bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 24: Current Quality of Cardiovascular Prevention for Million Hearts™: An Analysis of 115,737 Outpatients from The Guideline Advantage™
Authors: Eapen Zubin , Bufalino Vincent , Peterson Eric , Hernandez Adrian
Published: July 2021

Background:
Million Hearts™ is a national initiative to prevent 1 million heart attacks and strokes over 5 years by improving cardiovascular prevention. The degree to which outpatient providers are currently controlling hypertension, hyperlipidemia, and tobacco abuse has not been fully described.

Methods:
The Guideline Advantage™ is a nationwide quality improvement program for outpatient care, which collects data through existing electronic health records to report adherence to established guidelines. We examined practice-level variation in adherence to the Million Hearts™ clinical quality measures. We determined the percentage of patients aged 18 through 85 years who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmHg) during their most recent outpatient visit. We determined the percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus whose most recent LDL-C level was less than 100 mg/dL during the 12 months prior to their most recent visit. We determined the percentage of patients at each site aged 18 years and older who were screened for tobacco use at least once during the 24 months prior to their most recent visit and received a tobacco cessation intervention, if identified as a tobacco user.

Results:
From January 1, 2010 to March 31, 2012, there were 115,737 patients enrolled from 18 U.S. practices. Of these, 65,212 (56.3%) had hypertension, 67,826 (58.6%) had hyperlipidemia, 8,815 (7.6%) had diabetes mellitus, 3,073 (2.7%) had a history of a stroke or transient ischemic attack, and 23,624 (20.4%) had coronary artery disease. The median age was 63 years (25
th
to 75
th
: 51[[Unable to Display Character: –]]74), 59,057 (51%) were male, and 94,567 (81.7%) were white. Among the 18 sites, hypertension control ranged from 58.7% to 75.1% (median: 66.9, 25
th
to 75
th
: 60.9[[Unable to Display Character: –]]68.9), hyperlipidemia control among patients with diabetes mellitus ranged from 53.8% to 100.0% (median: 75.2, 25
th
to 75
th
: 65.3[[Unable to Display Character: –]]82.3), and tobacco abuse screening and intervention ranged from 53.8% to 86.1% (median: 80.0, 25
th
to 75
th
: 73.9[[Unable to Display Character: –]]83.9).

Conclusions:
Compliance with clinical quality measures for the Million Hearts™ initiative varies widely across outpatient practices. Our findings identify multiple opportunities to improve the quality of outpatient care for cardiovascular prevention.
Abstract 258: Dabigatran Etexilate is Associated with Shorter Hospital Length of Stay and Lower Hospital Costs Compared to Warfarin in Treatment-Naive, Newly-Diagnosed Nonvalvular Atrial Fibrillation Patients
Authors: Fonseca Eileen , Walker David R , Hess Gregory P
Published: July 2021

Background:
Warfarin and dabigatran etexilate (DE) are oral anticoagulants (OAC) used to reduce the risk of stroke among patients with nonvalvular atrial fibrillation (AF). However, DE does not require titration and INR monitoring. This study examined whether hospital length of stay (LOS) and total hospital costs differed between the two therapies among treatment-naive, newly-diagnosed AF patients.

Methods:
LOS and total hospital costs were evaluated for hospitalizations with a primary or secondary discharge diagnosis of atrial fibrillation (AF) between 1/1/2011-3/31/2012, with DE or warfarin administered during hospitalization, and excluding hospitalizations of patients with valvular AF, previously diagnosed with AF, or previously treated with OAC. Hospitalizations were identified from a Charge Detail Masters database containing 397 qualified hospitals. Samples were propensity score matched using nearest neighbor within a caliper of 0.20 standard deviations of the logit, without replacement and a 2:1 match. Differences in LOS and hospital cost were then estimated using generalized linear models, fitted by generalized estimating equations (clustered by hospital) to account for possible correlation between observations. The hospitalization’s charged amount was multiplied by the hospital’s inpatient cost-to-charge ratio to estimate the total hospital cost. Covariates estimating the propensity score, LOS, and costs included patient age, payer type, CHADS
2
and HAS-BLED scores, use of bridging agents, comorbid conditions, and hospital attributes. As a sensitivity analysis, LOS and costs were estimated with the same parameters and covariates among the raw, unbalanced sample.

Results:
Matched samples included 1,292 warfarin and 646 DE hospitalizations of treatment-naive, newly diagnosed patients out of 4,619 and 715 hospitalizations, respectively. No covariates used in matching had standardized mean differences > 10% after matching. Two comorbidities (thromboembolism, coronary artery disease) had statistically different distributions after matching (DE: 3% vs. warfarin: 8%, p<0.001 and DE: 40% vs. warfarin: 45%, p=0.048); these were included as model covariates. Among the sample, DE had an estimated 0.7 days shorter stay compared to warfarin (DE: 4.8 days vs. warfarin: 5.5 days, p<0.01) and a $2,031 lower estimated total cost (DE: $14,794 vs warfarin: $16,826, p=0.007). Sensitivity analysis confirmed a shorter DE LOS (DE: 5.5 days vs. warfarin: 6.6 days, delta=1.1 days, p<0.01) and a lower DE hospital cost (DE: $18,362 vs. warfarin: $22,602, delta=$4,240, p<0.01).

Conclusions:
Among hospitalizations of treatment-naive patients newly diagnosed with nonvalvular AF, the hospitalizations during which DE was administered had a shorter LOS and at least a 12% lower total hospital cost compared to hospitalizations where warfarin was administered.
Abstract 269: Influence of Medical Therapy and Co-Morbidities on Long-Term Outcomes in Patients with Aortic Aneurysms
Authors: Heinecke Carl A , Bulibek Batyrjan , Ojha Chandra , Britton Lewis , Torosoff Mikhail , Huang Helen , Contino Chase
Published: July 2021

Background:
We investigated effects of medical therapy and co-morbidities on long-term outcomes in patients with documented aortic aneurysms.

Material and Methods:
Medical records of 162 consecutive patients (64+/-13 years old, 37% females, 91% Caucasians) enrolled in the Aortic Aneurysm clinic at a single tertiary medical center were reviewed. Long-term outcomes (28+/-29 months) were determined using Social Security Death Index. ANOVA, chi-square, and logistic regression tests were employed.

Results:
Older patients (73+/-8.9 vs. 62+/-13, p=0.006; HR 2.1 per decade, 95%CI 1.2-3.6, p=0.008) or patients with larger aneurysm diameter (5.4+/-0.8 vs. 4.7+/-0.7, p=0.005; HR 3.8 per 1 cm, 95%CI 1.4-10.3, p=0.008) were more likely to die during the follow-up. There was a trend towards increased mortality when history of smoking was present (76% vs. 23% in non-smokers, p=0.042; HR 3.7, 95%CI 0.97-13.9, p=0.055). None of the 11 patients with atrial fibrillation expired (0 vs. 10% in NSR, p=0.273). Gender, body surface area, systolic and diastolic blood pressures on presentation, history of CAD, CHF, hypertension, diabetes, dyslipidemia, or renal disease had no discernible effects on mortality in our study cohort.

There was a trend towards reduced mortality in patients treated with aspirin or clopidogrel (3.4% vs. 12.1%, p=0.064; HR 0.3, 95%CI 0.05-1.1, p=0.083), beta-blockers (5.4% vs. 10.4%, p=0.282; HR 0.5, 95%CI 0.13-1.85, p=0.290) and Ca-channel blocker (0% vs. 10.6%, p=0.067; HR 0.9, 95%CI 0.9-1.1, p=0.972). Treatment with ACE inhibitors or ARBs, statins, or diuretics did not affect the outcomes.

In multivariate analysis only advanced age (HR 2.2, 95%CI 1.0-4.5, p=0.038) and larger aortic aneurysm diameter (HR 2.9 per 1 cm, 95%CI 0.9-9.1, p=0.069) were predictive of increased long-term mortality.

Conclusions:
In patients with documented aortic aneurysms mortality is largely determined by patient’s age and vessel diameter. When compared to vasodilators and diuretics, beta-blockers and Ca-channel blockers may be preferable in patients with aortic aneurysm. Treatment with anti-platelet agents is not detrimental and may have a potential to improve long-term outcomes.
Abstract 276: A Qualitative Analysis of Shared Decision Making in Cardiac Surgery
Authors: Gainer Ryan , Buth Karen , David Jennie , Garson Rose , Mufti Hani , Hirsch Greg
Published: July 2021

OBJECTIVES
Comprehension of risks, benefits, and alternative treatment options is poor among patients referred for cardiac interventions. We have previously demonstrated that frail, elderly patients undergoing cardiac surgery require complex procedures and are at markedly increased risk of postoperative death and prolonged institutional care. An effective informed consent process is critical in this population. We suggest this vulnerable patient population may benefit from the institution of a formalized shared decision making (SDM) process.

METHODS
Three focus groups were convened for CABG, Valve, or CABG +Valve patients over 70 who were either within two years post-op, within 4-8 weeks post-op or had had a complicated post-operative course. Two focus groups were convened for the caretaker group: IMCU nurses & ICU nurses and surgeons, anesthesiologists & cardiac intensivists. In a semi-structured interview format, groups were asked questions regarding personal experience with informed consent, comprehension of discussions prior to surgery, potential improvements to the consent process, and SDM in cardiac surgery. Transcribed audio data was analyzed to develop consistent and comprehensive themes.

RESULTS
Patient groups were supportive of changing standard consent by including patient-specific risk factors through graphics, reduced language complexity and increased font size as means to improve comprehension and discussion. Patient groups felt access to this information earlier on in their care would allow time to identify personal values and desires for treatment. Both care provider groups supported a consent process that would provide patients with information earlier through decisional aids presented in a structured SDM process. All groups were supportive of a dedicated RN employed as a decisional coach to meet with patients and families prior to surgery to discuss their values, concerns, and questions to facilitate SDM with the care team.

CONCLUSIONS
Data from these groups will aid in the development of decision aids that serve to educate patients about their disease, the procedure proposed, and its risks and alternatives. Utilizing validated risk prediction models from our own experience allows us to provide patient specific risks for in-hospital mortality, major morbidity, and prolonged institutional care as well as long term outcomes freedom from mortality and re-hospitalization for cardiac cause.
Abstract 278: Lipid Control in Patients With New Symptoms of Peripheral Arterial Disease Evaluated at Vascular Specialty Clinics
Authors: Smolderen Kim , Elshof Jan-Willem , van Zitteren Moniek , Spertus John A , Denollet Johan , Nooren Maria , Heyligers Jan , Vriens Patrick W
Published: July 2021

Background:
Obtaining adequate lipid control (LDL-Cholesterol [LDL] <100 mg/dL) in patients with peripheral arterial disease (PAD) is a critical, guideline-directed secondary prevention target. Current compliance with this recommendation is unknown.

Methods:
A total of 616 patients had their LDL levels measured at 2 vascular specialty clinics in the Netherlands (March 2006-November 2011) during the evaluation of new PAD symptoms. A year following this evaluation, 417 (68%) patients had their LDL levels re-assessed. Information about patients’ demographic and clinical factors was systematically abstracted from medical records. Categories of patients were created based on the attainment of the recommended LDL target (<100 mg/dL [on target] vs. ≥100 mg/dL [off target]). Predictors of being off target at initial evaluation and at 1-year follow-up were identified through multivariable logistic regression analyses.

Results:
Of the total group, 57% (351/616) were off target at initial evaluation and 81% (496/616) were on lipid-lowering drugs after the initial evaluation at the PAD specialty clinic. One year later, only 25% (103/417) got on target, while 35% (147/417) patients remained off target, and an additional 10% (43/417) saw an increase in LDL to become off target. A total of 30% (124/417) remained on target. Patients with hypertension, diabetes, a history of myocardial infarction, and a lower ankle-brachial index were less likely to be off target at initial evaluation. Predictors of being off target at 1-year follow-up were male sex, and having a higher ankle-brachial index (
Table
).

Conclusion:
About half of patients with PAD seen at vascular specialty clinics had above-target LDL levels both upon entry and 1 year later. Patients with existing cardiovascular risk factors were much better controlled, as compared with patients without such risk factors. Males and those with higher ankle-brachial indices were less likely to be on target 1 year following management at the specialty clinic. Reasons for poorly regulated lipids need to be further explored, and appropriate quality-of-care improvement strategies will likely be needed to optimize secondary prevention.
Abstract 282: Impact of a Multi-Disciplinary Heart Failure Post-Discharge Management Clinic on Heart Failure Readmission Rates
Authors: Jackevicius Cynthia , de Leon Noelle , Lu Lingyun , Chang Donald , Warner Alberta , Mody Freny
Published: July 2021

Background:
Specialized heart failure (HF) clinics have demonstrated significant reduction in readmission rates. We evaluated a new multi-disciplinary HF clinic focused specifically on those recently discharged from a HF hospitalization.

Methods:
In this retrospective, cohort study, patients discharged with a primary HF diagnosis who attended the HF post-discharge clinic in 2010-11 were compared with historical controls from 2009. Within an average of six clinic visits, patients were seen by a physician assistant, a clinical pharmacist and a nurse case manager, with care overseen by an attending cardiologist. The clinic focused on identification of HF etiology and precipitating factors, medication titration to target doses, patient education, and medication adherence. The primary outcome was 90-day HF readmission, with secondary outcomes of mortality and a composite of 90-day HF readmission and mortality. A Cox proportional hazards model with adjustment for potentially confounding demographic and comorbidity variables was constructed to compare outcomes between groups.

Results:
Among the 277 patients (144 clinic and 133 control) in the study, 7.6% of patients in the clinic group and 23.3% of patients in the control group were readmitted for HF within 90 days (aHR 0.26; 95%CI=0.13-0.53 p = 0.0003;aRRR=74%; 95%CI= 47%-87%; ARR=15.7%;NNT=7). There were few deaths, but adjusted all-cause mortality was lower in the clinic group. For the composite of 90-day HF readmission and mortality, clinic patients had a lower risk (9.0% vs 28.6%; aHR 0.23; 95%CI=0.12-0.45; p<0.0001; aRRR=77%; 95%CI=55%-88%;ARR=19.6%;NNT=6).

Conclusion:
The multidisciplinary HF post-discharge clinic was associated with a significant reduction in 90-day HF readmission rates and all-cause mortality.
Abstract 290: Comparison of Lipid Control in Patients with Coronary versus Peripheral Arterial Disease
Authors: Sharma Suresh , Thapa Rashmi , Myers Taylor , Hu Casper , Brimacombe Michael , Vacek James L , Dawn Buddhadeb , Gupta Kamal
Published: July 2021

Objectives:
Patients with Peripheral artery disease (PAD) have similar cardiovascular morbidity and mortality as those with established coronary artery disease (CAD). Thus the recommended LDL goal is < 100 mg/dl for both CAD and PAD patients. This study assesses the degree of lipid control and statin drug use in CAD and PAD patients in current clinical practice.

Methods:
We did a retrospective chart review of patients with a diagnosis of PAD, CAD and both PAD and CAD seen at our institution between Jan 2009 to March 2012. Demographic data, lipid levels and statin use were compared between CAD, PAD and PAD & CAD groups. To enable comparison of the doses of various statins, we used statin potency unit where 1 potency unit = 10mg of Simvastatin.

Results:
There were a total of 11498 subjects in the chart review (CAD-9879, PAD-623, both PAD & CAD -996). PAD patients were younger with more females & lower BMI compared to CAD and both PAD & CAD groups (Table 1). Mean LDL level in the PAD group was 93.4±35.5 mg/dL, CAD group was 82.7±33.1 mg/dL and both PAD & CAD group was 80.5±31.0 mg/dL. Although all groups had a mean LDL of < 100mg/dL, significantly fewer number of PAD patients achieved target LDL <100 mg/dl and LDL <70 mg/dl, as compared to CAD and combined group (Table 1). The PAD group had significantly higher mean total cholesterol and mean LDL levels as compared to the CAD group and combined PAD & CAD group (Table 1). The mean HDL and mean triglyceride (TG) levels in PAD group were significantly higher than the CAD and combined PAD & CAD group. The PAD patients had significantly greater use of less potent statins than the CAD and PAD & CAD groups which was not compensated for by a higher mean dose of the lower potency statins (Table 1). PAD patients were receiving significantly lower mean potency unit of statins as compared to PAD and combined CAD and PAD group (Table 1).

Conclusion:
Even though both PAD and CAD groups had mean LDL < 100mg/dL, we found that lipid control assessed by absolute mean lipid levels were significantly better in patients with CAD and combined PAD & CAD group. Thus, our study indicates that physicians tend to be more aggressive with lipid control in patients with a diagnosis of CAD when compared to patients with PAD alone.
Abstract 295: Serum Sodium-Potassium ratio as a predictor of long-term Heart Failure morbidity.
Authors: Okafor Chimalum R , Wariboko Minaba , Abdullahi Oseni , Olurunkemi Oluwole , Sawyer Douglas , Okafor Henry E
Published: July 2021

Background:
Electrolyte abnormalities particularly hyponatremia and hypokalemia are known to be associated with poorer outcomes in heart failure (HF). Some other studies have also suggested that the Sodium-Potassium ratio (Na/K) could serve as a prognostic marker of cardiovascular disease (CVD). However, most of these studies relate mainly to the intake of the electrolytes as opposed to the serum concentrations, suggesting that decreasing sodium intake and increasing potassium intake could reduce CVD risk.

Less is known about the relationship between the serum Na/K ratio and outcomes in HF. Given that serum electrolytes are routinely monitored during HF management in the hospital, we sought to retrospectively examine any prognostic impact of the admission and discharge Sodium-Potassium ratios on outcomes.

Methods:
Outcomes (HF admissions, Length of stay & cardiac admissions, non-cardiac admissions, and emergency room visits) were assessed for 331 HF patients from the Meharry Heart Failure Registry- a comprehensive retrospective HF database comprised of patient care data from January 2006 to December 2008. The database population consists of 72% African-American (AA), 19% Caucasian, and 9% other. The mean age of the cohort is 61 years (age range of 25-98) 37% of whom are females. Normal serum sodium and potassium levels were defined per the laboratory standards (i.e. normal serum Sodium range of 135mmol/L-145mmol/L and Potassium 3.5mmol/L-4.5mmol/L respectively). The individual admission and discharge serum Sodium-Potassium ratios were calculated and the relationship with heart failure outcomes determined using the Spearman correlation and Wilcoxon-Mann-Whitney test.

Results:
Our study showed no significant correlation between admission and or discharge serum Na/K ratio and HF outcomes (P value 0.339 - 0.987 with admission ratios and 0.101 - 0.699 with discharge ratios). These findings were consistent even in subgroup analysis (gender, Preserved versus reduced EF and Age > versus < 60).

Conclusions:
Our study suggests that there is no relationship between either the admission and or discharge Sodium-Potassium ratio and heart failure morbidity. These findings may be because most of the subjects had normal serum Sodium and Potassium levels therefore minimizing any differences. There is also the inherent biases associated with retrospective studies making it difficult to control for various contributing factors. A larger prospective study might be helpful in elucidating this further.
Abstract 296: Characteristics Of Ambulatory Cardiovascular Patients In India: Findings From The First 18,000+ Patient Encounters In The PINNACLE India Outpatient Registry
Authors: Glusenkamp Nathan T , Grant Purvez , Kumar Ganesh , Castellino Nirmala , Gupta Rahul , Sinha Ajay , Mullen Brendan , Oetgen William J
Published: July 2021

Background:
In India, patients usually are responsible for medical records, carrying them to ambulatory clinic visits. Little is known about the characteristics of cardiovascular (CV) patients visiting Indian hospital outpatient departments (OPDs), as this information is not collected or analyzed in a standardized fashion.

Methods:
We used paper scanners along with an electronic data collection tool to systematically collect CV patient records in hospital OPDs. Standardized data definitions were used for all elements, including demographics, vital signs, and lab values. We normalized and analyzed the data collected, producing totals, means, medians, and standard deviations for all element values.

Results:
We collected 18,804 CV patient encounters in the OPDs of two tertiary facilities in Maharastra state from 2/12 to10/12. Of 18,622 records with gender recorded, 12,386 were male (66.5%). Only 22% of records were for patients over age of 65. Mean age was 57, the same mean age for males. Mean age for females was 54.

Systolic blood pressure (BP) was documented in 8,481 (45%) of patient visits. Diastolic BP was documented in 8,477 (45%) patient visits. Mean systolic BP was 130, with a standard deviation of ± 18. Mean diastolic BP was 81 ± 9. Most BPs were high, with 6,651 (78%) greater than 120. Hypertension diagnoses could be applied to 2,566 (30%) of the encounters with a systolic BP over 140 documented.

Ejection fraction (EF) was present in 857 patient encounter records (4.5%). Most EFs (704) fell within the normal range of ≥ 50%. Mean ejection fraction was 56% ± 11. For EFs outside normal range, 74 were mildly reduced (an EF of 40-49%), 57 moderately reduced (26-29%) and 22 severely reduced (≤ 25%).

Complete lipid panel, consisting of values for total cholesterol, HDL, LDL, and triglycerides, was present in 594 patient records (3.2%). LDL values were present in 601 encounter records, with mean LDL of 101 mg/dL ± 35. 288 LDL values were over 100 mg/dL, the upper bound of optimal range.

Conclusion:
Indian ambulatory CV patients appear to be younger and more heavily male than outpatient CV populations in the US. Opportunity remains for increased documentation, allowing for performance measure generation.
Abstract 299: Poor Right Ventricular Function Predicts Poor Prognosis in Patients with Nonischemic Cardiomyopathy
Authors: Earle Tiffany R , Wasemiller Stephen E , Foster Gary P , Silvet Helme
Published: July 2021

Background:
Diagnosis of heart failure carries poor prognosis, especially in left ventricular (LV) systolic dysfunction. The prognostic implications of right ventricular (RV) function in the setting of cardiomyopathy (CM) is unclear.

Methods:
All patients at VA Loma Linda Healthcare System who underwent cardiac computed tomography angiography between 2005 and 2011 with LV ejection fraction (EF) of ≤40% were included. LV and RV volumes were calculated from gated 3 dimensional datasets. Coronary analysis was performed using standard multiplanar reformatted image sets. Outcomes data was obtained by chart review and phone. Kaplan-Meier statistics and survival curves were generated.

Results:
130 patients met inclusion criteria. All the patients were men, age 62±9 years, LVEF of 28±8%, and mean RVEF of 33±11%. Ischemic etiology of CM was found in 56 patients (43%) and nonischemic in 74 (57%). Average follow-up was 871 days. Overall mortality was 43% in the ischemic group, compared to 20% in the nonischemic group, even with higher LVEF in ischemic group (28.4 vs 27.4%, p=0.03). Survival in the whole cohort was associated with age, coronary disease (HR 2.0), chronic pulmonary disease (HR 2.1), and left anterior descending artery disease (HR 2.5). Decreased RVEF predicted worse prognosis in patients with nonischemic but not ischemic CM.

Conclusions:
Decreased RV function is associated with worse prognosis in nonischemic CM. Ischemic etiology of CM carries poor prognosis regardless of RV function.
Abstract 322: Optimizing Cardiac Catheterization Laboratory Utilization
Authors: Lawson William E , Wilbert Lisa , Sokoloff Lisa , Jeremias Allen , Mani Anil
Published: July 2021

Background:
Optimizing efficient utilization of the catheterization lab is an important concern. Inefficient use of this limited resource increases costs and can compromise patient care. At times of high hospital and specialty care unit census, cath lab throughput is also limited by the availability of recovery beds which may further compromise efficient throughput. At SBUH the cardiac cath lab is staffed from 0630-2300 daily Monday-Friday with an on-call team to provide 7 x 24 hour coverage for STEMI’s. Lab usage was evaluated to determine if this was an efficient and effective use of this limited resource.

Methods:
All cardiac catheterizations during the period of 10/1/12-12/31/12 were reviewed. The distribution of daily cases, mean and median hours to catheterization by day of the week and median length of stay (ALOS) were determined. Elective outpatient, inpatient, and emergent cases were included.

Results:
There were a total of 997 cases during this quarter. Average weekday case volume ranged from 13-17 cases/day with the greatest average number of cases performed on Mondays (24% of the weeks cases). Median hours to the cath lab averaged 4.2 hours with the greatest delay on Mondays (5.4 hrs) and Fridays (5.7 hrs). The median number of hours to the cath lab was 31.3 hours with the greatest delay on Fridays (38.5 hrs) and gradually decreasing times from Monday through Thursday with the lowest time delay being on Thursdays (18.9 hrs). The median length of stay averaged 1.11 days, with Mondays patients averaging the longest stays at 1.26 days. There were 45 emergent STEMI cases (5% of the total) during the reviewed period.

Conclusions:
The marked disparity in mean and median hours reflects a skewed distribution, with many inpatients delayed in going to the CCL. Both median and mean hours were prolonged on Mondays and Fridays along with median length of stay. Further drill down suggested hand-offs, inter-hospital transfer delays, high bed occupancy, and high patient volume contributed to delays on these days. Operator availability, procedure variance, and case mix also contributed to distortions in scheduling and the effective use of lab time. Mid week, Wednesday, was the most efficient day. Block scheduling has since been implemented to better accomodate operators and procedure types within the current staffing constraints. Also as a result of this analysis fewer outpatients are being scheduled on Mondays, changes have been made in ACS protocols, hand-offs, rounding and transfers, and opening the cath lab on a weekend day for inpatients is planned.
Abstract 329: Barriers To Hypertension Screening, Treatment And Control As Reported By Patients And Healthcare Providers
Authors: Khatib Rasha , Nieuwlaat Robby , Schwalm J-D , Khan Maheer , Haynes R Brian , Connolly Stuart , Yusuf Salim
Published: July 2021

Background:
Despite established knowledge on the importance of hypertension (HT) screening and treatment to control blood pressure, the majority of HT patients remain uncontrolled. There are many possible barriers causing this evidence-practice gap, but there is no systematic overview of studies assessing these barriers. This review aims to synthesize findings from the literature on the prevalence and importance of barriers to HT control using a theoretical framework.

Methods:
Electronic databases MEDLINE, EMBASE and Global Health were systematically searched up to August 2011 and experts in the field were contacted. Two reviewers independently selected eligible studies based on the following criteria: 1) subjects were patients with HT or at risk of HT, or health care providers (HCP) managing HT patients; 2) studies examining barriers, obstacles, or facilitators to HT screening, management, or control; 3) qualitative and quantitative studies. Two reviewers extracted data, including study methodological quality items, and labeled identified barriers by expanding on a theoretical framework for behaviour change. Clinical importance of barriers was assessed by means of association with HT treatment and BP control.

Results:
Seventeen qualitative studies (10 reporting patient barriers and 7 reporting HCP barriers) and 37 quantitative studies (24 reporting patient barriers, 9 reporting HCP barriers, and 4 reporting both HCP and patient barriers) met the inclusion criteria. Of these, 81% (n=44) were from high income countries. Most studies had methodology issues; most commonly was the bias in measuring barriers. Discrepancies were observed between results from qualitative and quantitative studies. In qualitative studies, environmental barriers, specifically availability of care barriers, were most commonly discussed among patient as well as HCP studies.

Results from quantitative studies suggest that among HCP knowledge barriers were most commonly reported (83% of the HCP population). Results for patient reported barriers were different: Intention barriers were the most common barriers to HT screening (reported by 17% of the population), lifestyle change (reported by 37% of the population), and HT treatment adherence (reported by 63% of the population). Knowledge was the most common barrier to overall BP control among patients (reported by 64% of the population). Medication related barriers, specifically side effects, appeared to have the largest effect on HT treatment adherence (HR: 1.91, 95%CI: 1.47-2.47).

Conclusions:
Barriers to HT control as reported by HCP and patients are multifactorial and largely modifiable, but evidence is primarily from high income countries and not comparable among settings due to methodological limitations. A more systematic way of measuring barriers to HT management is necessary.
Abstract 345: Hospital Variation in Admission to Intensive Care Units for Patients with Acute Myocardial Infarction
Authors: Chen RuiJun , Strait Kelly M , Dharmarajan Kumar , Li Shu-Xia , Martin John , Masoudi Frederick A , Cooke Colin R , Nallamothu Brahmajee K , Krumholz Harlan M
Published: July 2021

Background:
The intensive care unit (ICU) has been credited with reducing mortality for patients hospitalized with AMI in a past era when life-threatening post-infarction ventricular arrhythmias were more common. With the evolution in the clinical profile and treatment of AMI, the marginal benefit of ICU care for many patients is less clear. As a result, the use of ICU care for patients with AMI may vary substantially among institutions, creating implications for treatment strategies and patient outcomes.

Methods:
We identified 114,980 hospitalizations for AMI from 311 hospitals in the 2009-10 Premier database using ICD-9-CM codes. We excluded hospitals with <25 AMI admissions, patients <18 yrs, and transfers. Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. For each quartile, we calculated (1) usage rates of critical care therapies and (2) in-hospital risk-standardized mortality rates (RSMRs) among all patients admitted with AMI. Kruskal-Wallis and Cochran-Armitage Trend tests assessed for statistical significance.

Results:
ICU admission rates for AMI patients varied markedly among hospitals (median 48%, IQR 35%-61%, range 0%-98%, Figure). Hospitals admitting more AMI patients to the ICU (higher quartiles) were (1) more likely to use critical care therapies in AMI patients overall (mechanical ventilation [Q1 to Q4: 13% to 16%], vasopressors/inotropes [17% to 21%], intra-aortic balloon pumps [4% to 7%], and pulmonary artery catheters [4% to 5%]; p for trend<0.05 in all comparisons). However, (2) there was no association between the hospital ICU admission rate and overall RSMR for all AMI patients (6% all quartiles; p=0.7271, Figure).

Conclusion:
ICU admission rates for AMI vary substantially across hospitals with evidence of greater use of ICU therapies in high admitting hospitals but without evidence of lower overall mortality. There is a need for further research to determine the optimal use of ICU care for contemporary populations of patients with AMI.
Abstract 355: Relationship between Female Gender and Mortality after Isolated Aortic Valve Replacement
Authors: Sun Xiumei , Ellis Jennifer , Kanda Louis , Lowery Robert , Boyce Steven W , Corso Paul J
Published: July 2021

Background:
Previous studies have shown that female gender is an independent predictor of increased operative mortality after coronary artery bypass surgery. It remains inconsistent whether female gender is associated with increased mortality after aortic valve replacement (AVR). The purpose of this study is to investigate the role of female gender inoperative mortality after AVR.

Methods:
The study population included isolated AVR performed between January 2003 and December 2012 at a single Instituation.

Results:
During this period, 1,262 patients underwent isolated AVR. The major preoperative characteristics and operative outcomes are detailed in the following table.

R>Conclusions:
In this study, female patients had increased operative mortality after isolated AVR.
Abstract 358: Annual Quality of Care Evaluations of Cardiac Surgery in British Columbia
Authors: Abel James G , Wong Daniel R , Ng Carmen H , Ding Lillian , Kmetic Andrew
Published: July 2021

Background:
Cardiac Services BC (CSBC) is responsible for planning, coordinating, monitoring, and, in some cases, funding cardiac services across British Columbia (BC) in collaboration with senior administrators and physicians from five regional health authorities. CSBC maintains the BC Cardiac Registry (BCCR), a longitudinal clinical registry of all invasive cardiac procedures performed in BC. For over 10 years, CSBC has used BCCR data to evaluate annually quality of care indicators for isolated coronary artery bypass graft (CABG), isolated valve, and CABG+valve surgeries.

Methods:
In preparation for each annual review, CSBC meets with an established Planning Committee of representative surgeons. BCCR data is linked to provincial Vital Statistics data, to the national Discharge Abstract Database, and for the last 3 yearly analyses to the provincial Central Transfusion Registry which provides robust data on red blood cell (RBC) transfusion. At the annual review, CSBC meets with surgeons who are included in the analyses to present the indicator data.

Results:
In the 2012 evaluation, the following quality of care indicators were presented for the 2007-2011 period: 30-day mortality and 30-day stroke; 30-day RBC transfusion; and indicators for evidence-based medications at discharge. Risk-adjusted analyses were prepared for the 30-day mortality and 30-day stroke indicators to provide valid comparisons over time and according to hospital and surgeon. Patient characteristics and pre-procedural factors were included in the risk models. The risk-adjusted models performed well with C-statistics for the 30-day mortality models for isolated CABG, isolated valve, and CABG+valve surgeries of 0.86, 0.89, and 0.81, and for the 30-day stroke models 0.80, 0.83, and 0.74, respectively. Expected rates by hospital and by surgeon were determined from each risk model, and observed to expected (O/E) ratios were used for comparison of hospitals and surgeons. Rates of RBC transfusion varied by hospital, and a large reduction in transfusion rates from 69% (378 of 546) in 2007 to 43% (252 of 589) in 2011 was observed at one site with historically higher rates.

Conclusion:
Presenting quality of care indicators annually has raised awareness of outcome rates and variations which existed across the province. The annual process of engaging surgeons in the evaluation process and linkage with other administrative databases to obtain outcome data has been associated with a reduction in use of RBC transfusion and instigated further investigations into regional variation in mortality rates. The addition of new indicators and other risk-adjusted analyses in the future may further improve quality of care in cardiac surgery in BC.
Abstract 5: The Association between Patient Rural Status, Distance to Cath Lab, and Likelihood to Undergo Coronary Angiography: Insights from the VA CART Program
Authors: Carey Evan P , Bradley Steven M , Strand Matthew J , Ho P M , Maddox Thomas M , Tsai Thomas T , Rumsfeld John S , Grunwald Gary K
Published: July 2021

Background.
Prior studies suggest rural patients are less likely to receive coronary procedures. This finding may represent the fact that rural patients live further than urban patients from the closest cath lab, but these studies failed to incorporate a direct measure of distance to cath lab. Accordingly, we incorporated patient distance to cath lab with rural location on the likelihood to undergo elective coronary angiography as a better explanation of this relationship.

Methods.
Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all patients who underwent elective coronary angiography from October 2007 through September 2010. We calculated geodesic distance from patient home to cath. Patient rural status was determined using the VA Urban/Rural/Highly Rural (URH) system. Normal coronary angiography (an indirect measure of patient selection for elective coronary angiography) was defined as <20% stenosis in all vessels. Using generalized linear mixed modeling, we estimated the probability of angiographically normal coronaries as a function of distance to cath, modified by patient rural status.

Results.
Among 22,523 patients undergoing elective coronary angiography, 22.8% of patients had normal coronaries. Rural patients were more likely to have high Framingham risk (highly rural 44.2% vs. rural 39.8% vs. urban 36.9%, p<0.001). Rural patients who lived further from cath labs were associated with a lower probability of normal coronaries compared to rural patients closer to cath labs and urban patients across all distances(p=0.0014). For patients living within 50 miles of a cath lab, urban/rural status did not influence the probability of normal coronary angiography. From 50 to 150 miles, rural patients were less likely to have normal coronaries at angiography. (Figure 1).

Conclusions.
Among patients undergoing elective angiography in the VA, those who lived further from cath labs in rural locations were less likely to have normal coronaries. These findings suggest that patient location, rather than clinical factors, may affect the use of coronary procedures. Further study to understand the causes of this relationship, including potential for under- or over-use based on distance and rural status, may help optimize patient access for coronary procedures.
Abstract 53: Health Care Utilization and Cost among Type 2 Diabetes Mellitus (T2DM) Patients with Cardiovascular Disease (CVD) or Cardiovascular Disease Risk Factors
Authors: Kern David M , DeVore Stephanie , Kim Jennifer , Wu Ying , Tunceli Ozgur , Wu Bingcao , Hirshberg Boaz
Published: July 2021

CV events among T2DM patients are major contributors to high healthcare utilization and cost. Healthcare utilization and costs among T2DM patients with established CVD and CVD risk factors in a large US database were explored.

T2DM patients aged ≥40 years were identified from the HealthCore Integrated Research Environment from 1/1/2007 to 4/30/2011 and followed from first T2DM diagnosis (index date) until loss of eligibility or death. Established CVD [Group 1] included patients with MI, stroke, peripheral vascular disease, coronary heart disease, congestive heart failure, or revascularization in the year prior to index. CVD risk [Group 2] included patients with older age (men ≥55 y, women ≥60 y) and prior diagnosis for either dyslipidemia or hypertension. Per person year (PPY) utilization and cost following T2DM diagnosis were calculated as the total number of events/cost divided by total number of person years of follow-up.

There were 177,140 Group 1 (mean age: 68 y; 57% men) and 191,441 Group 2 (mean age: 66 y; 57% men) patients who met the selection criteria. During the 12, 24, 36, and 48 months following index, a higher proportion of Group 1 vs Group 2 patients had ≥1 inpatient visit (35%, 50%, 61%, 69% vs 16%, 27%, 36%, 44% respectively) and ≥1 ED visit (6.2%, 17%, 29%, 41% vs 2.9%, 9%, 18%, 28% respectively). T2DM patients have high healthcare utilization and costs. Those with established CVD have higher PPY event rates (Figure 1) and costs (Figure 2), compared with patients with CVD risk factors. Inpatient hospitalizations and outpatient visits are key cost drivers in this T2DM population.
Abstract 54: The SAQ-7: A Short Version of the Seattle Angina Questionnaire
Authors: Jones Philip , Chan Paul , Gosch Kensey , Li Yan , Reid Kimberly , Tang Fengming , Spertus John
Published: July 2021

Background:
The Seattle Angina Questionnaire (SAQ) is a well-validated and widely used 19-item instrument that measures patient-reported symptoms, function and quality of life for patients with coronary artery disease. We sought to develop a shortened version to reduce response burden and facilitate greater use within busy clinical environments.

Methods:
We used data from 4 U.S. multicenter longitudinal cohorts studies (2 PCI: n=1,507 and 2,206; 2 AMI: n=2,487 and 4,340) to develop and validate a short version of the SAQ. We included items from the Physical Limitation, Angina Frequency and Quality of Life scales, which directly measure patients’ current health status. We conducted parallel analyses for 3 distinct clinical scenarios (stable CAD, peri-PCI, acute MI). In development cohorts, we used equidistant item-total correlation methods to identify items that best correlated with their respective full-version score across the entire range of scores. We also considered item response variability and missingness in choosing between similarly performing items. Using the selected items, we calculated summary scores for each of the 3 scales, and an overall summary score as the average of the 3 scale scores. (As in the full SAQ, scores were rescaled so that 0 denotes the worst and 100 the best possible health status.) Finally, in independent validation cohorts, we conducted a range of analyses to investigate the validity, reproducibility, and responsiveness of the short-version scores.

Results:
We identified 7 items that tracked strongly with their corresponding full-version scores (3 of 9 Physical Limitation items; 2 of 2 Angina Frequency items; 2 of 3 Quality of Life items). These items were consistently identified across all 3 clinical scenarios. Correlations between the resulting short-version and full-version scores were excellent (r=0.95 to 1.00), and missing rates were the same or lower for all scores. In validation studies, the SAQ-7 demonstrated strong performance comparable to the full SAQ (Table).

Conclusions:
The SAQ-7 is a valid, reproducible, responsive instrument for assessing disease-specific health status among patients with coronary artery disease, with properties and performance similar to the full SAQ but with a substantially reduced response burden.
Abstract 72: Outcomes Of Patients With Left Ventricular Diastolic Dysfunction In Adult Hematopoietic Stem Cell Transplantation
Authors: Garikapati Kiran , Hassan Syed , singhvi Aditi , Dania Khoulani , Qureshi Sophia , mittal chetan , Alirhayam Zaid , Qureshi Waqas
Published: July 2021

Background:
With better health care, hematopoietic stem cell transplantation has become possible for older patients. These patients have higher prevalence of diastolic dysfunction. However, it is not known if diastolic dysfunction has an impact on prognosis of these patients.

Methods:
Retrospective data was obtained for adults (>18 years) that underwent hematopoietic stem cell transplantation over a period of 1991 - 2012 (22 years). Demographic, echocardiogrpahic and mortality data were obtained. Cox proportional hazard model was used to analyze diastolic dysfunction as a predictor of mortality, graft versus host disease (GVHD), systolic heart failure (ejection fraction ≤50%) and sepsis. Diastolic dysfunction was defined according to American Society of Echocardiography guidelines.

Results:
Out of 770 patients (mean age 48.9±13.4, women 47.7%) had 91 (11.8%) patients with pre - transplant diastolic dysfunction. Patients with diastolic dysfunction were more likely to be older, hypertensive, ≥2 comorbidities and suffer from solid organ malignancy (p <0.05). Diastolic dysfunction was associated with GVHD (HR 2.69; 95% CI 1.42 - 5.10, p =0.002), post - transplant systolic heart failure (HR 3.25;95% CI 1.68 - 6.29, p=0.0001), 30 - day rehospitalizations (HR 1.81;95% CI 1.22 - 2.45, p = 0.003) and mortality (HR 2.62;95% CI 2.11 - 3.25, p = 0.0001). However, intensive care unit treatment, length of stay and sepsis were not associated with pre - transplant diastolic dysfunction.

Conclusion:
Pre - transplant diastolic dysfunction in this group of patients was associated with worse prognosis after transplantation. These findings might help guide therapies and early treatment/management of these patients, so that these complications might be prevented.
Abstract 88: Preoperative Hyponatremia is Associated with Increased Risk of Heart Failure Hospitalization and Mortalityamong Veterans Undergoing Cardioverter-Defibrillator Implantation
Authors: Schneider Preston M , Katz David F , Pelligrini Cara N , Heidenreich Paul A , Aleong Ryan G , Keung Edmund C , Massie Barry M , Varosy Paul D
Published: July 2021

Introduction:
It is unknown whether hyponatremia is associated with risk of heart failure hospitalization or mortality among patients undergoing implantable cardioverter-defibrillator (ICD) implantation. This study was undertaken to assess whether or not hyponatremia is an independent risk factor for heart failure hospitalization or mortality following ICD implantation.

Methods:
The Outcomes among Veterans with Implantable Defibrillators (OVID) registry is a prospectively identified national cohort of VA patients who underwent ICD implantation between 2003 and 2009. There were 3,918 patients who were identified and having serum sodium measured at the time of implantation. Hyponatremia was the primary exposure and was defined by a serum sodium of less than 135 milliequivalents per liter (mEq/L). We assessed the association of hyponatremia with heart failure hospitalization and mortality using Cox proportional hazards regression adjusted for demographics, comorbidities, and type of device.

Results:
The mean serum sodium was 138.5 mEq/L and 579 patients (15.0%) had hyponatremia. Over a mean follow up time of 2.52 years, the rate of heart failure hospitalization was 14.1 per 100 person-years, and mortality was 9.6 per 100 person-years for subjects with hyponatremia at the time of implantation, compared to 10.0 per 100 person-years and 6.5 per 100 person-years, respectively, for those without hyponatremia. After multivariable analysis, hyponatremia at the time of implantation was associated with increased risk of both heart failure hospitalization (adjusted HR, 1.29; 95% CI, 1.06 - 1.57; P = 0.012) and mortality (adjusted HR, 1.31; 95% CI, 1.05 - 1.64; P = 0.016).

Conclusions:
Preoperative hyponatremia is associated with a modestly increased risk of both subsequent heart failure hospitalization and mortality among veterans undergoing ICD implantation. Further studies should assess whether hyponatremia at the time of ICD implantation is a modifiable risk factor that can be optimized or whether it is a representation of overall health status.