bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 240: Continuous Positive Airway Pressure as a Therapy of Atrial Fibrillation in Obstructive Sleep Apnea. A Systematic Review and Meta-analysis
Authors: Alqalyoobi Shehabaldin , Nasir Usama B , Mawri Sagger , Sabbagh Salah , Qureshi Waqas
Published: March 2022

Background:
Atrial fibrillation (AF) is a significant health care problem in obstructive sleep apnea (OSA) patients. Continuous positive airway pressure (CPAP) as therapy for OSA is underutilized and it is not known if it may reduce rates of AF.

Methods:
We have systematically reviewed CPAP use and risk of AF. MEDLINE, EMBASE, CINAHL, Web of Science, meeting abstracts, presentations and Cochrane central databases were searched from inception through January 2015. For a study to be selected, it had to report the rates of AF in participants on CPAP and not on CPAP. Data were extracted by 2 independent authors. Forrest plot was created to show the effect sizes (Figure).

Results:
A total of 8 studies (2 randomized controlled trials) with 698 CPAP user and 549 non-CPAP users OSA patients were included. In a random effects model, patients treated with CPAP use had a 43% decreased risk of AF (pooled RR 0.57; 95% CI 0.44-0.74, p <0.001). There was low heterogeneity in the results (I2 = 28%). In meta-regression analysis, the beneficial impact of CPAP on AF was significantly stronger for younger, obese and males (p <0.05).

Conclusions:
In this meta-analysis, a strongly inverse relationship of CPAP therapy with AF was observed. This further supports aggressive case finding of OSA in patients that undergo treatment for AF.
Abstract 249: Formative Evaluation of a National Social Network of Heart Failure Providers: What is its Perceived Value by the Participating Members?
Authors: Sahay Anju , Mittman Brian , Heidenreich Paul A
Published: March 2022

Objective:
There is growing interest in the use of networks to facilitate knowledge exchange in health-care settings. The goal of the Dept. of Veterans Affairs (VA) Chronic Heart Failure (CHF) QUERI program is to improve the quality of care for heart failure (HF) patients and implement evidence-based practices (EBP) throughout the VA system. One strategy to achieve this goal was to create a VA Heart Failure Provider Network which occurred in 2006. We sought to conduct a formative evaluation of this well-established network to assess its perceived value by the members participating in it to improve HF care for Veterans.

Method:
Qualitative data was gathered using semi-structured phone interviews with selected HF Network members (n=25). All current members who had been participating in the HF Network for at least six months and hadn’t participated in the phone interview completed a web-based survey (n=878). The survey response rate was 24.9%. The HF Network members include leaders from Central Office, regional and facilities, chiefs of cardiology, physicians, nurses and others from all VA facilities (n=144).

Results:
Qualitative analysis of interviews showed that members participated in the HF Network to stay informed and maintain or enhance their knowledge in this area. Collaboration within and between VA facilities was frequently mentioned as a facilitator to achieve the goals of the HF Network. Also, many members mentioned that the web-based meetings and conference calls about HF clinics/programs were the most helpful because these methods provided access to new and practical ideas about solving problems and implementing changes in their own facility and to the members stay informed concerning heart failure care. Regarding barriers to greater involvement in HF Network activities, the most commonly noted barrier was lack of resources with members frequently mentioning lack of staff, time and local support.

Quantitative findings strongly support the findings. Among the respondents (n=219), 90% of all members reported that the HF Network helped them establish collaborations and/or to network among members of the HF Network at least to a moderate extent. Interestingly, 63.8% of all members also reported that their participation in the HF Network provided them with names of contacts for networking and potential problem solving. 94.1% of the members found attending the web-based meetings and conference calls helpful in learning about barriers and facilitators in setting up or running HF program.

Conclusions:
Members perceived this social network of heart failure providers as a platform for the exchange of both explicit and tacit knowledge with the goal of improving quality of care for Veterans with heart failure.

Implications for Policy or Practice:
Social networks offer an effective platform for the implementation of EBP to improve the quality of HF care from local, regional to national levels.
Abstract 25: Hospitals That Serve Minority Patients Do Less to Reduce Readmissions Yet Report More Barriers: Results of a National Survey of Hospital Leaders
Authors: Figueroa Jose F , Joynt Karen , Jha Ashish
Published: March 2022

Objective:
The Hospital Readmissions Reduction Program (HRRP), initiated in 2012, penalizes hospitals with higher-than-expected readmission rates. This is particularly salient for minority-serving hospitals (MSHs), which have higher readmission rates than peer institutions, and may face unique barriers. The objective of this study was to determine whether there were differences in the strategies used and barriers faced by MSHs in their efforts to reduce readmission rates.

Methods:
We surveyed leadership at 1600 U.S. acute-care hospitals between January 2013 and January 2014, oversampling minority-serving institutions. We achieved a 62% response rate. We defined three categories: 1) Major MSHs: Top 10% of hospitals with the highest proportion of black patients, 2) Minor MSHs: top 10 to 25%, and 3) non-MSH: the remaining 75% of hospitals. We compared survey responses between groups, adjusting for non-response and sampling strategy.

Findings:
Of the 992 respondents, 219 (22.1%) were hospital leaders at Major MSHs, 341 (34.4%) Minor MSHs, and 432 (43.5%) non-MSHs. Major MSHs were less likely than non-MSHs to use the following strategies: 1) discharge planner (67.9% vs. 76.5%, p<0.001), 2) electronic tools to share discharge summary (65.3% vs. 72.9%, p<0.005), 3) pharmacists to reconcile discharge medications (29.6% vs. 39.5%, p<0.001), and 4) contact patients within 48hrs after discharge (60.1% vs. 67.3%, p=0.005). Major MSHs were more likely to report the following as important barriers: 1) availability of primary care in the community (36.4% vs. 24.8%, p<0.0001), availability of financial resources (70.0% vs. 62.9%, p=0.018), and adequacy of transitions of care (52.3% vs. 44.8%, p=0.009). There were no significant differences in the perceived availability of nursing homes, visiting nurse services, or mental health/substance abuse services in the community between the three groups. Major MSHs were also more likely to report homelessness (40.2% vs. 25.3%, p<0.001) and lack of transportation (55.5% vs. 43.6%, p<0.0001) as significant challenges than non-MSHs. Additionally, minor MSHs also reported that language barriers (21.3% vs. 17.3%, p=0.02) and mental health/substance abuse (74.5% vs. 69.5%, p=0.016) were greater challenges than non-MSHs.

Conclusions:
In a nationally representative survey, we found that hospitals that serve a high proportion of blacks were less likely to use several important strategies in their efforts to reduce readmissions, and identified availability of primary care, poor transitions of care, financial resources, and patient-related factors as barriers to reducing readmissions. These findings suggest that additional resources to support in-hospital interventions to reduce readmissions may help close the racial gap in readmission rates. Policies that help build community capacity may also be an important component of readmission reduction.
Abstract 252: Use of a Chest Pain Score by Emergency Department and Hospitalist Physicians and Subsequent Utilization of Cardiac Imaging and Left Heart Catheterization at a Large Community Hospital
Authors: Manalac Raoul , Wascome Eric , Giarrusso Amy , Slataper Richard
Published: March 2022

Background:
Chest pain is the chief complaint of approximately 10% of all Emergency Department (ED) admissions. Optimal care is difficult to achieve in the ED environment and often requires involvement of hospitalists physicians to aid in triage decisions.

Hypothesis:
Introduction of a web-based chest pain scoring system will result in decreased cardiac imaging and catheterizations.

Methods:
ED physicians and hospitalists of a large community hospital were provided web-based copies of the chest pain score. The basis of the score was previously validated scores found in the published literature for patients presenting to an ED with chest pain.

All hospitalist consultations from the ED with a chief complaint of “chest pain” from 10/8/2014 to 2/1/2015 were assigned a chest pain score by ED providers. STEMI, emergent non-cardiac, and surgical causes were excluded (e.g. pneumothorax, acute trauma, aortic dissection). A hospitalist then assessed each consultation and assigned his or her own score. These scores corresponded with pre-specified disposition and management plans. When there were discrepancies in scoring, ED and the hospitalist collaborated on further work-up and disposition.

Primary variables of interest were the number of imaging studies and left heart catheterization performed. Imaging and catheterization data were captured from hospitalist physician Computerized Physician Order Entry (CPOE) and Electronic Medical Record (EMR) data. Imaging data were compared approximately four months prior to (6/1/2014-10/7/2014) and after (10/9/2014-2/1/15) initiation of the study. Catheterization data were compared approximately two months prior to (8/1/14-10/8/14) and after (10/8/14-11/25/14) initiation of the study.

Results:
During the study period there was a decrease of 49% [(39-20)/39] in urgent catheterizations. Regarding imaging, there was a roughly 34% [(699-463)/699] decrease in all cardiac imaging and an approximately 46% [(585-317)/585] decrease in nuclear perfusion scanning. Notably there was a 28% [(146-114)/114] increase in the use of stress echo. These findings are summarized in Figure 1.

Conclusions:
The findings show a significant decrease in left heart catheterizations and total number of cardiac imaging studies with a concurrent increase in use of stress echo.
Abstract 258: A Novel Process to Reduce Mortality Associated with In-Hospital STEMI
Authors: Choudhry Muhammad W , Kovacs Richard , Cook Holly
Published: March 2022

Background:
According to recently published data mortality due to ST-elevation myocardial infarction (STEMI) occurring in hospitalized patients (pts) can be as high as 40%. Reasons for the high mortality are not completely understood, but delays in diagnosis and treatment, as depicted by prolonged (129 minutes) diagnostic ECG to first intra-coronary balloon inflation (E2B) time, may play a major role. The hospitals of the academic health center (AHC) of Indiana University Health put in place a process for the early identification and treatment of in-hospital ST-elevation Myocardial Infarction (i-STEMI). The process went into place in August of 2009 and consisted of three simple steps: 1) bedside nurses were empowered to obtain a 12 lead ECG on any patient with signs or symptoms of acute coronary syndrome, 2) Providers from the hospital rapid response team (RRT) interpreted the ECG within 10 minutes of acquisition, 3) The rapid responders were empowered to activate the cardiac catheterization laboratory as a Level 1 STEMI emergency. Prior to launch of the i-STEMI process, multiple approaches were employed in order to ensure nurses were adequately educated. We report on the mortality results from the first 40 months of the novel process.

Methods:
The emergent cardiac catheterization database was queried to identify 141 hospitalized pts for whom cardiac catheterization laboratory was activated emergently between August 2009 and 2013. Electronic health records were reviewed to record demographics, admission diagnosis, comorbidities, current cardiac medications, indication for obtaining diagnostic ECG, time of diagnostic ECG, time of first intra-coronary balloon inflation, post i-STEMI ejection fraction, and discharge disposition for each patient.

Results:
We found 52 confirmed cases of i-STEMI out of total 141 pts. Out of 52 i-STEMI pts 49 (94%) underwent emergent coronary angiography. The reason for not performing angiography in remaining pts was increased risk of bleeding and altered mental status. Percutaneous coronary intervention (PCI) was performed in 29 (56%) pts. Reasons for not performing PCI in remaining pts included: occlusion of saphenous vein graft and absence of critical stenosis in infarct-related coronary artery as predicted by diagnostic ECG. E2B time for i-STEMI pts at our AHC was 81 minutes. Overall in-hospital mortality was 17%. In-hospital mortality in pts who received PCI was 6.6%. Our E2B time and hospital mortality were much lower when compared with recently reported data i.e. 81 minutes vs. 129 minutes and 17% vs. 40% respectively.

Conclusion:
A simple protocol that empowers adequately trained bedside medical personnel can significantly reduce time to optimal treatment and in-hospital mortality associated with i-STEMI. For patients who receive timely intervention, i-STEMI can be managed with survival rates very similar to pts presenting to hospital with STEMI.
Abstract 261: Insights into Hospital Readmission Patterns of Atrial Fibrillation Patients
Authors: Gupta Ashwin , Bumpus Sherry M , Sylvester Rachel , Montgomery Daniel , Kline-Rogers Eva , Froehlich James B , Eagle Kim A , Rubenfire Melvyn , Vaishnava Prashant
Published: March 2022

Background:
Atrial fibrillation (AF) is associated with morbidity, mortality, and rising costs. There is a paucity of data to inform best practices for care transition following AF hospitalization. We sought to characterize unplanned readmissions of AF patients.

Methods:
Retrospective data of patients discharged after AF hospitalization and referred to the NP-led transitional care program, BRIDGE, were abstracted from 2008-2012. Unplanned readmissions were dichotomized as early (<30 days) or late (31-180 days) readmits and classified as either AF-related; CV/non-AF; or non-AF/non-CV. Cases were adjudicated by a senior cardiologist. Demographics and readmission variables were compared.

Results:
Of 255 patients, 97 (38.0%) had unplanned readmissions within 180 days of discharge; 45 (46.4%) were early and 52 (53.6%) were late. AF and CV causes only accounted for 48.9% (n=31) of early readmissions and 65.4% (n=34) of late. Late readmits were more likely to have diabetes (32.7% v 17.7%, p=.022) and higher CHADS2VASc scores (3.63 v 2.98, p=.026) than those not readmitted. No other differences in baseline characteristics were seen between groups. The 30-day AF readmission rate in this sample was 17.6% (n=45).

Conclusions:
Readmissions following hospital discharge for AF are common and often for reasons that are neither AF nor CV-related. In order to reduce AF-related readmissions further research is needed to characterize readmission predictors and effective transitional care interventions.
Abstract 263: Incidence of Recurrent Cardiovascular Events and Disease Burden Among High-Risk Patients with Hyperlipidemia
Authors: Punekar Rajeshwari S , Fox Kathleen M , Richhariya Akshara , Fisher Maxine D , Gandra Shravanthi R , Cziraky Mark J , Toth Peter P
Published: March 2022

Background:
This study evaluated the real-world patterns and time to first and recurrent cardiovascular (CV) events among patients with hyperlipidemia.

Methods:
Patients (age 18-64) with hyperlipidemia diagnosis or using lipid-lowering therapy (LLT) from 1/1/2007 to 12/31/2008 were selected from the HealthCore Integrated Research Database
SM
(HIRD) and followed until the end of study period (02/28/2013) or health plan enrollment or death (whichever occurred first). Patients who had ≥ 1 CV events (myocardial infarction, ischemic stroke, unstable angina, coronary artery bypass graft or percutaneous coronary intervention) 12 months before the first occurrence of hyperlipidemia diagnosis or LLT use (baseline period) were included in the CV event history cohort. Patients without any CV event(s), but who had ischemic heart disease, stable angina, peripheral arterial disease, abdominal aortic aneurysm, transient ischemic attack, or type 2 diabetes during the baseline period were included in the modified CV RE cohort. Baseline use of LLT, incidence and time to first and subsequent CV events were quantified.

Results:
In the CV event history cohort (n=9890, mean age=55 years), 41.8% had ≥1 new CV event with 18.9% having 3 or more new CV events; 33.3% of patients with CV RE (n=27,352, mean age=55 years) had ≥1 new CV event with 12.5% having 3 or more new CV events. At baseline, in both cohorts, about 64% were using LLT. In the CV event history cohort, time to first new CV event was 786 days and time between the first and second and second and third CV events was 270 days and 208 days, respectively. In the CV RE cohort, time to first new CV event was 939 days and time between the first and second and second and third CV events was 258 days and 193 days, respectively. Mean 1-year total cost of the second CV event and the third CV event was 30%-48% and 34%-46% higher than the first CV event in both cohorts.

Conclusions:
CV event-related risk and long-term costs are significantly greater among high-risk patients with shorter time intervals between recurrent CV events. Underutilization of LLTs in these patients highlights the need for improving clinical management and treatment options for these patients.
Abstract 264: Impact of Obesity on Index Presentation for ST-segment Elevation Myocardial Infarction
Authors: Ogunsua Adedotun A , Touray Sunkaru , Lui Justin K , Dallasen Renee , Dheyab Abduljabbar , Tighe Dennis , Aurigemma Gerard
Published: March 2022

Background:
Obesity is associated with cardiovascular risk factors such as diabetes, hypertension and hyperlipidemia. Previous studies have examined the relationship between obesity and outcomes in patients who were diagnosed with ST-segment myocardial infarction (STEMI). However, the impact of obesity in patients with no prior myocardial infarction (MI) who were diagnosed with STEMI and underwent percutaneous coronary intervention (PCI) has not been established.

Aims:
We examined the relationship between obesity, coronary lesions and probability of STEMI in patients who were admitted with STEMI and subsequently had PCI at our center between July 1, 2009 and November 30, 2010.

Methods:
Body Mass index (BMI) was computed as weight divided by square of the height (Kg/m2) and classified into categories on the basis of world health organization criteria. Multivariate logistic regression models were built incorporating age, gender, hypertension, hyperlipidemia, smoking, BMI, heart failure and chronic liver disease. The models were used to calculate the predicted probabilities of STEMI.

Results:
We studied 728 patients with no prior MI (mean age 61 years, 65% females). Prevalence of acute coronary syndrome increased with age with a peak occurrence a decade later in females compared to males (60-69 years in females vs. 50-59 years in males, p<0.01). Proximal right coronary artery lesions were significantly more common in females than males (15% vs. 10% p 0.04) Mid left anterior descending lesions were also more common in females (28% vs. 21% p 0.05). Males tended to be more obese than females (31% vs. 19% obesity class I p=0.001, and 52 % vs. 44%, obesity class II p=0.005). Computed predicted probabilities showed that the highest probability of STEMI among females occurred in the morbidly obese category while among males, normal weight and overweight individuals had higher probabilities than other obesity categories (figure 1)

Conclusions:
We conclude that in patients with no prior MI who were diagnosed with STEMI and had PCI, morbidly obese females had a higher probability of presenting with STEMI compared to other BMI categories. These results suggest that obesity plays a bigger role in females compared to males.
Abstract 271: Knowledge of Heart Disease in Female and Male College Students
Authors: Granieri Michael J , Koulova Anna , Cordova Juan Pablo , Agarwal Vikram , Trignano Sarah , Tamis-Holland Jacqueline E
Published: March 2022

Background:
Educational programs and campaigns aimed at raising awareness of heart disease (HD) in women have resulted in an improvement in women’s knowledge of HD and related risk factors (RF). Less is known regarding awareness of HD in the younger generation of women and men.

Objective:
We evaluated knowledge of HD and related RF, among a cohort of female and male college students.

Methods:
Students attending a private college were invited to complete an online anonymous survey consisting of 44 questions.

Results:
A total of 243 students completed the survey; (mean age 18.9 +/- 1 years; 66% female; 81% Caucasian, 7% Asian 1% black and 12% other). The responses to the survey are depicted in the table. Although the majority of college students correctly identified HD as the leading cause of death in men, less than half of all students, and only 30% of male students reported HD as the leading cause of death in women. Furthermore, knowledge of RF for heart disease was low in both female and male students.

Conclusions:
Future educational campaigns should aim to target the younger generation, focusing on RF and lifestyle modification.
Abstract 272: Association of Renal Insufficiency With Outcomes of Percutaneous Coronary Intervention
Authors: Gupta Tanush , Harikrishnan Prakash , Kolte Dhaval , Khera Sahil , Aronow Wilbert S , Mujib Marjan , Palaniswamy Chandrasekar , Ahmed Ali , Cooper Howard A , Fonarow Gregg C , Panza Julio A
Published: March 2022

Background:
Limited data are available on the impact of chronic kidney disease (CKD) and end stage renal disease (ESRD) on outcomes after percutaneous coronary intervention (PCI).

Objectives:
To determine the association between baseline renal insufficiency with in-hospital outcomes after PCI.

Methods:
We queried the 2003-2011 Nationwide Inpatient Sample databases to identify all patients aged ≥ 18 years undergoing PCI. Patients who underwent coronary artery bypass grafting during the same admission were excluded. Patients with concomitant diagnosis of CKD (ICD-9 codes 585.1-585.5 and 585.9) and ESRD (ICD-9 diagnosis code 585.6 or procedure code for hemodialysis [39.95, excluding patients with concurrent diagnosis of acute renal failure] or peritoneal dialysis [54.98]) were then identified. Multivariable logistic regression was used to compare outcomes between patients with CKD and patients with ESRD to those without CKD or ESRD.

Results:
Of 6,417,970 patients who underwent PCI, 93.3% (mean age 64.2±12.3 years, 33.7% females) had no CKD/ESRD; 4.9% (mean age 71.5±11.3 years, 35% females) had CKD; and 1.8% (mean age 64.2±11.8 years, 42.2% females) had ESRD. The prevalence of smoking was highest in patients with no CKD/ESRD; that of dyslipidemia, coronary artery disease, prior myocardial infarction, atrial fibrillation, and obesity was highest in CKD patients; diabetes mellitus, hypertension, and congestive heart failure were most prevalent in ESRD patients (p<0.001 for all). Of patients undergoing PCI, 61.2% patients in no CKD/ESRD group had an acute coronary syndrome, as compared to 65.4% in CKD group, and 58.2% in ESRD group (p<0.001). Compared to patients with no CKD/ESRD, those with CKD and those with ESRD had higher in-hospital mortality and higher incidence of post-procedure hemorrhage. Baseline renal insufficiency was also associated with longer average length of stay and higher average total hospital charges (Table).

Conclusions:
In patients undergoing PCI, baseline renal insufficiency is associated with worse outcomes. Patients with CKD and patients with ESRD had increased in-hospital mortality, higher hemorrhagic complications, longer average length of hospital stay, and higher average hospital charges than those without CKD or ESRD.
Abstract 274: Root Cause Analysis of Deaths in ST Elevation Myocardial Infarctions: What Can We Do Better?
Authors: El Sakr Fredy H , Kenaan Mohamad , Menees Daniel , Nallamothu Brahmajee , Gurm Hitinder
Published: March 2022

Background:
Improving quality of care for patients presenting with ST elevation Myocardial infarctions (STEMI) is a national priority. However, recent data demonstrate that mortality has not changed despite numerous targeted efforts. Identifying potential areas in care that can be further optimized to decrease mortality remains a priority.

Methods:
We performed a root cause analysis of all patients who died following primary PCI during index hospitalization from 2008 to 2013 at the University of Michigan (n=25 deaths). Using a standardized data collection form, two interventional cardiologists reviewed patient care received prior to arrival to the catheterization lab, while in the catheterization lab, and after primary PCI to determine cause of death and to rate potential preventability of death on a Likert scale.

Results:
Majority of deaths were deemed unpreventable. Symptom-onset-to-medical care time was rated as the most common potentially preventable factor.

Conclusion:
Mortality following primary PCI was deemed mostly unpreventable. However, improvement in total ischemic time, and in particular symptom-onset to-medical care, was identified as one potential target that might be of value in further reducing the mortality associated with STEMI.
Abstract 288: Consistency of Hemoglobin A1C Testing and Amputation Risk
Authors: Goodney Philip P , Newhall Karina , Bekelis Kimon , Faerber Adrienne , Stone David H , Skinner Jonathan S
Published: March 2022

Importance:
While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if preventive measures such as hemoglobin A1C testing have been associated with these improvements.

Objective:
To determine associations between hemoglobin A1c testing and amputation risk.

Design, Setting, and Participants:
We identified 11,942,840 Medicare patients with diabetes over the age of 65 between 2002-2012, and followed them for a mean of 6.6 years. We recorded the occurrence of lower-limb amputation and hemoglobin A1C testing. We examined associations between amputation risk and hemoglobin A1C testing. We measured both the presence of any testing, as well as testing consistency, using three categories: poor consistency (hemoglobin A1C testing in 0-50% of years), medium consistency (testing in 50-90% of years)), and high consistency (testing in >90% of the years in the cohort).

Main Outcome Measure:
Major (above or below-knee) amputation rate.

Between 2002 and 2012, the incidence of major amputation in Medicare patients with diabetes declined by 54% during the study period, from 1.15 per 1,000 in 2002 to 0.53 per 1,000 in 2012 ( rate ratio = 0.53, 95% CI =0.51-0.54). Hemoglobin A1C testing increased from 78% of patients in 2002 to 83% of patients in 2012, and black and Hispanic patients were least likely to receive high consistency. In multivariable analysis adjusting for patient characteristics, including race, any use of hemoglobin A1C testing was associated with a 15% decline in amputation risk (HR 0.85, 95% CI 0.83-0.87, p<0.0001). However, high consistency hemoglobin A1C testing was associated with a 39% decline in amputation (HR 0.61, 95% CI 0.59-0.62, p<0.0001).

Conclusions:
Amputation rates have declined similarly across black, Hispanic, and white patients in recent years. Longitudinal quality measures emphasizing consistency in hemoglobin A1C testing may be an effective pathway towards limiting amputation in all races.
Abstract 301: Healthcare Costs Following Stroke and Major Bleeding Events in Nonvalvular Atrial Fibrillation Patients
Authors: Naccarelli Gerald , Stokes Michael , DeLeon Anthony , Tate Natalie , Wang Rosa , Wang Alan , Fredell Jeremy
Published: March 2022

Objectives:
We sought to determine the impact of stroke and major bleeding excluding intracranial hemorrhage (MB) events on healthcare costs in a real-world nonvalvular atrial fibrillation (NVAF) population.

Methods:
Healthcare claims data from U.S. commercial and Medicare health plans were used to identify beneficiaries with NVAF during 2008-2012. Patients were classified into cohorts according to event type (No event, Stroke only, MB only, or Stroke plus MB). All-cause total healthcare costs and inpatient costs related to stroke and MB were calculated during 1-year period following the index date (date of initial event or first qualifying AF claim for No event group). Inpatient hospitalizations related to events were identified using ICD-9-CM diagnosis codes. Costs were standardized to 2012 US dollars.

Results:
Of the 40,654 patients included in the study, 28% had events (8.9% Stroke only, 14.5% MB only, and 4.7% Stroke plus MB). Relative to the No event cohort, all-cause unadjusted per-patient per-month (PPPM) total costs were $4,669 higher for Stroke only and $4,160 for MB only. For Stroke plus MB patients, unadjusted all-cause PPPM total costs were $6,322 higher compared to the No event cohort. Among Stroke only and MB only patients, the economic burden of hospitalizations related to MB (57% of total costs) was similar to Stroke only (63% of total costs). Hospitalizations related to stroke or MB accounted for 65% of total costs for Stroke plus MB.

Conclusions:
NVAF patients who have a stroke or MB event incur higher healthcare costs relative to patients without events. Interventions preventing stroke or MB events have the potential to reduce the healthcare burden associated NVAF.
Abstract 305: The Accuracy of Profiling Methods to Identify Hospital Outliers for Ischemic Stroke Mortality in the Presence of Missing Data: Effect of Hospital Volume
Authors: Thompson Michael P , Luo Zhehui , Gardiner Joseph , Burke James F , Reeves Mathew J
Published: March 2022

Objective:
We used simulation modeling to assess the impact of missing risk adjustment data, exemplified by incomplete National Institute of the Health Stroke Scale (NIHSS) documentation, on the ability of risk adjustment models to accurately identify hospital ischemic stroke mortality performance outliers using a complete case analysis.

Methods:
Simulation parameters were generated from analysis of 10,716 ischemic stroke patients aged 65 and older from the Michigan Stroke Registry (MSR). 250 datasets were simulated in a way such that distributions of risk score (including NIHSS) and mortality within and between 100 hospitals were similar to the MSR. We randomly assigned missing NIHSS data to each simulated dataset using a plausible range of hospital-level NIHSS documentation (30%-100%). Hospitals were assigned a random intercept from a distribution of intercepts observed in the MSR (true performance), and estimated from a hierarchical mortality model using a complete case analysis of the simulated data (observed performance). If the assigned (true) or estimated (observed) random intercepts were outside their respective 95% CIs, they were considered outliers. Accuracy was assessed as the percent of true outliers and non-outliers correctly identified by the hierarchical model, i.e., sensitivity (Se) and specificity (Sp). To understand the impact of case volume, we modified hospital patient volume as 100, 300 and 500.

Results:
As NIHSS documentation fell, Se decreased while Sp increased. (Figure) The relative change in both Se and Sp was strongly impacted by patient volume: in hospitals with low stroke volume (n=100), Se was <50% even with complete documentation, while Sp remained high (>90%). In moderate (n=300) and high (n=500) stroke volume hospitals when NIHSS documentation was very high, Se was near perfect, but declined rapidly with reduced documentation. Conversely, as NIHSS documentation fell, Sp increased in both moderate and high volume hospitals.

Conclusions:
Reductions in sample size when using a complete case analysis in the presence of missing data have a dramatic effect on correctly identifying performance outliers, especially in lower case volumes. Limitations to identifying ischemic stroke performance mortality outliers - even with complete NIHSS documentation - should be appreciated.
Abstract 311: Comparative Effectiveness of Outpatient Cardiovascular Disease Care Delivery Between Physician and Non-Physician Primary Care Providers: Implications for Care Under the Affordable Care Act
Authors: Virani Salim S , Akeroyd Julia M , Ramsey David J , Chan Winston J , Rajan Suja S , Ballantyne Christie M , Petersen Laura A
Published: March 2022

Introduction:
With the Affordable Care Act (ACA) implementation, the current number of physicians will not be sufficient to accommodate 30-40 million Americans receiving health care access. A proposed solution is to utilize non-physicians (nurse practitioners, physician assistants) for chronic disease care. Recent studies have shown comparable quality of outpatient cardiovascular disease (CVD) care between physicians and non physicians in cardiology practices. We compared the quality of CVD care between non-physicians and physicians in a primary care setting.

Methods:
We identified CVD (ischemic heart disease, cerebrovascular or peripheral artery disease) patients with a primary care visit between October 2013 and September 2014 in 130 Veterans Affairs facilities. Using hierarchical regression adjusting for illness-severity and other covariates (
Table
), we compared proportion of patients with BP <140/90 mmHg, LDL-C <100 mg/dL, receiving a statin, receiving moderate to high intensity statin, or receiving a beta-blocker (in those with MI in the last 2 years) among patients receiving care from physicians (n=934,950) and non-physicians(252,085). We also compared the proportion meeting the 3 measures (BP <140/90mmHg, receiving a statin, and receiving a beta-blocker) among eligible patients receiving care from physicians and non-physicians.

Results (Table):
Although quality of care was numerically comparable; patients receiving care from non-physicians were statistically more likely to have BP control, whereas, patients receiving care from physicians were more likely to have cholesterol control (LDL-C <100 mg/dL, statin or moderate-high intensity statin use), or receive a beta-blocker in adjusted models. Importantly, overall CVD care quality did not differ, with only 54.0% and 54.8% of those receiving care from physicians and non-physicians meeting all 3 eligible measures.

Conclusion:
Overall CVD care quality delivered by physicians and non-physicians was comparable with modest differences in specific measures. Therefore, a collaborative care delivery model employing physicians and non-physicians may deliver comparable CVD quality to a physician-only model. Regardless of the provider type, there is a need to improve global performance on all eligible measures in CVD patients.
Abstract 314: Longitudinal Changes in the Case-mix of Patients Admitted to the Cardiac Intensive Care Unit
Authors: Sinha Shashank S , Sjoding Michael W , Cooke Colin R , Nallamothu Brahmajee K
Published: March 2022

Background:
Data on longitudinal shifts in diagnoses, co-morbidities, illness severity and procedure use among patients admitted to the cardiac intensive care unit (CICU) are limited. Improving our understanding of the evolving case-mix of these critically ill patients has important implications.

Methods:
We performed a retrospective cohort study of hospitalized, elderly (age ≥ 65 years), fee-for-service Medicare beneficiaries using Medicare Provider Analysis and Review files from 2000-2010. Analysis was limited to patients billed for a CICU stay. Using the Clinical Classification Software from the Agency for Health Care Research and Quality, we collapsed primary ICD-9-CM admission diagnosis codes into broad disease categories. We assessed for changes in patient demographics, primary admission diagnosis, co-morbidities (Elixhauser), organ failure, procedure use, and outcomes. Time trends were assessed using Poisson regression. Comparisons between patients in 2000 and 2010 were performed using chi-squared analysis.

Results:
Among 5.4 million CICU admissions from 2000-2010, the primary admission diagnosis changed substantially, with non-cardiac diagnoses becoming more prevalent (Table). Primary admission diagnoses of coronary artery disease (CAD) and congestive heart failure (CHF) decreased from 32.7% to 9.9% and 9.6% to 7.7%, respectively. In contrast, infectious diseases increased from 7.6% to 13.5% and respiratory diseases increased from 6.1% to 7.8% (p for trend < 0.001 for all). An increase in the percentage of patients with cardiovascular co-morbidities including CHF (11.9% to 28.7%), pulmonary vascular disease (1.2% to 5.1%), valvular disease (4.2% to 9.1%), and ≥1 organ failure (20.9% to 38.1%) was noted. Also, hemodialysis rates (2.7% to 4.2%), non-invasive ventilation rates (0.6% to 3.5%), and central venous catheter use (5.5% to 12.7%) increased, while pulmonary artery catheter use decreased (2.1% to 0.9%). Crude in-hospital mortality rate decreased from 9.4% to 8.3%.

Conclusions:
Case-mix of CICU admissions has shifted over the last decade, with a significant decrease in primary admission cardiac diagnoses but rising cardiovascular co-morbidities. The CICU has become a setting where patients with advanced cardiac conditions are treated for a wide variety of acute illnesses.
Abstract 320: Accuracy of ICD-9 Codes for Identifying Acute Heart Failure Hospitalizations
Authors: Huang Hans D , Turner Matthew , Lederle Frank
Published: March 2022

Background:
Hospitalization for acute decompensated heart failure (AHDF) is an important outcome, either as a primary or composite endpoint, in clinical trials and large heart failure (HF) registries. However, it remains unclear how accurately International Classification of Diseases-9 (ICD-9) discharge codes can identify clinically significant episodes of acute HF hospitalizations.

Objective:
To evaluate the accuracy of principal ICD-9 discharge codes associated with HF in identifying hospitalizations for ADHF.

Methods:
ICD-9 codes associated with HF were identified from previous studies. All 2,202 hospitalizations within the Minneapolis VA Medical Center between 2009 and 2014 containing a principal discharge ICD-9 code of interest were identified. Of these, 446 were adjudicated. Using the electronic medical records, two independent reviewers (HH, MT) classified each case as probably ADHF, probably not ADHF, or cannot be determined. Agreement between the reviewers was considered to represent a true outcome (i.e. true positive or true negative). The sensitivity and positive predictive value (PPV) for identifying ADHF was then calculated for the ICD-9 discharge codes.

Results:
The reviewers agreed on 399 of the 446 adjudications (89.5%). Among the 399, the sensitivity and PPV of the ICD-9 codes were: 402.91 (unspecified hypertensive heart disease with HF): .03 (95% CI: 0.02-0.06) and .73 (95% CI: .45-.91); 404.x (hypertensive heart and chronic kidney disease): .07 (95% CI: .05-.11) and .87 (95% CI: .68-.96); and 428.x (congestive HF): .87 (95% CI: .83-.90) and .92 (95% CI: .89-.95); and 428.x excluding chronic HF codes (428.22 and 428.32): .68 (95% CI: .63-.73) and .98 (95% CI: .94-.99).

Conclusion:
ICD-9 codes 428.x was reasonably sensitive for identifying ADHF and, if chronic HF codes were excluded, had high predictive value. More evaluation is needed to assess the ability of secondary codes to further categorize hospitalizations coded as chronic HF.
Abstract 322: Duration of Resuscitation Efforts for In-Hospital Cardiac Arrest by Predicted Survival Outcomes: Insights from Get With The Guidelines - Resuscitation
Authors: Bradley Steven M , Liu Wenhui , Chan Paul S , Girotra Saket , Goldberger Zachary D , Valle Javier A , Perman Sarah M , Nallamothu Brahmajee K
Published: March 2022

Background.
The duration of cardiopulmonary resuscitation has implications for patient survival of in-hospital cardiac arrest (IHCA). However, the duration of resuscitation efforts should be balanced against the probability of patient survival. It is unknown whether the duration of attempted resuscitation for IHCA is associated with the predicted probability of patient survival.

Methods.
We identified 40,563 non-survivors of resuscitation efforts for IHCA within the Get With The Guidelines [[Unable to Display Character: –]] Resuscitation Registry between 2000 and 2012. In these patients, we determined the pre-arrest predicted probability of survival to discharge with good neurologic status using the previously validated GO-FAR score. Using this tool, predicted survival was categorized into very low (<1%), low (1-3%), average (>3% to 15%), and above average (>15%). Duration of resuscitation efforts were measured in minutes from the onset of cardiac arrest to termination of resuscitation efforts. We then compared the duration of resuscitation efforts by predicted survival categories.

Results.
Among 40,563 non-survivors of IHCA, the predicted survival to discharge was very low in 4801 (11.8%) patients, low in 8889 (21.9%), average in 19910 (49.1%) patients, and above average in 6963 (17.2%) patients. The median duration of attempted resuscitation was 19 minutes and the duration of attempted resuscitation was longer in non-survivors with a higher predicted probability of survival (median duration in minutes from very low to above average categories of predicted survival, 16 vs 17 vs 20 vs 23, P<.001). However, the duration of attempted resuscitation was often discordant with predicted survival (Figure), including shorter than median duration of attempted resuscitation in 31.9% of patients with above average predicted survival.

Conclusions.
In a national cohort of non-survivors of IHCA, the duration of attempted resuscitation correlated overall with predicted arrest survival. However, nearly a third of patients with above average predicted survival received shorter than average attempted resuscitation efforts. Emphasis on an adequate duration of attempted resuscitation, particularly among patients with better than average predicted outcomes, may have implications for improving in-hospital cardiac arrest outcomes.
Abstract 329: Potential Role of Enrichment Strategies with CAC Testing for Future Clinical Trials Assessing PCSK-9 Inhibitors Efficacy Among Diabetics Without Established Cardiovascular Disease
Authors: Nasir Khurram , BittenCourt Marcio , Blanskstein Ron , Blaha Michael , Veledar Emir
Published: March 2022

Introduction:
To date multiple ongoing clinical trials are testing impact of human monoclonal antibody against proprotein convertase subtilisin/kexin type 9 (PCSK9) with established CVD already receiving optimal statin treatment. There is considerable interest in exploring added value of these therapies among high risk groups free of established CVD such as those with diabetes mellitus (DM). Coronary artery calcium (CAC) testing has shown to accurately identify those at high and low risk for cardiac event in short-intermediate term. The aim of the current study is to assess potential implications of enrichment strategies via CAC testing for future clinical trials evaluating impact of PCSK-9 inhibitors in DM free of established CVD

Methods:
In our analysis, 5-year CVD rates among DM individuals were estimated from published literature. In the placebo (control) group, 30% relative risk reduction (RRR) with highest tolerated statin dose was considered. The NNT and drug cost with additional PSCK-9 inhibitor therapy to prevent one cardiac event were calculated across varying (20-40%) RRR thresholds. The annual cost of PCSK-9 inhibitors was estimated in range of $3000-$7,000. We considered ≤ $0.5 million as upper limit for willingness to pay to prevent 1 CVD event in 5 years.

Results:
The table highlights a) absolute event rates with additional PCSK-9 inhibition, b) the calculated NNT, and c) costs to prevent one cardiac event across the entire DM cohort as well among CAC subgroups. Among all diabetics, the NNT to prevent one event ranged from 48-95 with estimated additional 20-40% RRR with PCSK-9 inhibitors; the threshold for willingness to pay in all scenarios was >$ 0.5 million. The respective NNT among 38% of diabetics with CAC=0 were 89-179 and unacceptable high cost to prevent 1 event. Among individuals with at least moderate CAC burden (>100 & >400), the threshold for willingness to pay was realized in most scenarios

Conclusion:
It is imperative that future discussion designing clinical trials assessing efficacy of PCSK-9 inhibitors such as DM focus on enrichment strategies such as CAC testing for recruiting an appropriately ‘high risk’ cohort as well as excluding those who are least likely to benefit. These strategies will likely facilitate acceptable NNT and public willingness to pay for these emerging novel therapies
Abstract 331: Early Empowerment Strategies Boost Self-efficacy to Improve Health Outcomes
Authors: Kashani Mariam D , Eliasson Arn H , Walizer Elaine M , Fuller Claire E , Engler Renata J , Villines Todd C , Vernalis Marina N
Published: March 2022

Background:
An important mechanism in improving health status in behavioral cardiovascular (CV) self-management programs is patient self-efficacy, or a patient’s belief in their ability to make lifestyle changes to reach healthy goals. Little is known on when the optimal time is to incorporate self-efficacy enhancing strategies. We examined the impact of a jumpstart self-efficacy approach in the introductory phase of a multicomponent intervention on CV health outcomes.

Methods:
Participants enrolled in a 12-month CV behavioral health intervention, part of a prospective registry, completed validated questionnaires focusing on the four domains of the program: nutrition (Rate-Your-Plate), exercise (minutes of continuous exercise per week), stress (Perceived Stress Scale), sleep (Pittsburgh Sleep Quality Index) and CV-relevant Self-Efficacy Questionnaire. Empowerment strategies comprised a comprehensive risk assessment report with detailed lifestyle recommendations on optimizing risk reduction and a multi-disciplinary educational workshop with interactive healthy food demonstration and stress management instruction. For the remainder of the program, patients received ongoing motivational health-coaching to achieve healthy goals in the four domains. Self-Efficacy Questionnaire was administered at baseline and after the workshop, at 6 weeks from baseline. All other measures at entry to and at 6-months of the program were assessed with paired t-tests.

Results:
Of 88 consecutive completers of the registry, 65 subjects (77%) had a family history of premature CV disease. These high risk subjects (36 men, age 57.4 ± 12.7 years, 42 white, 15 black, 8 other) showed clinically and statistically significant improvements in all four domains as well as improvement in subjective fatigue and self-efficacy for CVD behaviors.

Conclusion:
A comprehensive CV health intervention emphasizing empowerment strategies early in the sequence of the program improves self-efficacy leading to substantial behavioral improvements in CV health parameters. These findings are highly relevant particularly in high-risk individuals who are vulnerable to CV disease and may have the opportunity to make behavioral lifestyle modifications to lower their risk of overt disease.