bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 213: Engaging Cardiology Patients Via Electronic Patient-Reported Outcomes: A Usability Assessment
Authors: Kavalieratos Dio , Sullivan Sarah M , Hess Rachel
Published: March 2022

Background:
The use of electronic patient-reported outcomes (ePROs) in clinical practice is a powerful method of engaging the patient voice to help design, assess, and improve the healthcare we provide. Understanding how well patients interact with technology underlies our ability to engage patients to share their experiences regarding health, illness, and treatment using computers. To date, little is known regarding patients’ perceptions of ePROs in clinical practice; the literature is even thinner regarding patients’ experiences with ePROs in the cardiology setting.

Methods:
In 2012, we implemented an ePRO collection system throughout the University of Pittsburgh Medical Center’s (UPMC) Heart and Vascular Institute; sites included both community and academic cardiology practices. Patients use tablet computers to complete various symptom and quality-of-life assessments, which are seamlessly integrated into the electronic medical record. In this study, patients completed a short usability assessment at the conclusion of their ePRO survey. We assessed five types of trouble using the system: visibility, item comprehension, physical limitations, tapping, and other. Patients’ clinical and demographic data were abstracted from the electronic medical record, and matched to their ePRO assessments .We conducted univariate and bivariate statistics to describe the sample, as well as to identify associations between patient characteristics and patient-reported difficulty using the ePRO system.

Results:
From 01-August-2012 to 15-August-2013, 2,728 cardiology outpatients completed ePRO questionnaires. The average patient was a 63-year-old White male with a Charlson comorbidity score of 1. Eighty-two percent (n=2,247) of patients reported no difficulty using the ePRO system; of the 481 patients reporting any difficulty, 47% (n=221) found the tablet unresponsive to tapping, and 14% (n=66) of patients reported issues with item comprehension. Patients ≥65 years old and patients with rheumatoid disease were more likely to report difficulty (p<0.0001 and p=0.056, respectively) using the ePRO system. Patients who reported difficulty with the tablets were likelier to have reported worse health at the time of interview than a year prior (p=0.002), and were likelier to report both poorer physical and mental health than those patients without difficulty (p<0.001 and p<0.001, respectively).

Conclusions:
We have implemented a usable system to collect ePROs in cardiology patients across a variety of clinical settings. Although only a minority of patients reported difficulty with the system, future research is needed to facilitate maximal patient engagement with this method of data collection.
Abstract 215: Use of Chronic Medications among Patients with Non-Valvular Atrial Fibrillation
Authors: Kocis Paul T , Liu Guodong , Makenbaeva Dinara , Trocio Jeffrey , Velott Diana L , Trainer JoAnn B , Leslie Douglas L
Published: March 2022

Introduction:
Patients with non-valvular atrial fibrillation (NVAF) typically have other chronic comorbid conditions. However, little is known about the dosing regimens of medications that are prescribed to NVAF patients.

Objectives:
Estimate the proportion of real world NVAF patients with at least 1 CHADS
2
risk factor for stroke that may take chronic medications more than once per day.

Methods:
Using claims data from the Truven Health MarketScan® Commercial Claims and Encounters database, which contains health insurance claims data on a national sample of privately insured individuals, we identified NVAF patients with CHADS
2
≥ 1 during the period January 1, 2008 through September 30, 2012. Chronic medications were identified as those for which the patient had at least a 90 day supply during the study period, excluding oral anticoagulants. A “medication portfolio” was developed for each NVAF patient characterizing the chronic prescription medications taken on a regular basis. Information from the medication’s FDA approved product label and pharmacy claims data were used to add detail to each patient’s medication list. This detail included the medication name, recommended dosage and administration, and prescribed strength, quantity, and days supply. Patients were identified as taking medications multiple times per day if they were prescribed a medication with a >1 time per day dosing regimen per the product label, or one medication typically taken in the morning and another medication typically taken in the evening, or, in cases where the typical administration was unclear from the label or from clinical practice, were prescribed more than 1 pill per day, while the total daily strength of the medication was equal to an available strength of a single pill. The proportion of NVAF patients that took medications multiple times per day was then determined.

Results:
Overall, 324,172 NVAF patients were selected for the study. The mean age of the patients was 75.3 years and over half (54.6%) of the patients were male. Of these patients, 299,716 (92.5%) were prescribed chronic medications and 215,527 (66.5%) were identified as possibly taking medications more than once per day. Overall, among patients who were prescribed chronic medications, 71.9% were identified as possibly taking their medications more than once per day.

Conclusion:
Patients with NVAF typically have other chronic conditions and a large proportion of these patients may be on treatment regimens that require taking medications more than once per day.
Abstract 221: Degenerative Neurological Comorbidities In Patients Hospitalized With Congestive Heart Failure
Authors: Okunji Priscilla O , Daniel Johnnie
Published: March 2022

BACKGROUND/OBJECTIVES:
Chronic heart failure (CHF) has recently been known to be one of the most important public health concerns and a challenge to cardiovascular disease researchers, having increasing incidence and prevalence rates of CHF in industrialized countries. Although there are several sources of data on the congestive heart failure in selected populations, there are less few studies regarding the comorbidity of degenerative neurological disorders in patients diagnosed with congestive heart failure.

METHODS:
Cross-sectional data of a population-based nationwide inpatient CHF (797,113) subjects, average age (73 years) were analyzed to determine the prevalence of CHF and association of major neurological conditions in the inpatients admitted with CHF. The International Classification of Disease ICD-9 codes were used (CHF - 4280, Alzheimer - 3310, Parkinson- 3320 and Multiple Sclerosis - 340) for the selection.

RESULTS:
The overall gender-prevalence of CHF was 47% (n = 377,580) for males and 53% (n = 419,481) for females. Inpatients with CHF also had Alzheimer (n = 22,521; 31.65%), Parkinson (n = 10,969; 15.42%), and Multiple Sclerosis (n = 1,620; 2.28%). The prevalence of CHF strongly increased with age, less than 1% (n = 1,299) for subjects < 1 year age to ~4% (n = 31,488) among 82 year old subjects. The regression results for patients who were admitted with CHF as their primary complaints (71,130) showed a significance difference between patients who died in the hospital and most inpatients’ characteristics for age (p = .000), race (p = .000), hospital total charge (p = .000) and median household income (p = .015). However, gender (p = .090) was not statistically significant at p < .05.

CONCLUSION:
The prevalence of CHF increase appears higher in males than in female gender in this study. Patient age, economic status and hospital charges showed significant results with the mortality rate of the patients hospitalized in 2010. The associated degenerative neurological conditions in these inpatients could be attributed to other comorbidities and progressive neurological/degenerative disorders prevalent in elderly populations.
Abstract 224: Strength of Evidence for Cardiovascular Devices Approved by the FDA's Humanitarian Device Exemption Pathway
Authors: Redberg Rita F , Dhruva Sanket S
Published: March 2022

Introduction:
Cardiovascular devices have important benefits on morbidity and mortality in patients with heart disease. High-risk devices must show evidence of safety and effectiveness to receive Food and Drug Administration (FDA) approval. However, the FDA’s Humanitarian Device Exemption (HDE) pathway regulates devices which are intended to benefit patients by treating or diagnosing a disease or condition that affects fewer than 4,000 U.S. patients annually, and this pathway does not require evidence of effectiveness. We aimed to characterize the type and quality of evidence on which FDA HDE approval for cardiovascular devices is based.

Methods:
We performed a systematic review of all cardiovascular devices that have received HDE approval from 1999-2013. We analyzed the FDA’s “Summary of Safety and Probable Benefit” for these devices and examined the studies and primary endpoints for methodological characteristics considered essential to minimize confounding and bias.

Results:
Twelve cardiovascular devices have received FDA HDE approval. Eighteen studies form the basis of the clinical evidence justifying approval for these twelve devices. None of the eighteen studies used to support FDA HDE approval were randomized and none were blinded. One trial (6%) compared the study population to controls, and those controls were retrospectively chosen. Twelve studies (67%) stated the mean age of patients. Ten studies (56%) stated the sex distribution. Four studies (22%) looked for differences in device safety or efficacy by sex. Five (28%) studies clearly stated a primary endpoint, and one of the five (20%) employed surrogate measures for the primary endpoint. Three of the twelve devices (25%) were reviewed by the Circulatory System Devices Panel prior to FDA HDE approval.

Conclusions:
HDE cardiovascular devices used to treat patients with heart disease are commonly approved without randomized studies or control groups. Primary endpoints are not often clearly delineated in HDE studies. As there may be limited data before approval, it is important to monitor the post-market safety and effectiveness of these high-risk devices.
Abstract 227: Estimating the Value of Effective Lipid Management in China
Authors: Vanderpuye-Orgle Jacqueline , Stevens Warren , Peneva Desi , Liu Larry Z , Lakdawalla Darius
Published: March 2022

Background:
Increasingly sedentary lifestyles and dietary changes associated with economic development in China, combined with progress in the treatment of infectious disease have resulted in a shift in the disease burden - the so-called epidemiological transition. Cardiovascular disease (CVD), including coronary heart disease (CHD) and other non-communicable diseases now play an increasingly important role in the disease burden faced by China. However, little is known about the future burden of CHD morbidity and mortality, as well as the cost-effectiveness of particular CHD-prevention policies in China.

Objectives:
To estimate the impact of aging and epidemiological transition on the burden of CHD morbidity and mortality over the next 15 years in China and to estimate the net value of effective lipid management.

Methods:
First, we estimate the prevalence of CHD and other risk factors based on the China Health and Nutrition Survey. Next, using prediction from the literature regarding trends in demographic and cardiovascular risk factors, such as elevated low-density lipoprotein cholesterol (LDL-C), we model how CHD risk will evolve between 2015 and 2030. We then estimate how expanded use of statins for lipid management over the next 15 years would alter the prevalence of elevated LDL-C as a risk factor, and determine how this would dampen the future growth in CHD burden. Accounting for the costs of statin use, we assess the net value of a policy that expands statin utilization for lipid management in China.

Results:
We find that - left unchecked - rising prevalence of CHD risk factors and the aging of the Chinese population will lead to the incidence of heart attacks rising from 4 million in 2015 to over 6 million in 2030. Similarly, the number of CHD deaths will rise from 1.3 million in 2015 to over 2 million in 2030. Treating all hyperlipidemia patients with statins would avert 10.5 million heart attacks and 3.5 million CHD deaths between 2015 and 2030. Based on current estimates of treatment costs in China and the cost of statins, we predict that such a policy would produce a net social value of $176 to $226 billion over the next 15 years.

Conclusions:
In light of its aging population and continued economic development, China faces near-certain increases in the incidence of CHD morbidity and mortality. Preventative measures such as effective lipid management may reduce the CVD burden substantially and also provide large social value to the society. At a time when the Chinese government is taking steps towards a more systematic approach to health care delivery, primary and secondary prevention of CVD should be high on the agenda.
Abstract 229: An Urban Garden Initiative: A Component of Project Healthy Schools
Authors: Wei Wen-Ching R , Heeres Alison , Aaronson Susan , Rogers Robert , Lee Alexander , Pew Alexandra , Foti Alisa , Vuong Belinda , Corriveau Nicole , Jiang Qingmei , Kline-Rogers Eva , Goldberg Caren , DuRussel-Weston Jean , Jackson Elizabeth A , Eagle Kim A
Published: March 2022

INTRO:
Childhood obesity has been a growing problem in the US, with its prevalence linked to cardiovascular disease.

School gardens can provide a hands-on method of teaching healthy dietary habits for students. Project Healthy Schools (PHS) is a school-based wellness program, a collaboration between the University of Michigan Health System and community groups that focuses mainly on middle school students. PHS currently has educational programming in 42 schools across lower and mid-Michigan. In 2010, PHS began implementing a garden initiative in select Detroit schools.

METHODOLOGY:
The goal of the garden initiative is to familiarize students with fruits and vegetables and increase their interest in eating fresh produce and other healthy foods. Students are invited to participate in the gardening, which increases time spent outdoors, away from televisions, computers and video games. Initial funding for this project came from multiple donors interested in promoting healthy lifestyles in school-age children: The University Cultural Center Association, Detroit’s Garden Resource Program, Lowe’s Education Toolbox Grant, Whole Kids Foundation and the American Heart Association.

RESULTS:
Six Detroit schools participated in the garden initiative. The gardens are located either directly at or within walking distance of the school. At each school, the garden initiative consists of an afterschool club, led by a PHS Wellness Coordinator and/or a teacher. Students from regular classes also visit the garden as a way to engage additional students with the project. Each year, the gardening starts in April and the harvest season ends in October. During summer vacation, students have the opportunity to remain involved. In the fall, the produce they harvest has been used in lessons where students consume the produce raw, learn to cook with produce, or even sell the garden produce.

While not all changes reached a level of significance, there were some notable trends, including an increase in vegetable consumption in four schools in 2012. The gardens have also encouraged parental involvement as some parents accompanied their children to the school garden.

CONCLUSIONS:
Garden initiatives have given a number of Detroit students the opportunity to learn about fresh produce, encouraged healthy eating, and promoted parental involvement. Garden initiatives for this program will continue with the goal of incorporation into the schools’ curricula. As the project expands, future studies will further evaluate the effects of students’ participation in the gardens on students’ eating habits and physiological markers.
Abstract 23: Cost-Benefit Analysis of Home Blood Pressure Monitoring: A Business Case
Authors: Arrieta Alejandro , Woods John , Jay Stephen , Qiao Nan
Published: March 2022

BACKGROUND:
Home blood pressure monitoring (HBPM) is more effective than clinic monitoring (CBPM) for both diagnosing and managing hypertension. However, reimbursement of home blood pressure monitors is uncommon in the United States due to a lack of evidence that HBPM is cost-beneficial from an insurance perspective.

METHODS:
We analyzed claims data from a large U.S. health insurer, which included both a commercial plan as well as a Medicare Advantage plan. We used a decision analytic model to depict transitions among various states from initial physician visit, to hypertension diagnosis, to treatment, to hypertension-related cardiovascular disease states, and beneficiary deaths or resignations from the plan. Model inputs were derived from the insurer’s 2008-2011 claims data, the 2009-2010 National Health and the Nutrition Examination Survey (NHANES), and from published literature. We estimated both short- and long-run (10-year) cost-benefit and return on investment (ROI) (net-savings relative to cost) of HBPM compared to CBPM for different age groups. We conducted a sensitivity analysis to estimate financial risk to the insurer under various implementation scenarios.

RESULTS:
Overall net savings per member were $33.80 (ROI = 0.94) in the first year and $414.80 (ROI = 8.37) after 10 years for the age group 20-44, $32.70 (ROI = 0.84) in the first year and $439.10 (ROI = 7.50) after 10 years for those age 45-64, and $166.20 (ROI = 3.75) in the first year and $1,364.3 (ROI = 19.34) after 10 years for Medicare beneficiaries age > 65. For non-elderly adults most of the savings were related to the superior diagnostic specificity of HBPM. Conversely, for Medicare beneficiaries most of the savings were related to better blood pressure control when HBPM was used to monitor hypertension treatment following diagnosis. For example, in those age 20-44 the ROI was positive in both the short run (1 year = 0.87) and long run (10 year = 11.26) when HBPM was used to diagnose hypertension, but negative when it was used to monitor hypertension treatment (1 year = -0.87; 10 year = -0.33). On the other hand, when HBPM was used to diagnose hypertension in elderly adults (age > 65), the ROI was initially negative (1 year = -0.36) but then became positive (3 year = 0.81; 10 year = 3.75), and when used to monitor treatment the ROI was positive throughout (1 year = 4.37; 10 year = 18.54).

CONCLUSIONS:
Our analysis shows for the first time that paying for HBPM is cost-beneficial for insurers. We also show that ROIs can be optimized, while minimizing financial risk, by focusing on specific uses of HBPM for different age groups. Our study suggests that optimal ROIs may be achieved if HBPM is used for hypertension diagnosis in non-elderly adults (age < 65) and for both diagnosis and management in the elderly (age > 65).
Abstract 244: Anticoagulant Options and Inpatient Costs for Patients with Non-Valvular Atrial Fibrillation
Authors: Laliberté François , Pilon Dominic , Raut Monika K , Nelson Winnie W , Olson William H , Germain Guillaume , Schein Jeff R , Lefebvre Patrick
Published: March 2022

Background:
For decades, warfarin has been the primary oral anticoagulant prescribed for stroke prophylaxis in non-valvular atrial fibrillation (NVAF). With the recently introduced target specific oral anticoagulants (TSOAC), coagulation laboratory monitoring and the need to achieve and maintain the target international normalized ratio (INR) are no longer required. We hypothesized that use of a TSOAC may reduce hospitalization costs for patients with NVAF requiring stroke prophylaxis.

Objective:
To compare hospitalization costs between hospitalized NVAF patients using warfarin or rivaroxaban in a real-world setting.

Methods:
A retrospective claims analysis was conducted using the Premier Perspective Comparative Hospital Database from 11/2010 to 9/2012. Adult patients hospitalized for NVAF after November 2011 were included. The first hospitalization for NVAF was defined as the index hospitalization. Patients using rivaroxaban during hospitalization were matched with up to four warfarin users by propensity score analyses. Index hospitalization and all hospitalization (i.e., both index and readmissions occurring between November 2011 and September 2012) costs were compared between the cohorts using generalized estimating equations with gamma distribution, log link, and adjusting for the matched design. A sub-analysis was performed for patients who received their first oral anticoagulant treatment on day three or later of their hospital stay. Sensitivity analyses were also conducted on matched cohorts with a primary diagnosis of AF.

Results:
The characteristics of the matched cohorts (2,809 rivaroxaban and 11,085 warfarin users) were well balanced. The mean age of both cohorts was 71 years and 49% of patients were female. The average index hospitalization cost of the rivaroxaban cohort was $11,993 vs. $13,255 for the warfarin cohort, and the cost difference (CD; $1,284) was significant (P<.001). Similarly, the corresponding all hospitalization cost were $13,900 vs. $16,697 for the rivaroxaban and warfarin cohorts, respectively, also significantly lower (CD= $2,798) for the rivaroxaban cohort (P<.001). The subset of patients who first received oral anticoagulation on day three or after also incurred significantly lower costs with rivaroxaban compared to warfarin (index hospitalization: $15,703 vs. $20,042, CD= $4,350, P<.001; all hospitalization: $18,499 vs. $24,897, CD= $6,388, P<.001). In patients with a primary diagnosis of AF, the rivaroxaban cohort had significantly lower costs compared to the warfarin cohort (index hospitalization: $6,686 vs. $8,376, CD=$1,609; all hospitalization: $8,157 vs. $10,746, P<.001, CD=$2,612, P<.001).

Conclusion:
In propensity-matched cohorts of NVAF patients treated with warfarin or rivaroxaban, a TSOAC, our data demonstrated significant index and overall hospital cost reductions associated with the TSOAC strategy.
Abstract 245: Achieving Appropriate Use Metrics for Angioplasty
Authors: Lawson William E , Wilbert Lisa , Gumersell Kellie , Sokoloff Lisa , Santora Carolyn , Mani Anil
Published: March 2022

Background:
With the development of appropriate use metrics for coronary angioplasty, application of these criteria to the NYS PCI data base resulted in 14.3% of PCIs in NYS being deemed “inappropriate”. While “inappropriate” has been changed to “rarely appropriate’’ in professional society guidelines, public interpretation of this designation, medicolegal issues, and reimbursement for procedures in this category remain concerns. Because the bulk of PCI procedures are ad hoc, appropriateness of treatment is largely determined by preprocedural documentation and treatment.

Procedure:
The 2010 SBUH “inappropriate” PCI rate from NYS was utilized as a baseline and compared with post intervention Qtr 4, 2012 - Qtr 3, 2013. Trained abstractors audited charts to identify patients that would potentially be classified “inappropriate” and determine which data elements were missing most frequently. A preprocedural screening tool was developed and implemented to establish PCI appropriateness as supported by adequate documentation and preprocedural medical therapy. Pretest outpatient NP screening identified and addressed concerns identified by using the preprocedural tool. A monthly meeting was organized where Physician Specific compliance reports that had been created were reviewed.

Results:
Baseline “inappropriate” interventions at SBUH comprised 24.8% of total PCI. Inappropriate classification was due to both inadequate documentation and less than optimal medical therapy. Implementation of the PCI AU tool resulted in a sustained decline in the “inappropriate” procedures to 1.6% (NCDR mean 2.5% for this time period). An additional unanticipated benefit of the process has been that the feedback provided to referring attendings continues to improve required documentation and medical therapy supporting PCI revascularization. The tool will be shared at presentation.

Conclusions:
The combination development of a PCI screening tool for potential ad hoc intervention patients and outpatient review of documentation and medical therapy allowed a substantial improvement in PCI appropriateness. Appropriate feedback to referring physicians augmented the effect of these process changes and improved appropriate utilization.
Abstract 263: The Risk of Stroke or Systemic Embolism for Antithrombotic Treatment Episodes among Non-Valvular Atrial Fibrillation (NVAF) Patients
Authors: An JaeJin , Niu Fang , Lang Daniel T , Le Paul T , Jazdzewski Kristin P , Rashid Nazia , Mendes Robert , Dills Diana , Meissner Brian , Bruno Amanda
Published: March 2022

Background:
The quality of antithrombotic therapy during routine medical care is often suboptimal.This study evaluated stroke or systemic embolism (SE) risk for real-world antithrombotic treatment patterns in NVAF patients within an integrated healthcare system.

Methods:
Patients aged ≥18 years and newly diagnosed with NVAF (index date) were identified between 01/01/2006-12/31/2011 within Kaiser Permanente Southern California, categorized by baseline CHADS
2
risks, and followed until 12/31/2012. Longitudinal analyses examined time-varying antithrombotic treatment episodes for each individual patient. The unadjusted and adjusted relative risk (RR) of stroke/SE was reported from generalized estimating equation models for 6 different treatment episodes: 1) warfarin time in therapeutic range (TTR) ≥55%, 2) warfarin TTR <55%, 3) off warfarin, 4) on aspirin (ASA), 5) off ASA, and 6) never on antithrombotic therapy.

Results:
Among 23,297patients with CHADS
2
≥1, 1,782 stroke/SE events occurred during 60,021 person-years of follow-up. The warfarin TTR ≥55% category had the lowest stroke/SE rate (Rate = 0.87 per 100 person-years, 3.23 TTR<55%, 4.38 off warfarin, 3.11 ASA, 3.81 off ASA, and 3.76 never on therapy). Warfarin TTR ≥55% was associated with a 77% lower risk of stroke/SE, and ASA was associated with a 27% lower risk of stroke/SE compared to never on therapy (adjusted RR [95% CI] = 0.23 [0.19-0.29], 0.73 [0.65-0.82] respectively). Warfarin TTR <55% was only marginally associated with the stroke/SE reduction compared to never on therapy (adjusted RR = 0.83 [0.70-0.99]). The stroke/SE risk for off warfarin and off ASA were not statistically different from never on therapy. Other significant factors associated with stroke/SE included older age, female, Black or Hispanic race, having diabetes, hypertension, previous stroke/TIA, peripheral vascular events, higher comorbidity score, and not having a major bleed.

Conclusion:
Warfarin TTR ≥55% was associated with the greatest reduction in stroke/SE among the antithrombotic treatment groups examine here. Future studies should examine modifiable factors to improve outcomes for patients with warfarin TTR <55% or those who are off antithrombotic therapy.
Abstract 269: Does Functional Recovery After Stroke Vary by Hospital Type?
Authors: Prvu Bettger Janet , Liang Li , Thomas Laine , Bushnell Cheryl , Xian Ying , Wu Jingjing , Peterson Eric D
Published: March 2022

Background:
Functional recovery following an acute ischemic stroke is a highly important outcome from a patient’s perspective. Whether functional outcomes following stroke vary among treating hospitals is unknown.

Methods:
We examined 3 month functional recovery measured by the modified Rankin Scale (mRS) among 2,076 ischemic stroke patients treated at 82 U.S. hospitals in the Adherence eValuation After Ischemic stroke Longitudinal (AVAIL) study and Get With The Guidelines-Stroke registry. We used multivariable hierarchical models to examine the association of hospital characteristics (number of beds, region, academic/teaching center, annual ischemic stroke discharges, primary stroke center certification, hospitals’ composite score indicating stroke quality of care) and the outcome after adjusting for patient characteristics (socio-demographics and clinical factors including stroke severity as measured by the NIHSS). Rankin scores were classified as moderate-severe disability (mRS 3-5) vs. minor to no disability (mRS <2) and evaluated as continuous scores.

Results:
Overall by 3 months after discharge, 35.9% of stroke patients had moderate-severe disability. Rates of moderate-severe disability varied by treating hospital (Figure) (mean 36%, IQR 26%-45%). Patients cared for in a teaching hospital (adjusted OR 0.71, 95% CI 0.52-0.96) or primary stroke center certified hospital (adjusted OR 0.69, 95% CI 0.51-0.93) were significantly less likely to have moderate-severe disability at 3 months. Relative to the Northeast, care in hospitals in the Midwest or South was associated with higher likelihood moderate-severe disability (OR 1.45, 95% CI 1.04-2.03 and OR 1.57, 95% CI 1.06-2.30, respectively). In contrast, functional outcomes did not vary by hospital stroke care quality, stroke volume, or hospital bed size. Findings were similar for mRS as a continuous outcome.

Conclusions:
A third of acute ischemic stroke patients had moderate-severe disability three months after hospital discharge and these rates varied considerably among U.S. hospitals. Receiving stroke care at a teaching or primary stroke center hospital was associated with significantly better post discharge functional status.
Abstract 27: Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction
Authors: Kureshi Faraz , Kennedy Kevin F , Jones Philip G , Thomas Randal J , Buchanan Donna M , Sharma Praneet , Fendler Timothy , Arnold Suzanne V , Ho P M , Nallamothu Brahmajee K , Spertus John A
Published: March 2022

Background:
Cardiac rehabilitation (CR) is a class Ia recommendation and endorsed performance measure for the quality of care in acute myocardial infarction (AMI) survivors. While participation in CR after AMI is associated with reduced mortality, conflicting data exists on its association with health status outcomes.

Methods:
Using data from 2 prospective AMI registries (TRIUMPH and PREMIER), we identified patients for whom baseline and follow-up health status scores and documentation of CR participation (attendance of 1 or more sessions within 6 months post-AMI) were available. Health status was assessed by four Seattle Angina Questionnaire (SAQ) domain scores (quality of life [QoL], angina frequency [AF], treatment satisfaction [TS], and physical limitation [PL]), as well as SF-12 physical and mental health composite scores (
PCS
&
MCS
). We created propensity matched cohorts of CR participants and non-participants to examine the association between CR participation with health status (6 and 12 months) and all-cause mortality (up to 7 years), using conditional repeated measures and proportional hazards models, respectively.

Results:
Among 3,957 AMI patients from 31 sites, 2,015 patients (51%) participated in CR after discharge. Compared to non-participants, CR participants were more often Caucasian (83.6% vs. 65.4%), had higher rates of health insurance (90.6% vs. 79.3%), but clinically similar baseline SAQ and SF-12 scores in all domains. After propensity matching, all covariates were well-balanced (Standardized Difference <10 for all patient characteristics) between CR participants and non-participants. In the repeated measures analysis, the mean SAQ and SF-12 domain scores were clinically similar for both groups at 6 and 12 months after hospital discharge (Table). Using a conditional proportional hazards model, a decrease in all-cause mortality was noted in the CR participant group (HR 0.59, 95% CI [0.46, 0.75]).

Conclusion:
In a large, multi-center AMI cohort, we found that although CR participation seemed to improve survival, CR participants had similar health status improvements after AMI as non-participants. Further investigation is required to identify how CR programs can further maximize the health status benefits to post-AMI participants.
Abstract 270: Primary and Specialty Care Follow-up Appointments after Stroke: Rates, Variability, and Opportunities for Improvement
Authors: Prvu Bettger Janet , Katzan Irene , Lender Stacy , Liskay Alice , Loechler Abby , Bayt Demetria , Pryor Barbara , Peterson Eric D , Nutter Diane
Published: March 2022

Background:
Follow-up care after an acute stroke can facilitate patient recovery and limit recurrence. In other disease states, scheduling a follow-up appointment with primary and specialty care prior to hospital discharge can facilitate smooth care transitions. However there are limited data on the variability in care continuity after acute stroke.

Methods:
We examined overall and hospital specific rates of follow-up appointments with primary care and specialty care scheduled prior to hospital discharge among the 44 Ohio Coverdell Stroke Program hospitals. Patients of any stroke type, without documented comfort measures, and discharged home, alive and not to hospice care were eligible for a follow-up appointment with primary care. To be eligible for the specialty care appointment, patients of any stroke type needed an order for a follow-up appointment with a neurologist or neurosurgeon, be without documented comfort measures, and discharged home, to rehabilitation or a skilled nursing facility. Multivariable logistic regression was used to examine patient and hospital factors associated with each follow-up appointment measure. Facilitators and barriers to scheduling appointments prior to discharge were reported by stroke team members at a meeting of participating hospitals.

Results:
Of the 4,162 patients eligible for the specialty care measure over 6 months, 24.8% had a neurologist or neurosurgeon appointment scheduled before hospital discharge. Hospital-level specialty appointment arrangement ranged from 0-83%. Among 3,141 patients eligible for a primary care appointment, 14% had one scheduled prior to discharge; hospital specific variability ranged from 0-50%. In the multivariable model, age, gender, stroke type, insurance type, and hospital stroke volume were not associated with either primary or specialty care appointments. Facilitators of follow-up care reported by some participating hospitals were paradoxicallly reported as barriers by others. These included availability of dedicated personnel to plan with the patient and family and schedule with post-hospital providers, functionality of electronic medical records, provider perspectives on the importance of follow-up, schedule availability of post-hospital providers, geographic accessibility for patients, integration with other discharge planning processes, and inclusion of the scheduled appointments on discharge summaries for patients.

Conclusions:
A high proportion of patients with acute stroke failed to have a primary care or specialty care follow-up appointment scheduled prior to discharge and this varied widely across participating hospitals. A collaborative approach for data-driven change and exchange of local best practices and facilitators could lead to significant improvement.
Abstract 280: Cardiologist Consultation and Associated Outcomes for Older Women with Heart Failure after Breast Cancer Therapy
Authors: Chen Jersey , Long Jessica , Chen Carol , Wang Shi-yi , Steingart Richard , Gross Cary P
Published: March 2022

Background:
Commonly employed breast cancer therapies can cause cardiomyopathy (CM) and heart failure (HF). Whether breast cancer patients who subsequently develop HF/CM are treated by cardiologists, and whether this is associated with higher use of guideline-recommended treatments for HF/CM is unknown.

Methods:
We used data from SEER-Medicare to identify women with early stage breast cancer diagnosed 2000-2009 who received potentially cardiotoxic adjuvant therapy (anthracyclines, trastuzumab) and developed HF/ CM. We assessed the frequency of consultation or office visit with a cardiologist within 90 days of HF/CM (as ascertained by diagnostic billing codes). Using Medicare Part D pharmacy claims (available 2006-2011, N=177), we assessed differences in use of guideline-recommended treatments (angiotensin converting enzyme [ACE]-inhibitors, angiotensin-receptor blockers [ARBs] and beta-blockers specifically indicated for HF/CM) stratified by cardiology consultation using χ
2
test. We compared differences in survival after HF/CM stratified by cardiology consultation using the log-rank test.

Results:
We identified 1028 older women with stage I-III breast cancer diagnosed between 2000 and 2009 who developed HF/CM in the 3 years after adjuvant cancer therapy. Mean patient age was 73.1 years (standard deviation=4.8); 71%received anthracyclines alone, 17%received trastuzumab alone, and 12% received both. There were 345 (34%) women seen by a cardiologist within 0-90 days after the HF/CM diagnosis. Among women with pharmacy claims, a cardiologist visit was significantly associated with higher use of ACE-inhibitors or ARBs (60% v 44%, p=.039), and beta-blockers specifically indicated for HF treatment (40% v 24%, p=.026), compared to women who did not have cardiologist visit. One-year survival after HF/CM was higher patients with cardiologist consultation compared with no cardiologist consultation (79% v 91%, p=.001).

Conclusions:
The majority of women who developed HF/CM after breast cancer therapy were not treated by a cardiologist, and had lower quality of care with higher 1-year mortality. This represents an important area for collaboration between oncologists and cardiologists to improve the care and outcomes of patients with HF/CM as a complication of breast cancer therapy.
Abstract 29: Temporal Trends in Incidence and Outcomes of Peripartum Cardiomyopathy in the United States: A Nationwide Population-Based Study
Authors: Kolte Dhaval , Khera Sahil , Aronow Wilbert S , Palaniswamy Chandrasekar , Mujib Marjan , Ahn Chul , Jain Diwakar , Gass Alan , Ahmed Ali , Panza Julio A , Fonarow Gregg C
Published: March 2022

Background:
The reported incidence of peripartum cardiomyopathy (PPCM) in the United States varies widely. Furthermore, limited information is available on the temporal trends in incidence and outcomes of PPCM.

Objectives:
To determine the overall incidence and complication rates of PPCM, and to analyze temporal trends in incidence and outcomes of PPCM in the United States.

Methods:
We queried the 2004 to 2011 Nationwide Inpatient Sample databases to identify all women aged 15 to 54 years with the diagnosis of PPCM using ICD-9-CM codes 674.5x. Temporal trends in incidence (per 10,000 live births), maternal major adverse events (MAE defined as in-hospital mortality, cardiac arrest, heart transplant, mechanical circulatory support, acute pulmonary edema, thromboembolism or implantable cardioverter defibrillator/permanent pacemaker implantation), cardiogenic shock, and length of stay were analyzed.

Results:
From 2004 to 2011, we identified 34,219 women aged 15 to 54 years with PPCM. The overall PPCM rate was 10.3 per 10,000 (or 1 in 968) live births. PPCM incidence increased from 8.5 to 11.8 per 10,000 live births (p
trend
<0.001) during the study period. MAE occurred in 13.5% of patients. The most common complication in women with PPCM was thromboembolism (6.6%). The incidence of other complications was - in-hospital mortality in 1.3%, cardiac arrest in 2.1%, heart transplant in 0.5%, use of mechanical circulatory support in 1.5%, acute pulmonary edema in 1.8%, ICD/PPM placement in 2.9%, and cardiogenic shock in 2.6% There was no temporal change in MAE rate, except a small increase in in-hospital mortality [0.7% in 2004 to 1.8% in 2011, adjusted OR (per year) 1.08, 95% CI 1.02-1.14, p
trend
=0.006] and use of mechanical circulatory support [0.9% in 2004 to 2.2% in 2011, adjusted OR (per year) 1.08, 95% CI 1.03-1.14, p
trend
=0.002]. Cardiogenic shock increased from 1.0% in 2004 to 4.0% in 2011 [adjusted OR (per year) 1.16, 95% CI 1.11-1.21, p
trend
<0.001]. Mean length of stay decreased during the study period.

Conclusion:
From 2004 to 2011, the incidence of PPCM has increased in the United States. Maternal MAE rates overall have remained unchanged while cardiogenic shock, need for mechanical circulatory support, and in-hospital mortality have increased during the study period. Further study of the mechanisms underlying these adverse trends in the incidence and outcomes of PPCM are warranted.
Abstract 300: Determinants and Impact of Platelet Transfusions After Cardiac Surgery
Authors: Al-Attar Paul , Bolling Steven F , Paone Gaetano , DeLucia Alphonse , Theurer Patricia F , Prager Richard L , Likosky Donald S
Published: March 2022

Objectives:
Patients undergoing cardiac surgery may receive blood products during the perioperative period. While increasing attention has been drawn to red blood cell transfusions given its associated cost and morbidity, less work has been devoted to other frequently delivered blood component therapies, including platelets. We sought to identify pre-operative determinants and outcomes of platelet transfusion in the setting of coronary artery bypass grafting (CABG) surgery.

Methods:
Data from 4,574 patients undergoing on pump, isolated, non-emergent CABG surgery between July 2011 and June 2012 were entered into a statewide collaborative database. Logistic regression models were constructed to assess determinants and impact of platelet transfusions, and calculate crude and risk-adjusted odds ratios (OR). Post-operative outcomes included in-hospital mortality, re-operation for bleeding and prolonged (>24 hours) ventilation.

Results:
Platelet transfusions occurred among 14.7% (674 of 4574) of CABG procedures. Platelet transfusions were associated with increased odds of death (OR
adj
4.2), reoperation for bleeding (OR
adj
23.3), and prolonged ventilation (OR
adj
3.4), all p<0.001. As expected, those receiving platelets had higher odds of having received packed red blood cells (OR 7.9, p<0.001). We found 10 variables significantly associated with platelet transfusions, including: adenosine diphosphate (ADP) receptor inhibitors or antiplatelet medications, ejection fraction, albumin, creatinine, platelet count, intra-aortic balloon pump use, prior cardiovascular operation, body surface area, and age. Adjusted ORs (with 95% confidence intervals) are displayed in the Figure.

Conclusions:
Platelet use was associated with increased odds of morbidity and mortality after CABG surgery. We identified 10 pre-operative factors associated with platelet transfusions. This study enhances our understanding of risk factors for traditionally overlooked yet potentially harmful blood components. Given these findings, future work should focus on identifying practices that may assist in reducing rates of platelet transfusions.
Abstract 305: Post-discharge Costs in Heart Failure: Kidney Disease Severity as a Key Contributor
Authors: Chan Wing , Swindle Jason P , Waltman Johnson Katherine , Becker Laura K , Blauer Peterson Cori , Riedel Aylin
Published: March 2022

Background:
This study examined post-discharge costs among individuals hospitalized with heart failure (HF) by stage of chronic kidney disease (CKD).

Methods:
A retrospective claims-based study of medical and pharmacy data linked to laboratory results from a large US health plan (Jan2007-Sep2012) was conducted. Earliest inpatient stay with HF diagnosis was defined as index hospitalization. Post-index costs were calculated per-member-per-month (PMPM) for the subset of individuals with a post-discharge observation up to 6 months. Individuals were assigned to CKD stages 1-5 using the CKD-Epidemiology Collaboration Group equation. One-way ANOVA was used to examine differences in follow-up health care costs across CKD stages.

Results:
A total of 24,023 individuals hospitalized with HF (mean age 70 y, 51% female, 71% white, 65% Medicare Advantage) were included. Subjects with at least moderately reduced renal function (eGFR <60 mL/min, stages 3-5) when compared to individuals with normal/mild reduction (eGFR ≥60 mL/min, stages 1-2) experienced higher follow-up ambulatory ($1,508 vs. $1,236) and inpatient ($3,725 vs. $3,152) all-cause costs. HF-related medical costs accounted for approximately 40% of all-cause medical cost for CKD stages 2-4 (table).

Conclusion:
Findings from this study suggest that medical costs following HF hospitalization increase by severity of CKD stage, with HF-related costs comprising a large portion of inpatient and outpatient costs.
Abstract 316: Arm Exercise Heart Rate, Stress Test Findings and Outcome
Authors: Marshall Cynthia , Xian Hong , Chandiramani Pooja , Bainter Emily , Martin Wade
Published: March 2022

Attainment of 85% age-predicted peak heart rate (APPHR) during leg exercise is widely accepted and emphasized in clinical textbooks as a condition for adequate diagnostic stress test sensitivity. However, there is little direct evidence for this belief and relationships among peak heart rate, diagnostic sensitivity, coronary revascularization and mortality are poorly characterized. In addition, the prognostic significance of chronotropic incompetence as a predictor of mortality is underappreciated and there is almost no data relating arm exercise heart rate responses to abnormal stress test results and mortality.

Thus, the purpose of this study was to investigate relationships among arm exercise heart rate responses, abnormal stress tests findings, coronary revascularization and mortality in patients who could not perform leg exercise. From 1997 to 2002, we conducted arm cycle ergometer stress tests on 446 veterans aged 64±11 years, of whom 253 underwent myocardial perfusion imaging (MPI). We evaluated associations of quartiles of %APPHR and heart rate reserve (%HRR) with an abnormal electrocardiographic (ECG ST depression ≥ 1 mm) or MPI stress test, coronary revascularization and all-cause mortality during follow-up ≥ 10 yrs. An abnormal arm exercise ECG occurred in 62/427 (14.5%) of patients with an interpretable ECG. MPI was abnormal in 157/253 (62.1%). Over 12.0±1.3 yrs. follow-up, there were 256 deaths (57.4%) and 105 patients (23.5%) underwent coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). An abnormal arm exercise ECG was directly associated with quartile of %APPHR (p = 0.009) and %HRR (p = 0.02) but an abnormal arm exercise MPI exhibited an inverse trend (p = 0.10 and 0.12, respectively). There was a sharp upward inflexion point for increased percent of abnormal arm exercise ECG tests at 69%APPHR. Results for abnormal ECG and MPI tests were similar for patients taking beta blockers. Both %APPHR and %HRR were inversely related to all-cause mortality (p = 0.02 and p = 0.004, respectively) after adjustment for significant demographic and clinical variables. CABG and PCI were each predicted by an abnormal arm exercise ECG (p < 0.04) and PCI alone by abnormal MPI (p= 0.02) with no interaction of %APPHR or %HRR. We conclude that higher %APPHR and %HRR are associated with greater likelihood of an abnormal arm exercise ECG, particularly above 69%APPHR, but borderline reduced likelihood of abnormal arm exercise MPI in patients unable to perform leg exercise. An abnormal arm exercise ECG predicts CABG and PCI and MPI predicts PCI with no apparent influence of %APPHR or %HRR. Higher arm exercise %APPHR and %HRR are related to lower all-cause mortality.