bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 225: Determinants of Compensation for US Academic Physicians: Does Gender Matter?
Authors: Golbus Jessica R , Cai Tongan , Najarian Daniel , Trumpower Brad , Kao Timothy , Waljee Akbar , Nallamothu Brahmajee K
Published: April 2019

Introduction:
Academic physician compensation remains opaque, despite its critical importance for negotiating equitable salaries. In particular, prior studies have suggested inequity between male and female physicians. We set out to broadly define determinants of compensation in US academic physicians focusing on gender.

Methods:
We performed an online pilot survey using a convenience sample of US academic physicians in clinical practice recruited through social media. Survey questions focused on demographic information, practice environment, job requirements, compensation, and overall satisfaction. Respondents failing to provide information on gender (n=2), salary (n=43) or key compensation questions (n=7) were excluded. Predictors of total salary, defined as the sum of base salary plus bonuses, and satisfaction with position (range 0-100) were explored in a generalized regression model.

Results:
252 respondents met inclusion criteria for analysis of total salary. Of the respondents, 32.9% were female, 59.9% Caucasian, 35.7% were associate professors or professors, 54.8% were employed in an urban setting, 44.9% performed major procedures, and 72.8% practiced in internal medicine or an internal medicine subspecialty. Median total salary was $270,000 (Interquartile range 208,000-348,500). After multivariable adjustment, female physicians made $44,512.55 less in total salary. Performing major procedures (p<0.001), living in a major urban area (p=0.034), and being a professor or associate professor (p<0.001) also predicted greater total salary (Table). Age and years since clinical training ended were significant predictors of total salary in a univariable but not a multivariable model. There was no significant interaction between gender and rank or between gender and performing major procedures. Median job satisfaction in 241 respondents was 77.0 (Interquartile range 64.0-86.0). In a multivariable model, only years since clinical training ended but not total salary or other covariates predicted physician satisfaction.

Conclusions:
This pilot online study suggests gender disparities exist with respect to US academic physician compensation. Further studies are needed to better define these disparities and to enhance transparency with respect to physician compensation.
Abstract 230: The Efficacy of Diuretics in Hypertension Control When Multiple Agents Are Prescribed: The Importance of Adherence to the Hypertension Guidelines
Authors: Haddadin Faris I , Munoz Estrella Alba , Berookhim Joshua , Wu Lingling , Moctezuma Sananda , Huang Lucas Claire , Sud Karan , Patel Dipal
Published: April 2019

Background:
Hypertension (HTN) management has been updated in the 2017 ACC/AHA guidelines. The guidelines continued emphasizing on the use of diuretics, especially Chlorthalidone, as an essential component of first line therapy and as a preferred agent when 3 or more agents are required.

Methods:
This is a retrospective cross-sectional study evaluating the efficacy of diuretics when 3 or more agents are required in obese (BMI >=30) and high-risk overweight pts (BMI >=27 & <30 plus one or more metabolic comorbidities). 760 eligible pts were screened by chart review between Oct/2017 to Oct/2018 in an Internal Medicine residency primary care clinic located in an urban federally qualified health care facility. Mean BP was calculated on 2 visits. We compared mean systolic (SBP) and diastolic blood pressure (DBP) based on adherence of the provider to prescribe a diuretic and pt compliance.

Results:
Of the 760 pts, 157 (55.4% females, 7.1% white, 37.5% black, 55.4% hispanic) had 3 or 4 BP lowering agents prescribed. Mean age was 65y and mean BMI was 34.8, 144 (92%) reported compliance, 97 (61.7%) had DM, 19 (12%) were smokers and 59 (37.5%) had CKD stage 3 or above. Among the 144 compliant pt, 117 (81.2%) were on a diuretic, Chlorthalidone in 31 (26.5%) of them, 93 (64.5%) were on 3 BP lowering agents with one agent being a diuretic in 68 (73%) of them, and 55 (38.1%) were on 4 agents with one agent being a diuretic in 51 (92.7%) of them. Two or more agents were on maximum dose in 20 (29.4%) of those on 3 BP agents including a diuretic, in 7 (28%) of those on 3 BP agents without a diuretic and in 32 (58.1%) of those on 4 BP agents including a diuretic. Results were calculated in compliant pts only. Pts who were on a diuretic vs without were less likely to have BP >130/80 (34% [40 of 117] vs 63% [17 of 27], p<0.001) and had significantly lower mean SBP (124 vs 132 mmHg, p<0.001). Same results for those on 3 BP agents including a diuretic vs without (29% [20 of 68] vs 64% [16 of 25] for BP >130/80 and 122 vs 131 mmHg for mean SBP, p <0.001). Mean DBP was not significantly different in any group.

Conclusion:
Adherence to the guidelines in prescribing a diuretic when multiple BP lowering agents are required results in significantly lower SBP and better HTN control. We hope providers identify high risk pts early and institute a more evidence and guideline based anti-hypertensive regimen.
Abstract 232: Effect of Oral Anticoagulation Use on Thromboembolic Risk and Bleeding in Women Compared with Men with Atrial Fibrillation: Findings from the PINNACLE Data Registry
Authors: Henderson Kamal , Jones Phillip , Peterson Pamela , Masoudi Frederick , Daugherty Stacie
Published: April 2019

Background:
Among those with atrial fibrillation (AF), women have a higher risk of thromboembolic events and lower use of oral anticoagulation (OAC) when compared to men. Whether the effect of gender on thromboembolic risk in patients with AF is mediated by lower use of OAC among women is unknown. We examined whether gender differences in OAC use mediated the relationship between gender and thromboembolic risk in patients with AF.

Methods:
Adults 65 years and older with AF in the PINNACLE Registry from October 2008 to December 2014 were identified. Adults with valvular AF and contraindications to OAC use were excluded. Thromboembolic events (stroke, systemic embolism) and major bleeding events were determined using linked Medicare claims data. Site-stratified proportional hazard models adjusting for patient and practice-level characteristics compared thromboembolic and bleeding events by gender, as well as the mediating effect of OAC use as a time-dependent covariate on these outcomes.

Results:
Among 667,287 patients, the mean ±standard deviation age was 77±8 years and 46% were women. Compared to men, women had higher CHA2DS2-Vasc scores (mean 4.8 vs. 3.8, p<0.001), had similar prevalence of bleeding risk factors, but were prescribed OAC less frequently (51.5% vs. 53.8%, p<0.001). Over a median 2 years of follow up (range 0-6 years), there were 25,947 thromboembolic events and 40,967 major bleeding events. Women had a higher risk of thromboembolic events compared to men (5-year cumulative incidence 8.3% vs. 6.0%, adjusted hazard ratio [HR] 1.24, 95% CI 1.16-1.33) and a slightly lower risk of major bleeding (5-year cumulative incidence 10.4% vs. 11.2%, adjusted HR 0.90, 95% CI 0.83-0.98). Among adult patients with AF, OAC use was associated with lower thromboembolic risk (HR 0.90, 95% CI 0.86-0.94) and greater bleeding risk (HR 1.51, 95% CI 1.42-1.60). Among women, OAC use did not mediate the relationship between gender and either thromboembolic or major bleeding events (HR 1.24 and 0.90 respectively, identical to the unmediated effects).

Conclusions:
In a national US sample of older adults with AF, women had lower rates of OAC use, higher risk of thromboembolic events and lower risk of major bleeding. However, the difference in OAC use did not explain the gender differences in these outcomes. These findings underscore that women with AF are independently at higher risk for thromboembolic events and lower OAC use among women does not significantly explain this higher risk.
Abstract 233: Geographic Variability in the Utilization of Remote Monitoring for Pacemakers and Implantable Cardioverter-Defibrillators
Authors: Holtzman Jessica N , Wadhera Rishi K , Fraiche Ariane M , Choi Eunhee , Shen Changyu , Kramer Daniel B
Published: April 2019

Background:
Remote monitoring (RM) of pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) reduces the need for in-office visits, of particular importance to patients in rural areas. Whether adoption of RM varies by geography is unknown.

Objective:
To evaluate geographic variability in the use of RM among Medicare beneficiaries.

Methods:
Medicare carrier files (2012-2015) were queried for RM and in-office professional claims of PM or ICD interrogations. Patient location was identified using residence ZIP code. Geographic variability was assessed using standard deviation of county-based proportion of RM vs in-office interrogations. We also assessed the relationship between counties’ proportional use of RM and population density.

Results:
Across the US, the proportion of remote to in-office interrogations increased from 2012-15 for both PMs (18.5% to 27.6%, 420,480/2,269,305 to 682,200/2,476,100) and ICDs (31.4% to 33.8%, 440,130/1,401,350 to 466,605/1,380,380) (FIGURE). However, marked variability across counties was noted, with the standard deviation of the proportion of RM ranging from 16.8-17.9% by year and device type. Significant county-to-county variability in the rate of change in proportion of RM from 2012 to 2015 was also observed (standard deviation of 2012-15 change in proportion of RM: 11.8% for PMs; 14.1% for ICDs). Population density accounted for only 1.7-4.6% of observed variability in RM utilization over time (PM: r=0.20; ICD: r=0.19; p<0.001).

Conclusion:
Counties varied widely in their relative use of RM and rate of adoption over time, yet population density accounted for just a small fraction of RM use variability. These findings suggest a need to target rural populations for adoption of this technology.
Abstract 236: Investigation of the Effects of the Affordable Care Act within the BRIDGE Population
Authors: Khan Sarah , Krallman Rachel , Feldeisen Delaney , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: April 2019

Background:
The U.S. Patient Protection and Affordable Care Act (ACA) aimed to provide all United States citizens access to health care and reform the way healthcare was delivered. A key provision of the ACA was the Readmission Reduction Program (RRP) that penalizes hospitals for excessive readmissions. This study sought to determine if changes exist after ACA implementation in demographics and outcomes of myocardial infarction (MI) and heart failure (CHF) patients referred for transitional care (BRIDGE).

Methods:
MI and CHF patients referred to BRIDGE between 2008-2016 were divided into pre-ACA (2008-2013) and post-ACA (2014-2016) cohorts. Demographics and outcomes (ED visits, readmissions) were compared between groups. Post-hoc, a subset of patients of low socioeconomic status (SES) were analyzed. Low SES was defined as a median household income (based on the patient’s zip code) less than the 2012 household income for the state of Michigan ($46,859).

Results:
Compared to pre-ACA patients, post-ACA patients had higher Charlson comorbidity scores and were more likely to be readmitted within 6-months. In addition, when examined independently, both MI and CHF patient subsets had higher Charlson scores post-ACA. Similar differences were seen in the subset of low SES patients, with post-ACA patients having higher Charlson scores, 6-month readmission rates, and 6-month ED visits rates than pre-ACA patients.

Conclusions:
There were few differences in outcomes between pre-ACA and post-ACA groups in this sample. Overall, post-ACA patients were sicker. There were no differences in participation in the BRIDGE transitional care program or in early readmissions or ED visits. Notably, there were higher rates of readmission and ED visits within 6-months, potentially suggesting greater access to care. This finding was consistent both in the total MI and CHF population as well as among those of low SES. More research is needed to determine whether changes as a result of ACA implementation can in part explain these findings.
Abstract 239: Prevalence and Predictors of Diastolic Dysfunction in HIV-Infected and HIV-Negative Tanzanian Adults: A Cross-sectional Study
Authors: Kingery Justin , Kennard Chelsea , Desarius Bernard , Damas Edmund , Fadhil Salama , Mungo Boniface , Walsh Kathleen , Seo Grace , Abel Kevin , Chebrolu Puja , McNairy Margaret , Peck Robert
Published: April 2019

Objective:
To compare the prevalence and predictors of myocardial dysfunction in HIV-infected and HIV-negative Tanzanian adults.

Methods:
A cross-sectional study including 256 HIV-infected, ART-naïve and 263 HIV-negative Tanzanian adults. Traditional cardiovascular risk factors for myocardial dysfunction (age, sex, hypertension, body mass index, abdominal obesity and tobacco use) were determined by standard investigations. Bedside echocardiography was performed at time of enrollment. The primary outcome was echocardiographic prevalence of myocardial systolic and/or diastolic dysfunction as classified by the American Society of Echocardiography/European Association of Echocardiography guidelines.

Results:
The average age of HIV-negative and HIV-infected participants was similar (36.8 vs 36.6 years). No study participants met criteria for systolic dysfunction. Compared with HIV-negative controls, more HIV-infected adults were classified as diastolic dysfunction (OR[CI]: 2.47[1.61-3.80], [78/256 (30.7%) vs 40/263 (15.2%)], p<0.0001, respectively), with HIV-infected adults also classified as Grade II/III more commonly than those HIV-negative (p=0.04). Diastolic dysfunction was significantly associated with hypertension, age and diastolic and systolic blood pressure in both HIV-infected and HIV-negative participants (3.26[1.56-6.81] and 5.67[2.68-11.99], 1.13[1.08-1.17] and 1.11[1.07-1.15], 1.03[1.01-1.06] and 1.09[1.06-1.13], 1.02[1.01-1.04] and 1.05[1.02-1.07], respectively). CD4 count was also associated with diastolic dysfunction in HIV-infected participants (0.998[0.997-0.999]). Additionally, HIV-infected participants required fewer traditional risk factors for dysfunction prevalence Probability of disease with one or fewer risk factors present was greater in HIV-infected as compared to HIV-negative adults (p=0.02).

Conclusions:
HIV-infected Tanzanian adults have a higher prevalence of myocardial diastolic dysfunction and have more advanced disease as compared to HIV-negative controls. This dysfunction is present at a much younger age and with fewer traditional risk factors than previously reported HIV-negative populations. The most significant predictor for diastolic dysfunction is hypertension; therefore, echocardiography may be indicated for hypertensive, HIV-infected adults, independent of age.
Abstract 24: Diabetic Ketoacidosis in Patients with Type 2 Diabetes Treated with Sodium Glucose Co-transporter 2 Inhibitors versus Other Antihyperglycemic Agents: An Observational Study of Four US Administrative Claims Databases
Authors: Wang Lu , Voss Erica A , Weaver James , Hester Laura , Yuan Zhong , DeFalco Frank , Schuemie Martijn J , Ryan Patrick B , Sun Don , Freedman Amy , Alba Maria , Lind Joan , Meininger Gary , Berlin Jesse A , Rosenthal Norman
Published: April 2019

Introduction:
Diabetic ketoacidosis (DKA) is a serious acute metabolic complication of diabetes. Rare DKA events have occurred in patients taking sodium glucose co-transporter 2 inhibitors (SGLT2i). This study evaluated the risk of DKA in patients with type 2 diabetes mellitus (T2DM) taking SGLT2i versus other antihyperglycemic agents (AHAs) in clinical practice.

Methods:
This study, per protocol reviewed and approved by the European Medicines Agency, identified patients from 4 large US claims databases using broad and narrow definitions of T2DM; the broad definition captured all patients with a T2DM diagnosis and the narrow definition was intended to exclude T1DM misclassified as T2DM. DKA was identified from diagnosis codes in inpatient or emergency room claims. Eligible new users of SGLT2i and 7 groups of AHA comparators were matched (1:1) on exposure propensity scores (PS) to adjust for imbalances in baseline covariates. Cox proportional hazard models conditioned on PS-matched pairs were used to estimate hazard ratios (HR) of DKA risk for new users of SGLT2i versus other AHAs.
P
values were calibrated using negative control outcomes to address potential residual bias. Pooled HRs were calculated when I
2
was <40% across 4 databases.

Results:
The number of new users of SGLT2i in each database ranged from 11,141 to 152,728 using the broad T2DM definition and from 7,779 to 130,708 using the narrow definition. Across databases, the unadjusted incidence rates of DKA (events per 1000 patient-years) ranged from 2.75 to 8.84 with SGLT2i and 1.38 to 15.82 with other AHAs using the broad T2DM definition and from 1.15 to 3.91 with SGLT2i and 0.75 to 7.94 with other AHAs using the narrow definition. Using the broad T2DM definition, a significantly increased risk of DKA was observed among new users of SGLT2i versus 5 groups of other AHAs; when using the narrow definition, an increased risk of DKA with SGLT2i was observed only compared with sulfonylureas (
Figure
).

Conclusion:
In this claims database study, an increased risk of DKA was observed for new users of SGLT2i versus new users of several non-SGLT2i AHAs when T2DM was defined broadly. When T2DM was defined narrowly to exclude possible misdiagnosed T1DM patients, an increased risk of DKA with SGLT2i was observed compared to sulfonylureas.
Abstract 241: An Investigation of Sex Differences in the BRIDGE Transitional Care Clinic Population
Authors: Lee Monica , Krallman Rachel , Feldeisen Delaney , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: April 2019

Background:
Although cardiovascular disease (CVD) is the leading cause of death in men and women, women are less likely than men to received certain evidence-based treatments for CVD or be enrolled in CVD clinical trials. This study sought to identify sex differences in outcomes among patients referred to the BRIDGE transitional care clinic following hospitalization for a cardiac event.

Methods:
Retrospective data on patients referred to BRIDGE from 2008-2016 were analyzed. Demographics and outcomes (readmissions, emergency department [ED] visits, death) were compared between male and female patients in five populations: 1) the total BRIDGE population, 2) acute coronary syndrome (ACS) patients, 3) congestive heart failure (CHF) patients, 4) atrial fibrillation/flutter (AF) patients, and 5) patients who attended BRIDGE clinic.

Results:
Of 4159 patients, 1710 (41.1%) were female. In the total population, women were significantly older than men (66.8 v 64.8, p=0.010), were less likely to be married (45.2% v 68.2%, p≤0.001), and had higher Charlson Comorbidity Index (CCI) scores (4.90 v 4.60, p=0.001). Women were also less likely to have ACS (20.7% v 28.6%, p≤0.001), more likely to have CHF (25.1% v 20.9%, p=0.001), and were more likely to have an ED visit within 6 months post-discharge. No significant differences were seen in outcomes between males and females in the CHF and AF populations; however, female ACS patients were more likely to have had an ED visit within 6 months of discharge than male ACS patients. In regards to transitional care, women were less likely to attend their BRIDGE appointment (68.7% v 72.4%, p=0.008). Among BRIDGE attendees, females were older (66.8 v 64.9, p=0.001), less likely to be married (45.9% v 68.8%, p=0.001), and had higher CCI scores (4.80 v 4.55, p=0.016) than males. Female attendees were more likely than male attendees to have had an ED visit both within 30 days and 6 months.

Conclusions:
Among the total population, BRIDGE attendees, and ACS patients, women were more likely to visit the ED than men. Additionally, women were less likely than men to attend their BRIDGE transitional care appointment. Efforts should be made to improve BRIDGE clinic attendance among women and develop targeted strategies to improve outcomes for female patients, specifically those with a primary diagnosis of ACS.
Abstract 242: Comparison of Pharmacist-Managed Initial Dosing of Direct Oral Anticoagulants with Non-Pharmacist Practitioner Prescribing Patterns
Authors: Levito Marissa , Felix-Getzik Erika , Berkowitz David , Philippides George , Tataronis Gary
Published: April 2019

Background:
There is currently a lack of data regarding pharmacist-managed DOAC (direct oral anticoagulant) therapy. The objective of this study was to assess the impact of pharmacist-managed initial dosing of apixaban and rivaroxaban utilizing a Pharmacy and Therapeutics Committee approved guideline when compared with general practitioner/cardiologist practitioner prescribing practices for patients with Non-Valvular Atrial Fibrillation (NVAF).

Methods:
A retrospective, chart review was performed during the period of January 2015 to January 2018 and included adults 18-95 years old, who were prescribed apixaban or rivaroxaban for documented NVAF. Patients eligible for this study were split up into two cohorts: a pharmacist-managed cohort and a non-pharmacist-managed cohort. The primary endpoint of the study was the percentage of patients who received appropriate initial apixaban or rivaroxaban dosing. Any incorrect initial doses of apixaban or rivaroxaban were then analyzed to determine the reason for error. The secondary endpoints included thromboembolic and hemorrhagic adverse events. Exploratory analyses included: provider follow up-time, inappropriate DOAC use in valvular atrial fibrillation (VAF), and correct transition from warfarin to DOAC.

Results:
For the primary endpoint, the pharmacist practitioner was significantly more accurate when initially dosing apixaban and rivaroxaban compared to non-pharmacist practitioners (97% [63 out of 65] vs. 74% [48 out of 65] correct prescriptions, p=0.001). When evaluating the reason for error in prescribing, non-pharmacist providers were significantly less likely to dose the patient appropriately based on renal function or drug interactions (p=0.003). For the secondary endpoint of hemorrhagic or thromboembolic events, there were no statistically significant differences among the two provider types. The exploratory analyses revealed that 3% (2 out of 65) of the patients in the non-pharmacist managed cohort had VAF and received a DOAC for antithrombotic therapy. The patients in the pharmacist managed cohort had zero patients receive a DOAC for VAF. The pharmacist was also significantly better at transitioning patients from warfarin to DOACs correctly compared to non-pharmacist practitioner (100% [12 out of 12] vs. 50% [3 out of 6], p=0.025) and following up with patients within a four-month time frame compared to non-pharmacist practitioners (100% [65 out of 65] vs. 82% [53 out of 65], p=0.001).

Conclusion:
Additional research is required to evaluate the benefits of pharmacist-managed anticoagulation; however, based on the results of this study, pharmacists are significantly better equipped to initiate DOAC therapy for patients with NVAF. Based on the findings of the study results, pharmacist-managed DOAC services may be transferrable to a variety of different disease states requiring anticoagulation therapy.
Abstract 244: Identifying Differences in Demographics, Management, and Outcomes Between Type 1 and Type 2 NSTEMI Patients
Authors: Leyden Madeline , Krallman Rachel , Feldeisen Delaney , Montgomery Daniel , Kline-Rogers Eva , Eagle Kim A , Bumpus Sherry M
Published: April 2019

Background:
A type 2 NSTEMI (T2) is defined as ischemia secondary to another condition resulting in either an increase in myocardial oxygen demand or decrease in oxygen supply. Little is known about this population or management. This study sought to compare demographics, outcomes, and the utility of a cardiac transitional care program (BRIDGE) between type 1 (T1) and T2 patients.

Methods:
The BRIDGE database was queried for patients referred between 2012-2017 with a primary discharge diagnosis of NSTEMI. Patients were randomly selected and classified as either T1 or T2 NSTEMI based on a retrospective chart review using criteria proposed by Saaby et al. (2013). Demographics, discharge medications, and outcomes (BRIDGE attendance, readmission, ED visits, death) were compared between groups.

Results:
Of 149 NSTEMI patients, 33 (22.1%) were T2. A higher percentage of T2 were female. T2 were more likely to have anemia and had longer hospital stays. At discharge, T2 patients were less likely to be prescribed medications for secondary prevention; specifically, aspirin, antiplatelets, or nitrates. T2 patients were less likely to attend their BRIDGE appointment. Comparison of cumulative adverse events at 180 days post-discharge was suggestive of worse outcomes for T2 patients.

Conclusions:
Management of the T2 NSTEMI patient depends on the underlying condition. This poses a challenge for developing universal standards. A larger sample is needed to identify standards that may be appropriate for all T2 NSTEMI patients and to identify T2 NSTEMI subsets that may share similar management strategies.
Abstract 246: Validating the Accuracy of Routine Electrocardiogram Arrhythmia Diagnosis From an Electronic Repository
Authors: Liu Hongwei , Collins Reid , Miller Robert J , Southern Danielle A , Har Bryan J , James Matthew T , Wilton Stephen B
Published: April 2019

Background:
Most health services research uses claims or administrative data for rhythm diagnosis. Including coded data from electrocardiogram (ECG) repositories may enhance diagnostic yield, but validation is needed.

Objective:
We performed a diagnostic study comparing the Marquette Universal System for Electrocardiography (MUSE, GE Healthcare) coded ECG interpretation of atrial fibrillation and atrial flutter (AF/AFL) and conduction diseases with that of expert over-readers.

Methods:
We used the institutional MUSE repository to develop ECG cohorts for AF/AFL (n = 369) and conduction diseases (n = 800). We randomly selected 50 cardiologist-interpreted ECGs coded for each diagnosis, plus competing diagnoses and normal controls. Two reviewers unaware of MUSE interpretation independently interpreted all ECGs, with discrepancies resolved by consensus (Reference). We tested agreement between MUSE and Reference using Cohen’s kappa statistic, and assessed diagnostic accuracy with sensitivity and specificity.

Results:
For both AF/AFL and conduction diseases, agreement between MUSE and Reference was acceptable (See Table 1). Sensitivity of MUSE for AF/AFL was between 60.6 - 75.7% depending on diagnostic criteria. Sensitivity for conduction diseases ranged from 68.1% for non-specific interventricular conduction block to > 88% for 2nd or 3rd degree atrioventricular block. Specificity was ≥ 93% for all diagnoses.

Conclusion:
Routine ECG interpretation using MUSE coding is highly specific and moderately sensitive. These findings validate use of MUSE data to enhance AF/AFL and conduction diseases case identification algorithms based on claims or administrative data.
Abstract 252: PredischaRge Initiation of Ivabradine in the ManagEment of Heart Failure: Results of the PRIME-HF Trial
Authors: Mentz Robert J , DeVore Adam , Tasissa Gudaye , Heitner John , Pina Ileana , Lala Anuradha , Cole Robert , Lanfear David , Patel Chetan , Ginwalla Mahazarin , Old Wayne , Salacata Abraham , Peterson Tim , Bigelow Robert , Fonarow Gregg , Hernandez Adrian
Published: April 2019

Background:
Prior studies suggest that the hospital setting provides an important opportunity to initiate guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF). Ivabradine is a specific inhibitor of the
I
f current in the sinoatrial node that is FDA-approved for use in chronic HFrEF. A randomized trial conducted outside the US demonstrated that heart rate reduction with ivabradine improved clinical outcomes for ambulatory patients with chronic, symptomatic HFrEF. The initiation of ivabradine specifically in patients following stabilization for acute HF has not been evaluated and there are limited trial data on the use of ivabradine in US patients.

Methods:
The PredischaRge Initiation of Ivabradine in the ManagEment of Heart Failure (PRIME-HF) trial was a randomized, open-label study of pre-discharge initiation of twice-daily ivabradine versus usual care (i.e., post-discharge initiation of ivabradine at discretion of routine physician) for 180 days. Eligible patients were those hospitalized for acute HF but stabilized and preparing for discharge, with left ventricular ejection fraction ≤35%, in sinus rhythm with resting heart rate ≥70 bpm and on optimal GDMT including maximally-tolerated doses of beta-blockers. Given an aim to understand real-world use and barriers to medication acquisition, study drug was not provided. The primary endpoint was the proportion of patients using ivabradine at 180 days. Additional endpoints included heart rate change, patient-reported outcomes, beta-blocker use, barriers to ivabradine acquisition and clinical outcomes.

Results:
A total of 104 patients were randomized at 23 US hospitals. The primary results of the PRIME-HF study and important secondary endpoints will be presented.

Conclusion:
PRIME-HF is a trial evaluating implementation of evidence in the hospital following stabilization from acute HF in patients with HFrEF receiving optimal GDMT. This study also provides important data on the use of ivabradine in patients from the US.
Abstract 254: Utilization and Outcomes of Early Respiratory Support in 6.5 Million Acute Heart Failure Hospitalizations
Authors: Metkus Thomas S , Stephens R. Scott , Schulman Steven , Hsu Steven , Morrow David , Eid Shaker
Published: April 2019

Background:
Patients with acute heart failure (AHF) often require non-invasive ventilation (NIV) via facemask or invasive mechanical ventilation (IMV) via endotracheal tube, yet the incidence and prognostic connotation of IMV and NIV use in AHF are not well established.

Methods:
We used the National Inpatient Sample (NIS), a US database of hospital admissions. Using ICD-9 codes, we identified all patients admitted with AHF between 2008 and 2014. The exposure variable was IMV or NIV use compared to no respiratory support. We analyzed the association between ventilation strategies and in-hospital mortality using Cox proportional hazards models.

Results:
We included 6,534,675 hospitalizations for AHF. Of these, 271,589 (4.16%) included NIV and 51,459 (0.79%) included IMV within the first 24 hours of hospitalization. Rates of NIV and IMV use increased over time [Fig 1]. In-hospital mortality for AHF patients treated with NIV was 5.0% and 27% for those treated with IMV. In an adjusted model, requirement for NIV was associated with over 2 fold higher risk for in-hospital mortality compared to no respiratory support (HR 2.10, 95% CI 2.01-2.19, P<0.001) and requirement for IMV was associated with over 3 fold higher risk for in hospital mortality (HR 3.39, 95% CI 3.14-3.66, P<0.001) [Fig 2].

Conclusion:
Respiratory support is used in many AHF hospitalizations, and AHF patients who require respiratory support are at high risk for in-hospital mortality. Our work should inform prospective intervention trials and quality improvement ventures in this high-risk population.
Abstract 260: COMPASS-CP for HF: An Electronic Application to Capture Patient-Reported Outcomes of Individuals with Heart Failure
Authors: Pastva Amy M , Croxton Rachel D , Stopyra Jason P , Duncan Pamela W
Published: April 2019

Purpose:
Heart failure (HF) admission variance is significantly influenced by functional, social, and behavioral health determinants. The Institute of Medicine and Centers for Medicare/Medicaid Services now recommend that these determinants be captured in the electronic health record (EHR) for personalized, value-based care and population health management. However, mechanisms for doing so within clinical workflow have not been fully developed. The purpose of this pilot project was to capture and evaluate patient-reported outcomes (PROs) prior to hospital discharge using a HF-specific version of Comprehensive Acute Care Services-Care Plan (COMPASS-CP) (Duncan et al,
Circ Cardiovasc Qual Outcomes
2018), a web-based application that integrates PROs into clinical care to generate personalized electronic care plans.

Methods:
Consecutively sampled patients with HF admitted to Wake Forest Baptist Medical Center Cardiology Service were assessed by a Cardiac Wellness Educator or Research Coordinator (RC) using the COMPASS-CP for HF application. The RC performed 30-day post-discharge phone calls to collect PROs and healthcare utilization.

Results:
Seventy-six patients (mean 65yrs, 35% female, 31% black, 95% living at home) provided COMPASS-CP PROs. The COMPASS-CP PROs revealed 47% with fair/poor health ratings and deficits in physical function included 63% unable to walk 6 min without difficulty, 59% unable to negotiate 10 steps independently, and 24% with at least one fall within 3 months of hospital admission. Deficits in health management included 25% unable to purchase meds, 27% forgot to take meds often or sometimes, 30% without a caregiver, and 64% lacked a living will. Only 51% properly identified at least one HF risk factor and only 26% knew HF symptoms that warrant contacting their provider. Strikingly, deficits in psycho-cognitive function indicated 41% screened depression positive yet only 21% had depression listed in the EHR and 53% failed 5 minute 3-word recall. Forty-seven patients (62% of original sample, mean 62yrs, 23% female, 43% black, 93% living at home) provided 30-day PROs. The 30-day PROs revealed low Global PROMIS-10 scores (mean 30.6 on 10-50 scale), 60% with fair/poor physical health ratings, 66% with moderate to severe difficulty in everyday ADLs, 77% with moderate to severe fatigue, and 30% with ED visits and/or readmissions.

Conclusion:
COMPASS-CP for HF detected global deficits known to drive all-cause healthcare utilization. This tool can aid in the generation of personalized care plans, based on PROs and availability of community services, to improve health outcomes among individuals with HF.
Abstract 261: Gender-Specific Differences in Behavioral and Physiological Risk Factors Associated with Childhood Obesity
Authors: Pfeifer Liliana , Krallman Rachel , Bernardo Sabrina , Montgomery Daniel , DuRussel-Weston Jean , Kline-Rogers Eva , Eagle Kim A , Jackson Elizabeth A
Published: April 2019

Background:
Prior research has shown differences in physiologic and behavioral measurements of adolescent boys and girls. This study sought to determine if similar gender-specific differences exist between participants of the Project Healthy Schools (PHS) school-based wellness program, both at baseline and post-PHS intervention.

Methods:
Demographics, physiological measures and health behaviors were compared between 6
th
grade girls and boys enrolled in PHS between 2004-2017 at baseline and post-PHS intervention.

Results:
Health behavior data were collected in 19,995 students (46.1% girls); physiological measures were collected in 2,922 students (52.7% girls). Boys within the physiological sample were older than girls (11.62 v. 11.55, p<0.001). At baseline, girls had lower HDL cholesterol and higher resting and recovery heart rates, but reported greater consumption of fruits and vegetables and less sugary beverages and fried meats than boys. Boys reported more vigorous exercise but greater hours of television and video game screen time than girls. Post-intervention, girls showed greater improvement in resting heart rate, fruit consumption and video game time.

Conclusion:
Girls had better health behaviors but poorer physiological markers at baseline. Lower rates of physical activity in girls at baseline highlight a potential area of focus for the PHS intervention in this population. Future exploration of gender-specific targeted strategies to improve health behaviors is warranted.
Abstract 263: Real World Outpatient Treatment Patterns of Patients with Cancer-Associated Venous Thromboembolism in the US
Authors: Guo Jennifer D , Hlavacek Patrick , Poretta Tayla , Wygant Gail , Lane Daniel C , Gorritz Magdaliz , Wang Xin , Chen Chi-Chang , Pan Xianying , Rajpura Jigar , Stwalley Brian , Rosenblatt Lisa
Published: April 2019

Objective:
The aim of the study is to describe post-discharge treatment patterns in patients with cancer-associated venous thromboembolism (VTE) following an emergency department (ED) visit or inpatient (IP) admission.

Methods:
Adults (≥ 18 years) with VTE diagnosed during an ED or IP visit with a cancer diagnosis, and their respective VTE treatments were identified from the IQVIA Real-World Data Adjudicated Claims - US
TM
database between 7/1/15 and 6/30/17. Initial outpatient (OP) treatment received within 6 months post-discharge was assessed. Treatment duration, adherence, persistence, and switching were evaluated over variable follow-up in patients who had ≥ 6 months of continuous health plan eligibility after initiation of OP therapy.

Results:
A total of 3,064 cancer-associated VTE patients (54% female; mean age 54.3 [SD=9.9] years) were included. 53% were diagnosed with VTE in the ED and 47% IP. The most common initial post-discharge OP treatments observed were direct-acting oral anti-coagulants (DOACs; 37%), low molecular weight heparin (LMWH; 30%), and warfarin (12%); 10% of patients had no evidence of treatment within 6-months of discharge. Median follow-up after treatment initiation was 412 days among the 2,698 patients who had at least 6 months of follow-up after initiation of post-discharge therapy. Duration of treatment (allowable gap=60 days) was longest with DOACs (231.5 days [SD=183.1]), followed by warfarin (223.0 days [SD=200.0] and LMWH (138.3 days [SD=138.2]. Adherence to initial treatment prior to discontinuation was high across all therapies, with 80% of patients having a medication possession ratio (MPR) ≥ 80%. The proportion of patients who remained on therapy for ≥ 6 months was highest among patients who initiated DOACs (55%), followed by warfarin (51%) and LMWH (33%) patients. A total of 1,597 (59%) patients discontinued their initial post-discharge treatment within 6 months of initiation, with an average time to discontinuation of 87.5 days (SD=53.4) for DOACs, 76.7 days (SD=51.6) for warfarin patients, and 61.3 days (SD=49.3) for LMWH. Among these, 30%, 54%, and 65% of DOAC, warfarin, and LMWH patients, respectively, switched to a new OP treatment. Patients who initiated OP therapy with DOACs were most likely to switch to LMWH (33%) or warfarin (21%), while those who initiated therapy with warfarin or LMWH were most likely to switch to DOACs after discontinuation (74% and 70%, respectively).

Conclusions:
This real-world study showed that DOACs or LMWH were the most common initial post-discharge therapies for cancer-associated VTE. Although treatment adherence was high, only DOAC and warfarin patients had a 6-month persistence rate on initial treatment ≥ 50%. Switching was most common in patients treated with warfarin or LMWH, most of whom switched to DOACs.
Abstract 266: Referral Pathways in the Evaluation of Syncope
Authors: Rogers John , Rosemas Sarah , Sims Jason , Homsy Diana , Garman Audrey , Richards Catherine
Published: April 2019

Background:
The evaluation of syncope is challenging and is often associated with a high volume of repeat diagnostic testing. Early use of an implantable cardiac monitor (ICM) is recommended for patients with unexplained syncope following initial non-diagnostic workup. However, limited data is available on the patient journey prior to ICM. The aim of this study was to characterize healthcare utilization and referral pathways experienced during syncope evaluation, prior to insertion of ICM.

Methods:
ICM patients were identified in the 2014-2016 U.S. Medicare Fee-for-service claims database. Included patients were ≥18 years of age, had a syncope claim within 3 months prior to ICM insertion, and had continuous enrollment for ≥2 years baseline. Syncope-related encounters were defined as unique healthcare visits with a syncope diagnosis code. All specialist consultations within an encounter were captured.

Results:
Of 982 patients identified, 550 (56%) were female; mean age was 74 years. Mean time from first syncope encounter to ICM insertion was 236 days (min-max 1-1,081), with mean of 4.7 (min-max 1-30) total syncope-related encounters per patient. Out of 6 possible service locations, patients presented at a mean of 2.2 (min-max 1-5) different sites of service for syncope; 38% (375 of 982) of patients had been seen at ≥3 sites of service. Of 982 patients, 362 (37%) had presented to the ED, 399 (41%) had been hospitalized, 668 (68%) had been seen in outpatient hospital, and 534 (54%) in an office setting. A mean of 2.9 (min-max 0-9) specialist types had been consulted per patient, out of a total of 11 possible categories. One quarter of patients (745) had seen a cardiologist, 300 (10%) had seen an electrophysiologist (EP), and 155 (5.3%) a neurologist (Table). During initial syncope encounter, a cardiologist was consulted in 449 (27%) and EP in only 105 (6.2%) of patients.

Conclusion:
Wide variability was observed in both time and patient pathway between first syncope presentation and ICM. A more standardized approach to the triage and management of syncope patients has potential to reduce the volume of repeat evaluations and diminish associated delays in establishing diagnosis and appropriate treatment.
Abstract 267: Impact of Socio-demographic Factors on a 30-day Readmission in Patients with Acute Myocardial Infarction
Authors: Rzechorzek Wojciech , Sabharwal Basera , Haddadin Faris , Weininger David , Yue Bing , Khandaker Mariam , Munoz Alba , Lee Shawn , Ahsan Syed , Lemor Alejandro , Selby Allison , Tamis-Holland Jacqueline
Published: April 2019

Background:
A significant number of patients with acute myocardial infarction (AMI) are readmitted within 30 days of discharge from the hospital (30-Re-admit). This substantially impacts healthcare costs. The available risk scores for 30-Re-admit are not specific for an AMI diagnosis and few incorporate socio-demographic variables. We investigated the impact of socio-demographic factors on 30-Re-admit.

Methods:
We analyzed adult patients enrolled in a Quality Improvement Program (QIP) aimed to improve the post discharge care of patients with an AMI. Patients discharged to subacute rehab, or discharged prior to enrollment were excluded. The QIP included 30-minute counseling on care after an AMI, an educational pamphlet, 48-hour phone call, and mandatory 1-2-week post discharge office appointment. We examined the univariate predictors of 30-Re-admit including demographic, clinical and psychosocial variables related to education, employment, language, and support at home. Variables with p <0.2, were included in the multivariate logistic regression model.

Results:
Among 173 patients enrolled in our QIP, (Age 65 ± 0.9 years; female 31%), 21 (12%) had 30-Re-admit. The univariate predictors of 30-Re-admit are included in the table. Being married, or having a domestic partner was associated with an 80% lower chance of 30-Re-admit, and was the only independent predictor of 30-Re-admit, while a high HOSPITAL risk score was associated with an over 7 fold higher 30-Re-admit.

Conclusion:
Married patients or those living with a domestic partner are less likely to be re-admitted after an AMI. Given this information, it is possible that providing a stronger support network for those patients without a spouse/partner may improve 30-Re-admit.
Abstract 269: Patients >65 Years of Age Have Higher Mortality After In-hospital Cardiac Arrest With Lower Utilization of Healthcare Resources
Authors: Rzechorzek Wojciech , Skaf Michel , Narasimhan Bharat , Lopes Jan , Herzog Eyal
Published: April 2019

Background:
Studies have shown that age is not an independent predictor of short-term and long-term neurological outcomes after cardiopulmonary resuscitation. These findings were reported for both in-hospital and out-of-hospital cardiac arrest. Yet, elderly patients are less aggressively treated and have higher mortality. We investigated the current outcomes and therapeutic approach in a large unselected population of patients.

Methods:
In a retrospective cohort study, using the 2014 Nationwide Inpatient Sample, we analyzed patients >65 years of age with in-hospital cardiac arrest. We performed univariate analysis of age, sex, race, hospital location, hospital teaching status, insurance type, hospital bed size, Charlson Comorbidity Index and other relevant comorbidities such as ventricular arrhythmias and we included variables with p<0.2 in the multivariate logistic regression model.

Results:
A total of 39397 patients, who underwent in-hospital cardiopulmonary resuscitation (CPR) were identified. Patients >65 years of age (55%) had mean age of 78+/_0.06, vs 50+/_0.22, p<0.001 and a higher percentage of them were female (46% vs 40%, p<0.001). They were less likely to have ESRD (9% vs 11%, p<0.001), abuse drugs (0.7% vs 10%, p<0.001) and alcohol (0.3% vs 11.5%, p<0.001) and had lower incidence of ventricular tachycardia or ventricular fibrillation (20% vs 23%, p<0.001). They were more likely to have chronic kidney disease (25% vs 11%, p<0.001), diabetes mellites (29% vs 21%, p<0.001), hypertension (69% vs 50%, p<0.001) and heart failure (26% vs 17%, p<0.001). Patients >65 years of age had higher mortality (OR=1.51, 95%CI =1.43-1.61, p<0.001) and were less likely to undergo therapeutic hypothermia (OR=0.66, 95%CI=0.56-0.79, p<0.001), receive cardioverter-defibrillator (OR=0.77, 95%CI=0.64-0.92, p=0.005) and extracorporeal membrane oxygenation (OR=0.32, 95%CI =0.23-0.45, p<0.001). There was no difference in utilization of short-term mechanical circulatory support, dialysis in the setting of acute kidney injury and blood product transfusion. There was also no difference in the incidence of ischemic stroke and placement of percutaneous endoscopic gastrostomy with lower utilization of tracheostomies (OR=0.64, 95% CI= 0.56-0.73, p<0.001) and higher utilization of palliative care consult (OR=1.44, 95% CI=1.33-1.56, p<0.001) in older patients. Patients >65 years of age had lower length of stay (Coef. =-1.46, 95% CI=-1.85- -1.08), p<0.001) and the total charges from hospital stay (Coef. =-49889$, 95% CI= -56803$- -42975, p<0.001).

Conclusion:
Patients >65 years of age, who underwent in-hospital CPR had higher mortality, which could be related to lower utilization of healthcare resources and contribute to a shorter hospital stay and lower total charges. Furthermore, our study unravels lower utilization of a palliative care consult in a younger population of patients.