CDST was used, was 3.3% (2/61) (95% CI 0.4-11.4%) before and 50.8% (31/61) (95% CI 37.7-63.9%) after CDST availability (p<0.0001). Risk documentation in the control group was 0% in both the pre and post periods. Risk documentation rates between the cases and controls in the pre CDST time period were not significantly different (p=0.50), while rates between the cases and the controls in the post CDST time period increased significantly The increase in risk documentation for cases from pre CDST to post CDST implementation was not dependent on the specific PCP (p=0.42).

Conclusion:
The use of an auto populating point of care CDST integrated into the EMR was associated with improved documentation of a global cardiovascular risk score.
Abstract 214: Multidisciplinary Approach to Improve Process Measures and Prevent Heart Failure Readmissions
Authors: Syros George , Kabadi Mitesh , Blanchard Sarah , Aviles Kristin , Melvin Claire , Tsao Lana
Published: July 2021

Background:
Approximately 5.2 million Americans have heart failure (HF). HF morbidity and mortality is high, and 27% of patients are readmitted at 1 month and 50% at six months.

Objective:
To determine the effect of a multidisciplinary approach on Hospital Quality Alliance (HQA) performance and 30-day HF readmission rates.

Methods:
A one year, prospective, observational study on the effect of a multidisciplinary approach on 30-day HF readmissions was performed and compared to the prior year’s readmission rate at a University affiliated community hospital. HF patients were identified by case and unit nurse managers, who also screened for intravenous diuretic use to determine if patients had HF but were admitted under another diagnosis. HF patients were clustered geographically where daily multidisciplinary rounds with the unit nurse and care manager, pharmacist, social worker, nutritionist, medical and nursing staff took place. The goal was to ensure compliance with the established HQA Performance Measures, initiate appropriate discharge planning, and assess functional status. Patients were educated on 2 gram sodium diet, 2 liter fluid restriction, daily weight monitoring, and smoking cessation. Follow-up appointments with their PCP or cardiologist were scheduled. Upon discharge, nursing and medical staff provided medication and home management instructions. The patient’s PCP was called by the attending physician or cardiovascular fellow as well as the Skilled Nurse Facility, Rehabilitation, and Home Care staff, when applicable. Targeted in-home support immediately following discharge from the hospital was provided. High risk patient had an in-home 2-3 day post discharge visit by VNA and a Pharmacist to access their weight, medications, and physical activity progress.

Results:
During the intervention year, 355 CHF patients were discharged and compared to 318 patients in the year prior. The 30 day readmissions were reduced from 79 (24.8 %) to 64 (18.03%),
p = 0.04
by Wilcoxon Signed-Rank Test. The Heart Failure National Inpatient Quality Measures performance increased from 95% ± 3.8% (2010) to 99.6% ± 0.5% (2011) -
p = 0.008
.

Conclusions:
With implementation of penalties by Medicare in 2013 for 30 day HF readmissions, strategies to reduce them are critical. A comprehensive intervention involving multiple specialties and appropriate patients’ disposition can reduce 30-day readmission rates as well as improve Heart Failure National Inpatient Quality Performance Measures. Further evaluation of this treatment approach, including an assessment of cost-effectiveness, is warranted.
Abstract 22: Outcome Of Patients With Basilar Artery Bifurcation Aneurysm Who Underwent With Endovascular Approach
Authors: Lodi Yahia M , Sethi Khalid , Gaylon Dan , Bajwa Syed
Published: July 2021

Background:
Due to a high surgical risk, endovascular repair of the basilar artery (BA) aneurysm is considered the primary option for most of the cases. However, procedure related complications, clinical outcome and rate of recurrence in BA bifurcation aneurysms are not specifically addressed. Objectives: is to describe the incidence of endovascular procedure related complications, recurrence of aneurysm and long-term clinical outcome of BA aneurysm.

Methods:
Consecutive patients who underwent endovascular repair of BA bifurcation aneurysm were enrolled from 2007 to 2010. Patient’s demographics including the Hunt & Hess (H&H) grade, Fished scale, and size of aneurysm were collected. Complications including aneurysm rupture, intracranial hemorrhage or thromboembolic event were recorded. Additionally, 90-days outcome measurement was obtained using Glasgow Outcome Scale (GOS).

Results:
36 patients with a mean age of 50 plus-minus 14 years required 48 successful procedures to treat 36 BA bifurcation aneurysms. Ruptured aneurysm was present in 20 cases (H&H I in 6, II in 4, III in 4 and IV in 6). 30 patients (83%) had wide neck aneurysm, 25 (69%) of which required stent in order to secure the aneurysm. There was no intraoperative rupture of aneurysm or thromboembolic event. However, one patient developed diplopia with visual incoordination on day one and other developed diplopia due to a small pontine stroke while stopping clopidogrel on post operative day 30 of stent-assisted repair. Both patients recovered completely with no disability. Ten patients (28%) had recurrence of aneurysm and required subsequent procedure. In recurrent aneurysms, repeat procedures had no negative impact on the clinical outcome. One patient died (GOS 1) who initially presented with H&H IV and never recovered. Good outcome was observed in 32 (89%) patients (GOS 5 in 31, GOS 4 in 1) including all unruptured cases and 3 of 5 ruptured BA aneurysm patients who presented with H&H of IV. Poor outcome was observed in 3 (8%) patients (GOS 3 in 3, 2 of which presented with H&H IV).

Conclusion:
Endovascular repair of the BA bifurcation aneurysms are associated with good clinical outcome despite requirement of multiple procedures to complete the treatment. However, the recurrence of aneurysm is very high. Therefore, a very close angiographic follow-up is necessary.
Abstract 223: Innovations in Quality Improvement
Authors: Ansani-Jankowski Nicole , Madder Robert
Published: July 2021

Innovative Medical Platform Optimizing Research and Technology (IMPORT)>

Background:
A medical group, pharmaceutical company, and data harvesting and integration company collaborated to test an innovative approach to quality improvement (QI) that utilizes clinical expertise, advanced outcomes analytics, electronic medical records (EMR), and a cloud technology data harvesting platform. The objective of this project was to measure the ability of this collaborative project to effectively and efficiently identify quality improvement opportunities.

Methods:
This was a retrospective EMR analysis which utilized Solution for Quality Improvement (SQI) platform on an advanced electronic medical record system. All patients in one primary care medical practice seen from 7/1/2009 - 7/31/2011 were included. The primary outcomes were effectiveness of the platform to integrate data, measured by data density of diabetes laboratory and clinical quality performance values from structured EMR fields and unstructured physician notes; and efficiency, measured as the time period from SQI data mapping to final results analysis. A secondary outcome was the ability of the project to identify and target meaningful QI opportunities.

Results:
SQI collected data from 9,294 patient records, including 73,706 office visits and 35,602 physician dictated visit notes. Of these records, 6,251 cardiovascular patients were identified with diabetic patients accounting for 1,561 (25%) of these. Values and measurement dates for A1c, LDL, and blood pressure values were harvested in 83%, 75%, and 96% of these diabetic patients, respectively. The collection of other diabetic preventive services performance indicators was relatively low. Additional QI is being done to ensure complete capture of data. The time period for analysis, including 3 iterative rounds of expanded data identification, was 15 weeks total. Through this project, 3 specific areas of QI were prioritized: improve dictation/documentation of preventative diabetes care recommendations; implement diabetes panel management; and develop electronic diabetes patient reported outcomes screening tools.

Conclusion:
This collaboration led to an efficient and effective QI analysis in diabetes care. Results of the analysis have led to development and implementation of meaningful QI initiatives. Future implications include the use of this project’s approach to rapidly re-measure performance after implementation of the QI initiatives and expansion of the collaboration from a 4 physician practice to the network of 100 primary care physicians.
Abstract 226: Impact of Reporting Cardiac Magnetic Resonance Examination Duration on the Total Scan Time: A Tertiary Academic Health Care Hospital Experience
Authors: Sidhu Manavjot S , Lumish Heidi , Uthamalingam Shanmugam , Engel Leif-Christopher , Kalra Mannudeep , Francis Sanjeev , Holmvang Godtfred , Abbara Suhny , Brady Thomas , Hoffmann Udo , Ghoshhajra Brian
Published: July 2021

Background:
The core components of a quality improvement (QI) program focus on consistent, high-quality service delivery. We report our experience with a QI program focused on cardiac magnetic resonance (CMR) examination duration reduction.

Methods:
Department policy for the scan time allotment for a clinical CMR examination was reviewed. Medical records of all patients who underwent CMR examination from January 2010 to December 2010 were reviewed. Scan duration from time of the initial to the final image acquisition was recorded. An intervention was implemented from January 2011 to September 2011 to report the scan durations weekly to all CMR physicians. Monthly comparisons were performed between the 2010 and 2011 exams. No changes were made in department protocols.

Results:
The allotted time for a CMR examination was 90 minutes. From January to September 2010, the mean (±SD) scan duration for CMR examinations was 105 (± 32) minutes, as compared with a mean of 87 (±21) minutes for the same months in 2011. Comparison between the 2010 and 2011 scan durations using a Wilcoxon test indicated a significant difference between the two samples (p<0.05; Figure 1). The percentage of all scans exceeding 120 minutes in duration decreased from 27.4% (n=529) in 2010 to 5.3% (n=451) in 2011. The indications for CMR examinations were found to be similar between 2011 and 2010 (p<0.05). All exams were reported to be of diagnostic quality.

Conclusions:
The simple step of publicly reporting weekly scan durations to house staff and attending physicians resulted in significant reduction in CMR scan durations, with preserved diagnostic quality. We propose that increased awareness led to higher efficiency.
Abstract 236: Complex Patients: The Majority Hospitalized with Heart Failure also Receive Treatment for Acute Respiratory Conditions
Authors: Dharmarajan Kumar , Strait Kelly M , Lagu Tara , Li Shu-Xia , Lynn Joanne , Lindenauer Peter K , Tinetti Mary E , Krumholz Harlan M
Published: July 2021

Background:
Inpatients with heart failure (HF) may be treated for other acute conditions such as concomitant respiratory disease due to diagnostic uncertainty, coexisting illness, or other reasons. We investigated the frequency and mortality associated with respiratory treatments added to usual HF care.

Methods:
We included hospitalizations with a primary discharge diagnosis of HF from 2009-10 Premier, Inc. hospitals and age>18y, known admission source, non-pediatric attending physician, receipt of HF treatment (loop diuretics, inotropes, or IV vasodilators) and >2 day hospital stay. For hospital days 1-2 and 3-5, we noted receipt of potential respiratory treatments (short-acting inhaled bronchodilators, antibiotics, high-dose steroids). Hospitalizations with present-on-admission codes for infections besides pneumonia or inflammatory, allergic, or autoimmune conditions besides COPD were excluded. Hospitalizations were split into mutually exclusive and exhaustive groups based on treatments received in days 1-2 (table); odds of in-hospital mortality were determined for each after adjusting for age, sex, and Elixhauser comorbidities.

Results:
Among 164,494 HF hospitalizations, 54% (88,122) received treatment for acute respiratory conditions during hospital days 1-2 (table). At least 1 respiratory treatment was continued after day 2 in 60% (52,452) of patients who received initial treatment. Odds of in-hospital mortality increased with receipt of respiratory treatments in days 1-2 (table).

Conclusions:
HF inpatients are frequently treated for respiratory conditions. As these treatments are often given throughout hospitalization and identify patients at higher risk of death, coexisting comorbidities or a new cardiopulmonary syndrome may often be present, as may diagnostic uncertainty or overtreatment. Greater knowledge of patient complexity can improve treatment guidelines, patient outcomes, and risk-adjustment for performance measures.
Abstract 240: Survey of Patients With Atrial Fibrillation on the Use of Warfarin and the Newer Anticoagulant, Dabigatran
Authors: Choi Jiyoon , DiBonaventura Marco , Kopenhafer Lewis , Nelson Winnie
Published: July 2021

BACKGROUND:
In 2010 and 2011, U.S. atrial fibrillation (AF) patients had two choices for oral anticoagulation therapy. However, limited real world data exist as to the patient characteristics, usage patterns, and medication perceptions of patients on these newer treatments.

OBJECTIVE:
To describe and compare characteristics of AF patients who have used warfarin or the newer anticoagulant, dabigatran.

METHODS:
Patient surveys were conducted via phone or internet from September 2011 to November 2011. Study patients were ≥18 years old, had a diagnosis of AF, and have used either warfarin or the newer anticoagulant, dabigatran. Characteristics differences were tested using chi-squared and ANOVA for categorical and continuous variables, respectively.

RESULTS:
We surveyed 361 patients. Of those, 204 were warfarin users and 160 were newer anticoagulant users (NAU). Mean patient age was 65.1. Patients were predominantly male (68.7%) and non-Hispanic white (91.2%). Nearly half (44.0%) of patients were obese and more than half (58.0%) had a Charlson Comorbidity Index (CCI) of ≥1. Average number of years with an AF diagnosis was 7. Patients were taking 6.26 medications on average. NAU were more likely to be female (36.9% vs. 27.0%), younger (60.93 vs. 68.36 years), diagnosed more recently (5.78 vs. 8.10 years), and had more education compared to warfarin patients (all p<.05). Levels of obesity (31.9% vs. 53.4%) and CCI burden of ≥1 (51.9% vs. 62.7%) were lower among NAU (p<.05). NAU were more likely to use an OTC medication (38.7% vs. 12.1%) or both a prescription and OTC medication (11.3% vs. 4.3%) to treat stomach-related symptoms (p<.05). NAU were more likely to have had a discussion about their treatment options with their physicians (36.9% vs. 24.5%) rather than have their physician prescribing (60.6% vs. 73.5%) (p<.05). NAU were significantly less likely to have considered switching their medication (10.7% vs. 31.9%). Among those considered switching, cost (62.5%) and insurance coverage (18.8%) were the most common reasons for NAU, and inconvenience factors (“too much of a hassle”; 19.5% and “interfering with my lifestyle”; 12.2%) for warfarin users.

CONCLUSIONS:
There were some characteristic differences among AF patients. Understanding patients' characteristics may be the first step in helping patients to be adherent to their stroke prevention medications.
Abstract 249: Medical Cost Avoidance among the General and Elderly Atrial Fibrillation Populations Differs According to Specific Anticoagulant Use, Based on the ARISTOTLE and RE-LY Trials
Authors: Amin Alpesh , Deitelzweig Steve , Jing Yonghua , Makenbaeva Dinara , Wiederkehr Daniel , Lin Jay , Graham John
Published: July 2021

Introduction:
The randomized ARISTOTLE and RE-LY clinical trials demonstrated that the new oral anticoagulants (NOACs) apixaban and dabigatran were effective and safe options for stroke prevention among non-valvular atrial fibrillation (AF) patients. It is unclear how the use of NOACs for the treatment of AF affects total medical costs.

Hypothesis:
This study evaluates the hypothesis that medical costs associated with the use of apixaban and dabigatran vs. warfarin are different among the general and elderly AF populations.

Methods:
Clinical event rates in patients receiving warfarin, apixaban, and dabigatran were estimated for the general and elderly (age ≥ 75 years) AF patient populations. Event rates associated with warfarin were calculated as weighted averages from NOAC trials among AF patients; NOAC rates were estimated by adjusting trial hazard ratios to these weighted averages. Annual incremental costs among patients with clinical events from the US payer perspective were obtained from published literature and inflation adjusted to 2010 cost levels. Medical cost avoidance was evaluated for each NOAC vs. warfarin.

Results:
Compared to warfarin, apixaban-mediated total medical cost reductions (Table) in both populations were driven by decreased major bleeding excluding hemorrhagic stroke (MBEHS) and stroke and systemic embolism (SSE). Dabigatran use reduced costs for the general population and increased costs for the elderly population; cost reduction in the general population was primarily due to reduced SSE while cost increase in the elderly population was primarily due to increased MBEHS. MI, PE or DVT, and non-major bleeding each made smaller contributions to the cost differences among both populations.

Conclusions:
Compared to warfarin, apixaban use may be associated with reduced medical costs in both general and elderly AF populations. Dabigatran use may be associated with a reduction of medical costs in the general AF population, but increased medical costs among the elderly.
Abstract 253: Comparative Effectiveness of Clopidogrel in Medically Managed Patients with Unstable Angina and non-ST Segment Myocardial Infarction
Authors: Solomon Matthew D , Shilane David , Kazi Dhruv S , Chang Tara I , Boothroyd Derek B , Go Alan S , Hlatky Mark A
Published: July 2021

Background:
The CURE trial demonstrated improved outcomes with the addition of clopidogrel to aspirin in unstable angina (UA) or NSTEMI, leading to guideline adoption and widespread use. Although the role of clopidogrel after PCI is well studied, 40-50% of patients with UA/NSTEMI are medically managed, i.e., without revascularization during the index hospitalization. The effectiveness and optimal duration in real-world medically managed patients is unknown.

Methods:
We conducted a retrospective cohort study of all adult members of Kaiser Permanente of Northern California, a large, integrated health care delivery system, without known CAD or prior clopidogrel use who presented with UA/NSTEMI from 2003-2008 and did not receive revascularization (PCI or CABG) during the index hospitalization or within 7 days post-discharge (i.e., “medically managed”). We measured the association between use of clopidogrel within 7 days of discharge with subsequent all-cause mortality and MI at 2 years of follow up. Outcomes were examined in unmatched and propensity-matched multivariable Cox regression analyses, adjusted for demographics, comorbidities, longitudinal medication use and secular trends.

Results:
We identified 18,771 patients (mean age 69.3 years; 42.4% women) with incident UA (34.7%) or NSTEMI (65.3%) followed for a mean 2.5 years after the initial event. Clopidogrel prescription within 7 days of discharge was observed for 34.5% of the sample. Among these, the mean duration of continuous clopidogrel use was 255 days. An additional 1.6% filled a clopidogrel prescription between 7 and 30 days after discharge, and 5.0% filled a prescription after 30 days. During the first 2-years of follow up, patients prescribed clopidogrel within the first 7 days after discharge had lower unadjusted rates of all-cause mortality (7.5% vs 19.2%, p < 0.001; HR = 0.42, 95% CI [0.38-0.45]) and subsequent MI (6.5% vs 8.2%, p = 0.002; HR = 0.85 [0.76-0.95]). In multivariable Cox regression models, clopidogrel users had lower risk of 2-year all-cause mortality (HR = 0.65, [0.60-0.71]) but similar rates of MI (HR = 1.07, [0.96-1.20]). Propensity-matched models demonstrated similar results. A sensitivity analysis in which clopidogrel use was defined by initiation within 30-days post-discharge also demonstrated similar results.

Conclusions:
In a large community-based sample of patients with incident medically managed UA/NSTEMI, receipt of early post-discharge clopidogrel was independently associated with lower rates of death but similar rates of MI. Future research should identify the subset of patients who experience the greatest net clinical benefit with clopidogrel after UA/NSTEMI as well as the optimal duration of treatment.
Abstract 254: Gender and Race Specific Re-Admission Characteristics in Heart Failure Patients: Insights from the Get With The Guidelines Cohort
Authors: Amery Sahar , Lee Ji , Hirst Colin , Torosoff Mikhail , Philbin Edward , Fein Steven
Published: July 2021

Hypothesis:
We investigated gender and race specific re-admission characteristics in heart failure patients enrolled in the Get With The Guidelines (GWTG) study.

Material and Methods:
Retrospective chart review of 49 GWTG cohort patients (15 females, 24 males) requiring readmission was performed. Demographic and clinical parameters were collected. Interval change in endpoints was classified as “Increase”, “Decrease”, or “No change”. Analysis of variance (ANOVA) and chi-square analyses were performed. Study was approved by the institutional IRB.

Results:
Amongst readmitted patients there was a trend for females to be older (73+/-14 vs. 66+/-15 years in males, p=0.208), more likely to have CAD (11 of 15 vs. 14 of 24 males, p=0.342), less likely reside at home (9 of 15 vs. 19 of 24 males, p=0.196), and have shorter time to readmission (16+/-14 vs. 20+/-14 days in males, p=0.435). There were no gender-specific differences in doses of beta-blockers, vasodilators, including ACE inhibitors-ARBs or Hydralazine/Nitrate combination, aldosterone receptor antagonists, or digoxin. However, re-admitted women were less likely to be on diuretics (6 of 15 vs. 1 of 24 males, p=0.029). There was a trend for males to be more likely readmitted with a decrease in systolic (7 of 16 vs. 2 of 10 females, p=0.216) or diastolic (5 of 16 vs. 2 of 10, p=0.258) blood pressure and have an increased heart rate (11 of 16 vs. 5 of 10 females, p=0.263). Predictably, majority of patients were noted to have an increased BNP (8 of 9 females vs. 10 of 15 males, p=0.224) and rise in creatinine (8 of 13 females vs. 14 of 24 males, p=0.982) or potassium (8 of 13 females vs. 16 of 24 males, p=0.298). Race had no effect on readmission (Caucasian females 7 of 12 vs. 12 of 18 males, p=0.643).

Conclusion:
Gender-specific differences in re-admission characteristics may be present in heart failure patients as suggested by observed trends in readmission timing, place of residence, and hemodynamic parameters, and significant difference in diuretic dosing. Race does not appear to affect readmission in the studied population. More studies of this important subject are required.
Abstract 255: Temporal Trends and Factors Associated with Referral for Cardiac Rehabilitation Post Acute Coronary Syndrome: Insights from the Canadian Global Registry of Acute Coronary Events (GRACE)
Authors: Nguyen Thang , Abramson B.L. , Galluzzi Aaron , Tan Mary , Yan Andrew T , Goodman Shaun G
Published: July 2021

Introduction:
The beneficial effects of cardiac rehabilitation (CR) on morbidity and mortality after an acute coronary syndrome (ACS) are well established. Despite guidelines, CR referral rates have been low. Determining factors associated with CR referral would assist in closing this care gap and improve outcomes. Using the Canadian Global Registry of Acute Coronary Events (GRACE) database, we examined 1) the temporal trends of CR referral rates in Canada and its associated factors in a contemporary setting; 2) use of evidence-based medical therapies after ACS and its relationship with CR referral during index hospitalization.

Hypothesis:
CR referral rates have increased over time but remain below current guideline recommendations.

Methods:
From the Canadian GRACE registry, we retrospectively analyzed data from 11 Canadian centers during 2000 - 2007. CR referral rates were established and analyzed over time. We compared the CR Referral group to the Non-CR Referral group using univariate logistic regression in regards to patient characteristics, in-hospital diagnosis, clinical events and investigations. Categorical and continuous variables were compared using the chi-square and the Wilcoxon rank sum tests, respectively, with statistical significance at p<0.05. Data of guideline-recommended medication use at discharge and 6 months post-discharge were also analyzed.

Results:
In the 8-year period, 3338 patients (median age 64 years, 32% women) were assessed. Initial CR referral rate in 2000 was 2.7% (6/219) and increased to 51.2% (220/430) in 2007 (p<0.0001). Univariate factors for CR referral include younger age, larger infarct size, and a diagnosis of STE-ACS. Univariate factors for non-CR referral include CHF, higher GRACE score, and previous CAD. Hospitals with on-site supervised CR facilities had higher CR referral rates. CR Referral group had higher usage of evidence-based medications at time of discharge as well as 6 months post-discharge (all p< 0.0001).

Conclusions:
There has been a steady increase in CR referrals; however, contemporary numbers are still below the current recommendation of an 85% referral rate. Higher usage of recommended medications in the CR Referral group were noted, likely reflecting the association of CR referral with overall quality of care. Factors associated with CR referral include younger age, larger infarct size, and STE-ACS. Lack of referral was associated with CHF, previous CAD and high GRACE score. Targeting non-referred populations may improve quality of care and close care gaps in secondary prevention.
Abstract 264: Voluntary Registry Participation Rapidly Improves Physician Quality Performance: A Single Practice Experience
Authors: May David , Fiocchi Fran , Oetgen William , Risch Samantha A
Published: July 2021

TITLE
Voluntary registry participation rapidly improves physician quality performance: a single practice experience

AUTHORS
David May, MD
1
, PhD, Samantha Risch, BS
2
, Fran Fiocchi, MPH
2
, William Oetgen, MD, MBA
2
1 Cardiovascular Specialists PA, Dallas, TX 2 The American College of Cardiology, Washington, DC

BACKGROUND
Registry participation has been used to gain evidence on rare disorders and collect data on a variety of medical conditions and procedures. The use of clinical data registry systems to monitor provider quality is less widespread and the effect of such participation on providers’ quality performance is unknown. The American College of Cardiology’s Practice Innovation and Clinical Excellence (PINNACLE) Registry allows a glimpse into the voluntary use of such a registry system for assessing rapid provider performance improvement. We assessed the hypothesis that voluntary registry participation by practicing cardiologists in a busy private practice setting would result in rapid improvements across provider performance metrics.

METHODS
Cardiovascular Specialists PA (CVS) is a six-physician, single-specialty cardiovascular medicine practice averaging approximately 2160 patient evaluation and management visits per month. The PINNACLE Registry is the first national ambulatory quality improvement (QI) registry in the U.S. Participating practices enroll patients with atrial fibrillation, hypertension, coronary artery disease or heart failure at the point of care, documenting 27 performance metrics. CVS has been participating in the PINNACLE Registry since mid-2009. Quarterly reports detailing practice and individual physician performance relative to the cohort of national PINNACLE Registry participants are provided to CVS physicians. No report review with individual physicians is performed. Comparison of physician performance metrics for the first quarter 2010 and first quarter 2011 were performed with paired-samples t-test.

RESULTS
There was a significant difference in the scores for provider performance for the first quarter 2010 (Mean = 71.16; SD=26.72) and the first quarter 2011 (Mean = 79.73; SD=25.43); t(27)=2.883, p = 0.008. Large improvements were observed across several metrics including: initial laboratory tests of patients with newly diagnosed HF, documentation of an advance care plan and cardiac rehab patient referral from an outpatient setting.

CONCLUSION
These results suggest that voluntary registry participation resulted in rapid, statistically significant improvement in global performance metric achievement in a private practice setting. Characters without spaces: 1947
Abstract 268: Multidisciplinary Approach to the Heart Failure Patient Significantly Improves Adherence to Evidence-Based Medicine Beyond Core Measures
Authors: Sokos George G , Lazar Jessica , Hilliard Terri , Ozanich Evelyn , Raina Amresh , Kanwar Manreet , Benza Raymond L , Murali Srinivas
Published: July 2021

Background:
Adherence to heart failure core measures has been a focus of all hospitals in the past several years and has become even more important with the advent of pay for performance. Core measures address basic heart failure care, but do not include utilization of all evidence-based therapies which improve long term outcomes. We hypothesized that an in-hospital multidisciplinary heart failure (HF) management program could improve adherence to evidence-based guidelines beyond core measures.

Methods:
As a quality improvement initiative, we formed a multidisciplinary team to improve compliance with HF evidence-based therapy. Interventions included multiple educational sessions, discharge and post-discharge transition improvements, concurrent and post-discharge chart abstraction, revised patient education, and real-time provider education. Charts were abstracted in 525 consecutive HF inpatients between Jul 2010 and Mar 2011. Data was collected in the GWTG-HF (Outcome Inc) Registry. Pre-intervention compliance data (Jul-Sep) was compared to post-intervention (Nov-Mar) data with a paired
t
test and the Mann-Whitney rank sum test. Direct variable cost was analyzed for defect-free cases versus cases with defects.

Results:
Baseline Demographics: Mean age was 69 years, 42% female, 20% black, 55% ischemic etiology, mean LVEF=37%. Prior to the multidisciplinary intervention, overall defect-free care was excellent at over 89% (see figure) but there was a relative underutilization of aldosterone antagonists, hydralazine/nitrate therapy, CRT-D and anticoagulation for AF. Post-intervention, adherence improved to over 90% for all 8 evidence based therapies including: evidence-based beta-blocker (p=0.002), aldosterone antagonist (p<0.001), hydralazine nitrate (p=0.04), ICD placed or prescribed (p<0.001), CRT-D (p=0.002), anticoagulation for afib (p=0.04), and DVT prophylaxis (p=0.04). Mean direct variable cost per case was higher at $8249 in defect cases versus $6951 in defect-free cases.

Conclusions:
In this single center experience, interventions led by a HF multidisciplinary team can significantly improve adherence to evidence-based therapies, beyond core HF measures. A multidisciplinary approach to inpatient HF care has the potential to decrease HF related costs.
Abstract 279: The Impact of Heart Failure on Depression and Quality of Life is Greater in Men than Women
Authors: Hachamovitch Rory , Griffin Brian , Klein Alan , Nutter Benjamin , Katzan Irene , Marwick Thomas H
Published: July 2021

Background.
Patients (pts) diagnosed with congestive heart failure (HF) have been reported to have more frequent depression and worsened health related quality of life (HRQOL). Although depression is more common in women than men in this condition, the impact of HF on depression and HRQOL in men versus women is unclear. We sought to examine the relationship between pt sex, HF diagnosis, and pt-perceived depression and HRQOL.

Methods.
Depression (PHQ-9) and HRQOL (EQ5D) data were collected using tablet computers from pts presenting for routine outpatient cardiovascular assessment at our institution between November, 2010 and December, 2011. Demographic, clinical, and historical data was collected as per routine. We examined the association of pt sex and clinical diagnosis of HF with instrument results after adjusting for potential confounding information using mutliple linear regression.

Results.
Of 3046 pts (age 61±15), 39% were female and 8.7% were diagnosed with HF. Overall, PHQ-9 was greater, and minor or major depression (PHQ-9≥10) was more frequent, in women than men (4.6±4.6 vs. 3.3±4.4; 14.0% vs. 8.9%, both p<0.05) and in HF pts than pts without HF (5.9±5.6 vs. 3.6±4.3, 22.0% versus 9.6%; both p<0.05). Similarly, HRQOL was worse in women than men (EQ-5D 0.80±0.18 vs. 0.87±0.16; p<0.01) and in HF pts than no HF (EQ-5D 0.76±0.18 vs. 0.85±0.17; p<0.01). However, the difference in PHQ-9 between pts with versus without HF was greater in men (6.23±6.06 vs. 3.02±4.06, p<0.01) than women (5.43±4.85 vs. 4.55±4.58, p=0.09). After adjusting for cardiovascular diagnoses, comorbidities, clinical and demographic data, multivariable modeling of PHQ-9 revealed a significant interaction between pt sex and HF diagnosis (p=0.001; see Figure) such that women had greater PHQ-9 scores compared to men without HF, but in the setting of HF, mens' PHQ-9 scores were greater. Modeling of EQ-5D also revealed that after risk-adjustment an interaction between HF diagnosis and sex was present with a similar pattern of findings.

Conclusion.
Although depression is more frequent and severe in women compared to men, and in pts with versus without HF, HF appears to impact depression severity more in men compared to women.