bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 80: Patterns of Statin Use, Adherence, and Persistence among Elderly Patients with High-Risk Vascular Diseases
Authors: Zhao Zhenxiang , Zhu Yajun , Fang Yun , McCollam Patrick L
Published: March 2022

BACKGROUND:
High-risk vascular diseases (HRVD), including cerebrovascular disease (CVD), coronary artery disease with diabetes (CADD), acute coronary syndrome (ACS), and peripheral artery disease (PAD), are still the leading cause of death in the US, despite progress in treatment. Little research has been done to systematically study statin use patterns, adherence, and persistence for HRVD patients using real-world large claims databases. The objective was to examine statin use patterns, adherence, and persistence in elderly patients with HRVD.

METHODS:
A large US administrative claims database for over 10 million beneficiaries annually from more than 100 self-insured Fortune 500 companies was used to conduct a retrospective cohort study. Patients with HRVD, defined as CVD, PAD, CADD, or a history of ACS (≥30days through 365 days after discharge for ACS) between 10/01/2008 and 09/30/2009, were ≥65 years of age and identified with minimum 12-month pre-index and 24-month post-index health plan eligibility. Statin use, statin median/mean dose, percent of patients using maximal statin dose (defined as atorvastatin ≥80 mg and rosuvastatin ≥40 mg), and statin adherence (calculated using the medication possession ratio [MPR]) were measured at 6 months, 12 months, and 24 months. Persistence was assessed with survival analysis techniques using a ≥30-day gap to define a discontinuation.

RESULTS:
A total of 525,893 patients with HRVD were identified; 50.3% used statins during the baseline period (PAD: 44.9%; CVD: 45.2%; CADD: 63.9%; ACS: 61.7%). This number changed slightly to 49.2%, 51.8%, and 54.3% during the 6-month, 12-month, and 24-month follow-up periods, respectively, with PAD and CVD patients having greater increase of statin use (49.7%, 50%, respectively) during the 24-month follow-up period. Simvastatin (41.6%, 42.2%, 42.8%), atorvastatin (31.9%, 30.5%, 28.8%), and rosuvastatin (11.5%, 12.0%, 12.4%) were the most commonly used statins with 4.8%, 4.6%, and 4.3% of patients using maximum statin doses at 6-month, 12-month, and 24-month follow-up periods. There appeared to be few changes in statin doses during the 24-month follow-up period (mean/median dose: simvastatin 34.6/40 mg, 34.8/40 mg, 34.8/40 mg; atorvastatin 29.6/20 mg, 29.8/20 mg, 30.2/20 mg; rosuvastatin 14.1/10 mg, 14.2/10 mg, 14.4/10 mg). The mean/median MPR was 0.66/0.68, 0.67/0.74, and 0.60/0.65 among HRVD patients who used a statin with only 17.4%, 20.9 %, and 20.7% of patients adherent (MPR≥80%) to their statin therapy during the 6-month, 12-month, and 24-month follow-up periods, respectively. The median time to statin discontinuation was 406 days during the 24-month follow-up period.

CONCLUSIONS:
Statin adherence is suboptimal for elderly patients with HRVD and the patterns of statin adherence persist over time with little titration in doses.
Abstract 85: Trends In Hospital Readmission Rates among Older Adult Survivors of Mitral Valve Surgery
Authors: Dodson John A , Wang Yongfei , Sugeng Lissa , Hashim Sabet W , Krumholz Harlan M
Published: March 2022

Background:
While several studies have shown declining mortality rates after mitral valve surgery (MVS) in older adults, less is known about changes in experience among survivors. The purpose of our study was therefore to determine hospital readmission rates and days spent in the hospital (after index admission) in patients who survived mitral valve surgery up to one year.

Methods:
Inpatient Medicare data was used to identify 100% of Fee-for-Service patients ≥65 years of age who underwent mitral valve surgery between 1999 and 2010 and survived to one year (N=146,877). We used proportional hazards regression to analyze the all-cause post-MVS readmission rate in each year, number of days spent in the hospital (after index admission), and readmission rates by subgroups of age (65-74, 75-84, ≥85), sex, and race (black, white, other).

Results:
The overall one year post-MVS readmission rate among survivors of MVS decreased over time (49.5% to 46.9%, P =0.0029, for trend) (Figure). Mean number of hospital days per post-MVS hospitalization decreased as well (6.2 to 5.3, P<0.01). The readmission rate among survivors was highest in oldest patients, but declined in all age subgroups over time (65-74: 47.4% to 44.4%; 75-84: 51.4% to 49.2%, ≥85: 56.4% to 50.0%, all P<0.01). There were declines in women and men (women: 51.7% to 50.8%, P<0.01; men: 46.9% to 43.0%, P<0.01), and in whites and patients of other race, but not in blacks (whites: 49.0% to 46.2%, P<0.01; other: 55.0% to 48.9%, P<0.01; blacks: 58.1% to 59.0%, P=0.1823).

Conclusions:
Among older adults who survive MVS at one year, fewer than half are readmitted to the hospital. There has been a modest decrease in hospitalization rate and mean hospital days over time, although significant variations among subgroups deserve further study.
Abstract 89: Utility of Stress Echocardiography in Cocaine Associated Chest Pain
Authors: Sekhar Aravind , Raheja Prafull , Stoddard Marcus F
Published: March 2022

Background:
Patients presenting with Cocaine associated chest pain are typically younger than patients with traditional risk factors but are at risk for accelerated Coronary artery disease. Radiation exposure associated with modes of stress testing such as Coronary CT or SPECT, makes it concerning especially in young females of childbearing age group presenting with cocaine associated chest pain. Stress echocardiography avoids radiation exposure, is more cost effective, saves time and adds to diagnostic information especially in patients with chest pain. However, safety of stress echocardiography has not been well studied in cocaine positive patients. Pharmacological testing with dobutamine raises concerns regarding provoking vasospasm or an exaggerated hypertensive response in these patients due to excessive sympathetic stimulation. Hypertensive response with stress testing can cause wall motion abnormalities without coronary disease and affect specificity of stress echocardiography.

Methods:
We conducted a retrospective analysis of patients who presented with chest pain and underwent stress echocardiography and had toxicology screen for cocaine positive during that visit. Cocaine positive patients were compared with age matched cocaine negative patients and assessed for hypertensive response, ischemic changes and complications during stress echocardiography.

Results:
No sustained arrhythmias, cardiac arrests or major complications occurred in both groups and overall safety in cocaine positive patients was similar to the control group both with treadmill and dobutamine stress echocardiography. Incidence of hypertensive response was not increased compared to controls with both exercise and dobutamine stress testing.

Conclusion:
Stress echocardiography appears to be a safe and useful procedure for risk stratification for cocaine associated chest pain patients once acute coronary syndrome is ruled out.
Abstract 93: Utility of Stress Testing in a Chest Pain Center: A Bayesian Analysis
Authors: Raheja Prafull , Sekhar Aravind , Roberson Catherine , Coram Rita , Stoddard Marcus F
Published: March 2022

Background:
Chest pain is one of the most common reasons for Emergency Department (ED) visits and Chest pain centers (CPC) improve efficiency by triaging low and intermediate risk patients more effectively. We examined the Length of stay (LOS) in CPC and the utility of stress testing and further risk stratification during the CPC visit using a Bayesian analysis. Based on this analysis we suggest some performance improvement measures which may reduce costs and improve efficiency.

Methods:
We conducted a retrospective analysis of patients evaluated in our CPC in 2011. For each patient the pre and post stress test conditional probability of coronary artery disease (CAD) was calculated using Bayes Theorem. Based on the estimated pretest probability, patients were classified into low, intermediate and high risk groups. The post stress testing conditional probabilities were calculated and used to determine if results of stress testing had a significant impact on further cardiovascular risk assessment.

Results:
95% of patients tested were negative for ischemia and were not admitted, reducing length of stay in ED. Stress echocardiography was the most utilized modality of stress testing, which provided additional diagnoses such as valvular heart disease in 2% of patients while avoiding radiation exposure. A Bayesian analysis indicated that in the low (pre-test) probability group consisting of young females with atypical symptoms remained in the low probability group irrespective of stress testing results. Also most intermediate risk patients remained in the intermediate risk category despite negative testing.

Conclusions:
CPC has improved cost-effectiveness due to reduced length of stay in ED, avoiding inpatient admissions and thereby reducing costs. As highlighted by the Bayesian analysis that most intermediate risk patients remained in the intermediate risk category despite negative testing, the need for pre-discharge testing needs to be re-examined as negative stress tests do not eliminate risk of CAD and avoiding these test can help further reduce costs and improve efficiency. Once acute coronary syndrome is ruled out, CPC visits should be more centered on establishing a primary care physician, risk factor modification, smoking cessation and promoting primary prevention.
Abstract 96: Sex Differences in Pre-Event Health Status of Young Patients with Acute Myocardial Infarction: The VIRGO Study
Authors: Dreyer Rachel P , Smolderen Kim G , Strait Kelly M , Beltrame John F , Lichtman Judith H , Lorenze Nancy P , D’Onofrio Gail , Krumholz Harlan M , Spertus John A
Published: March 2022

Background:
Young women are presumed to be at low risk for coronary artery disease and may have pre-existing angina that is undetected until they present with an acute myocardial infarction (AMI). The health status (symptoms, function and quality of life) of patients prior to their AMI has received little attention in the medical literature and the pre-existing health status of young women presenting with an AMI, as compared with men, is unknown.

Methods:
VIRGO is a prospective observational study that enrolled 2990 AMI patients aged 18-55 years. We abstracted clinical information from medical records and health status data was collected through patient interviews that included the Seattle Angina Questionnaire [SAQ], Short Form 12 [SF-12] and EuroQol [EQ-5D]. We calculated summary statistics using t-test/chi-square analyses and used multivariable linear regression analysis to identify clinical factors associated with patients’ health status.

Results:
The median age was 48 yrs (IQR: 44, 52) and did not differ by sex. Women were more likely to present with obesity (54% vs. 47%), and have a history of stroke (6% vs. 3%), diabetes (40% vs. 27%), heart failure (6% vs. 3%), and renal failure (13% vs. 9%; all P-values <0.001), but less likely to have a history of dyslipidemia (66% vs. 72%, P=0.0001). Women had significantly lower general health scores (SF-12 physical summary score= 45±12 vs. 42±12, mental summary score= 48±12 vs. 44±13 and EQ-5D visual analog scale= 66±20 vs. 63±22, p<0.001 for all), more angina (SAQ angina frequency=86±18 vs. 82±22, p<0.001), worse physical function (SAQ physical limitation=86±21 vs. 78±27, p<0.001) and worse quality of life (SAQ QoL= 86±18 vs. 82±22, p<0.001) before the event as compared with men. Table 1 shows the independent effect size for women (for both SAQ-assessed physical limitation and angina frequency), confirming that female sex was independently associated with worse pre-existing health status in adjusted analyses.

Conclusion:
Compared with men, young women presenting with an AMI seem to have worse health status with poorer physical functioning and quality of life prior to their event. In light of these findings, it may be useful for healthcare providers to identify young women who are at increased cardiovascular risk at an earlier stage in order to optimize their health status.
Abstract 12: Accuracy and Validation of an Automated Electronic Medical Record Algorithm to Identify Patients with Atrial Fibrillation at Risk for Stroke
Authors: Navar-Boggan Ann M , Rymer Jennifer , Piccini Jonathan P , Shatila Wassim , Ring Lauren , Stafford Judith , Al-Khatib Sana M , Peterson Eric
Published: March 2022

Background:
Anticoagulation rates remain suboptimal for patients with atrial fibrillation (AF). Although these rates could potentially be improved with performance measures, there is no universal algorithm for identifying AF patients at risk for stroke using the electronic medical record.

Methods:
Patients with AF seen between 6/1/2011-5/31/2012 were identified. CHADS¬2 and CHA2DS2-Vasc scores were calculated with a broader algorithm that uses codes dating back 10 years, and a restrictive algorithm requiring comorbidity diagnoses within the past year. The accuracies of a claims-based AF definition and of each of four stroke risk classification algorithms (broad and restrictive each using CHADS¬2 and CHA2DS2-Vasc scores ≥2) were evaluated using data obtained from manual chart reviews for 300 patients. Electronic medication data were used to evaluate rates of anticoagulation among AF patients identified as at risk for stroke.

Results:
6397 patients with prevalent AF were identified. Chart reviews confirmed a diagnosis of AF or atrial flutter in 95.7%. Patients with AF at risk for stroke were most accurately assessed using a restrictive algorithm based on a CHA2DS2-Vasc score ≥2 (PPV 97.5%, NPV 65.1%). The PPV of the broader algorithm based on CHADS2 score was 88.0%; 12% of those identified as high-risk electronically had CHADS2 scores <2 by chart reviews. Rates of anticoagulation evaluated using CHADS2 scores were identical using the broad (n=4498 with score ≥2, 58.3% anticoagulated) and restrictive algorithms (n=4008 with score ≥2, 58.3% anticoagulated). Anticoagulation rates calculated for patients with electronic CHA2DS2-Vasc scores ≥2 were similar based on broad comorbidity definitions (n=5711 with score ≥2, 56.0% anticoagulated) and restrictive comorbidity definitions (n=5533 with score ≥2, 56.0% anticoagulated).

Discussion:
Automated methods can be used to identify patients with prevalent AF indicated for anticoagulation, but may suffer from misclassification of up to 12%. Misclassification is minimized by requiring a diagnosis of AF within the prior year and using a CHA2DS2-Vasc based algorithm. Despite differences in accuracy between definitions, system-wide anticoagulation rates assessed using these definitions were similar. The diagnosis codes validated in this study can be applied for internal quality improvement and observational studies, and might be adapted for use in nationwide quality reporting programs.
Abstract 129: Severity of Symptoms from Atrial Fibrillation is Associated with Depression and Anxiety: Preliminary Data from the InRhythm Study
Authors: O'Day Kevin , Sazcynski Jane S , Kiefe Catarina I , Goldberg Robert J , Richardson Heather M , Floyd Kevin C , Rosenthal Lawrence S , Browning Clifford , McManus David D
Published: March 2022

Background:
Atrial fibrillation (AF) affects approximately 4 million Americans, and two out of three AF patients are affected by troublesome symptoms. Symptomatic AF often leads to hospitalization, diminishes quality of life, and imposes considerable stress on affected individuals. Depression and anxiety are exceedingly common in AF, affecting up to one-half of these patients. Nevertheless, few investigations have examined the association between severity and type of AF-related symptoms with depression or anxiety.

Methods:
A cohort of 113 ambulatory patients treated for symptomatic AF in the University of Massachusetts Medical Center’s AF Treatment Program were assessed for depression using the Patient Health Questionnaire (PHQ), anxiety by the Generalized Anxiety Score (GAD), and health-related quality of life using the Atrial Fibrillation Effect on Quality of Life (AFEQT) as part of an ongoing study of AF treatment and psychosocial factors. We used logistic regression models to examine the association between severity of AF symptoms in four symptom classes (palpitations, dizziness, pauses in heart activity, and irregularity) and severity of depression or anxiety.

Results:
Participants were 34% female with a mean age of 64 years. Seventy-six percent had paroxysmal AF, and the average AFEQT score was 67 ± 23 (range 0-100, 100 = no disability). Twenty-five percent (n=28) reported moderate or severe anxiety and 40% (n=46) had moderate or severe depression. In multivariable analyses adjusting for age, sex, race, AF type, history of heart failure and coronary artery disease, participants with severe palpitations (23%) and dizziness (25%) were 3 to 5 times more likely to report moderate or severe symptoms of depression and anxiety (
Table
, p for all <0.05). Those with severe pauses (9%) and moderate irregularity (29%) were 3 to 7 times more likely to report high depressive symptoms, but not anxiety, than participants with minimal or no symptoms (
Table
, p for all <0.05).

Conclusion:
Participants with AF commonly had symptoms, and the severity of symptoms was positively associated with depression and anxiety. In light of the known association between AF, depression and anxiety, rhythm control strategies such as catheter ablation for AF might improve quality of life as well as symptoms of depression or anxiety.
Abstract 133: Comparative Effectiveness and Clinical Outcomes of Clopidogrel versus Prasugrel in Acute Coronary Syndrome Patients with Diabetes Mellitus Undergoing Percutaneous Coronary Intervention
Authors: Porten Brandon R , Strauss Craig E , Garberich Ross F , Chavez Ivan J , Poulose Anil K , Chambers Jeffrey W , Baran Kenneth W , Henry Timothy D
Published: March 2022

Background:
Compared to the common antiplatelet clopidogrel, randomized trials have shownthe novel antiplatelet prasugrel reduces ischemic events without increasing major bleeding in diabetic acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). However, the clinical and cost implications of clopidogrel versus prasugrel in diabetic ACS patients are limited in real-world settings.

Methods:
Using a shared electronic medical record we reviewed all primary PCI cases at three high volume centers from July 1, 2009 to December 31, 2013. Any complication, red blood cell transfusions, bleeding <72 hours, peri-procedural myocardial infarction, cerebrovascular accident, mortality, length of stay (LOS) and total variable costs were compared between diabetic ACS patients receiving clopidogrel or prasugrel. All patients ≥75 years, <60 kilograms, or with history of cerebrovascular disease were excluded to account for contraindications and bleeding risk factors associated with prasugrel use.

Results:
Among 2,165 PCI cases, 1,899 (87.7%) received clopidogrel and 266 (12.3%) received prasugrel. The only difference in baseline demographic and clinical characteristics was older age in patients who received clopidogrel (62 years vs. 60 years; p<0.001). No significant differences in any complication, red blood cell transfusions, bleeding <72 hours, peri-procedural myocardial infarction, cerebrovascular accident or mortality were observed between treatment groups. Total variable costs were $1,271 higher in patients who received prasugrel (p<0.001) and LOS was 0.2 days longer (p=0.011) (Table).

Conclusions:
In diabetic ACS patients undergoing PCI in a real-world clinical setting, there was no significant difference in peri-procedural complications with prasugrel versus clopidogrel antiplatelet therapy. Prasugrel was associated with higher costs and longer LOS.
Abstract 141: Outcomes Associated with Temporarily Interrupting Anticoagulation in Outpatients with Atrial Fibrillation: Results from ORBIT-AF
Authors: Steinberg Benjamin A , Kim Sunghee , Thomas Laine , Sherwood Matthew W , Gersh Bernard , Fonarow Gregg C , Mahaffey Kenneth W , Kowey Peter R , Peterson Eric D , Piccini Jonathan P , Ansell Jack
Published: March 2022

Background:
Interruption of OAC is often required for invasive procedures, yet the frequency, management, and outcomes of temporary interruptions (TIs) in community practice are unknown.

Methods:
We assessed the frequency and reasons for TI in outpatients with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF). Patient characteristics and use of bridging anticoagulants were analyzed. Endpoints included periprocedural adverse events (bleeding, thrombotic, or other) and cause-specific hospitalization within 30 days after TI.

Results:
Overall 7,372 patients were treated with OAC at baseline; 30% (n=2200) required at least 1 TI during median follow-up of 1 year. Patients requiring TI were similar in age (mean age 74 for both) and CHADS2 scores (mean 2.4 for both) to those not requiring TI. Among 3104 interruptions, the most commonly-identified reasons were for non-cardiac surgery (n=827, 27%), followed by endoscopic procedures (n=551, 18%) and cardiac catheterization (n=308, 10%). Bridging anticoagulants were used in 23% (n=709) of interruptions, including low-molecular weight heparin (n=512) or unfractionated heparin (n=109). Rates of bridging were highest during cardiac surgery (44%), cardiac catheterization (32%), and catheter ablation (33%). Patients with a prior stroke or TIA were significantly more likely to receive bridging (35% vs. 25%, p=0.0003), however there was no difference between patients with CHADS2 score >=2 vs. 0-1 (27% vs. 25%, p=NS). Adverse events during interruption were more common in bridged patients (5.1% vs. 2.9%, p=0.02), including bleeding events (3.6% vs. 1.8%, p=0.02); thrombotic events were uncommon (0.7 [n=4] vs. 0.5% [n=10], p=NS). After interruption, adverse events occurred early in follow-up (Figure), and bridged patients were more likely to experience any adverse event (13% vs. 6.3%, p<0.0001), cardiovascular hospitalization (4.3% vs. 2.3%, p=0.02), and bleeding hospitalization (2.2% vs. 0.7%, p=0.002) within 30 days.

Conclusions:
Temporary interruptions are common in patients receiving OAC for AF, however, bridging anticoagulation is used in a minority. Bleeding events following TI occurred significantly more often in patients receiving bridging anticoagulation.
Abstract 148: Initial Results from Electronic Referrals for Cardiac Rehabilitation
Authors: Wasfy Jason H , Traynor Kathleen C , Brown Carol , Leavitt Marcia , Cierpial Chelby , Kathiresan Sekar , Rosenfield Kenneth
Published: March 2022

Background:
Cardiac rehabilitation programs are an underutilized component of secondary prevention for patients with coronary disease.

Methods:
With the intent of increasing cardiac rehabilitation access for inpatients after discharge, we switched the mechanism of referral for inpatients to cardiac rehabilitation from a paper-based system to an order embedded within the inpatient electronic medical record at the beginning of December 2013. We compared the monthly number of cardiac rehabilitation referrals before and after intervention with a t-test, and compared inpatient versus outpatient referrals with a chi-squared test.

Results:
In a five-month pre-intervention period, cardiac rehabilitation received 307 total consults, of which 8 were from inpatients. After the intervention, over two months, cardiac rehabilitation received 131 consults, of which 34 were from inpatients. Total volume of consults from inpatients did not increase (61.4/month to 65.5/month, p = 0.335) at this early stage although proportion of consults from inpatients increased (2.6% versus 30.0%, p < 0.0001). Time trends of referrals patterns are shown in Figure 1. Of the referrals from inpatients during the entire 7 months, 21/42 (50.0%) were either scheduled in cardiac rehabilitation at MGH or referred to another cardiac rehabilitation program. 9/42 (21.4%) refused cardiac rehabilitation, 9/24 (21.4%) are still in process, and 2/42 (4.8%) were excluded for medical reasons.

Conclusions:
Introduction of an electronic referral system in the provider order entry system increased the proportion of cardiac rehabilitation referrals from inpatients. This type of innovation may lead to more prompt access and better outpatient care after discharge.
Abstract 149: Long-term Survival after Heart Failure Hospitalization: Comparison of Those with vs. without Reduced LVEF
Authors: Zoble Robert G , Torres Benji , Zoble Adam , Foulis Philip , Gelzer Bell Ramona , Neugaard Britta
Published: March 2022

Background:
Heart failure (HF) is associated with high mortality, but the major focus of HF care has been on those with reduced left ventricular (LV) ejection fraction (HFrEF). We sought to determine whether or not HF with preserved EF (HFpEF) was associated with better long-term survival than HFrEF.

Methods:
We studied 999 Veterans hospitalized for HF from January 2004 to December 2009. Baseline characteristics examined were co-morbidities, ECG, labs, medications and ECHO LVEF. Univariate analyses compared baseline characteristics. Significance was defined as p-value <0.05. Survival in the two groups was compared with a Kaplan-Meier survival plot employing a log-rank test.

Results:
Of the 999, 540 (54%) had HFrEF (<40%), while 459 (46%) had HFpEF (>=40%). HFpEF patients were significantly older (73.2 vs. 70.7 yrs), had significantly more HTN (72% vs. 59%), diabetes (51% vs. 42%), anemia (27% vs. 18%), COPD (24% vs. 19%), obesity (17% vs. 10%), and had significantly higher creatinine (1.7 vs. 1.5) and lower hemoglobin (11.8 vs. 12.9). The HFrEF group had significantly lower LVEF (24% vs. 53%), higher BNP (1,344 vs. 646), more prior HF (31% vs. 24%), a trend toward more CAD (47% vs. 41%; p =0.07), higher troponin (0.49 vs. 0.12), higher heart rate (89 vs. 79 bpm) and wider QRS duration (125 vs. 108 msec). Survival in the overall group was 94%, 71%, 60%, and 51% at 30 days, 1 year, 2 years and 3 years, respectively. The plot shows that both HFrEF (solid line) and HFpEF (dashed line) are associated with reduced survival ~50% at 3 years. The trend toward worse survival for HFrEF was not significant (log rank p = 0.17).

Conclusion:
HFpEF is not a benign entity.Our observations are consistent with HFpEF being driven by diastolic dysfunction and/or pulmonary HTN relating to HTN, COPD, and obesity, whereas HFrEF results from structural heart damage and loss of myocardium (higher troponin, higher heart rate and wider QRS) along with a trend toward more CAD.
Abstract 163: Hurry Acute Stroke Treatment and Evaluation (HASTE): Improving Door-to-Needle Times and Reducing Variation for Acute Ischemic Stroke using a Six-Sigma Approach
Authors: Kamal Noreen , Smith Eric E , Demchuk Andrew M , Hill Michael D , Stephenson Caroline , Suddes Michael , Kashyap Devika
Published: March 2022

Background:
The importance of immediate tissue-type plasminogen activator (tPA) therapy for acute ischemic strokes has long been recognized to achieve better outcomes. Clinical Best Practice Guidelines state that an acceptable treatment window for acute ischemic stroke patients is 4.5 hours from symptom onset. Within this time window, general consensus is the patient should arrive at the hospital within 3.5 hours of symptom onset, and the door-to-needle (DTN) time should be within 60 minutes of arrival. However, compliance with this DTN time is low with as few as 27% of acute stroke patients in the US being treated within 60 minutes.

Methods:
The Calgary Stroke Program, a comprehensive stroke center at the Foothills Medical Centre, engaged in a six-sigma quality improvement project to improve DTN times. Six-sigma is a data-driven improvement approach with five phases: define the system and project goals; measure the process; analyze the data; improve the process; and control the improvements. The factors that led to improvement were: physician leadership; stroke team engagement with EMS, emergency department, admitting and diagnostic imaging; use of STAT! stroke pager to alert the stroke team when EMS or triage identified an eligible tPA patient; distribution of a weekly reports for DTN; and provision of a weekly award for the best case of the week under 30 minutes.

Results:
The six-sigma approach resulted in a significant reduction in DTN. Data analysis was done for three periods: 1) the pre-implementation period (June 2011 to May 2013, n=300); 2) the implementation period (June 2013 to September 2013, n=46); and 3) the post implementation period (October 2013 to December 2013, n=39). The results showed a reduction in DTN from a median time of 53 minutes (mean=61 min) in the pre period to a median time of 51 minutes (mean=58 min) in the implementation period, and finally to a median time of 39 minutes (mean=46 minutes) in the post period. Based on six-sigma data analysis, the defects, defined by a DTN greater than 60 minutes, went down from 38 for every 100 patients (sigma level of 1.81) in the pre period to 26 for every 100 patients (sigma level of 2.15) in the post period. Furthermore, the results from a one-way ANOVA for the DTN times for these 3 periods reached statistical significance (p=0.013) with post-hoc analysis revealing that the difference between the pre and post periods results were significant.

Conclusions:
The use of quality improvement approaches such as six-sigma can result in significant improvement in DTN. The data-driven approach of six-sigma allowed the Calgary Stroke Program to identify and improve various processes that effect the DTN time, which resulted in a lower average DTN time and a reduction in variation.
Abstract 165: Premature Clopidogrel Discontinuation after Drug-Eluting Stent Placement
Authors: Khalili Houman , Moss Elizabeth E , Wood Michael , Singh Rajeev , Edwards Anthony , Berry Jarett , Vongpatanasin Wanpen , de Lemos James A , Das Sandeep R
Published: March 2022

Background:
Clopidogrel non-adherence is a strong predictor of stent thrombosis, myocardial infarction, and death after drug-eluting stent (DES) placement. Previous studies on the prevalence of premature clopidogrel discontinuation are based on self-report and have short follow-up.

Methods:
All patients who underwent DES placement between January 2007 and December 2011 at Parkland Memorial Hospital were considered for inclusion; those with < 1 year follow-up were excluded. We retrospectively collected one-year refill data from a large, closed (county hospital subsidized care) pharmacy system. Our primary outcome was time to failure to obtain a clopidogrel refill, allowing a 5-day grace period.

Results:
Of 452 patients (61% male, 38% Hispanic, 29% White, 24% African American) meeting entry criteria English was preferred by 71% of study patients, while 27% preferred Spanish. Median time to failure to obtain a clopidogrel refill was 91 days (Figure). By 6 months 58% of patients and by 12 months 85% of patients had failed to obtain a refill allowing a 5-day grace period. At follow-up 26% of patients had failed to obtain their first refill within 5-days after first prescription ending. By one year follow-up, 21% of patients had 100% proportion of days covered (PDC), 60% had PDC ≥ 80%, and 40% had PDC < 80%.

Conclusions:
We identified a high prevalence of clopidogrel non-adherence in a multi-ethnic urban poor patient population, despite the facts that clopidogrel was provided on discharge and at nominal cost ($5 per month) thereafter, that patients were identified by treating physicians as likely to adhere to treatment, and that intensive patient education on the importance of clopidogrel adherence post-DES was routinely provided. These data call into question the implicit assumptions made about clopidogrel adherence in routine clinical practice.
Abstract 170: Improving Radiation Safety in the Cardiac Catheterization Lab
Authors: Lawson William E , Gulino Kathie , Dervan John P , Wilbert Lisa , Callias Patricia , Kar Subrata , Bonvento Michael
Published: March 2022

Objective:
Ionizing radiation, while necessary for cardiac catheterization and angioplasty, is an ever present and often unappreciated safety concern for the patient and operator. Radiation exposure has both deterministic and stochastic effects, with risk estimated by peak Skin Dose and Air kerma Area product . Exposure guidelines have been set for radiation safety (4,000 mGray and 20,000 c Gray cm
2
).

Procedure:
The frequency of guideline excessive radiation exposure for cardiac cath lab patients was tracked. Operator, patient, anatomic, procedural variables associated with high radiation exposures were identified and specific interventions to minimize radiation exposure identified.

Results:
Over a 3 year period 17% of interventions [2011- 220/1,543 (14.3%), 2012- 268/1,420 (18.9%), 2013- 270/1,476 (18.3%)] received excessive skin or total body radiation. In 2013 the average peak skin dose/patient for operators ranged from 1,250 -3,252; the average total area dose/patient ranged from 7,360- 20,988 for operators, with only one operator exceeding 20,000 as an average. Advances in equipment and operator experience have been offset by the increasing disease complexity of attempted interventions. Frequency of excessive radiation by operator ranged from 1.4 - 46% of interventions. Patient risk factors included: obesity, multivessel disease and lesion complexity, highly angled views, number, length, and frame rate of cine and fluoroscopy runs. Specific interventions that decreased the frequency of excess radiation administered included: increasing operator feedback and awareness of radiation used, shortening cine runs, decreased frame rate for fluoroscopy and cine, staging procedures, increase use of stored images and mapping capabilities. Physicians adopting safer radiation practices decreased excess radiation cases from 15.8% [35/222] in 2012 to 8.0% [18/224] in 2013. The default settings of X-Ray equipment have been modified to encourage safe and appropriate use of radiation in the cardiac catheterization lab (however, physician overide of settings is still possible).

Conclusions:
Patient factors (e.g. obesity, prior CABG) and complex, multivessel interventions are potentially frequently associated with excess radiation. Changing default settings and implementing radiation safety practices can significantly decrease radiation exposure to patients and staff.
Abstract 175: The Association between Antihypertensive Medication Drug Class and Adherence: An Electronic Monitoring Study
Authors: Moise Nathalie , Bring Rachel , Schwartz Joseph , Shimbo Daichi , Kronish Ian
Published: March 2022

Introduction:
Prior studies that rely on pharmacy refill data suggest that there maybe an association between antihypertensive drug class and adherence. We aimed to determine whether there is a relationship between antihypertensive drug class and adherence measured electronically.

Methods:
We enrolled a sample of 188 participants with treated but uncontrolled hypertension from 2 urban primary care clinics. Adherence was measured during the interval between two clinic visits using a 4-compartment electronic pillbox (MedSignals) that records the date and time each compartment is opened. Adherence was calculated as the percent of days the correct number of doses of a particular medication was taken as prescribed. A mixed effects regression analysis was used to assess the association between drug class and percent adherence using Bonferroni adjusted alpha levels and adjusting for age, gender, ethnicity, number of BP medications/patient, coronary artery disease (CAD), depressive symptoms, and days monitored. Sensitivity analyses adjusted for dosing frequency.

Results:
The mean (SD) age was 64.2 (9.1) years; 71% were female (134/188); 75% Hispanic (141/188); 14% (27/188) had CAD. A total of 470 BP medications were assessed. On average, participants were monitored 48.3 (40.9) days, took 2.4 (1.0) BP medications each, and had 7.2 (6.0) depressive symptoms. Beta-blockers were the most commonly prescribed drug class (54.8%, 103/188), followed by calcium channel blockers (CCBs; 53.2%, 100/188), diuretics (43.6%, 82/188), angiotensin converting enzyme inhibitors (ACEIs; 40.4%, 76/188), angiotensin receptor blockers (ARBs; 28.7%, 54/188), and other classes (29.3%, 55/188). Beta-blockers and other drug classes had significantly higher dosing frequencies. In the mixed effects analyses, a significant effect for drug class was observed. In the unadjusted model, mean percent adherence was 67.7% for beta-blockers, 73.7% for ARBs, 74.3% for CCBs, 75.4% for diuretics, and 76.3% for ACEIs. In the adjusted model, adherence to beta-blockers was 9.2% (SE 1.4%) lower than diuretics (adj p <0.0001), 8.7% (SE 1.6%) lower than ACEIs (adj p gt 0.30). After adjusting for dosing frequency, no relationship remained between drug class and adherence. Adherence was associated with systolic blood pressure in adjusted regression analyses (B=0.34, SE= 0.08, p <0.0001).

Discussion:
To our knowledge, this is the first study to compare and electronically monitor several drug classes simultaneously. Adherence was suboptimal for all drug classes and associated with suboptimal BP. Physicians should account for low adherence, particularly to beta-blockers, and the significant effect of dosing frequency when prescribing antihypertensives.
Abstract 179: Documented Medication Use among Coronary Artery Disease Outpatients in India: Insights from PINNACLE India Outpatient Registry
Authors: Risch Samantha A , Vicera Veronique D , Glusenkamp Nathan T , Kumar Ganesh , Kerkar Prafulla , Oetgen William J
Published: March 2022

Introduction:
Coronary artery disease (CAD) affects Indians with greater frequency and at a younger age than people in other countries, and is the leading cause of death in India. For patients with CAD, treatment is aimed at controlling symptoms and progression of disease through lifestyle change and medication therapy. Secondary prevention with medication therapy reduces cardiac mortality and CAD-related complications. To our knowledge, there is no published literature that details medication use in India among CAD patients. In a country that is in the midst of an escalating CVD epidemic, examining documented medication patterns for CAD in India is needed to focus prevention and control efforts.

Methods:
PINNACLE India is the first CV data collection and reporting program implemented in India. The database receives clinical data through transmission from paper scanners and an electronic data collection tool. Patients are followed longitudinally if they return to a data collecting outpatient site.

Results:
A total of 9,047 patients in PINNACLE India are documented as having CAD. Aspirin, Beta Blockers and Clopidogrel are the three most frequently documented medications.

Conclusion:
A study examining US PINNACLE data found among CAD patients eligible, beta-blockers were prescribed in 73.3% (63,800/86,999), ACEI/ARBs in 69.4% (55,933/80,552), and statins in 68.2% (18,833/27,628) of patients. Although the rates of documented medication use among CAD patients in the PINNACLE India registry is lower than in PINNACLE US, contraindications are not often documented in PINNACLE India, and thus, not all patients in our cohort may have been eligible for such medications, which may explain the lower rates of usage. Additionally, we suspect under-documentation of medications that are inexpensive and readily available, such as aspirin. While the data on documented medication use among CAD patients in PINNACLE India are still limited, the information it reveals thus far elicits meaningful questions. Taking a closer examination at the trends in medication use in the Indian population would impel investigation into the socioeconomic, cultural, and genetic factors that influence CAD prevalence in this country.
Abstract 19: Episode of Care Payments Across Two Cardiac Conditions: Where Does the Money Go?
Authors: Reilly Emily M , Kim Nancy , Bernheim Susannah M , Ott Lesli S , Hsieh Angela , Xu Xiao , Spivack Steven , Han Lein F , Krumholz Harlan M
Published: March 2022

Objective:
One approach to reduce health care spending and improve coordination of care is to pay for an episode of care rather than individual services. Anchoring these episodes around an index hospitalization is sensible because hospitalizations are a leading contributor to rising healthcare costs and an index admission provides a clear time to begin the episode. Understanding which care settings are responsible for a greater proportion of expenditures can inform efforts to improve efficiencies in the care provided. Our objectives were to: 1) characterize total episode payments for two conditions and 2) examine the care settings accounting for the highest proportions of the 30-day episode of care payment.

Study Design:
We used Medicare Claims data from 2008 and 2009 to identify hospital discharges for acute myocardial infarction (AMI) and heart failure among fee-for-service beneficiaries ≥ 65 years. We defined an episode as admission plus 30 days. To reflect differences in payments due to clinical care rather than geographic or policy adjustments, we omitted or averaged payment adjustments such as wage index and indirect medical education. For hospitalizations involving transfers, we summed the per diem and diagnosis related group payments and attributed this amount to the transfer-out hospital.

Principal Findings:
For AMI and heart failure patients respectively, the median unadjusted episode payment was $15,581 (interquartile range (IQR) $11,416, $24,675); and $10,139 (IQR $6,972, $17,827). For AMI, 77% of total payments were for index admission and 23% for post-acute care. Among post-acute care payments, 35% were for readmissions, 30% for skilled nursing facilities (SNF), and 13% for non-acute inpatient stays (i.e., inpatient rehabilitation, inpatient psychiatric facilities, and long-term care facilities). For heart failure, 61% of total payments were for index admission and 37% for post-acute care. Among post-acute care payments for heart failure, 35% were for readmissions, 33% for SNF, and 7% for non-acute inpatient stays.

Conclusions:
Total episode payments vary by condition. For heart failure, which does not routinely require procedures, 61% of total episode payments are attributable to the index admissions compared to 77% for AMI. Across both conditions, the highest proportion of payments made after discharge were for readmissions, SNF, and non-acute inpatient stays. These results can inform efforts to reduce costs, including payment reforms such as bundled payment initiatives.
Abstract 203: Patterns of Dofetilide Use for the Treatment of Atrial Fibrillation
Authors: Bhave Prashant , Shen Sharon , Passman Rod , Goldberger Jeffrey , Kim Michael
Published: March 2022

Introduction:
Dofetilide is a costly medication that requires hospitalization at initiation. Patterns of dofetilide use for the control of atrial fibrillation (AF) have not been reported. We sought to determine what percentage of dofetilide initiations at our institution were concordant with the tiered maintenance of sinus rhythm (MSR) algorithm for anti-arrhythmic drug (AAD) use outlined in the AHA/HRS guidelines for the management of AF.

Methods:
We performed a chart review of consecutive patients admitted for dofetilide initiation at our institution from 2004-09. Follow-up data were collected through November 2012. Patients were classified to mirror the MSR algorithm.

Results:
A total of 122 patients were included. The mean age was 62±13 years. The mean ejection fraction was 50% ± 12% and the average baseline sinus rate was 62±11bpm. Within the MSR classification, 36 patients had no significant structural heart disease, 12 had hypertension without LVH, 16 had hypertension with LVH, 18 had CAD without CHF, and 40 had CHF. In patients with no prior AAD exposure [56/122 (46%)], dofetilide use was significantly more discordant with the MSR guidelines than for patients in whom dofetilide was used as a second line agent [46% discordant vs 15% discordant, p<0.001]. Eighty patients were in AF at the time of admission; rates of chemical cardioversion with dofetilide were significantly higher among patients in whom it was used as a second-line agent (53% vs 29%, p = 0.026). The average duration of dofetilide therapy for patients in whom dofetilide was their first AAD was 787 days. Rates of discontinuation of dofetilide during the initial admission (due to ventricular arrhythmia or excessive QT prolongation) were similar between the AAD naïve (18%) and second-line (20%) cohorts.

Conclusions:
A significant percentage of dofetilide use for the control of AF is as first-line AAD therapy. Electrophysiologists appear to be basing their choice of AAD on patient specific factors, such as baseline bradycardia, rather than the MSR algorithm. Given that the average duration of dofetilide therapy was little more than 2 years in AAD naïve patients, the cost-effectiveness of hospitalizing patients for dofetilide loading as a first line agent for the control of AF warrants further examination.
Abstract 206: Gender Bias among Cardiology Physicians
Authors: Daugherty Stacie L , Blair Irene V , Havranek Edward P , Main Debbi , Dickinson Miriam , Bronsert Michael , Karimkhani Elhum , Masoudi Frederick A
Published: March 2022

Background:
Physician bias is a likely contributor to gender disparities in the use of cardiac procedures. The Implicit Association Test (IAT) is a validated tool to measure implicit (unconscious) attitudes but has not been used to study gender disparities in health care. We measured attitudes around patient gender among cardiology physicians using the IAT.

Methods:
We developed two web-based IATs focused on gender attitudes applicable to cardiology procedures. The IAT measures implicit biases by comparing the speed with which concepts can be sorted, when paired in different combinations (i.e. women=strength and men=weakness vs. men=strength and women=weakness). The Strong-IAT measured gender associations with “strength versus weakness” and the Risk-IAT measured gender associations with “risk-taker versus risk-averse”. The IAT is scored from –2.0 to +2.0 with negative scores suggesting a pro-female bias (e.g. women are stronger than men), a positive score suggesting a pro-male bias (e.g. men are stronger than women) and “0” meaning no bias. We emailed a web-based survey including the IATs to all physician members of a state cardiology association. Potential participants received three weekly reminders and, for validation purposes, a subset re-took the survey after 30-days.

Results:
Of the 317 cardiology physicians with valid email addresses, 52 (16.4%) completed the survey. Participants’ mean age was 48.2 (+/- 12.1), 81% were male, and 77% were white. Most (63%) were non-invasive cardiologists (22% interventional cardiologists and 16% electrophysiologists) and 67% practiced in an academic setting. The mean Strong-IAT score was 0.60 (SD = 0 .42) and Risk-IAT score was 0.45 (SD = 0.54) revealing a significant pro-male bias. Over 38% had a high degree of pro-male bias for both IATs (Figure). Among the 11 participants who retook the survey, test-retest reliability was high (Strong-IAT r=0.68; Risk-IAT r=0.79).

Conclusions:
On average, cardiology physicians exhibited implicit gender bias suggesting they are more likely to view men as being stronger and more likely to take risks than women. These attitudes appeared to be relatively stable over time. Future work is needed to understand whether these attitudes influence treatment decisions and contribute to gender disparities in cardiology care.