bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 276: Identification of Echocardiographic Imaging View Using Deep Learning
Authors: Long Gary , Wessler Benjamin S
Published: March 2022

Objectives:
Echocardiography plays a central role in the identification and treatment of heart disease and image interpretation requires extensive experience and time. Deep learning techniques can identify complex patterns from large labeled datasets and have revolutionized image classification, object detection and segmentation. To date, state-of-the-art automated image interpretation has not been widely applied to echocardiogram interpretation. The first cognitive step in image interpretation is imaging view identification. The aim of this study is to create an automated processing pipeline for determining the echocardiographic imaging view and evaluate the accuracy of various deep learning algorithms.

Methods:
Individual parasternal long-axis (PLAX) and non-PLAX (other) DICOM images were obtained and de-identified for testing. Images were individually sorted based on imaging view (PLAX vs other) by a board certified echocardiographer. Deep convolutional neural networks were trained to sort images in a similar fashion. The algorithm was trained on an 80% sample of images and accuracy was tested on the remaining 20%. The accuracy of each network architecture was compared to view identification by a blinded echcoardiogapher. Three separate network architectures (LeNet, VGG-16, and DenseNet) were implemented using the TensorFlow API in python. Input images to each network were resized to 224x224 pixels to balance resolution, memory, and compute.

Results:
42,459 individual parasternal long-axis (PLAX) and 301,557 non-PLAX (other) DICOM images were used for analysis. The accuracy of the LeNet (11.3 million parameters), VGG-16 (40.4 million parameters), and DenseNet (7 million parameters) networks on the validation set of echocardiogram images was 85.0%, 97.50%, and 99.94% respectively for image identification. The compute time for forward pass inference is comparable for each network taking only milliseconds.

Conclusion:
Vendor independent deep learning networks can rapidly and accurately identify features on standard echocardiogram images. DenseNet network architecture matched human level performance. Deep learning has the potential for rapid, automated image interpretation and can improve the accuracy and efficiency of echocardiogram interpretation.
Abstract 28: Variation in High-Value Cardiovascular Diagnostic Testing: Patient, Payer, and Hospital Effects
Authors: Kini Vinay , Ho P. Michael , Magid David , Mosley Bridget , Khazanie Prateeti , Salcedo Ernesto , Groeneveld Peter , Masoudi Frederick
Published: March 2022

Background:
In patients hospitalized with 1) newly diagnosed heart failure (HF) or 2) acute myocardial infarction (AMI), assessment of left ventricular systolic function is a high-value test supported by guidelines. We examined the degree to which patient-, payer-, and hospital-level characteristics impact use of testing.

Methods:
We analyzed data from the Colorado All-Payer Claims Database, a repository of billing claims from all insurers who provide care in the state. We identified all patients with an index hospitalization for HF and AMI from 2010 to 2014. We excluded patients with a prior diagnosis of HF, and hospitals with fewer than 40 HF or AMI hospitalizations. We determined whether patients had a systolic function assessment performed within 60 days of hospitalization. We calculated adjusted rates of testing at the hospital level, and assessed for correlation of rates between HF and AMI patients. We used multilevel logistic regression to assess patient- and payer- characteristics associated with testing, and used median odds ratios to determine the residual variation in testing attributable to hospitals.

Results:
We identified 9,516 patients with HF and 10,315 patients with AMI (mean age 73 years, 48% women) among 36 hospitals. Overall, 74% of HF patients and 73% of AMI patients received testing. Testing rates among hospitals ranged from 56% to 82% for HF and from 42% to 83% for AMI (Figure). Correlation of testing rates for AMI and HF patients among hospitals was moderate (Spearman r=0.58; p<.001). Medicaid insurance was associated with lower likelihood of testing for both AMI and HF (ORs 0.77 [0.67-0.88] and 0.54 [0.47-0.62]; both p<.001). After multivariable adjustment, use of testing across sites varied by a median odds ratio of 1.39 [1.28-1.49] for AMI patients and of 1.25 [1.17-1.34] for HF patients, meaning that on average, patients had 1.39 and 1.25 higher odds of being tested if they received care at a higher performing hospital.

Conclusions:
Despite adjustment for patient- and payer-level characteristics, there is 1) significant residual variation in use of high-value cardiac testing and 2) correlation in testing rates for AMI and HF patients among hospitals. These results suggest that hospital-level characteristics and care processes may have a strong influence on use of high-value testing.
Abstract 29: Cardiac Surgery Episode Expenditures Associated With Healthcare-Associated Pneumonia
Authors: Thompson Michael P , Harrington Steven D , Strobel Raymond J , Cabrera Lourdes , Zhang Min , Wilton Penny , Gandhi Divyakant , DeLucia Alphonse , Paone Gaetano , Prager Richard L , Likosky Donald S
Published: March 2022

Objective:
Pneumonia is the most common healthcare-associated infection (HAI) in patients undergoing cardiac surgery. While current efforts have focused on risk factors and clinical implications of pneumonia, few have examined its overall financial impact. Our objective was to compare 90-day episode expenditures for Medicare patients undergoing coronary artery bypass graft surgery (CABG) with and without pneumonia.

Methods and Results:
Using 2014-2015 Medicare Part A and B administrative claims data, we identified 50,550 patients undergoing isolated CABG. From this sample, we applied an established claims-based algorithm to identify 3,224 (6.4%) patients with new onset of pneumonia during their index admission and after their surgical procedure. Using generalized linear models, we found that average 90-day episode expenditures were 30% higher in patients with pneumonia ($55,442 vs. $42,745, p<0.001), adjusting for patient factors (age, sex, race, dual eligible status, and Elixhauser comorbidities) and hospital random intercepts (Table). Half of the added 90-day expenditures can be attributed to payments made for higher severity diagnosis-related group (DRG) billing codes in patients with pneumonia (+$6,275, p<0.001). The greatest relative increase in expenditures was for outlier hospitalization expenditures (+211%, p<0.001). Pneumonia was also associated with greater expenditures for post-discharge care, outpatient physician services, and readmissions, although these accounted for less than 20% of added expenditures. We estimated that 2% of all Medicare payments for CABG episodes during the study period are due to pneumonia.

Conclusion:
New onset pneumonia is associated with 30% higher 90-day episode expenditures in CABG, independent of patient case mix. Prevention efforts could reduce excessive hospital inpatient utilization and save payers hundreds of millions of dollars every year.
Abstract 30: Appropriate Cardiac Catheterization Lab Activation: Comparison Between Various Lab Activating Groups for Acute ST Elevation Myocardial Infarction
Authors: Ahmad Tariq Ali , Basit Abdul , Hernandez Edvin C , Pattison Zachary , Ross Leah , Munyon Ryan , Chambers Charles E , Gilchrist Ian C , Kozak Mark , Ettinger Steven M
Published: March 2022

Background:
Rapid activation of the cardiac catheterization laboratory for primary percutaneous coronary intervention (PCI) improves outcomes for ST-segment elevation myocardial infarction (STEMI), but selected emphasis on minimizing time to reperfusion may lead to an increased frequency of false -positive STEMI activations (FPSA). While delays in reperfusion therapy are associated with worse outcomes, inaccurate diagnosis also has potential clinical as well as cost related repercussions. According to prior reports, FPSA rates vary between 15-52 percent.

Method:
We analyzed consecutive patients referred for primary PCI for a possible STEMI at a single center from November 2013 to February 2017. False-positive STEMI activation was defined as lack of electrocardiographic criteria consistent with American College of Cardiology/American Heart Association guidelines for diagnosis of STEMI, and clinical assessments. Overall differences amongst various STEMI activators were evaluated using Chi-square test. Differences between working-hours (0700-1600) versus off-hours (1601-0659) were evaluated using Cochran-Mantel-Haenszel test.

Results:
Of 355 STEMI activations, 194 (55%) were called by emergency physicians (ED), 81 (23%) by emergency medical services (EMS) and 80 (22%) by other (inpatient services & out of hospital transfers). A total of 120 (34%) cases occurred during working-hours and 235 (66%) cases occurred during off-hours. The average age of the study population was 62 (13) years, with 245(68%) males and average BMI of 30 (6) kg/m2. The prevalence of FPSA initiated by the ED, EMS, and others was 32 (16.5%), 9 (11%), and 14 (18%), respectively (p=0.06). Of FSPA, 40% were anterior, 25% inferior, 21% lateral, and 14% inferolateral wall infarctions. Out of 55 total FPSA, 37 (67%) occurred during the off-hours. Comparing activators based on hours, the prevalence of FPSA during off-hours initiated by the ED, EMS, and others were 69%, 66%, and 66%, respectively (p=0.6).

Conclusion:
In this study, approximately 1 out of 6.5 STEMI activations was a false-positive. This trend is the same during working as well as off-hours and does not differ between various STEMI activators. Improved and structured communication between cardiology, emergency medicine, and paramedic teams may promote lower false positive rates and positively impact overall delivery of care.
Abstract 31: Contemporary Trends in Industry Payments to Cardiologists: A Three-Year Analysis of the Open Payments Data
Authors: Annapureddy Amarnath , Murugiah Karthik , Minges Karl , Curtis Jeptha
Published: March 2022

Background:
Industry payments made to physicians and hospitals are publicly disclosed through the Open Payments Program. The objective of this study was to analyze the trends of payments to cardiologists in the United States for 2014, 2015 and 2016.

Methods:
Descriptive analysis was performed on the non-research, non-ownership Open Payments data. The Gini index, a method to determine income dispersion, was calculated.

Results:
Cardiologists received a total of $187,180,369 for 2014, $173,309,019 for 2015, and $159,677,844 for 2016. The mean annual payment per cardiologist was $7,571 for 2014, $6,769 for 2015, and $6,309 for 2016 (p<0.001). The number of cardiologists who received annual payments of ≥$10,000 was 2,408 for 2014, 2,696 for 2015, and 2,701 for 2016. The Gini index was 0.96 for 2014, 0.91 for 2015 and 0.90 for 2016. Xarelto, Eliquis and Brilinta were associated with the highest amount of payments in all three years. Though the food and beverage category constituted the highest number of payments made to cardiologists, the highest amount of payments were made for services such as speaking at industry-sponsored drug talks at local restaurants.

Conclusion:
The mean annual payment amount per cardiologist decreased from 2014 to 2016; only a few cardiologists were receiving payments of a significant value every year. Further studies are needed to explore the impact of industry-cardiologist relationships on patient care.
Abstract 10: Hospital-Quality Following Percutaneous Coronary Intervention In Massachusetts: Experience From 2003-2008
Authors: Normand Sharon-Lise T , Silbaugh Treacy S , Zelevinsky Katya , Wolf Robert E , Cioffi Matthew , Lovett Ann , Resnic Frederic S , Ho Kalon K
Published: March 2022

Background:
Little information is available on hospital performance following percutaneous coronary intervention (PCI) using all-comer populations. Using a fully Bayesian approach, Massachusetts has publicly reported all-cause in-hospital mortality (IHM) following PCI procedures performed since 04/01/2003 in all non-federal hospitals.

Methods:
Trained data managers prospectively collected information using the ACC-NCDR instrument supplemented by Mass-DAC specific elements. Operators and data managers adjudicated selected elements via chart review. Bayesian hierarchical regression models of IHM were estimated annually for two cohorts: (1) cardiogenic shock or ST-elevation myocardial infarction (STEMI); and (2) no shock and no STEMI. Posterior risk-standardized IHM rates were estimated. The odds of death for a patient treated at a hospital 1 SD below average quality relative to treatment at a hospital 1 SD above average quality quantified variation.

Results:
Presence of shock; emergent or salvage status; and compassionate use were changed after adjudication for more than one-quarter of adjudicated cases. No Shock and No STEMI Cohort: Between 04/03-09/08, the number of annual PCI admissions ranged from 11121-14504; number of hospitals from 14-22; and median post-PCI length of stay (LOS) remained unchanged (2 days). The crude IHM declined from 0.76% (81 of 10689) in 2003 to 0.50% (56 in 11275)in 2007. Model discrimination using 9 risk factors was high (ROC = 0.86). The odds of death at lower versus higher quality hospital ranged between 1.38 and 2.14. Shock or STEMI Cohort: the number of PCI admissions ranged from 2606-2800; number of hospitals from 18-24; and median post-PCI LOS remained unchanged (4 days). IHM declined from 6.86% (135 in 1968) in 2003 to 4.78% (130 in 2721)in 2008. Model discrimination was excellent using 7 covariates (ROC = 0.89). The odds of death at lower versus higher quality hospital ranged from 1.49 to 6.35.

Conclusions:
Key clinical factors, including shock, status of PCI, and compassionate use require adjudication. A small number of risk factors have excellent discrimination of in-hospital survivors at the patient level. Estimates of between-hospital variation can be used to quantify performance at the hospital level.
Abstract 3: Treatment Intensification and Medication Adherence Are Factors in Improving Blood Pressure Trajectories Among Newly Diagnosed CAD Patients
Authors: Maddox Thomas , Ross Colleen , Tavel Heather , Lyons Ella , Ho P. Michael , Rumsfeld John , Magid David
Published: March 2022

Background:
Blood pressure (BP) control among coronary artery disease (CAD) patients is sub-optimal in clinical practice and may be due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships are limited.

Methods:
We assessed BP trajectories among managed care patients with hypertension and incident CAD. Patients were stratified by target BP goal (<140/90 or <130/80 among those with diabetes or renal disease) and BP trajectories were modeled over the year following CAD diagnosis. Treatment intensification (increase in BP therapies in the setting of an elevated BP) and medication adherence (percentage of days covered with BP therapies) were evaluated in multivariable models adjusting for patient variables.

Results:
2763 patients had a <140/90 BP goal and 9890 had a <130/80 BP goal. Within each BP goal group, four trajectories were identified - persistently uncontrolled (Group 1), uncontrolled to controlled (Group 2), controlled to uncontrolled (Group 3), and persistently controlled (Group 4). In multivariable models comparing Group 2 to Group 1, treatment intensification was associated with improved BP control over the year for both groups (OR for <140/90 BP goal 0.75, 95% CI 0.66, 0.84; OR for <130/80 BP goal 0.93, 95% CI 0.89, 0.98). Medication adherence was associated with improved BP control among the 130/80 target BP group only (OR for <140/90 BP goal 0.79, 95% CI 0.38, 1.69; OR for <130/80 BP goal 0.66, 95% CI 0.49, 0.9).

Conclusions:
In this managed care patient population, treatment intensification and medication adherence significantly affect BP trajectories in the year following CAD diagnosis.
Abstract P100: The Cardiovascular Consequences of Switching From Atorvastatin to Generic Simvastatin in the Netherlands
Authors: Liew Danny , Webb Kate , Meerding Willem Jan
Published: March 2022

OBJECTIVES
In January 2009, an authorisation form was implemented which required Dutch clinicians to justify the prescription of branded statins. The effect was significant switching of patients from atorvastatin to generic simvastatin. However, current prescription data indicates that much of this switching is occurring at less than equipotent doses. We sought to assess the potential consequences in terms of cardiovascular disease (CVD).

METHODS
Data from a pharmacy database covering the majority of drug dispenses in the Netherlands informed dose-specific patterns of switching from atorvastatin to generic simvastatin among 39,031 Dutch patients in Q1 2009. Dose-specific, lipid-modifying potencies of the two statins were derived from a recently-published meta-analysis. The relationship between reduction in LDL-C achieved by statin therapy and relative reduction in risk of CVD was derived from a recently-published meta-regression. This showed that for every 25mg/dL (0.65mmol/L) reduction in LDL-C, the relative risk (RR) (95% confidence interval [CI]) for any CVD event, a coronary event, stroke and cardiovascular death were 0.86 (95%CI 0.84-0.88), 0.84 (95%CI 0.82-0.86), 0.90 (95%CI 0.86-0.94) and 0.89 (95%CI 0.87-0.92), respectively.

RESULTS
In Q1 2009, 33.7%, 47.2% and 19.1% of Dutch patients initially on atorvastatin were switched to less potent, equipotent and more potent doses of simvastatin, respectively. The net (weighted-average) effect would have been a 5.6% increase in LDL-C. The predicted relative increases (95%CI) in risk of various cardiovascular events are dependent on baseline LDL-C, and are summarized in the
Table
.

CONCLUSIONS
In the Netherlands, many patients are being switched from atorvastatin to generic simvastatin at inferior doses, which might lead to a significant increase in future cardiovascular events.

Baseline LDL-C
Any cardiovascular event
Coronary event
Stroke
Cardiovascular death

2.0 mmol/L
2.4% (2.1-2.7)
2.7% (2.4-3.1)
1.7% (1.0-2.4)
1.9% (1.4-2.2)

2.5 mmol/L
3.0% (2.6-3.4)
3.4% (3.0-3.9)
2.1% (1.3-3.0)
2.4% (1.7-2.8)

3.0 mmol/L
3.6% (3.1-4.1)
4.1% (3.6-4.6)
2.6% (1.5-3.6)
2.8% (2.1-3.3)

3.5 mmol/L
4.2% (3.6-4.8)
4.8% (4.2-5.4)
3.0% (1.8-4.2)
3.3% (2.4-3.9)

4.0 mmol/L
4.8% (5.5-4.1)
5.5% (4.8-6.2)
3.4% (2.1-4.8)
3.8% (2.7-4.5)
Abstract P104: Higher Cost Burden of Adverse Events With Amiodarone Compared to Other Antiarrhythmics in Atrial Fibrillation Patients in the United States
Authors: Emons Matthew F , Dalal Mehul , Yu Hsing-Ting
Published: March 2022

Introduction:
Real-world data on the incidence of adverse events (AEs) associated with antiarrhythmic drugs (AADs) are limited. We compared the frequency of AEs/AE monitoring for organ toxicity in atrial fibrillation (AF) patients receiving amiodarone versus other AADs.

Methods:
In this retrospective cohort study, patients ≥18 years with AF (indicated by ≥1 AF hospital discharge or ≥2 non-diagnostic outpatient AF claims) and ≥18 months' continuous enrollment data between Jan 2003 and Sept 2007 were identified from the US MarketScan® database. Patients were required to be continuously enrolled for ≥12 months preceding and for ≥6 months following their first qualifying (index) AF diagnosis. For those patients undergoing ≥3 months of antiarrhythmic therapy, the frequency of AEs/AE monitoring after the index diagnosis was assessed from hospital/outpatient visits linked to specified diagnostic testing codes/procedures (Table).

Results:
In total, 20,051 AF patients (mean 73 years; 58% men) received amiodarone and 19,710 (mean 68 years; 55% men) received other AADs (mainly sotalol, propafenone and flecainide) [mean (±SD) duration of continuous enrollment 43.4 ± 13.2
vs
42.5 ± 14.0 months, respectively). Amiodarone-treated patients had higher incidences of HF [41% (n=8,184)
vs
17% (n=3,315)], diabetes [25% (n=5,014)
vs
18% (n=3,634)] and CAD [17% (n=3,405)
vs
11% (n=2,095)] than those on other AADs. Diagnostic testing/procedures and hospital admissions potentially associated with AEs (including thyroid and pulmonary function testing, dermatologic, ocular and chest x-ray examination, cardioversion and admissions for ventricular arrhythmia) occurred in a significantly higher proportion of patients on amiodarone compared with other AADs, and related costs were higher with amiodarone (Table).

Conclusions:
In clinical practice, AF patients on amiodarone experienced higher AEs/AE monitoring burden and costs than those on other AADs.

1

2
Abstract P107: Diagnostic Accuracy of Coronary Artery Stenosis With 64-Multidetector Row Coronary Computed Tomographic Angiography in Veteran Patients Presenting With Chest Pain
Authors: Mohsin Rabab , Mesgarzadeh Paymon , Ziada Khaled , Abdel-Latif Ahmed , Syed Mushabbar
Published: March 2022

Background:
The ACCURACY trial was a prospective multicenter study using 64-multidetector row coronary computed tomographic angiography (CCTA) to evaluate its diagnostic performance for the detection and exclusion of coronary artery stenosis in patients presenting with chest pain without known coronary artery disease (CAD). We evaluated patients at a Veterans Administration Hospital (VAH) to assess if CCTA possesses high diagnostic accuracy for detection of obstructive CAD at both thresholds of 50% and 70% stenosis compared to invasive coronary angiography (ICA).

Methods:
We conducted a retrospective study of 44 patients at a VAH from November 2008 to November 2009. Baseline demographics are noted in
Table 1
. Inclusion criteria were: age ≥ 21, no known history of CAD, and symptoms of typical or atypical chest pain. All patients underwent CCTA and subsequently had ICA performed within 1 month. CCTAs and ICAs were evaluated and scored for coronary stenosis by 2 independent blinded readers. A vessel based analysis was used to evaluate for ≥ 50% and ≥ 70% stenosis using a 15 segment American Heart Association coronary tree model.

Results:
A total of 176 vessels were analyzed. Compared to ICA, CCTA's sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for detecting greater than 50% stenoses were, 85%, 89%, 54% and 98%, respectively, and 86%, 91%, 51%, 98%, respectively, for stenoses greater than 70%. There were no statistically significant differences for sensitivity, specificity or NPV compared to the findings in the ACCURACY trial.

Conclusion:
Among veteran patients presenting with chest pain and no prior history of CAD, CCTA appears to be an effective noninvasive alternative to exclude coronary artery stenosis.

Table 1:

Baseline Demographics

Risk Factors
ACCURACY Trial
VHA patients

p-value

Age
57 ± 10
61 ± 9.9
0.016

Sex Male gender
59%
95%
p < 0.001

Race Caucasian African American Hispanic Other
87.8% 5.7% 3.5% 3.1%
86% 6.3% 3.8% 3.9%
NS

Body mass index (kg/m²)
31.4 ± 6.2
29.9 ± 6.1
NS

Heart rate (beats/min)
60 ± 12
63.2 ± 9.2
NS

Creatinine (mg/dl)
1.0 ± 0.2
0.97 ± 0.19
NS

Agatston coronary artery calcium score
284 ± 538
916 ± 805
p < 0.001

Diabetes
23.9%
21.6%
NS

Hypertension
67%
64%
NS

Hyperlipidemia
68.3%
66%
NS

Family History of coronary artery disease
73.5%
71.2%
NS

Smoker
55.7%
53.2%
NS
Abstract P114: Longitudinal Use of Echocardiography After Heart Failure Diagnosis in the Community
Authors: Dunlay Shannon M , Redfield Margaret M , Weston Susan A , Killian Jill M , Roger Veronique L
Published: March 2022

Background:
Echocardiography is an important component of the assessment of patients with heart failure (HF). However, its longitudinal use after initial HF diagnosis has not been evaluated.

Methods:
We studied patterns of echocardiogram use after HF diagnosis among a random sample of validated incident HF cases in Olmsted County, Minnesota, from 1987 to 2006.

Results:
Among 1472 HF patients (mean age 76.0 years, 45% male), 4817 echocardiograms were obtained over a mean follow-up of 5.1 years. The majority were transthoracic (n=3952, 82%), with fewer transesophageal (n=604, 13%) and stress (n=250, 5%) studies obtained. Most patients died during follow-up (n=1126, 76%), and thus had their entire lifetime after HF diagnosis captured. The number of echocardiograms per person ranged from 0-38 (Figure) with a median (25
th
, 75
th
percentile) of 2 (1, 4). The mean rate of echocardiograms obtained per 10 years of follow-up was 6.4, and increased over time with mean echocardiograms per 10 years follow-up of 4.9, 5.9, 7.2, and 7.8 for persons diagnosed from 1987-1991, 1992-96, 1997-2001, and 2002-06, respectively (p for trend <0.001). Men had echocardiograms more frequently than women (7.2 vs. 5.7 per 10 person years follow-up, p<0.001). Patients who were younger at diagnosis had more frequent echocardiography with rates of 7.1, 6.8, and 5.2 per 10 years follow-up for those who were <70 years, 70-79 years, and 80 years or older at diagnosis (p for trend <0.001).

Conclusions:
Most patients have multiple echocardiograms performed after HF diagnosis, and echocardiography use in patients with HF has increased over time. Men and younger patients have higher rates of use after HF diagnosis.
Abstract P124: Reduction of Ventilator Associated Pneumonia Rates Associated With Two Stage Intervention in a Cardiovascular Intensive Care Unit
Authors: Byrd Jeannie , Symlar Rochelle , Burns Kathleen , Parmley Lee , McPherson John
Published: March 2022

Background:
Prevention of hospital acquired infections in the critically ill patient is paramount to improving patient outcomes. A ventilator associated pneumonia (VAP) prevention bundle (head of bed elevation, hypopharyngeal suctioning, oral care, stress ulcer prophylaxis, deep vein thrombosis prophylaxis, and sedation management/spontaneous breathing trials) was instituted in a medical/surgical cardiovascular intensive care unit (ICU) in early 2007, but VAP rates remained above target goals for cardiac surgery patients.

Aim:
To identify patients at high risk for VAP and implement a second stage intervention (chest physiotherapy-CP) in addition to the VAP prevention bundle to decrease infection risk.

Methods:
An intensive analysis was done on VAP cases that occurred during a 5 month period (July-November 2008, n=7 cases). We determined that cardiac surgery patients who acquired VAP all shared the following factors: 1) prolonged intubation (>6 hours post-operatively and not able to complete rapid extubation pathway), 2) prolonged operative time (>8 hours) or reoperation within 24 hours, and 3) reintubation after post-operative extubation. In early 2009 we incorporated into the prevention bundle an automated CP option integrated into the ICU bed features for cardiac surgery patients identified with one or more risk factors.

Results:
The incidence of VAP decreased after implementation of the secondary stage of VAP prevention with CP in patients identified as high risk (Figure).

Conclusions:
We identified risk factors associated with VAP in cardiac surgery patients in our ICU. Addition of CP to the VAP prevention bundle was associated with lower VAP rates in the ICU.
Abstract P127: Improving Door-to-Balloon Time: How an Academic Teaching Hospital System Addressed the D2B Initiative
Authors: Cunnane Ryan , Ali Aman , Whitney Hannah , Du Hongyan , Sanborn Timothy
Published: March 2022

Objectives:
To outline how an academic teaching hospital system addressed the ACC D2B: An Alliance for Quality (D2B Alliance) initiative and improved adherence to the < 90 minute performance measure.

Methods:
Data on D2B performance were gathered beginning in 2006 through 2009. In total there were 230 STEMI presentations. All times were adjudicated by the Centers for Medicare and Medicaid Services via chart review. Over the course of the study there were a total of six interventions made in an attempt to improve guideline adherence. They were, in order; (1) single-pager system, (2) addition of a third member to the cardiac cath lab (CCL) team, (3) concurrent review of all STEMI cases, (4) securing a dedicated space to do ECGs in the ED, (5) requiring an ECG for all patients presenting to the ED with “pain from waist to ear” and (6) activation of the CCL team at the time of EMS STEMI call to the ED. Data were analyzed using the univariate Cochran-Armitage trend test to establish an overall linear trend and also condensed by intervention and compared in a pair-wise fashion.

Results:
The < 90 minute adherence rate was 36.8% (7 of 19) at the beginning of the study and improved to 90.0% (18 of 20) by the conclusion. In overall univariate analysis, as well as when grouped by intervention, there was a significant increasing linear trend of meeting the < 90 minute goal over time (p<0.0001 and p<0.0001 respectively). Pair-wise comparisons revealed that increasing the size of the CCL team, the use of concurrent review, a dedicated room for ECGs in the ED, broad indications for ECGs and activation of the CCL team at the time of EMS call to the ED had the biggest impact on improving < 90 minute performance (Bonferonni adjusted p=0.0313, 0.0015, 0.0007 and 0.0009 respectively).

Conclusions:
Adherence to guidelines recommending primary angioplasty for STEMI in less than 90 minutes from patient arrival significantly improved over the course of the study. Multiple system-wide interventions were made during that time but those with the greatest impact included increasing the size of the CCL team from 2 to 3, ongoing real-time review of all STEMI cases, ensuring space for rapid performance of ECGs in the ED, broad indications for ordering ECGs in the ED and early activation of the CCL team.
Abstract P128: Get With the Guidelines Coronary Artery Disease Program Helps Attain Quality Care in Minority Population: 5 Year Experience in the Inner City Bronx
Authors: Dharmarajan Lekshmi
Published: March 2022

Background:
Gender and race based disparities in health care delivery are reported. Our acute care, non interventional hospital serves a Bronx population comprising predominantly Hispanic/Latino and African Americans.

Hypothesis:
Get with The Guidelines Coronary Artery Disease (GWTG-CAD) Patient Management Tool helps providers adhere to guideline recommended secondary prevention therapies in hospitalized patients with acute myocardial infarction (AMI),
irrespective of gender, ethnicity or race
. Our objective was to verify that the program with a dedicated physician champion and staff cardiologists achieved and maintained a high level of adherence in this population by continued education and oversight.

Methods:
Patients admitted to coronary care unit with diagnosis of AMI were entered into GWTG database. Data entries were both concurrent and retrospective. Guideline recommended therapies were initiated prior to transfer to an interventional facility or discharge. No order sets or checklists were used; however written policy and procedure on AMI management was available as reference, in coronary care unit and Emergency Dept. The 5 year data from January 2004 to December 2008 were analyzed for “defect free care measures” (DFCMs) (% patients receiving all eligible interventions). Chi square testing was done with significance at p<0.05.

Results:
728 patient records reviewed, comprising 315 females, 379 males, 525 Hispanics (any race) and 157 non-Hispanics (includes blacks and whites). DFCMs achieved annually from 2004-2008 for sub groups as well as p values are listed in
table
.

Conclusions:
The analysis confirms that GWTG program with continuous education of providers helps impart high quality of care (DFCMS) in all subsets, including minority populations.

VARIABLE
2004
2005
2006
2007
2008

Male
93.8% (75/80)
97% (65/67)
96.1% (73/76)
100% (93/93)
98.4% (62/63)

Female
81.2% (52/64)
91.5% (54/59)
98.3% (58/59)
97% (65/67)
100% (66/66)

p value
0.04
0.03
0.79
0.33
0.98

Hispanic (Any Race)
90.5% (86/95)
96.3%(105/109)
96.2%(102/106)
98.4%(125/127)
98.9% (87/88)

Non Hispanic (Blacks / Whites)
81.1% (30/37)
84.2% (16/19)
100% (25/25)
97.3% (36/37)
100% (39/39)

p value
0.23
0.11
0.73
0.65
0.50
Abstract P138: Quality Improvment Strategy for Better Control of Warfarin Anticoagulaton in Outpatients
Authors: Lader Ellis W , Martin Natalie , Reiter Paul , Cohen Gary , Dimova Aneta , Parikh Dineshkant
Published: March 2022

Introduction:
Warfarin is currently the only effective oral anticoagulant for thromboembolic prophylaxis in patients at high risk for stroke or other thromboembolic complications. Maintaining a therapeutic level of anticoagulation as measured by the International Normalized Ratio (INR) can be challenging, due to genetic differences in drug metabolism, multiple drug interactions, and variations in dietary vitamin K intake. We designed a program to improve our ability to keep our patients' INR within the therapeutic range.

Methods:
We established a baseline degree of INR control in the fall of 2007, measuring the INR for 50 sequential patients who required warfarin therapy for at least one month for each of our 5 physicians; therapeutic range was 2-3 for most indications, or 2.5-3.5 for mechanical valves. We then instituted an INR improvement program, making certain our office gave directions for subsequent warfarin dosing and the next INR testing directly to the patient only; reviewing all drugs and potential interactions at each contact; reviewing potential dietary and alcohol consumption issues at each contact; and utilizing a standard dosing protocol for any dose changes. We reassessed the degree of INR control 6 months later and 18 months later in a similar cohort, measuring 50 sequential patients for each of our 5 physicians.

Results:
At our most recent survey, the average age of our patients was 73.7 and 43% (108 of 250) were female. The indication for anticoagulation was atrial fibrillation in 81.6% (204 of 250), mechanical heart valve in 11.2% (28 of 250), and other indications in 7.2% (18 of 250). The percentage of patients within their therapeutic range was 62.4% (156 of 250) at the baseline survey, 66.0% (165 of 250) at the second survey, and 65.6% (164 of 250) at the most recent survey, p=0.42 comparing first to second, p=0.45 comparing first to third, and p=0.92 comparing second to third, none significantly different.

Conclusion:
Achieving and maintaining a therapeutic INR with warfarin dosing even with an aggressive quality improvement program is a continuing therapeutic challenge. More effective management strategies or alternative anticoagulants which may be simpler to manage remain a high priority.
Abstract P139: Implementation of the PINNACLE Registry™: Initial Experience and Insights from a Large Cardiovascular Practice in Texas
Authors: May David , Fiocchi Fran , Kehoe Katie , Mitchell Kristi , Wright Janet , Oetgen William
Published: March 2022

BACKGROUND
The PINNACLE Registry, the first national CV practice-based outpatient QI program, is designed to optimize the quality of care through the standardized collection and reporting of clinical data. However, implementation presents unique challenges. Multiple EHR systems, lack of standardized database structure and absence of unique field identifiers across EHR platforms make single solution electronic data extraction impossible. At the same time, paper data collection and submission is unwieldy.

METHODS
Cardiovascular Specialists PA (CVS) is a 7 physician single specialty cardiovascular medicine practice with three office locations in suburban Dallas. Approximately 20% of encounters are new patients. Staffing levels include 2 medical assistants, 2 receptionists, 2 full-time IT specialists and a 7 member in-house transcription pool. In order to facilitate practice-wide adoption, a 3-phased process was implemented beginning in February, 2009: Planning Phase (60 days): Evaluation of the existing patient care delivery system and development of tools needed to assist data collection Development Phase (75 days): A team at a single office location designated to “operationalize” the system and begin a 1 month trial data collection Implementation Phase: All physicians and offices were brought online using teaching materials and training sessions. Simultaneous teaching of non-physician staff included scripting and role playing techniques.

CONCLUSION
It is possible to implement a QI-based clinical registry in a busy outpatient practice with real time data acquisition and no disruption to patient flow. Success depends on involvement of the full cardiac care team in development and implementation of the program. Implementation among remaining practice members is easily accomplished using practical, hands-on training and internally developed materials and protocols. Decisions to adapt the data collection and submission process can be both medically appropriate and fiscally responsible.
Abstract P141: Integration of Cardiology and Cardiac Surgery in the Cardiovascular Intensive Unit: Formation of a Multidisciplinary Approach to Optimize Patient Outcomes
Authors: McPherson John A , Wagner Chad E , Byrd Jeannie , Burns Kathleen , Byrne John G , Churchwell Keith B , Di Salvo Thomas G
Published: March 2022

Background:
In 2006, the Vanderbilt Heart and Vascular Institute significantly expanded its clinical operations, in part through the acquisition of large cardiology and cardiac surgical practices.

Objective:
In order to optimize patient (pt) outcomes in the face of rapidly growing inpatient volume and complexity, we sought to deliver seamless care across the spectrum of cardiovascular disease with the same nursing and core physician personnel.

Methods:
Important operational features of the integrated cardiovascular intensive care unit (CVICU) include:

Bedside nurses trained to care for both cardiology and cardiac surgical pts, and participate in all work rounds

A cardiovascular intensivist based full-time in the CVICU

A single cardiology team in charge of all nonsurgical pts

Daily interaction of the cardiology and cardiac surgical teams, including formal and informal consultation as needed

Availability of the intensivist to assist with the care of all complicated nonsurgical pts

A multidisciplinary team, including a cardiologist, a cardiovascular surgeon, and an intensivist that conducts daily rounds on cardiac surgical pts

Creation of multidisciplinary teams to acutely manage critical pts, such as those presenting with cardiogenic shock and pts treated with therapeutic hypothermia post cardiac arrest

A core leadership team (CL) comprised of a nurse manager, a clinical nurse specialist, a medical director, and a surgical director

Formal weekly meetings of the CL to discuss quality/operational initiatives, core measures, and clinical outcomes data

Results:
In 2009, 2154 pts were admitted to the CVICU, including 1201 pts who underwent cardiac surgery, a 267% increase from 2005. In nonsurgical pts, the prevalence of heart failure and cardiogenic shock was 63% and 9%, respectively. For all CVICU pts, the in-hospital mortality was 3.9%. Among the cardiac surgical pts, the observed/expected mortality ratio (Society of Thoracic Surgery data) was 0.80, compared to 0.85 in 2005.

Conclusions:
From 2006-2009, the number and complexity of CVICU pts increased significantly, with a dramatic increase in cardiac surgical pts. Through the creation of an integrated CVICU, multidisciplinary collaboration was enhanced, and pt outcomes remained excellent.
Abstract P147: Impact of Quality Improvement Initiatives on Core Measures Performance and Short-Term Mortality in Patients With Acute Myocardial Infarction
Authors: Filardo Giovanni , Nicewander David , Ballard David
Published: March 2022

Background:
Impact of compliance with process of care measures on acute myocardial infarction (AMI) outcomes is ambiguous. Baylor Health Care System, Dallas, TX (BHCS) invested substantial resources in measuring and improving performance on the Centers for Medicare and Medicaid Services (CMS) Core Measures, and sought to determine the changes in both compliance and short-term mortality over a 6-year period.

Methods:
CMS AMI core measure compliance and mortality were assessed in consecutive encounters eligible for at least one measure from July 2002 to June 2008 at 8 BHCS hospitals (n= 6,826). Adjusted odds ratios for in-hospital and 30-day post-admission mortality and rate ratios for core measure compliance were calculated using marginal structural models to assess differences over time.

Results:
Core measures compliance improved significantly. Adjusted odds ratios [95% confidence intervals] revealed significant decreases in in-hospital mortality in cohorts eligible for: aspirin at arrival (Year 5 versus baseline: 0.46 [0.27, 0.78]; Year 6 versus baseline: 0.37 [0.22, 0.65]), beta-blockers at arrival (Year 5 versus baseline: 0.38 [0.19, 0.74]; Year 6 versus baseline: 0.24 [0.11, 0.52]) and a bundle measure comprising aspirin at arrival, beta-blockers at arrival and timely reperfusion (Year 5 versus baseline: 0.46 [0.28, 0.78]; Year 6 versus baseline: 0.41 [0.24, 0.69]). Significant decreases in 30-day post-admission mortality followed the same pattern.

Conclusion:
AMI Core Measures compliance improved significantly and short-term mortality decreased significantly in patients eligible for 3 of the admission measures. Further research is needed to elucidate any causal relationship between the improved compliance and short-term survival.
Abstract P150: Modest Achievement of Guideline-Derived Treatment Goals in Diabetic Patients with Atherosclerotic Cardiovascular Disease Despite High Use of Guideline-Based Therapies
Authors: Beller George A , Akosah Kwame O , Simpson Allan G , Barbieri Kirk E , Megginson Gregory C , Goldberg Randal I , DeGuzman Pamela B
Published: March 2022

Background:
Recent emphasis has been placed on enhancing quality of cardiovascular care using practice guidelines and health information technology to provide feedback to individual physicians. How effective this has been in achieving treatment goals versus percent of appropriate patients receiving guideline-based therapy is unclear. Accordingly, the purpose of this study was to determine how successfully guideline-derived treatment goals were met for outpatients with diabetes (DM) and ASCVD in an academic general cardiology practice with an electronic medical record (EMR).

Methods:
A retrospective study was conducted on all outpatients managed in an academic general cardiology clinic who had diagnoses of both ASCVD and DM and had ≥ 2 outpatient visits between January 2008 and September 2009 (n =926), during which time EMR quarterly “report cards” were provided. Values for LDL, HDL, BP and BMI were abstracted for the first and last visits during the study period. Analysis was conducted on the percent of patients achieving treatment goals at each visit and differences in values between first and last visit.

Results:
A high percentage of patients were receiving guideline-based drug therapy at their last visit: Statin - 91.0%; Anti-hypertensive, ACE or ARB - 83.4%; Anti-platelet - 92.0%; β-blocker - 75.7%. However, mean LDL at the last visit was 80.4±33.7, and although 81% (649/797) had an LDL-C <= 100 mg/dl, only 41% (326/797) achieved an LDL-C <= 70mg/dl. Similarly, only 61% (563/921) achieved a systolic BP <= 130 mmHg, and mean reduction of BMI between the first and last visit was 1.3% (32.5±11.5 vs. 32.1±9.4, p=NS). The same number of patients gained 10% or more weight during the study period, as lost 10% or more weight, 5.3% (47/886).

Conclusion:
A very high percentage of patients were receiving guideline-based drugs, but with respect to achieving ATP III target LDL-C and systolic BP goals, there was less success. The greatest difficulty was in achieving weight loss. These results are similar to those achieved by randomized patients in the BARI-2D trial. In both studies, successful weight loss and achievement of LDL-C guidelines by ATP III were suboptimal although the use of appropriate therapy was high. Additional strategies are needed to achieve these targets.
Abstract P152: Patient Satisfaction at America's Worst Performing Hospitals
Authors: Girotra Saket , Cram Peter , Popescu Ioana
Published: March 2022

BACKGROUND
Previous studies have identified hospitals with significantly lower performance for cardiac care than the national average. Little is known about patient satisfaction at these consistently low performing hospitals.

METHODS
We used 2006-08 Hospital Compare data to identify hospitals that reported acute myocardial infarction (AMI) and heart failure (HF) process measures. We calculated performance scores as the total number of patients receiving recommended therapies divided by the total number of eligible patients for AMI and HF respectively. We classified hospitals as low performing (lowest decile for all 3 years [N= 92 for AMI, N= 177 for HF]), top performing (highest decile for all 3 years [N= 43 for AMI, N =123 for HF]), and intermediate hospitals (all others [N= 2440 for AMI, N =3283 for HF]). We obtained hospital characteristics from the AHA 2006 survey. We used 2008 Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data to determine the proportion of patients who 1) definitely recommend the hospital to others and b) rate hospital care as ≥ 9 on a scale of 1 - 10. We compared patient satisfaction ratings across hospital categories.

RESULTS
Low performing hospitals had significantly lower performance scores (77% vs. 95% vs. 100% for AMI, 43% vs. 85% vs. 99% for HF), had fewer beds (142 vs. 261 vs. 319 for AMI, 59 vs. 207 vs. 244 for HF), and were less likely to be teaching hospitals (0% vs. 11% vs. 11% for AMI, 0% vs. 8% vs. 12% for HF) as compared to intermediate and top performing hospitals (p < .01 for all). Low performing hospitals were more likely to not report HCAHPS data as compared to intermediate and top performing hospitals (15% vs. 0% vs. 0% for AMI, 28% vs. 5% vs. 5%, p < .01). Among those reporting, low performing hospitals had lower rates for recommending a hospital (60% vs. 67% vs. 70% for AMI, 64% vs. 67% vs. 70% for HF, p< .01) and rating the hospital at least 9 out of 10 (58% vs. 62% vs. 65% for AMI, 62% vs. 63% vs. 65% for HF p < .01).

CONCLUSION
Consistently low performing hospitals are less likely to report patient satisfaction data. Among those reporting, patients at low performing hospitals have significantly lower satisfaction. Efforts to improve hospital quality should focus both on improving performance and satisfaction with care.