bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P146: Depression Predicts Increased Healthcare Utilization and Death Among Community Patients with Heart Failure
Authors: Moraska Amanda R , Chamberlain Alanna M , Shah Nilay D , Vickers Kristin S , Dunlay Shannon M , Weston Susan A , McNallan Sheila M , Roger Véronique L
Published: July 2021

Background:
The increasing prevalence of heart failure (HF) and high associated costs has spurred investigation of factors related to adverse outcomes in these patients. Reports to date present discrepant evidence regarding the link between depression and HF outcomes, and only scarce data related to healthcare utilization in the form of emergency department (ED) visits are available.

Purpose:
To evaluate the relationship of depression with healthcare utilization and death among HF patients in the community.

Methods:
Residents of Olmsted, Dodge, and Fillmore, MN counties with HF were prospectively recruited between October 2007 and December 2010, and completed a 9-item Patient Health Questionnaire (PHQ-9) for depression categorized as: none-minimal (PHQ-9 score 0-4), mild (5-9), or moderate-severe (≥10). Anderson-Gill models were used to determine if depression predicted hospitalizations and ED visits while proportional hazards regression estimated hazard ratios for death.

Results:
Among 411 HF patients (mean age 73±13, 58% male), 15% had moderate-severe depression, 27% mild, and 58% none-minimal. Over a mean follow-up of 1.5 years, 613 hospitalizations, 786 ED visits, and 75 deaths occurred. The risk of all adverse outcomes increased stepwise with increasing severity of depression (Table). After adjustment for key clinical characteristics, moderate-severe depression was associated with nearly a 2-fold increased risk of hospitalization and ED visits, and almost a 4-fold increased risk of death. These results are independent of coexisting comorbidities.

Conclusions:
Depression is frequent among HF patients in the community and independently predicts a significant increase in the use of healthcare resources and mortality. Greater attention to the recognition and management of depression in HF may improve clinical outcomes and decrease healthcare utilization and expenditures in these patients.

Hazard Ratios (95%CI) for Hospitalizations and All-Cause Mortality by Severity of Depression

None-Minimal
Mild
Moderate-Severe
P for trend

Hospitalizations

Crude
1.00 (ref)
1.23 (0.91-1.66)
2.01 (1.39-2.89)
<0.001

Fully-Adjusted
*

1.00 (ref)
1.15 (0.86-1.54)
1.93 (1.37-2.71)
0.001

Emergency Department Visits

Crude
1.00 (ref)
1.42 (1.03-1.96)
1.99 (1.42-2.79)
<0.001

Fully-Adjusted
*

1.00 (ref)
1.39 (1.00-1.93)
1.98 (1.40-2.79)
<0.001

All-Cause Mortality

Crude
1.00 (ref)
1.53 (0.87-2.68)
3.33 (1.95-5.70)
<0.001

Fully-Adjusted
*

1.00 (ref)
1.55 (0.88-2.74)
3.84 (2.21-6.68)
<0.001

*

Adjusted for age, sex, and Charlson comorbidity index
Abstract P166: Blood Pressure Control Following Percutaneous Coronary Intervention at a VA Hospital
Authors: Healy Chris , McGraw Sloane A , Mohamedali Burhan , Shivaraju Anupama , Scholfield Michael , Shroff Adhir
Published: July 2021

Background:
Blood pressure (BP) control in patients with coronary artery disease (CAD) decreases morbidity and mortality. The US Joint National Committee VII (JNC-7) recommends patients with underlying CAD have a goal systolic blood pressure (SBP) < 130 and a diastolic blood pressure (DBP) < 80. These goals can be achieved by using multiple classes of drugs, including beta-blockers (BB), angiotensin antagonists (ACE-I/ARB), calcium channel blockers (CCB), diuretics, and nitrates.

Methods:
We conducted a retrospective cohort study focusing on the attainment of JNC-7 recommended BP goals in a diverse population of 857 veterans undergoing Percutaneous Coronary Intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Data was collected comparing both BP measurements and anti-hypertensive regimens pre and post PCI.

Results:
In the 857 patients studied, the mean SBP decreased from 134 mm Hg to 129 mm Hg (p<0.0001), and the mean DBP decreased from 73 mm Hg to 71 mm Hg (p<0.0001). In regards to the JNC-7 guidelines, the percent of patients who achieved SBP goals increased from 44% to 54% (377 to 463 of 857) (p<0.0001), and the percent of patients who achieved DBP goals increased from 71% to 78% (608 to 668 of 857) (p<0.0001). There was a change in the use of each drug class; the use of ACE-I/ARB increased from 72% to 89% (617 to 763 out of 857) (p<0.0001), the use of BB increased from 63% to 76% (540 to 651 out of 857) (p<0.0001), the use of diuretics increased from 41% to 43% (351 to 369 out of 857) (p=0.2997), and the use nitrates increased from 24% to 29% (206 to 249 out of 857) (p=0.0007). The use of CCB, however, decreased from 34% to 30% (291 to 257 out of 857) (p=0.0121).

Conclusions:
There was improvement in both mean BP and percentage of patients achieving JNC-7 recommended goals for SBP & DBP at six months post PCI, though overall percentages still remain suboptimal. Additionally, medication use improved in most drug classes, with the exception of calcium channel blockers. In particular, both beta-blocker and angiotensin antagonist use increased significantly.
Abstract P17: Delirium in the Cardiovascular Intensive Care Unit: Implementation of a Screening Tool, Prevalence and Lessons Learned
Authors: McPherson John A , Wagner Chad E , Boehm Leanne , Burns Kathy , Miller Leanna , Johnson Daniel , Ely E W , Pandharipande Pratik P
Published: July 2021

Background:
Delirium is common among critically ill patients (pts) and can lead to significant morbidity and mortality; yet the impact of delirium in a medical/surgical cardiovascular intensive care unit (CVICU) is unknown.

Objectives:
We sought to (1) determine the prevalence and risk factors for delirium in a CVICU using the Confusion Assessment method for the ICU (CAM-ICU); and (2) measure the effect of educating and implementing CAM-ICU in routine assessment on attitudes and knowledge gaps regarding delirium among CVICU staff.

Methods:
CVICU nurses were educated on delirium and trained in bedside CAM-ICU assessment. The CAM-ICU was performed at least once per shift, and reported during rounds. A survey assessed CVICU nurse attitudes and knowledge of delirium pre-and post-CAM-ICU implementation. Detailed clinical data were then prospectively obtained on 200 consecutive CVICU pts. Dementia or expected lengths of stay (LOS) < 1 day were exclusions.

Results:
Median CVICU LOS was 3 days (IQR 2, 5), the median APACHE II score was 23 (IQR 11, 28), and CVICU mortality was 4%. The prevalence of delirium was 26%; similar among medical (n=96) and surgical (n=104) pts. Compared with pre-implementation, post-implementation surveys demonstrated improvements in CAM-ICU use (53% vs 98%), knowledge of delirium and outcomes, and importance of CAM-ICU data for patient care. Using a negative binomial model, the prior use of statins (p = 0.01), dexmedetomidine (p = 0.05), and benzodiazepines (p = 0.05) were associated with the development of delirium, with a trend toward increasing age (p = 0.17). No association with cardiac output, on-pump surgery, or APACHE II score was observed. In addition, restraint use (chi-square 5.2; p = 0.02) or statins (chi-square 4.4; p = 0.04) during the previous 24 hours were associated with the daily prevalence of delirium.

Conclusions:
A detailed education intervention implementing routine CAM-ICU assessment increased knowledge of delirium and its clinical importance. Delirium is common in the CVICU, and is associated with the restraint use, dexmedetomidine, and benzodiazepines, likely representing a need for sedation. The association of delirium with prior statin use may reflect a higher burden of cardiovascular disease in these pts.
Abstract P183: Lipid Control in Veterans Following Percutaneous Intervention
Authors: McGraw Sloane A , Healy Chris , Mohamedali Burhan , Shivaraju Anupama , Shroff Adhir
Published: July 2021

Background:
Management of lipids is vital in patients with underlying coronary artery disease (CAD). According to the American College of Cardiology (ACC) guidelines, all patients with CAD should have low density lipoproteins (LDL) goals to be less than 100 mg/dl with the therapeutic option of treatment to less than 70 mg/dl. This can be achieved using multiple lipid lowering agents, however statin use is encouraged in CAD patients due to its multiple beneficial effects.

Methods:
We conducted a retrospective cohort study focusing on lipid management and statin use in 857 veterans undergoing percutaneous coronary intervention (PCI) between September 2004 and December 2009 at the Jesse Brown Veterans Hospital in Chicago, IL. Values were collected both pre-intervention as well as at six month follow up.

Results:
Both pre and post PCI, focus was maintained on the total cholesterol as well as the LDL levels. The mean total cholesterol prior to intervention was 166mg/dl and decreased to150mg/dl at six month follow up. The LDL mean pre-PCI was 98mg/dl and at six months the mean LDL decreased to 86mg/dl. With regards to ACC guidelines, the percent at goal for LDL less than 100mg/dl increased from 59% pre-PCI to 74% post-PCI Furthermore, treatment to less than 70mg/dl increased from 22 to 32% at six months. Lastly, the use of statins increased from 72 to 89%.

Conclusions:
There were in improvements in both total cholesterol and LDL values at six months post-PCI. There were also improvements in the percentage of patients who met the ACC recommended goal of LDL cholesterol less than 100mg/dl and the suggested goal of 70mg/dl. At six months, there was also an increase in usage of statin therapy.
Abstract P200: Computerized Clinical Decision Support Systems for Therapeutic Drug Monitoring and Dosing: A Decision Maker--Researcher Partnership Systematic Review
Authors: Nieuwlaat Robby , Connolly Stuart J , MacKay Jean A , Weise-Kelly Lorraine , Navarro Tamara , Wilczynski Nancy L , Haynes R B
Published: July 2021

Background
Optimization of the return on investments in information technology innovations requires that current best evidence be considered for an effect on care processes and health outcomes. Computerized clinical decisions support systems (CCDSSs) might improve therapeutic drug monitoring and dosing (TDMD) by providing patient-tailored clinical recommendations. We summarized current evidence from randomized controlled trials (RCTs) for the effect of CCDSSs on TDMD.

Methods
A decision-maker - researcher partnership systematic review was performed to optimize the practical implementation of results. Studies from a previous review on the effect of CCDSSs (Garg AX, 2005) were included if they addressed TDMD and were RCTs. Additional RCTs were sought until January 2010 in MEDLINE, EMBASE, Evidence-Based Medicine Reviews and Inspec databases. RCTs assessing the effect of a CCDSS on process of care or patient outcomes were selected by pairs of independent reviewers.

Results
In total, 33 RCTs were identified that assessed the effect of a CCDSS on management of vitamin K antagonists (14), insulin (6), theophylline/aminophylline (4), aminoglycosides (3), digoxin (2), lidocaine (1), or as part of a multifaceted approach (3). All studies combined enrolled 24,627 patients; 13,219 were in the largest study, and only 6 other studies enrolled over 500 patients. Most studies were performed in one center (63%) and cluster randomization, of either clinics or physicians, was rarely used (18%). CCDSSs were usually stand-alone systems (76%) primarily used by physicians (85%).

Overall, 18 of 30 studies (60%) showed an improvement in the process of care and 4 of 19 (21%) an improvement in patient outcomes. All evaluable studies assessing insulin dosing for glycemic control showed an improvement. In meta-analysis, CCDSSs for vitamin K antagonist dosing improved the time that patients spent in the therapeutic range by 6.1% (95% confidence interval: 0.46-11.83; p=0.03).

Conclusions
CCDSSs have potential for improving process of care for TDMD, specifically insulin and vitamin K antagonist dosing, but effects on patient outcomes were uncertain. More potent CCDSSs are needed and should be evaluated using cluster randomization, primarily assessing patient outcomes.
Abstract P203: Combination of Diet and Exercise is Preferred for Weight Loss and Weight Loss-Induced Blood Pressure Reduction
Authors: Masuo Kazuko , Hiromi Rakugi , Ogihara Toshio , Lambert Gavin W
Published: July 2021

Obesity and sympathetic activation are independent risk factors for cardiovascular disease. Weight loss (WL) is the first choice as the treatment for obesity and hypertension, however, there were few studies to compare the efficacy and mechanisms of WL and WL-induced BP reduction between a diet alone (D), exercise alone (EX) and a combination of diet + exercise (D+EX).

The present study compared the effects of WL achievement on WL-induced BP reduction over 24 weeks between D alone, EX alone and a combination with D+EX, especially focusing on the relationships of the sympathetic nervous activity (observed with plasma norepinephrine (NE) levels) and insulin resistance (homeostasis model of insulin resistance, HOMA-IR). The 3 groups were each composed of 20 obese hypertensive men. BMI, fat-mass, waist-to-hip ratio, BP, plasma NE, and HOMA-IR were measured at every 4 week period over 24 weeks.

All basal parameters were similar among the 3 groups. At 24 weeks, the combination group with D+EX had significantly higher prevalence of normotensive subjects (n=16) than the D alone (9) or EX alone group (6) (χ
2
=10.81, P<0.05). In the D alone group, plasma NE decreased significantly at 4 weeks, BMI, fat-mass and BP levels reductions were observed at 8 weeks, and waist-to-hip ratios decreased at 12 weeks. In comparison, in the EX alone group, significant reductions of fat-mass were observed at 4 weeks, BMI, waist-to-hip ratio, plasma NE and HOMA-IR significant reductions were observed at 8 weeks, and significant decreases in BP levels were detected at 12 weeks. In the D+EX group, BMI, fat-mass, waist-to-hip ratio, BP levels, plasma NE and HOMA-IR decreased significantly at 4 weeks. The magnitude of reductions of BMI, fat-mass, waist-to-hip ratio, BP, plasma NE, HOMA-IR and leptin were greatest among the 3 groups throughout the study.These results demonstrate that D+EX has stronger effects on WL, WL-induced BP reduction, normalization of hypertension and suppression of sympathetic activation compared to D or EX alone. In the 3 study groups, suppression of plasma NE was followed by reductions of HOMA-IR and BP reduction, suggesting that the suppression of sympathetic activation accompanying the improvement of insulin resistance might play a major role on WL-induced BP reduction.
Abstract P204: Clopidogrel Overuse Beyond the Guidelines: Predictors and Financial Outcomes
Authors: Sharma Shikha , Dollar Allen , Long Qi , McDaniel Michael C , Quairoli Kristi , Doyle Joyce P
Published: July 2021

Background:
Clopidogrel is widely used for the treatment and prevention of atherosclerotic events. Due to high cost, overuse of clopidogrel has significant implications on health care costs. The predictors for clopidogrel overuse and it's the financial implications have not been studied.

Methods:
This is a retrospective chart review done at the Grady Memorial Hospital. We identified 1267 patients from the pharmacy database who had received a prescription for clopidogrel from Jan 2009 to Dec 2010. After excluding patients with atrial fibrillation (n=7) and neurological indication (n=71) for clopidogrel use, 165 charts were reviewed sequentially to determine the indication, duration, cost of the clopidogrel use and factors associated with overuse.

Results:
The use of Clopidogrel was determined to be appropriate in only half (83/165) patients (group A). Eighty two (50%, group B) patients did not fulfill the criteria of clopidogrel use based on ACC/AHA guidelines 2007. Patients with inappropriately extended use (group B) were significantly older (mean age 67±11 vs. 59±11 years, p<0.001), predominantly female (76% vs. 55%, p<0.005) compared to group A patients. Notably 76% (62/82) of the group B patients had insurance compared to only 34% (28/83) in group A of this predominantly inner city population (p<0.001). Group B patients used clopidogrel for twice the duration compared to Group A (mean 608±239 vs. 300±255 days, p<0.001). Insured patients were nearly four times more likely (OR 3.8, 95% CI 1.6-8.8, p =0.002) than those without insurance to be on clopidogrel for an extended period beyond the guidelines, even after controlling for age, diabetes, total number of coronary lesions and stents. The extended use of clopidogrel incurred significant cost per patient to the hospital ($161±162 vs. $63±128, p<0.001) and to the health care insurance plans ($325±392 vs. $101±240, p<0.001).

Conclusion:
Nearly 50% of patients received clopidogrel for extended duration beyond the recommended guidelines causing significant costs burden. This practice is seen significantly more often in older, female patients with insurance. Further health care practice reforms are needed to avoid clopidogrel overuse and its financial burden.
Abstract P207: Determinants of Individual Differences in Patient-Centered Outcomes: A Meta-analysis of Type D Personality and Health Status
Authors: Denollet Johan , Versteeg Henneke , Spek Viola , Pedersen Susanne S
Published: July 2021

Background.
Knowledge of the determinants of individual differences in patient-centered outcomes is essential to identify high-risk patients and improve secondary prevention. We evaluated the evidence on the distressed (Type D) personality as a potential determinant of patient-reported physical and mental health status in cardiovascular patients.

Methods.
A computerized search of the literature through PUBMED and PsychINFO (1995-October 2010) was performed and studies were selected that analyzed the association between Type D personality and health status or health-related quality of life in cardiovascular patients. Two separate meta-analyses were performed for the effect of Type D personality on physical and mental health status.

Results.
Of all identified studies, 23 met the selection criteria; 9 studies were excluded from the meta-analyses as they originated from the same dataset or had limited methodological quality. The meta-analyses showed that Type D personality was associated with a 2-fold increased odds for impaired physical health status (n=3865 patients, OR=2.04; 95%CI:1.67-2.48) and a 3-fold increased odds for impaired mental health status (n=3043 patients, OR=3.02; 95%CI:2.09-4.36). Subgroup analyses showed that the association between Type D personality and mental health status decreased when adjusting for baseline health status and/or depression. All but one of the nine studies not included in the meta-analyses confirmed an association between Type D personality and impaired health status.

Conclusions
. Type D personality was shown to be an independent associate of impaired physical and mental health status across various cardiovascular conditions. Physicians should be aware of Type D personality as a potential determinant of patient-reported health status in cardiovascular outcomes research.
Abstract P208: Functional Status, Rehospitalization, and Mortality Outcomes Among Acute Myocardial Infarction Patients with Prior and New-Onset Atrial Fibrillation
Authors: Hornsby Kyle P , Gosch Kensey , Miller Amy L , Piccini Jonathan P , Lopes Renato D , Spertus John A , Wang Tracy Y
Published: July 2021

Background:
Little data are available regarding differences in prognosis and health status between new-onset and prior atrial fibrillation (AF) among patients with acute myocardial infarction (AMI).

Methods:
The TRIUMPH study enrolled 4340 AMI patients who received longitudinal follow-up including SF-12 health status assessments through 1 year post-AMI. We compared 1-year mortality, rehospitalization, and functional status according to AF type (none, prior, new) after adjusting for differences in baseline characteristics.

Results:
A total of 212 AMI patients (4.9%) had prior AF and 254 (5.9%) had new-onset AF. Compared with no AF, new AF was associated with older age, male sex, first MI, worse baseline physical function, home atrioventricular nodal blocker use, and worse ventricular function (c-index 0.77). Rates of 1-year mortality were 6.2%, 14.5%, and 13.0%, and 1-year rehospitalization rates were 29.1%, 44.2%, and 36.8% for no, prior, and new AF, respectively. After multivariable adjustment, neither prior nor new AF was associated with increased 1-year mortality, and only prior AF was associated with increased risk of 1-year rehospitalization (Figure). After adjusting for baseline SF-12 physical function scores, patients with prior AF had lower 1-year scores than those with no AF (40.6 vs. 43.7, p <0.003), whereas patients with new AF had similar scores (42.9 vs. 43.7, p=0.36).

Conclusion:
New-onset AF during AMI is associated with a number of comorbidities but, unlike prior AF, is not associated with adverse outcomes. These results raise the question of whether AF is itself a cause of or simply a marker of comorbidities leading to downstream adverse outcomes after AMI.
Abstract P21: Racial Disparity in Participation Among Patients in an Urban Cardiac Rehabilitation Program
Authors: Sobolev Maria , Prince David Z , Gao Ju , Taub Cynthia
Published: July 2021

Background:
Despite evidence of benefit on morbidity and mortality, cardiac rehabilitation (CR) remains underutilized. Studies have identified multiple reasons for lack of participation, but few have addressed racial disparities that may exist.

Methods:
A database of patients referred to CR between May 2001 and January 2011 was constructed. Data on gender, race, age, specialty of referring physician, co-payment, reason for referral, and attendance were collected. Racial groups were classified as Caucasian or minorities (African American, Hispanic, Asian, Pacific Islander, and multi-racial). Reasons for referral included acute MI, CAD, stable angina, CHF, and valvular heart disease. Data was analyzed using a Chi-square test to compare the initiation and non-initiation groups. A multivariate logistic regression estimated the odds ratio of variables predicting CR initiation.

Results:
Of the 822 patients referred to CR, 488 (59.4%) initiated CR and 334 (40.6%) did not. There was no difference in age (61.6 vs. 61.6, p = 0.987) or gender distribution (36.9% vs. 41.6% females, p = 0.161) between groups. Furthermore, need for co-payment (p = 0.091), reason for referral (p = 0.490), and whether the referring physician was a specialist or primary care physician (p = 0.740) did not affect attendance. Overall, minorities initiated CR less often than Caucasians (34.8% vs. 45.6%, p = 0.003). Based on the logistic regression analysis, Caucasians were 78% more likely to initiate CR (OR 1.78; 95% CI 1.13-2.80). Older age was a negative predictor of CR initiation, with each year of age decreasing likelihood of initiation by 2% (OR 0.98; 95% CI 0.96-1.00).

Conclusions:
Racial disparity exists amongst CR participants, with a clear under-representation of minorities in our urban medical center. Gender, physician referral patterns, and need for co-payment did not influence participation. Further investigation is required to determine why such disparity exists.

Logistic regression analysis of factors predictive of CR initiation

FACTORS
ADJUSTED OR
95% CI
P-VALUE

Age
0.976
[0.956-0.995]
0.016

Gender
1.285
[0.836-1.977]
0.253

Caucasian Race
1.775
[1.126-2.797]
0.013

Co-payment
1.010
[0.987-1.033]
0.389

PCP/Specialist Referral
0.841
[0.495-1.428]
0.521
Abstract P212: Benchmark Analysis of Genetic Testing Practice Patterns in a Real-World Population of Patients Receiving Clopidogrel or Prasugrel Therapy
Authors: Ewel Cynthia H , Agatep Barnabie C , Herrera Vivian , Markward Nathan J , Stanek Eric J , Charland Scott L
Published: July 2021

BACKGROUND:
Cytochrome P450 2C19 genotype has been shown to modify cardiovascular outcomes on clopidogrel therapy in patients post-acute coronary syndromes or percutaneous coronary interventions. Recent clopidogrel label changes have incorporated this information; however real-world application of genetic testing in patients receiving thienopyridine antiplatelet therapy is unknown.

METHODS:
A retrospective, integrated medical and pharmacy claims database, cohort analysis was conducted in patients with new clopidogrel or prasugrel prescriptions between 7/1/08-6/30/10, and continuous eligibility for 6 months pre- and 3 months post-initiation. Genetic testing was identified using CPT-4 codes present 1 month prior and 3 months post the index prescription date. Genetic testing incidence was calculated, and univariate comparisons of prescriber information, and patient demographic and clinical characteristics in cases tested vs not tested were performed.

RESULTS:
The analysis included 95,381 clopidogrel and 1,819 prasugrel patients. Genetic testing was recorded in 522 (0.6%) clopidogrel and 15 (0.8%) prasugrel patients, rendering the latter sample too small for detailed analysis. Clopidogrel patients receiving genetic testing (vs patients not tested) were a mean age of 58±13 yrs (68±13 yrs, p<0.001), 29% were ≥65 yrs old (61%, p<0.001), 56% were male (59%), 33% were Western US residents (18%, p<0.001), 35% were recently hospitalized for stroke (8%, p<0.001), and were less often prescribed clopidogrel by a cardiologist (22% vs 32%, p<0.001) and more often by a neurology specialist (8% vs 2%, p<0.001). The incidence of genetic testing did not vary over time.

CONCLUSION:
Although the FDA has provided numerous advisories that have lead to changes in clopidogrel provider information sheets, genetic testing is rarely employed in routine practice in patients prescribed clopidogrel or prasugrel therapy. Testing was biased toward younger clopidogrel patients with a recent stroke event, and non-cardiologist prescribers. While these data establish a national benchmark for future comparison, further exploration of barriers to testing, provider education and patient selection, and the impact of programmatic approaches to testing are warranted.
Abstract P230: An Observational Study of Deployment of American Heart Association Heart Failure Protocols and Educational Content Within the Intel® Health Guide System Post Discharge
Authors: Pina Ileana L , Albert Nancy M , Fonarow Gregg M , Catha Gloria , Wayte Patrick , Plank Tracy , Bruckman David , Kikano George
Published: July 2021

Background:
Telemonitoring (Tel) of heart failure (HF) patients (pts) post discharge has had variable results. However, Tel systems have not always integrated delivery of relevant pt education. The purpose of this study was to examine outcomes after implementation of the Intel Health Guide System (HGS). HGS was deployed with AHA guideline-based HF protocols for clinical status, symptoms and delivery of relevant pt education to enhance pts’ understanding of and management of HF.

Methods:
Twenty-six pts post discharge with a HF diagnosis were enrolled. Based on the pts’ clinical status, AHA-HF protocols were deployed into the HGS to assess key vital signs and health questions daily, weekly, or monthly for 60 days. Pts and caregivers were trained in use of the HGS and related peripherals, response to scheduled sessions, and access of educational content independent of scheduled sessions. Health status was assessed by Kansas City Cardiomyopathy Questionnaire (KCCQ) pre and post monitoring.

Results:
Of 26 pts, 62% NYHA were Class II, 29% Class III. Mean age 75.2 ±10.1 yrs; 62% women; 39% African Americans; 23% ischemic. Mean EF = 47% ±16. Adherence was 88%. KCCQ Clinical and Overall scores increased significantly from 49±25 and 51±23 to 63±26 and 65±22, respectively (p=0.039). Thirteen pts (50%) were rehospitalized at mean of 16+5 days, 4 for HF and 9 for other reasons, (30 day rehospitalization rate = 23% all cause; 15% for HF). Median compliance (completing scheduled sessions) and utility (days with activity/monitored) for those not rehospitalized were greater (97.2%, 96.9%) than for those rehospitalized (67.4%, 82.6%; p=0.013, p=0.005, respectively). Using generalized estimating equations, greater utility but not compliance correlated with better health status’ clinical (p=0.013) and overall scores (p=0.0056).

Conclusions:
This observational study showed feasibility of adding AHA-HF guideline protocols and education content to the HGS. Health status improved post discharge. Although the rehospitalization rate was > 20%, pts who were not readmitted were more likely to have greater Tel utility and compliance. In addition, clinical and overall health status measures improved during the study, and were associated with greater pt utilization of the system.
Abstract P237: The Society of Thoracic Surgeons Risk Score Is Superior to the EuroSCORE in Discriminating Long-Term Mortality in Patients Undergoing Nonemergent Unprotected Left Main Stenting
Authors: McNulty Edward , Ng William , Pencina Michael , Yeh Robert
Published: July 2021

Background:
Prior observational studies have demonstrated the ability of the EuroScore to discriminate long-term outcomes following unprotected left main (ULM) percutaneous coronary intervention (PCI). No studies have assessed the discriminatory ability of the Society of Thoracic Surgeons (STS) risk score in this context, nor have any compared the two scores.

Methods:
The study population consisted of 101 consecutive patients undergoing non-emergent ULM PCI. The discriminatory abilities of the EuroScore and STS scores to predict one year mortality were compared using area under the receiver operator characteristic curves (AUC). Optimal partitions of high and low risk were determined separately for the EuroScore and STS scores, and the net reclassification index (NRI) was computed after initial classification with the EuroScore.

Results:
The STS score provided superior discrimination for one year mortality than did the logistic EuroScore: AUC 0.78 (0.63 - 0.93) v. 0.68 (0.52 - 0.84), P = 0.04 and the additive EuroScore: AUC 0.78 (0.63 - 0.93) v. 0.67 (0.51-0.83), P = 0.01. Using an STS score of > 4 to reclassify all patients initially classified as high risk for death with EuroScore > 10 resulted in an NRI of 0.29 (95% CI 0.08-0.47, P = 0.004); NRI for events 0.16 (95% CI -.03 -.32) NRI for non-events 0.13 (95% CI .04-.22).

Conclusions:
The STS score provides superior discrimination of long-term mortality in patients undergoing non-emergent ULM PCI than does the EuroScore. The STS score is a useful tool to assess risk in patients eligible for ULM PCI, and may be an important covariate in future comparative effectiveness studies comparing PCI and bypass surgery.
Abstract P244: Do Interventions in Acute Myocardial Infarction Improve Outcome Past 30 Days?
Authors: Bryg Robert , Bryg David J
Published: July 2021

Survival after myocardial infarction (MI) has improved dramatically since the advent of thrombolytic therapy. Multiple therapies have been evaluated in the past 3 decades to attempt to improve both short and long term survival in patients suffering an acute MI. There is, however, little information on how survival from 1 month to 1 year after MI has changed since the advent of thrombolytic therapy. To answer this question, we searched for randomized clinical trials of acute MI that provided both 30 day and 1 year mortality rates. Utilizing a competing risk model, we calculated both the 1 year and the landmarked 30 day to 1 year mortality hazard ratios in each of the clinical trials. These mortality hazard ratios are in comparison to published US Life Tables and are normalized for age, gender and length of follow up. We then compared these mortality rates in each of the past 3 decades for both the one year and the landmark 30 day to 1 year timeframes. We performed meta-analysis on these interventions to determine if the change in 30 day to 1 year mortality is due to the interventions examined in these studies. There has been a marked improvement in survival with a 63% reduction in both 1 year, and 30 day to 1 year mortality. Meta analysis demonstrated that there has been no additional survival benefit seen after 30 days with the interventions evaluated: principally thrombolysis and antithrombotic therapies. Despite the dramatic improvement in mortality over time, the interventions in these trials do not appear to contribute to this improvement. Despite the lack of benefit after 30 days with acute thrombolysis, angioplasty and antithrombotic agents, profound improvement in survival has occurred. It is probable that other post MI interventions commonly utilized, including aspirin, beta blocker therapy, invasive strategies, and smoking cessation, are contributing to this marked reduction in post MI mortality.

Results

One Year Mortality Hazard Ratio
Landmark 30 Day to 1 Year Mortality Hazard Ratio

Year
# of Studies
Control
Treatment
Control
Treatment

1980-89
4
9.779
8.541
4.753
4.546

1990-99
7
5.052
4.808
2.353
2.217

2000-09
20
3.420
3.404
1.662
1.789
Abstract P247: Facilitation of the VA Hospital-to-Home Initiative to Reduce Readmissions for Heart Failure Patients: CHF QUERI
Authors: Sahay Anju , Heidenreich Paul A
Published: July 2021

Objectives:
Reducing readmission rates for heart failure (HF) patients is the primary goal of the Department of Veteran Affairs (VA) and its’ Chronic Heart Failure (CHF) QUERI. It is also the goal of Hospital to Home (H2H) national quality improvement (QI) initiative cosponsored by ACC and the IHI. In January 2010 the CHF QUERI through its HF Provider Network (625 providers/members from 150 VA facilities) launched the “VA H2H” QI initiative by facilitating the implementation of the national H2H initiative at the VA facilities with focus on H2H’s 3 key areas.

Methods:
A total of 122 VA facilities were identified with >100 discharges during 2007-2008. Randomly, half of these facilities were assigned to the intervention group (n=61) and the remaining to the control group (n=61). From Month 1 through Month 6 via e-mails and web-based meetings HF Network members at the intervention facilities were encouraged to (a) enroll own facility on the national H2H website, and (2) initiate and/or plan projects focusing on 3 key areas. In Months 6 members of both the intervention and control facilities were asked to complete a survey to find out (1) enrollment status and (2) number of projects initiated and/or planned for the VA H2H initiative, and other ongoing projects focusing on reducing HF readmissions.

Results:
The survey response rate was 37% (intervention n=24, 59%; and control n=21, 34%). It was seen that 33 intervention and 6 control facilities enrolled on the national H2H website. Self-reported data indicated that the intervention facilities had a total of 163 projects: 73=initiated and/or planned VA H2H projects, and 90=other ongoing projects. In sharp contrast, the control facilities had a significantly less number of total 66 projects: 25=initiated and/or planned VA H2H projects and 41=other ongoing projects.

Conclusions:
The findings show that the facilitation of the VA H2H initiative through its HF Provider Network was very successful in terms of increased enrollment and significantly larger number of projects to reduce HF readmissions.

Impact:
Facilitation of non-mandated QI initiatives is crucial to improve the quality of care for HF patients.
Abstract P252: Rates of Anticoagulation in Patients with Atrial Fibrillation and Flutter in the Kentucky Women's Health Registry
Authors: Scantlebury Dawn C , Mohsin Rabab , Bailey Alison L
Published: July 2021

Introduction:
Therapy with warfarin has been shown to decrease the risk of stroke associated with atrial fibrillation and flutter. Current guidelines recommend warfarin therapy for patients with atrial fibrillation who are at intermediate to high risk of thromboembolism. Multiple studies have shown that increasing age and female gender have been associated with underutilization of warfarin. We evaluated women in the Kentucky Women's Health Registry (KWHR) with self-reported atrial fibrillation to determine the rates of warfarin utilization in this population.

Methods:
Between November 2009 and June 2010, we administered electronic or mailed surveys to KWHR participants who reported an arrhythmia on the Registry questionnaire. Survey questions targeted arrhythmia identification and treatment, medical and social history, pregnancy history and demographics. Herein we analyze the data to determine baseline characteristics of the atrial fibrillation (and flutter) group, including CHADS
2
score and use of anticoagulation.

Results:
Of the 572 women initially surveyed, 365 responded to the questionnaire, yielding 107 cases of atrial fibrillation and flutter. Baseline characteristics of this group were notable for high education levels and greater than average annual income (see table). Of this population, 36 of 106, (34%) had a CHADS
2
score of >1. Of the women with CHADS
2
scores of >1 who reported their warfarin use, only 10 of 33 [30% (95% confidence intervals, 17-47%)] were receiving warfarin. As expected, the warfarin treated group tended to be older with mean age 73.4 years vs 61.8 years (p<0.001) with a higher CHADS
2
score (p<0.003).

Conclusion:
Warfarin anticoagulation is underutilized in this group of Kentucky women. This is not attributable to disparities in socioeconomic status given the relatively affluent, highly educated status of the survey respondents.

Baseline Characterisitics of Paticipants with Atrial Fibrillation and Flutter

Variable
Proportion of responders
n
95% Confidence Intervals

Age (mean years)
63.2
102
61.1-65.3

Hypertension
65% (68)
104
0.56 -0.74

Diabetes
13% (13)
102
0.08-0.21

Congestive heart failure
11% (11)
104
0.06-0 .18

Stroke/TIA
8% (8)
102
0.04-0.15

BMI in kg/m
2
(mean)

28.8
104
27.5-30.1

Aspirin use
49% (51)
104
0.40-0.59

Clopidogrel use
5 % (5)
104
0.02 -0.11

Warfarin use
15% (16)
104
0.10-0.24

CHADS
2
score >1

34% (36)
106
0.25-0 .43

White Race
93% (98)
105
0.87-0 .97

Level of education: Some college or higher
85% (89)
105
0.77-0.90

Median annual household income (Dollars)
60-79,999
101
Inter-quartile range: 40-89,999 (Kentucky median 41,489)
Abstract P268: Hospital Transfer of Ischemic Stroke Patients: Prevalence and Outcomes
Authors: Hanchate Amresh D , Schwamm Lee H , Hylek Elaine M
Published: July 2021

BACKGROUND
Little is known about transfers of patients across hospitals; inpatient outcome evaluation (report card) protocols are inconsistent in how transfers are accounted. For patients admitted for ischemic stroke in Massachusetts (MA), we estimated prevalence of transfers across hospitals, over time, and differences in inpatient mortality rates compared to patients not transferred.

METHODS
Discharge and American Hospital Association data were merged for all hospitalizations (2004-09) for ischemic stroke among adults (N=49,789) in all MA acute care hospitals (N=67). We linked all ischemic stroke hospitalizations with preceding and subsequent hospitalizations to obtain ischemic stroke episodes. A transfer was defined as an episode with >=2 hospitalizations such that discharge date for one coincided with admission date for another. We compared transferred and untransferred patients (episodes) in terms of patient risk factors for stroke, hospital characteristics and year. We also compared risk-adjusted inpatient mortality difference for transferred patients using a logistic regression model adjusting for patient demographics and clinical risk factors.

RESULTS
We identified 47,212 ischemic stroke episodes, of which 9.5% involved a transfer. This rate did not vary significantly during 2004-09. Blacks had higher transfer rates (13%; p<0.001) than Whites (9.3%) and Hispanics (9.6%). Weekend admission did not increase the risk of transfer. Transferred patients had significantly higher prevalence of risk factors for inpatient mortality: atrial fibrillation, hypertension, diabetes mellitus, heart failure and coronary heart disease. Risk-adjusted inpatient mortality among transferred patients was 26% higher than for untransferred patients (9.7% versus 7.3%; p<0.001). While transfer rates were higher for non-teaching and safety-net hospitals, and for hospitals with smaller general care and ICU bed size, substantial numbers of transfers occurred across all hospital types.

CONCLUSIONS
9.5% of patients admitted for ischemic stroke experienced a hospital transfer, and were at higher risk for inpatient mortality. Further study needs to explore causal pathways linking hospital transfers and risk of adverse stroke inpatient outcomes.
Abstract P274: Relationship Between Stroke Quality Metrics and Patient Outcomes: A Systematic Review
Authors: Parker Carol J , Reeves Mathew J
Published: July 2021

Background:
Stroke quality metrics play an increasingly important role in quality improvement efforts and policies, but the relationship between quality metrics and patient-orientated outcomes are not well described. We conducted a systematic review of observational hospital-based studies examining this relationship.

Methods:
We searched MEDLINE and EMBASE for studies published before December 31, 2010 that examined the relationship between 2 or more stroke quality metrics and patient-oriented outcomes in acute stroke admissions. Outcomes included mortality, length of stay, discharge to home, functional status, and stroke recurrence.

Results:
A total of 470 hits were identified. After screening the titles and abstracts, 27 studies underwent full review, and 14 were deemed eligible. Given the variation in study characteristics, quality metrics, and outcomes utilized, it was not possible to generate summary estimates describing the relationship between quality metric compliance and patient-oriented outcomes. Evidence of a positive relationship between quality metrics and improved patient outcomes was limited by the lack of high quality studies. Four of the 14 studies found a statistically significant relationship between increased compliance with acute care quality metrics and improved patient-oriented outcomes. Two studies failed to find an association between acute care measures and improved outcomes, but did find statistically significant positive relationships between compliance with post-acute rehabilitation measures and improved patient outcomes. Five other studies reported mixed findings, while the remaining three found no relationships.

Conclusions:
We found a limited evidence-base addressing the impact of compliance on stroke quality metrics and patient-oriented outcomes. Generation of data clarifying the relationship between compliance with stroke quality metrics and stroke-related outcomes should be prioritized so that the current investments undertaken to improve stroke care can be sustained.
Abstract P34: Use of a Behavioral Measure of Safety Culture Among Healthcare Workers in Cardiovascular Care
Authors: Cunningham Brittany L , Steaban Robin , Boord Jeffrey , Vogus Timothy
Published: July 2021

Medical error is a complex and systemic problem requiring systemic solutions. Developing a “safety culture” and adopting characteristics of high-reliability organizations (HROs, e.g. aviation, nuclear power) can form a basis for reducing error and patient harm in healthcare. Vanderbilt Heart and Vascular Institute (VHVI) has set a long-term goal of providing the highest level of patient safety in cardiovascular care. An early step in this process was measuring our current organizational status in order to achieve a safety culture. We created a survey tool that would gauge the current status of our organization in terms of HRO practices that underlie a safety culture. The tool (Table) utilized items adapted from concepts that comprise the process of mindful organizing seen in HROs: preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. Also, items were included that measured factors proposed to enable mindful organizing and high reliability including leader-member exchange, safety climate, and psychological safety. A baseline assessment of safety culture using the tool has been administered via electronic web-based survey to VHVI physicians, nurses, and staff. We have performed detailed analyses of responses by respondent role (e.g. physician, nurse, staff, and administrator) and area (e.g. clinic, stepdown unit, intensive care unit, diagnostic lab). These results have been shared with leaders and front-line staff in each clinical area to develop specific strategies to create a safety culture and more reliable performance. We intend to implement changes in our organization to promote patient safety and then re-administer the tool to gauge progress. We conclude that this tool can help assess and guide organizational change to create and sustain a safety culture that yields highly reliable performance

Survey Tool Summary

Survey Tool Concept Areas (example items)
Score Range
Total # Survey Questions

Mindful Organizing- (We spend time identifying activities we do not want to go wrong, We discuss alternatives as to how to go about our normal work activities, We talk about mistakes and ways to learn from them)
1-7
9

Leader-Member Exchange (In my workgroup we know where we stand with our clinical manager)
1-5
9

Safety Climate (My clinical manager approaches employees during work to discuss patient safety issues)
1-5
9

Psychological Safety (In my workgroup it is safe to take an interpersonal risk)
1-5
4
Abstract P35: Comparison of 10-Year CHD Risk Among Those with Diabetes and Prediabetes as a Function of Hemoglobin A1c Levels Versus a Self-Reported Diagnosis, Using the 2007-2008 National Health and Nutrition Examination Survey (NHANES)
Authors: Nair Radhika , Thakker Kamlesh M
Published: July 2021

Objective:
To estimate and compare the 10-year risk of CHD in individuals identified based on HBA1
c
or self-reported during interview as: (a) With diabetes; (b) Borderline diabetes; and (c) No diabetes.

Methods:
This study was conducted using the 2007-2008 NHANES, a cross-sectional, multi-stage probability sample survey. The data was appropriately weighted to represent the United States (US) population. Individuals ≥18years of age were included in the analysis. The 10-year CHD risk was estimated using Framingham point scores for men and women. Individuals were identified, categorized and compared based on HBA1
c
or self-reported during the interview (IQ) for diabetes: (a) With diabetes (HBA1
c
>7.0, HBA1
c
>6.5, IQ: Yes); (b) Pre-diabetes or borderline (HBA1
c
5.5-6.4, HBA1
c
5.7-6.4, IQ: Borderline); (c) No diabetes (HBA1
c
<5.5, IQ: No).

Results:
The 10-year CHD risk was 10-20% for 38.0-43.2% of the men assigned as pre-diabetes based on HBA1
c
. However, for individuals classified as borderline diabetes based on the interview, the 10-year CHD risk was 10-20% for 62.9% of the men. Majority of the women assigned as pre-diabetes or diabetes based on HBA1
c
ranges (87-90%) or interview (88.0-93.4%) had a low (<10%) 10-year CHD risk. Similarly, for both men and women, assigned as with “no diabetes” based on HBA1
c
, the 10-year CHD risk was <10% for 84.4% and 89.2%, respectively. However, individuals identified as those with "no diabetes" by interview, the 10-year CHD risk was <10% for 71.8% of men and 98.9% of the women.

Conclusions:
The differences in classification of 10-year CHD risk for those with diabetes as per HBA1
c
or diagnosed is more apparent for men than women.

Projected population: HBA1c Values or Response to the Interview Questions for Diabetes by Gender

Diabetes/Borderline Diabetes/No Diabetes

Categorized based on HBA1
C
or Response to Interview Question (Q)

N (projected in MM)
N (projected in MM)

Men
Women

With diabetes

HBA1
C
>7.0

4.8MM
4.1MM

With diabetes

HBA1
C
>6.5

7.4MM
6.3MM

With diabetes
Interview Q: Diagnosed with diabetes
8.9MM
9.0MM

Prediabetes or Borderline diabetes

HBA1
C
:5.5-6.4

37.5MM
41.9MM

Prediabetes or Borderline diabetes

HBA1
C
:5.7-6.4

20.8MM
24.2MM

Prediabetes or Borderline diabetes
Interview Q: With Borderline Diabetes
18.6MM
17.3MM

No Diabetes

HBA1
C
<5.5

41.4MM
40.0MM

No Diabetes
Interview Q: No Diabetes
76.5MM
82.1MM