bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P43: Trend in tPA Use for Acute Ischemic Stroke and Outcome in a Statewide Registry. Is Positive Trend Due to Increased Utilization or Ineligibility?
Authors: Pandey Dilip K , Ruland Sean , Gorelick Philip B
Published: March 2022

Background:
Thrombolytic therapy with intravenous recombinant tissue plasminogen (r-tPA) in acute ischemic stroke is the standard of care and is a quality indicator to for acute stroke care in US. We examined the rate of r-tPA utilization in the past five years and investigated whether increasing trend in r-tPA use is due to utilization or documentation of reasons for non-treatment.

Methods:
The Illinois CAPTURE Stroke registry is a prospectively collected data from patients admitted with a stroke in 56 acute care hospitals in Illinois.

Results:
A total of 5,964 patients were admitted between 01/2005 and 09/2009 with radiologically proven acute ischemic stroke. Patients were excluded if they were enrolled from hospital site that admitted < 50 patients. Among the total patient group, IV r-tPA administration rates were 3.21% in 2005, 3.96% in 2006, 3.79% in 2007, 5.44% in 2008, and 4.92% in 2009 (β coef. (95% confidence interval) for trend: 0.12 (0.014 - 0.22)). The documentation of reasons for non-treatment increased from 18.8% patients in 2005 to 85.1% in 2009 (β coef. (95% confidence interval) for trend: 0.70 (0.65 - 0.74)). Among eligible candidates for the time of onset < 180 minutes, the r-tPA utilization rates were 12.2% in 2005, 14.8% in 2006, 14.3% in 2007, 19.5% in 2008 and 12.4% in 2009, whereas, reasons for non-treatment were documented in 24.4% patients in 2005, 31.1% in 2006, 48.8% in 2007, 50.2% in 2008, 77.9% in 2009. After excluding patients who had documented reasons for non-treatment, the r-tPA utilization rates among eligible candidates were 16.1% in 2005, 21.5% in 2006, 27.9% in 2007, 39.3% in 2008, and 56.0% in 2009. The in-hospital case fatality rate was 6.0% for patients who received r-tPA.

Conclusion:
A small proportions of acute ischemic stroke patients receive thrombolytic treatment in Illinois for acute ischemic stroke and there has been no dramatic increase of r-tPA use in the past 5 years. Most of the apparent increase in r-tPA use may be explained by better documentation of reasons for non-treatments and exclusions of these patients from eligibility.
Abstract P56: Secondary Prevention: Developing the Guide “Medication Discussion Questions (MedDQ)”
Authors: Decker Carole J , Garavalia Brian , Spertus John A , Garavalia Linda S
Published: March 2022

Background:
Adherence to evidence-based therapies has emerged as a critical challenge in translating discoveries to clinical care. In particular, nonadherence to secondary prevention medications reduces the potential to optimize patients' outcomes. We conducted serial qualitative research studies to define relevant domains, from patients' perspectives, associated with discontinuing cardiac medications (clopidogrel or cholesterol lowering therapy) and developed a brief tool to identify myocardial infarction (MI) patients' risk of discontinuing medications.

Methods:
Using the Health Belief Model (HBM) as a theoretical framework, an interdisciplinary team (nurse, psychologist, anthropologist, and cardiologist) analyzed more than 50 in-depth patient interviews. Themes that emerged within and across patient interviews were used to derive assessment items. The items underwent several cycles of refinement and resulted in the 11-item MedDQ. This was then included in a 26-center registry of >700 MI patients. Lastly, the MedDQ was evaluated as to feasibility of use with the healthcare system by 49 healthcare providers.

Results:
The HBM provided a good fit for the data and development of items that mapped to the four primary factors of the model (susceptibility, severity, barriers, and cues to action While psychometric analysis continues, the feasibility interviews with healthcare providers were very positive. They indicated that the tool was perceived to be an important mechanism for systematically discussing medication issues with patients, could be adapted for a range of clinical settings, and provided valuable information that the providers could use to identify specific intervention needs.

Conclusions:
Hundreds of pages of narrative data, rich with cardiac patient's perspectives of medication discontinuance were reduced to a parsimonious survey. Feasibility interviews with healthcare providers indicated that the MedDQ can be easily administered to cardiac patients and could serve as an important source of information to guide supportive interventions. This creates an extraordinary opportunity for secondary prevention for cardiac patients. Formal testing of the impact of the MedDQ on patients' adherence to medications is needed.
Abstract P78: Changing Trends in the Management of Patients With St-Segment Elevation Myocardial Infarction in Kuwait and its Influence on Patient Outcomes
Authors: Al Jarallah Mohammed
Published: March 2022

Aim:
to evaluate changes in management practices and its influence on hospital outcomes in patients with ST-segment elevation myocardial infarction (STEMI) admitted to hospitals in Kuwait during two different time periods, 2004 and 2007.

Methods and results:
We studied STEMI patients from two separate registries carried out in Kuwait in 2004 and 2007. We included 673 and 724 patients from the 2004 and 2007 registries, respectively. When compared with 2004, patients from the 2007 registry had similar baseline clinical characteristics. In 2007 compared to 2004, STEMI patients received significantly more statins (95% vs. 69.7%, p<0.0001), ACE inhibitors (68.2% vs. 45.5%, p<0.001), and clopidogrel (38.5% vs. 2.2%, p<0.001). Beta-blockers use dropped in 2007 compared to 2004 (65.9% vs. 72.5%, p=0.007). The rates of in-hospital mortality and recurrent ischemia were significantly lower in the 2007 cohort compared with the 2004 cohort (for mortality 2.1% vs. 3.9%, P=0.047, for recurrent ischemia 14.2% vs. 18.4%, P=0.034). The increased utilization of ACE inhibitors and statins in 2007 had the greatest impact on lowering mortality.

Conclusion:
in the management of STEMI, there was significant increase in the use of statins, ACE inhibitors and clopidogrel in 2007 compared to 2004. This was associated with a significant decrease in the in-hospital mortality. Adherence to guidelines- recommended therapies improved in-hospital outcomes.
Abstract P87: Cost-Effectiveness of Using High Sensitivity C-Reactive Protein to Identify Intermediate and Low Cardiovascular Risk Individuals for Statin Therapy
Authors: Lee Keane K , Cipriano Lauren E , Owens Douglas K , Go Alan S , Hlatky Mark A
Published: March 2022

Background -
Half of all incident acute myocardial infarctions and strokes occur in individuals considered at low cardiovascular risk by conventional evaluation. In this study, we evaluated the cost-effectiveness of using high sensitivity C-reactive protein (hs-CRP) testing to identify low- and intermediate-risk individuals who may benefit from long-term statin therapy.

Methods and Results -
A decision analytic Markov model with a societal perspective and a lifetime horizon was used to follow hypothetical cohorts of individuals with normal lipid levels and no clinical evidence of coronary artery disease, peripheral arterial disease, or diabetes mellitus. The model was used to compare 1) a strategy of hs-CRP screening followed by statin therapy only in those with elevated hs-CRP levels, 2) current clinical practice guidelines and 3) a strategy of statin therapy at specified risk thresholds without hs-CRP testing. Assuming that statins are equally effective regardless of hs-CRP status and a cost of $1.10 per day, statin therapy without hs-CRP testing was the most cost-effective strategy. However, if hs-CRP identifies a subgroup of individuals with much greater than average relative risk reductions from statin therapy (54% vs. 29% relative risk reduction for myocardial infarction), then hs-CRP screening would be the most cost-effective strategy. Current clinical practice guidelines are the most cost-effective strategy if the incidence and severity of harms from statin use were higher than generally recognized.

Conclusion -
A strategy of statin therapy without hs-CRP testing is more cost-effective than current guidelines or a strategy of hs-CRP screening, assuming that statins are as effective in low- and intermediate-risk people as in high-risk individuals, are equally effective regardless of hs-CRP levels, and do not cause significant toxicity.
Abstract P88: Hospitalizations and Inpatient Mortality Over One Year in Patients With Atrial Fibrillation/Atrial Flutter and Without Heart Failure in the United States: Does Age Matter?
Authors: Naccarelli Gerald V , Johnston Stephen S , Dalal Mehul , Patel Parag P , Schulman Kathy L
Published: March 2022

Introduction:
In the ATHENA trial, conducted in elderly patients with atrial fibrillation/flutter (AF/AFL) and ≥1 other CV risk factor, dronedarone significantly reduced the risk of cardiovascular (CV) hospitalization/all-cause mortality by 24%. Patients <70 yrs without other CV risk factors were excluded from ATHENA. To determine if patients ≥65 yrs experience CV events/hospitalizations at a similar rate to older, ATHENA-like patients, we compared 3 age/CV-risk groups of insured AF/AFL patients without heart failure (HF) in a real-world setting.

Methods:
Data were drawn from the MarketScan® databases from Thomson Reuters for 2004-2006. Patients had to have ≥12 months' continuous enrollment pre- and post-AF/AFL index diagnosis (except for inpatient death). Hospitalizations and inpatient deaths were evaluated over 1 yr post index in 3 groups: all patients ≥65 yrs ± CV risk factors (all ≥65); ATHENA-like patients ≥70 yrs with ≥1 CV risk factor (ATHENA ≥70); and ATHENA-like patients ≥75 yrs (ATHENA ≥75).

Results:
55,774 AF/AFL patients were included in the all ≥65 (mean 78 yrs; 52% men [29,129 of 55,774]), 32,262 in the ATHENA ≥70 (mean 79 yrs; 46% men [14,899 of 32,262]) and 24,587 in the ATHENA ≥75 (mean 82 yrs; 44% men [10,716 of 24,587]) groups. Comorbidities were common in all 3 groups (Table). Over 30% of patients in each group had ≥1 hospital admission. Deaths during CV hospitalizations accounted for >30% of inpatient deaths in each group (Table).

Conclusion:
Insured AF/AFL patients ≥65 yrs without HF and ATHENA-like AF/AFL patients ≥70 and ≥75 yrs without HF have similarly high rates of CV comorbidity, hospitalization, and inpatient death. Studies to evaluate dronedarone in the wider population of AF/AFL patients ≥65 yrs are warranted.

Patients with AF/AFL ≥ 65 yrs without HF (n=55,774)
ATHENA-like patients with AF/AFL ≥ 70 yrs without HF (n=32,262)
ATHENA-like patients with AF/AFL ≥ 75 yrs without HF (n=24,587)

Pre-index hypertension, n (%)
44,877 (80.5)
29,397 (91.1)
22,413 (91.2)

Pre-index coronary artery disease, n (%)
12,871 (23.1)
7,838 (24.3)
5,789 (23.5)

Pre-index diabetes, n (%)
10,603 (19.0)
6,776 (21.0)
4,823 (19.6)

Pre-index valvular heart disease, n (%)
7,773 (13.9)
4,673 (14.5)
3,558 (14.5)

Any post-index hospitalization, n (%)
18,705 (33.5)
10,939 (33.9)
8,649 (35.2)

Post-index hospitalization for CV causes, n (%)
9,150 (16.4)
5,467 (16.9)
4,238 (17.2)

All inpatient deaths, n (%)
959 (1.7)
537 (1.7)
467 (1.9)

Inpatient deaths during a hospitalization, for CV causes n (%)
331 (0.6)
205 (0.6)
171 (0.7)
Abstract P92: Racial Differences in End of Life Care in Medicare Beneficiaries With Heart Failure
Authors: Greiner Melissa A , Unroe Kathleen T , Hernandez Adrian F , Curtis Lesley H
Published: March 2022

Background:
Attention to quality and consistency of care at the end of life has increased over the last decade. However, little is known about racial differences in health care use at the end of life in patients with heart failure, a complex disease with high mortality and morbidity.

Methods:
We used a 5% national sample of Medicare fee-for-service beneficiaries with heart failure who died from 2000-2007. Demographics included age at death, sex, comorbidities and race (“black” vs. “non-black”). We calculated frequency of all-cause hospitalizations, intensive care unit (ICU) and hospice use in the 180 days preceding death. We calculated total cost to Medicare (in 2007 US dollars). Chi-square and Kruskal-Wallis tests were used to test for differences by race and Cochran-Mantel-Haenzel tests for nonzero correlation were used to test trends. We used generalized linear models with a log link and Poisson distribution to model total costs in the last 6 months of life.

Results:
The cohort included 229,543 Medicare patients with heart failure who died from 2000-2007. The average age at death was 83 years and 18,141 (7.9%) patients were black. Black patients were more likely than non-black patients to be hospitalized in the last six months of life (86.1% vs 80.7%; p<.001). Among hospitalized patients, blacks had longer lengths of stay (27.6 days vs. 20.3 days; p<.001) and were more likely to spend time in the ICU (51.5% vs 46.6%; p<.001). Black patients were less likely to use hospice services compared to non-blacks (21.9% vs. 28.6%; p<.001). While hospice use among blacks increased over the study period (14.1% in 2000 vs. 30.6% in 2007; p<.001), use in non-blacks remained higher (19.4% in 2000 vs 38.7% in 2007; p<.001). Total costs to Medicare per patient were more than $11,000 higher for black patients ($42,625 vs. $31,295; p<.001). Even after covariate adjustment, black race was independently associated with higher end-of-life costs (Cost Ratio 1.2, 95% CI (1.19,1.22); p<.001).

Conclusion:
Resource use at the end of life is higher among black Medicare patients with heart failure compared to non-black patients. Further research is needed to identify the factors that contribute to these observed differences.
Abstract P93: Differences in Practice Patterns and Outcomes Between Hispanics and Non-Hispanic Whites Treated for ST-Segment Elevation Myocardial Infarction: Results From ACTION Registry - Get With the Guidelines
Authors: Guzman Luis A , Piña Ileana L , Tracy Wang Y , Aviles Larissa , Daviglus Martha , Exaire Jose , Rodriguez Carlos , Torres Vilma , Li Shuang , Funk Marjorie , Saucedo Jorge , Granger Chris , Cohen Mauricio G
Published: March 2022

Background:
Ethnic differences have been reported in the treatment and outcomes of patients with non-ST-segment elevation myocardial infarction (non-STEMI). Potential ethnic disparities in contemporary STEMI management have not been well characterized.

Methods:
We compared practice patterns and outcomes between 1,654 Hispanics (H) (4.1%) and 38,844 non-Hispanic Whites (NHW) treated for STEMI in ACTION Registry-GWTG between 01-2007 and 03-2009. Logistic generalized estimating equation modeling was used to examine associated risk-adjusted mortality.

Results:
Hispanic patients more frequently had diabetes (32% vs 21%, p<0.0001), whereas older age (median 61 vs 57, P<0.0001), female gender (30% vs 21%, p<0.0001), smoking (43% vs 38%, p<0.0001), dyslipidemia (55% vs 51%, p<0.006) and prior MI (19% vs 15%, p<0.0002) were more prevalent in the NHW group. While use of acute medications (aspirin, clopidogrel, B Blockers and GPIIb/IIIa inhibitors) was similar between groups, significant differences and delays in initial triage and reperfusion were observed (Table). After adjustment for patient and hospital characteristics, in-hospital mortality was similar in H and NHW patients (OR 1.07; 95% CI 0.81, 1.43, p=0.63).

Conclusions:
Despite similar in-hospital mortality, Hispanic STEMI patients had significant differences in process of care with longer triage and treatment delays than non-Hispanic Whites. As the fastest growing minority in the United States, this population needs further efforts to optimize their care processes

Hispanics
Non-Hispanic Whites
p value

Ambulance use
41.5%
47.0%
<0.0001

Pre-Hospital EKG
32.8%
37.5%
<0.0001

Onset of pain to arrival (median)
2.0 hrs
1.6 hrs
<0.0001

Arrival to EKG (median)
8 min
6 min
<0.0001

Arrival to EKG<10 min
61.2%
69.3%
<0.0001

Reperfusion therapy
91.6%
93.1%
0.04

Arrival to PCI (median)
74 min
69 min
<0.0001

DTB <90 min
69.4%
77.5%
<0.0001
Abstract P99: Improving Blood Pressure Control in a Workplace Setting: Evaluation of a Web-Based Self-Monitoring Program for Hypertensive and Prehypertensive Employees
Authors: Singh Kanwaljit , Watson Alice J , Myint-U Khinlei , McClure Douglas , Kvedar Joseph C
Published: March 2022

INTRODUCTION:
Many self-insured companies are exploring innovative programs to improve their workforce health. Hypertension and prehypertension are prevalent and lead to costly consequences for both employer and employee. New technologies allow individuals to play a greater role in self-management of their condition.

METHODS:
We conducted a cluster randomized clinical trial to explore the effect of a web-based self-monitoring program on blood pressure (BP) control of employees with hypertension and prehypertension. A total of 404 subjects across 6 EMC worksites in Massachusetts were randomized at the site level to intervention or control group. Intervention subjects received a BP monitor linked to a communication device that uploaded BP readings to a secure website. The website enabled intervention subjects to track BP readings over time, access tailored feedback and educational material, and prompted them to see a doctor if readings became, or remained, out of control. Control subjects had access to a BP monitor at the worksite. All subjects were monitored for 6 months.

RESULTS:
Overall, 56.9% (107/188) and 55.3% (104/188) of intervention subjects showed an improvement in systolic (SBP) and diastolic blood pressure (DBP) respectively, compared to 49.51% (101/204) and 35.78% (73/204) of controls (p=0.002 and p=0.002 respectively). A decline of >=5 mm Hg in DBP was seen in 28.7% (54/188) of intervention subjects compared to 16.2% (33/204) controls (p=0.03). Similarly, 22.3% (42/188) of intervention subjects achieved a >= 10 mm Hg decline in SBP compared to 16.7% (34/204) of controls (p=0.02). In addition, 63.4% (111/175) of intervention subjects reported improved communication with their doctor as a result of participation, compared to 51.1% (97/190) of controls (p=0.02); and 22.2% (26/117) of intervention subjects started a new BP medication as a result of participation, compared to 10.9% (12/110) of control subjects (p=0.03). Findings remained significant after adjusting for demographics, lifestyle factors etc.

CONCLUSION:
This study demonstrates the efficacy of a web-based BP self-monitoring program at improving employee BP control. Use of the program appears to promote discussions about BP management between patients and their physicians.
Abstract 4: The Association Between Admission Rate and 30-Day Risk Standardized Readmission Rate for Heart Failure and Acute Myocardial Infarction
Authors: Shah Sachin J , Ross Joseph S , Lin Zhenqiu , Normand Sharon-Lise T , Krumholz Harlan M
Published: March 2022

Background:
There is wide variation in regional admission and readmission rates and the association between the two is unknown. We sought to determine this association and whether it differs between heart failure (HF) admissions, more discretionary, and acute myocardial infarction (AMI) admissions, less discretionary.

Methods:
We used 2006-2008 Medicare ICD-9-CM claims data to determine AMI and HF admissions. Hospital referral region (HRR) admission rates were determined using Medicare denominator files. We estimated hospital level 30-day risk standardized readmission rates using hierarchical logistic models adjusting for age, sex and comorbidities and then aggregated them to HRRs level RSRRs. The correlation (R
2
) obtained by weighted linear regression characterized the relationship between admission rates and RSRRs for AMI and HF.

Results:
Among 306 HRRs, the median AMI admission was 9.2 per 1000 enrollees (range 2.8 to 26.5) and the median HF admission rate was 19.6 (range 7.6 to 41.4). Among the 306 HRRs, the median AMI RSRR was 0.196 (range 0.163 to 0.233) and the median HF RSRR was 0.242 (range 0.201 to 0.289). Regional AMI admission rate was weakly correlated with AMI RSRR (R
2
0.05, 95% CI 0.02 - 0.11) and HF RSRR (R
2
0.07, 95% CI 0.02 - 0.13). Regional HF admission rate was modestly correlated with both AMI RSRR (R
2
0.28, 95% CI 0.20 - 0.37) and HF RSRR (R
2
0.32, 95% CI 0.24 - 0.41).

Conclusion:
The modest association between HF admissions, a more discretionary admission condition, and both AMI and HF readmission rates suggest a systemic propensity to admit and readmit patients. In contrast, the same was not true of AMI, a less discretionary admission condition.
Abstract P105: A Single-Center Experience with Low-Dose Warfarin in Patients Undergoing Total Hip or Total Knee Replacement Surgery
Authors: Balcom William B , Bookhart Brahim K , Mishol David N , Eapen Sara , Nutescu Edith A , Schein Jeff R , Duh Mei Sheng
Published: March 2022

Background:
Current guidelines recommend thromboprophylaxis to prevent venous thromboembolism (VTE) (deep vein thrombosis [DVT]; pulmonary embolism [PE]) after total hip and total knee replacement (THR/TKR) surgery. We describe international normalized ratio (INR) levels and risks of VTE and bleeding among THR/TKR patients receiving low-dose warfarin postsurgery in a single center. Although such real-world observational data are limited by relatively small numbers, single-center analysis eliminates many confounding variables.

Methods:
Claims data and laboratory information were used to identify patients who (i) underwent TKR/THR between January 2000 and October 2009, (ii) had no warfarin use 60-30 days before surgery, (iii) were ≥18 years old at warfarin initiation, (iv) received warfarin <30 days before or ≤15 days after surgery, and (v) were continuously enrolled in a health plan from 30 days before to 90 days after warfarin initiation. INR levels and VTE/bleeding outcomes were recorded during continuous warfarin use 5-90 days after warfarin initiation.

Results:
Mean (SD) ages of THR (N=269) and TKR (N=423) patients were 67.7 (13.2) and 70.0 (9.8) years, respectively. During the study period, THR and TKR patients received warfarin for a mean (SD) of 30.8 (18.2) and 30.6 (17.8) days, respectively; the mean number of INRs performed in patients with ≥1 available INR measurement was 3.9 for both THR (N=110) and TKR (N=202) patients. Of those measurements, 2.3 in THR and 2.1 in TKR patients were <2.0; 47% (52 of 110) of THR and 53% (107 of 202) of TKR patients failed to ever achieve the American College of Chest Physicians-recommended INR range (2.0-3.0). Of THR patients with no prior VTE, 10% (26 of 261) had DVT and 0.8% (2 of 261) had PE; of TKR patients, 8% (32 of 401) had DVT and 1.5% (6 of 401) had PE; 2.6% (7 of 266) of THR and 1.7% (7 of 415) of TKR patients developed minor or major bleeds. Multivariate regression found that the risk of VTE in TKR patients who failed to achieve an INR of 2.0-3.0 was significantly higher than in those who did (HR=4.10;
p
=015), but this effect was not seen in THR patients (HR=0.51;
p
=0.30).

Conclusion:
These data suggest that ∼50% of patients receiving low-dose perioperative warfarin fail to achieve recommended INR levels.
Abstract P114: Fallacy of Same-Hospital Readmission Rates
Authors: Gorodeski Eiran Z , Landers Steven H , Arrigain Susana
Published: March 2022

Background:
It is unknown to what extent same-hospital readmission rates for patients with heart failure (HF) or acute myocardial infarction (AMI) underestimate a more robust assessment of readmission rates for a variety of patients discharged from a large academic medical center.

Methods and Results:
We retrospectively identified all patients discharged after hospitalization for HF or AMI from Cleveland Clinic Main Campus, a large academic medical center which is a part of an integrated 9 hospital health system in Cuyahoga County, Ohio. We abstract 30-day all-cause readmission rates for this cohort from administrative databases of all 9 health system hospitals. We then compared same-hospital to system-wide readmission rates. Over the 17 month study span 1,187 Cuyahoga County residents had a total of 1,458 discharge episodes from Cleveland Clinic Main Campus. Of these, 886 episodes were for primary HF hospitalizations, and 572 for primary AMI hospitalizations. We found that twenty-one percent (95% confidence interval [CI]: 16-26%) of HF readmissions, and 29% (95% CI: 20-39%) of AMI readmissions were to a hospital other than the one which initially discharged the patient.

Conclusions:
Within our integrated multi-hospital health system located in a single county in northeast Ohio, same-hospital readmission rates for HF and AMI substantially underestimated system-wide readmission rates. Hospitals should be wary of using this biased metric to assess performance or to track quality improvement efforts.
Abstract P123: The Introduction of Prehospital ECGs into a Provincial System of STEMI Care: Impact on Treatment Delays and the Process of Care
Authors: Lambert Laurie , Xiao Yongling , Boothroyd Lucy , Segal Eli , Ross Dave , Maire Sébastien , Kouz Simon , L'Allier Philippe , Rinfret Stéphane , Vanasse Alain , Bogaty Peter
Published: March 2022

Background:
Timely reperfusion therapy is associated with improved clinical outcomes in patients with ST-elevation myocardial infarction (STEMI). To improve treatment delays in Quebec (Canada), the Health Ministry set a goal of implanting prehospital ECG programs in all healthcare regions by the end of 2010.

Objective:
To investigate treatment delays and processes of care associated with the introduction of prehospital ECG programs in Quebec.

Methods:
All acute care Quebec hospitals that treated at least 30 acute myocardial infarctions (AMI) (n=82) participated in a systematic 6-month evaluation in 2008-9. Charts, prehospital ECGs and first in-hospital ECGs of all patients with a final diagnosis of AMI who presented to an emergency room with appropriate symptoms were reviewed to identify STEMI.

Results:
Of 1878 patients with STEMI who either received fibrinolysis or were sent for primary angioplasty (PPCI), 1118 (60%) came by ambulance. Of ambulance patients, 148 (13%) had a prehospital ECG. For 68% of these patients, there was an alert from the ambulance to the first emergency room. The prehospital ECG was transmitted to the first emergency room for 52% (77/148) of patients but a second in-hospital ECG was performed for 95% (141/148) of patients. The majority (61%) of patients with prehospital ECGs were brought directly to a PPCI center. However, almost 25% were brought to a non-PPCI center and then transferred to a PPCI center. In-hospital treatment delays were shorter in prehospital ECG patients without a substantial increase in the prehospital delay. However, even with a prehospital ECG, transferred patients experienced long delays to treatment.

Conclusion:
These findings suggest that the potential for improving times to treatment by implanting ECG programme depends on modifying the continuum of STEMI care. Specifically, the avoidance of unnecessary and time-consuming inter-hospital transfers should be the primary goal of a prehospital ECG program.

Prehospital and in-hospital treatment delays in STEMI patients who presented by ambulance

Type of reperfusion treatment
Prehospital Delay First medical contact to triage Median (10-90 percentile)
In-hospital Delay Triage to treatment Median (10-90 percentile)

With prehospital ECG
Without prehospital ECG
With prehospital ECG
Without prehospital ECG

Fibrinolysis n=195
38 min (20-56)
28 min (18-50)
19 min (14-55)
29 min (13-73)

Direct admission PPCI n=417
30 min (21-51)
29 min (19-45)
57 min (32-95)
78 min (43-170)

PPCI with transfer n=506
28 min (17-48)
27 min (18-47)
97 min (69-172)
109 min (75-207)
Abstract P128: Successful Facilitation of the Save 5 Million Lives Campaign at VA VISNs (Regions): CHF QUERI
Authors: Sahay Anju , Heidenreich Paul A
Published: March 2022

Objective:
Reducing readmission rates for heart failure (HF) patients has been a high priority nationally, for the Department of Veterans Affairs' (VA) and its' Chronic Heart Failure (CHF) QUERI. IHI's Save 5 Million Lives Campaign was a national voluntary quality improvement (QI) initiative to protect patients from five million incidents of medical harm. Early on the CHF QUERI took the initiative to facilitate the implementation of the Save 5 Million Lives Campaign at all the VA facilities. In August 2009 the VA invited representatives from all VISNs to attend the “Save 5 Million Lives Conference - Success and Strategies” and asked them to identify plans to achieve their CHF goals. To help achieve their goals the CHF QUERI invited all contacts to join its VA HF Provider Network and provided several resources.

Method:
A one-year follow up survey was sent to all VISN contacts to understand how they (1) rated own VISN's progress in achieving their CHF goals; (2) how helpful were the resources provided by the CHF QUERI; (3) how helpful were the HF Network's various activities including the VA H2H initiative; and (4) brief description of activities undertaken by the VISN since August 2009 to achieve their CHF goals. Based on attrition the survey was sent to contacts at 20 out of 21 VISNs.

Results:
With a response rate of 50% (10 VISNs) we found that all the 10 VISNs reported moderate to excellent progress in achieving their CHF goals. CHF QUERI's resources to achieve their CHF goals contacts for 7 VISNs (70%) were reported to be quite helpful. Similarly, contacts from 5 VISNs (50%) found their involvement in CHF QUERI's HF Network and it's facilitation of QI initiatives quite or extremely helpful. Since August 2009 these 10 VISNs reported undertaking a total of 42 activities to achieve their CHF goals (range 1-15).

Conclusions:
CHF QUERI's facilitation of the Save 5 Million Lives campaign at the VISN-level significantly contributed in helping the VISNs reduce their HF readmission rates.

Impact:
Facilitation of non-mandated QI efforts is critical to improve the quality of care for HF patients.
Abstract P133: Effect of Prior Cardiac Surgery on Survival After CABG Surgery
Authors: Likosky Donald S , Surgenor Stephen D , Kramer Robert S , Russo Louis , Leavitt Bruce J , Helm Robert E , Sardella Gerald L , DiPierro Francis , Baribeau Yvon R , Sisto Donato , Clough Robert A , Westbrook Benjamin M , DeFoe Gordon R , Malenka David J , MacKenzie Todd A , Frumiento Carmine , Brown Jeremiah R , Sorensen Meredith J , Olmstead Elaine M , Ross Cathy S ,   Northern New England Cardiovascular Disease StudyGroup
Published: March 2022

Background:
We examined a recent regional experience to determine the impact of a prior cardiac surgery on short and long-term outcomes following coronary artery bypass grafting (CABG) surgery.

Methods:
We identified 20,504 patients undergoing non-emergent CABG surgery at 8 centers in northern New England from 2000-2008, of whom 818 (4.0%) had undergone prior cardiac surgery. Prior CABG and/or valve surgery utilizing a mini- or full sternotomy was considered a prior sternotomy. Survival data was obtained by linkage to the Social Security Administration Death Index. Hazard ratios were estimated using a Cox Proportional Hazards regression model while adjusted survival curves were estimated using inverse probability weighting. Models were adjusted for age, sex, ejection fraction, acuity, vascular disease, diabetes, prior myocardial infarction, renal failure or creatinine >2 mg/dl, left main disease, chronic obstructive pulmonary disease, body mass index, medical center and year. We conducted a nearest-neighbor propensity matched analysis among a subset of 1,568 patients who were matched 1:1 having a prior cardiac procedure based on their history of a cardiac surgical procedure and aforementioned patient and disease characteristics.

Results:
In both instances, prior sternotomy was associated with increased risk of mortality for patients undergoing CABG: [adjusted unmatched HR: 1.68, (CI 95% 1.46, 1.93)]; [propensity matched HR: 1.44, (CI 95% 1.12, 1.86)].

Conclusions
In our recent regional experience with non-emergent CABG, a prior cardiac surgery was associated with a nearly two-fold increased hazard of mortality at up to 4 years of follow-up.
Abstract P141: Health Care Insurance, Financial Concerns in Accessing Care, and Nonelective Readmissions Following Acute Myocardial Infarction
Authors: Smolderen Kim G , Spertus John A , Nallamothu Brahmajee K , Krumholz Harlan M , Tang Fengming , Xiang Ying , Wang Tracy , Ross Joseph S , Ting Henry H , Rathore Saif S , Chan Paul S
Published: March 2022

Background:
While lack of insurance is known to be associated with worse outcomes after myocardial infarction (MI), it is unknown whether health insurance status is associated with rates of non-elective hospitalizations after MI.

Methods:
Using data on 3571 U.S. MI patients enrolled between April 2005 to December 2008 in the 24-center, prospective TRIUMPH registry, we examined the association between being insured (reference), underinsured, and uninsured on rates of non-elective readmissions (all-cause) in the 1
st
year following MI. Insurance status was obtained from medical records, and underinsurance was defined as those patients with insurance but with financial concerns about accessing care from patient interviews. Multivariable modified Poisson regression models were used to adjust for site, demographics, MI severity, risk factors, socio-economic, and psychological factors.

Results:
A total of 2269 (63.5%) patients were insured; 650 (18.2%) were underinsured; and 652 (18.3%) were uninsured. Emergency readmissions were highest for uninsured patients (25.0%), followed by the underinsured (21.8%), and lowest in insured patients (19.5%) (P<.001). After multivariable adjustment, uninsured patients had significantly higher rates of emergency readmission (adjusted RR, 1.52 [95% CI: 1.22-1.90] while underinsured patients did not (adjusted RR, 0.99 [95% CI: 0.81-1.21]) (Figure).

Conclusions:
Uninsured patients had a significantly higher adjusted risk of non-elective readmissions after MI, while underinsured patients did not. Future studies are needed to determine if providing even modest insurance coverage to the uninsured can minimize readmission rates.
Abstract P144: Determinants of Invasive Treatment in Intermittent Claudication: Insights from Real-World Clinical Practice
Authors: van Zitteren Moniek , Vriens Patrick W , Burger Desiree H , de Fijter W M , Gerritsen G P , Heyligers Jan M , Nooren Maria , Denollet Johan , Smolderen Kim G
Published: March 2022

Background:
Guideline-recommended care for intermittent claudication (IC) preferentially consists of conservative treatment with exercise therapy and optimal pharmacotherapy. Although health status, anatomic lesion location, and cardiovascular risk considerations need to be taken into account when referring patients with IC for invasive vs. conservative therapy, it is unknown whether these factors and site variations are associated with the decision to offer patients with IC invasive revascularization in real-world clinical practice.

Methods:
A total of 407 patients with IC, enrolled from 2 hospitals in The Netherlands, completed a health status survey (SF-12, Physical Component Scale [PCS]) upon diagnosis. Patients' primary treatment strategies: invasive (bypass surgery, endovascular therapy) vs. conservative ([un]supervised exercise therapy) administered ≤1 year following diagnosis, ankle-brachial index (ABI), and risk factors were documented from their medical charts. Lesion location (proximal vs. distal) was documented from duplex ultrasound readings. Multivariable Poisson regression analysis sequentially included (1) demographics, hospital site, PCS; (2) lesion location; (3) ABI and risk factors to identify predictors of invasive vs. conservative therapy.

Results:
Of 407 patients, 150 (36.9%) received invasive treatment. Patients with poorer health status were more likely to be referred for invasive therapy (adjusted for demographics, site RR=0.98, 95%CI 0.97-0.99, P=0.017); this association was explained by proximal lesion location (P<0.001). Proximal lesions (RR=3.94, 95%CI 2.75-5.64, P<0.001) and site (RR=2.00, 95%CI 1.27-3.23, P=0.003) were independently associated with invasive therapy in the final model.

Conclusions:
More than one third of patients with IC were treated invasively 1 year following diagnosis. Although lower health status and proximal lesion location were considered in providers' decision to refer patients for invasive treatment, hospital location also determined the type of treatment strategy patients would get. Future efforts will further need to evaluate the appropriateness of use of invasive treatment in IC, in order to improve quality of care and reduce site variations in care.
Abstract P150: Cardiac Cath Lab Handovers for Inpatients
Authors: Griner Todd , Wilson Dana , Polancich Shea
Published: March 2022

Background:
Patient handovers between clinical areas are a crucial period in clinical care. Poor communication between caregivers can increase the risk of adverse events. We identified gaps in the quality of patient handovers between the cardiac catheterization laboratory (cath lab) and inpatient units. We initiated a process redesign of handovers for hospital patients pre-procedure and post-procedure from the cath lab.

Aim:
To improve communication and patient safety by creating a standardized handover tool of appropriate detail for each segment (pre- and post-procedure), and to emphasize interactive person-to-person communication between staff of the cath lab and inpatient units.

Methods:
We engaged staff from each area to identify handover strengths and weaknesses with the existing process. A baseline audit of handover elements for each segment was performed by the hospital quality management office. A standardized handover tool with specific data elements was created for each segment. Phone handovers could be used in the pre-procedure segment, but the goal was for post-procedure handovers to be face-to-face. Rapid cycle process improvement was used to refine the handover process and tool. After piloting the new process, a follow up audit of handover data elements was performed. With successful piloting of the new process, a second phase was added to improve handovers by ensuring completion of post-procedure orders before the patient was returned to their inpatient unit.

Results:
There was improvement in completion of all elements from baseline to pilot phase post-implementation in both handover segments (Table). In the second phase, completion of post-procedure orders prior to patient return to the inpatient unit went from zero percent to 85 percent compliance.

Conclusion:
Collaboration of staff and development of a standardized handover process between the cath lab and inpatient led to major improvements in performance.

Cath Lab Handover Baseline to Pilot Improvements

Overall Quality
3.76
4.05
0.13

Pre and Post Cath Handover Elements
Baseline
Pilot
Improvement

Abnormal Lab Values
0.25
1.00
0.75

H&P Complete
0.60
1.00
0.40

DNR Status
0.50
0.90
0.40

Consent Complete
0.29
0.64
0.35

Isolation Status
0.50
0.67
0.17

Dye Administration
0.25
1.00
0.75

Pulse Assessment
0.73
0.94
0.21

Post Procedure Ambulation Time
0.64
0.82
0.18
Abstract P152: Differences in Symptom Presentation According to Type of Acute Myocardial Infarction
Authors: Canto Andrew J , Kiefe Catarina I , Goldberg Robert J , Rogers William J , Peterson Eric D , Wenger Nanette , Vaccarino Viola , Frederick Paul D , Sopko George , Zheng Z J , Canto John G ,   for the NRMI Investigators
Published: March 2022

Background:
Chest pain/discomfort is the hallmark symptom of Acute Myocardial Infarction (AMI). An important percentage of AMI patients may not present with chest pain/discomfort. We hypothesized that the presence or absence of chest pain/discomfort at the time of admission may be influenced by the AMI classification type: ST segment elevation MI (STEMI) or Non STEMI (NSTEMI).

Methods:
We analyzed data from 1,143,513 AMI patients (565,195 with STEMI; 578,318 with NSTEMI) in the National Registry of Myocardial Infarction (NRMI) during the 1994-2006 period. Multivariable models were developed to examine the predictors of AMI presentation without chest discomfort by AMI type, adjusting for age, gender, ethnicity, payer status, cardiac risk factors, past medical history and past cardiac history.

Results:
The proportion of AMI patients who presented with chest pain was significantly higher in patients with STEMI (72.9%) than NSTEMI (56.4%) (p <0.001). Conversely, percentage of AMI patients who presented without chest pain was higher in NSTEMI (43.6%) and much lower in STEMI (27.1%) p <0.001. Multivariable analysis indicates a strong association by AMI Type.

TABLE.

Differences in Presentation Without Chest Pain Among Patients Diagnosed By AMI Type: NRMI, 1994-2006

Unadjusted Odd Ratio + 95 CI
Adjusted Odds Ratio + 95 CI

STEMI
NSTEMI
STEMI
NSTEMI

Reference
2.07 [2.06, 2.09]
Reference
1.93 [1.91, 1.95]

Conclusions:
Hospitalized AMI patients without chest pain/discomfort were almost 2x more likely to have NSTEMI than STEMI. These findings may have important clinical implications when evaluating patients with a suspected acute coronary syndrome.
Abstract P158: A Training Program for Nursing Staff on Communicating Adverse Outcomes and Errors
Authors: Byrd Jeannie , Pichert James , Westlake Margaret , Boord Jeffrey
Published: March 2022

Background:
Nursing professionals are confronted with situations where adverse events (AEs) or errors occur, and communication and disclosure principles are required to manage these challenging situations ethically and effectively. We adapted and taught hospital cardiovascular nurses an established program at Vanderbilt for training “the how and when of communicating unexpected AEs and errors.”

Methods:
The two-hour communication skills training program was presented to inpatient nurses in the Vanderbilt Heart and Vascular Institute (VHVI) and was evaluated using participant surveys. Obvious errors require full disclosure communications, and a “balance beam” approach was taught to weigh alternatives in situations involving uncertainty. We used live case-based interactive training with exercises requiring application of key content. Key elements included: early identification of unexpected AEs and errors, advocating for “huddles” among healthcare team members to consider how to handle unexpected outcomes, and supporting consistent communication to patients and families by team members. Surveys assessed participant satisfaction and intentions to change behavior based on program content.

Results:
57 nurses completed the intentions survey and indicated 164 intentions to change (mean 2.9 intentions/respondent). These were grouped into 5 categories (Table). Results on standard participant satisfaction questions were positive for content and teaching methods.

Conclusions:
We conclude that disclosure training provided relevant information and resulted in nurses’ intentions to change consistent with program objectives. We believe this program can enhance communication, promote a just culture among unit professionals, and facilitate doing the right things for patients and families.

Response Categories for Post-Program Intentions to Change

Intent Response Category
N intentions (%)

Use “balance beam” tool in situations of uncertainty re errors and AEs
19 (11.6)

Employ “huddles” when health team needs to think through alternative approaches to disclosure
38 (23.2)

Improve ability to analyze complex situations
56 (34.1)

Fully evaluate patients’ unexpected outcomes
3 (1.8%)

Pursue further information and share information on this topic
48 (29.3%)
Abstract P16: Trajectories of Functional Status among Those with Cardiovascular Disease
Authors: Kucharska-Newton Anna , Foraker Randi , Kalbaugh Corey , Rose Kathryn , Windham Beverly G , Rosamond Wayne
Published: March 2022

Trajectories of functional status among those with cardiovascular disease A. Kucharska-Newton
1
, R. Foraker
2
, C. Kalbaugh
1
, K. Rose
3
, B.G. Windham
4
, W. Rosamond
1
(1) UNC at Chapel Hill, NC; (2) OSU, Columbus, OH; (3) SRA International, Durham, NC; (4) UM, Jackson, MS

Background:
We examined functional status trajectories prior to and after hospitalization for non-fatal events (coronary heart disease (CHD), stroke, and heart failure (HF)) among participants of the Atherosclerosis Risk in Communities (ARIC) Study cohort (1993-2007).

Methods:
At annual follow-up, ARIC participants were asked if they were able (Yes=1/No=0) to walk up and down a flight of stairs, walk half a mile, perform heavy household work, and perform usual activities. A functional status score (range: 0-4) was constructed by summing these responses at each of the five years prior to and following an event.

Results:
Figure 1 shows that persons with CHD had the highest functional status score (adjusted for gender, race, and age) pre- and post-event, as compared to those with HF or stroke. Functional status post-event was greatest among those with CHD, followed by those with stroke. We observed a significant decrease in functional status following hospitalization for HF with no recovery over five years.

Conclusions:
Self-reported functional status post CHD and post stroke was either similar to that pre-event or continued to rise. Functional status following HF hospitalization declined and remained depressed over time. Studies are needed to identify treatment strategies that optimize function following CVD events, especially in heart failure patients. Figure 1. Functional status prior to and following a CVD event.
Abstract P162: Percutaneous Balloon Aortic Valvuloplasty: A Single-Center Experience of 357 Patients Over 10 Years
Authors: Ambrose David , George Jon C
Published: March 2022

Background:
Percutaneous balloon aortic valvuloplasty (PBAV) is primarily used as a palliative therapeutic option for relief of severe aortic stenosis (AS) in patients who are poor candidates for definitive surgical therapy. The rationale for limited use of PBAV in severe AS is due to poor durability and high rates of recurrence in early studies. This study describes the largest published single-center experience of PBAV with current day outcomes.

Methods:
We reviewed the last ten years of all patients that underwent PBAV at Deborah Heart and Lung Center totaling 357 patients. Extensive pre- and post-procedural data were tabulated on the last 100 patients, from October 2006 to January 2010, as a preliminary screening to determine current day outcomes with PBAV. Number of balloon inflations, mean gradients pre- and post-procedure, change in mean gradients, duration until repeat PBAV or surgical valve replacement, and mortality were all recorded and evaluated for correlation with outcomes.

Results:
Of the last 100 patients, there were no hospital or procedure-related deaths, strokes, or emergent cardiac surgery. Mean gradients (MG) across the aortic valve improved from 38.5 mmHg to 19.2 mmHg with an average change in mean gradient (ΔMG) of 19.1 mmHg. The number of inflations peformed during PBAV correlated to increase in ΔMG (1 inflation = 17.4 mmHg ΔMG; >2 inflations = 20.0 mmHg ΔMG; >3 inflations = 20.9 mmHg ΔMG). The number of inflations also correlated to an increased duration until repeat PBAV (1 inflation = 7.9 months; >2 inflations = 10.4 months; >3 inflations = 11.3 months). The average ΔMG among those that required repeat PBAV was 20.9 mmHg. The ΔMG was further linked to duration until repeat PBAV such that when ΔMG < 20 mmHg, duration to PBAV = 8.7 months and when ΔMG > 20 mmHg, duration to PBAV = 10.8 months. The mortality rate after PBAV was 10% with an average ΔMG within this subset of 21.5 mmHg.

Conclusions:
PBAV, although transient, provides a relatively modest improvement in valve function and continues to be safe and feasible in experienced hands for patient subsets that are high risk for surgery. Additional inflations during PBAV and ΔMG > 20 mmHg result in better long-term outcomes and need to be further evaluated in larger prospective studies.