bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P235: Implications of the Selection of Target Markers for LDL Lowering
Authors: Williams Ken , Lawler Patrick , Sniderman Allan D
Published: July 2021

Our aim was to compare the implications of targeting LDL-lowering treatment to LDL-C, non-HDL-C, or apoB based on a recent meta-analysis of all published epidemiological studies with all three markers' vascular risk associations which found overall per standard deviation relative risk ratios (RRR) of 1.25 for LDL-C, 1.31 for non-HDL-C, and 1.41 for apoB. Our approach was to project the 10-year incidence of CHD events from NHANES 2005-2006 with 1697 subjects representing over 190 million adult US residents under different scenarios defined by the target marker and the percentage of people treated. Framingham equations were used to estimate each subject's 10-year CHD risk. We estimated each subject's risk if treated by dividing their initial risk estimate by the marker's RRR exponentiated to the number of standard deviations (LDL-C: 35 mg/dl, non-HDL-C: 42 mg/dl, apoB: 27 mg/dl) in 40% of the marker's measured level. The potential number of CHD cases prevented by the treatment was calculated by multiplying the difference between initial and treated risk by the number of people represented. The mean 10-year CHD risk was 7.00% indicating 13.3 million incident CHD cases would be expected over the subsequent 10 years with no treatment change. The expected numbers of incident CHD cases prevented under different treatment scenarios are shown in the figure. These results support recommendations to use apoB in clinical practice to identify candidates for LDL-lowering and to target their treatment.
Abstract P254: Health-Related Internet Use in Patients with Hypertension: A Population-Based Analysis
Authors: Finkelstein Joseph , Cha Eunme
Published: July 2021

Background:
With widely available web-based information about hypertension, internet has the potential to improve health literacy and to affect clinical outcomes. In this study we assessed the prevalence of health-related internet (HRI) usage by patients with hypertension and its association with health outcomes.

Methods:
Hypertension was defined by the question, “Have you ever been told by a doctor or health profession that you have high blood pressure?” Participants who answered “Yes” were included in the sample. If the participants stated that they accessed the Internet to look up health information, to learn about health topics in chat groups, to refill prescriptions, to schedule appointments, or to communicate with their provider, they were included in ‘HRI user’ group. Two logistic regression models were run to assess predictors of HRI usage and to explore the impact of HRI use on health status among hypertension patients. All models were controlled by age, gender, marital status, race, education, and poverty income ratio (PIR). Sampling weights were utilized to produce population-based results.

Results:
The prevalence of HRI use in hypertension patients was: 57% (40-55 yrs), 50% (56-65 yrs) and 26% (>65 yrs). In comparison, 58% (40-55 yrs), 56% (56-65 years) and 29% (>65 yrs) of population without hypertension used HRI. The difference between two groups was not statistically significant. Younger age (OR 4.0, p <.0001 for 40-55 group, and OR 2.6, p=0.001 for 50-65 group), women (OR 1.4, p <.0001), higher education (OR 3.8, p <.0001 for 12+ years of education), or higher PIR (OR 1.3, p=0.02 for PIR=2, and OR=3.1, p <.0001 for PIR>=3) were predictors of using HRI with statistical significance. Compared to Caucasians, Africans Americans (OR 0.5, p=0.04) were less likely to use the HRI. After adjusting for socio-demographic variables, patients who used HRI in the last 12 months were 1.3 time more likely to report improvement in health status (p=0.04).

Conclusions:
HRI usage between the hypertension patients and general population did not differ significantly in different age groups. Age, gender, education, PIR, and race were significant predictors of HRI usage pattern. HRI use was associated with improvement in health status within 12 months of using internet.
Abstract P27: Effect of Age on Sex Difference in In-Hospital Mortality by Type of Myocardial Infarction: Results from the MarketScan Database
Authors: Zhang Zefeng , Fang Jing , Gillespie Cathleen , Wang Guijing , Hong Yuling , Yoon Paula
Published: July 2021

Background:
Studies have shown consistently that younger women hospitalized with a myocardial infarction (MI) have poorer prognosis than men. It remains unclear whether this relationship is true for both ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) patients.

Methods:
Using the MarketScan 2004-2007 in-patient admission database, we assessed the sex difference in in-hospital mortality according to age among 87,962 (STEMI: 34,720; NSTEMI: 53,242) patients who were 18 to 89 years of age with an initial episode of MI as the primary diagnosis. The interaction between age (18-49, 50-59, 60-69, 70-79 and 80-89 yrs) and sex was examined by multivariable logistic regression for STEMI, NSTEMI and the combined population before and after adjusting for other risk factors.

Results:
STEMI patients had significantly higher in-hospital mortality than NSTEMI patients (4.40% vs. 3.57%, p<0.0001). Women had older mean age than men at admission for the STEMI (65.5 vs. 59.5 yrs), NSTEMI (69.0 vs. 64.5 yrs) and the combined population (67.9 vs. 62.4 yrs). Women had higher comorbidity scores, and were less likely to undergo revascularization during hospitalization in all three populations. In both STEMI and the combined population, younger women had higher in-hospital mortality compared to men of similar age, and the mortality difference between women and men decreased with aging, with women having better outcomes after 80 years of age in the combined population. After adjustment for potential confounding factors, the excess risk in in-hospital mortality for younger women compared with men persisted. In NSTEMI patients, the difference between younger women and younger men was not statistically significant, however, older women (age ≥70) had better outcomes than men (see Table).

Conclusions:
Higher risk of in-hospital mortality in younger women is confined to STEMI, but not NSTEMI, patients. Management of younger women with STEMI may require more use of intensive care.

Table Odds Ratios (Women vs. Men) of In-hospital Mortality by Type of Myocardial Infarction

Variable
Combined population
STEMI
NSTEMI

Before adjustment
After adjustment
Before adjustment
After adjustment
Before adjustment
After adjustment

18-49 yrs
1.822 (1.29, 2.56)
1.648 (1.15, 2.36)
2.285 (1.48, 3.54)
1.960 (1.23, 3.11)
1.480 (0.86, 2.56)
1.254 (0.71, 2.22)

50-59 yrs
1.531 (1.26, 1.86)
1.446 (1.18, 1.78)
1.699 (1.29, 2.23)
1.531 (1.14, 2.06)
1.451 (1.10, 1.91)
1.284 (0.96, 1.72)

60-69 yrs
1.339 (1.14, 1.57)
1.262 (1.06, 1.50)
1.481 (1.17, 1.88)
1.310 (1.01, 1.70)
1.301 (1.04, 1.62)
1.241 (0.98, 1.57)

70-79 yrs
1.019 (0.89, 1.16)
0.970 (0.84, 1.12)
1.306 (1.07, 1.59)
1.253 (1.01, 1.56)
0.848 (0.71, 1.01)
0.817 (0.68, 0.99)

80-89 yrs
0.888 (0.79, 0.99)
0.887 (0.78, 1.01)
0.988 (0.81, 1.20)
0.956 (0.77, 1.19)
0.823 (0.71, 0.95)
0.820 (0.73, 0.99)

P value for interaction
<0.0001
<0.0001
0.0010
0.0234
0.0002
0.0073
Abstract P33: Improving Heart Failure Metrics: A Multidisciplinary Team Approach
Authors: Cunningham Brittany L , Cox Zachary L , Lewis Connie M , Lenihan Daniel
Published: July 2021

Background:
Quality of care has become a priority as heart failure (HF) core measures and readmission have been publically reported on the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website. In an effort to decrease readmissions Vanderbilt University Medical Center (VUMC) joined the H2H (Hospital to Home) initiative. Based on the CMS data for 2005 to 2008 the middle Tennessee region was in the 5
th
Quartile of readmission scores (25.2%-29.0%). The 30-day HF readmission rate at VUMC (25.7%) was comparable to the national rate of 24.5%.

Aim:
The goal of this project was to decrease readmissions by 20% as suggested by the ACC through participation with the H2H initiative.

Method:
A multidisciplinary team, including Physicians, Pharmacist, Case Management, Nutrition, Nursing, and a Social Worker, was structured to round on the heart failure floor each morning to identify HF patients as part of a demonstration project. All identified patients were assessed by the multidisciplinary team for teaching needs and self care abilities based on their specialties. Based on their initial assessment, teaching was performed for newly diagnosed or reinforcement teaching. Education materials were updated for all patients and given to all heart failure patients regardless of status in the demonstration project.

Results:
Thirty day follow-up has been completed on 52 patients and 7 have been readmitted for any cause. This has decreased the readmission rate from 25.7% to 13.4%. There are 5 interventions which could have been completed. The most frequent, the Pharmacy intervention was completed on 76% of the patients; however there is not a statistical correlation between this intervention alone and readmission. Discharge instructions in core measures were also associated with a positive trend as evidence by quarter 4 2009 at 88.4% and quarter 4 2010 at 96.8%.

Conclusions:
Our project targeted recognizing the needs of the patient and matching them with the appropriate consult. This approach has been associated with reduction in readmission rates and in an increase in core measure compliance. Further data collection will be needed to confirm findings.
Abstract P36: Venous Thromboembolism Prophylaxis in Hospitalized Medically Ill Patients
Authors: Pendergraft Trudy , Vera-Llonch Montserrat , Kartashov Alex , Liu Xianchen C , Phatak Hemant , Liu Larry , Oster Gerry
Published: July 2021

Background:
Many hospitalized medically ill patients are at risk of VTE, during admission and after discharge. Risk factors include prior VTE, older age, immobility, obesity, heart or respiratory failure, and cancer. ACCP guidelines recommend use of low-molecular weight heparin (LMWH) or unfractionated heparin (UFH), and mechanical prophylaxis otherwise, in high-risk patients. VTE prophylaxis may be underutilized, however.

Methods:
Using a database linking admission records from >150 US hospitals to health insurance claims, we identified all persons, aged >=40 years, hospitalized from 2003 to 2008 and at high risk of VTE (based on ACCP guidelines). We excluded patients who: (1) underwent surgery; (2) were hospitalized in prior 30 days; (3) were treated for VTE in prior 30 days; (4) had hypercoagulability at admission; and (5) received LMWH, UFH, or fondaparinux (FOND) at therapeutic dosages on hospital day 1 or 2. We examined use of VTE prophylaxis during hospital admission and post-discharge.

Results:
We identified 35,606 patients who met all study entry criteria. Mean age was 67 years. Only 17.9% of study subjects received in-hospital VTE prophylaxis, most frequently LMWH (10.1%), intermittent pneumatic compression (4.5%), warfarin (2.9%), and/or stockings (2.0%). Prophylaxis use exceeded 25% only in patients with history (>30 days) of VTE and those admitted from nursing homes. Very few patients (1.7%) received post-discharge VTE prophylaxis; use was limited to LMWH. While there were several significant predictors of VTE prophylaxis (nursing home admission [odds ratio, 2.15; 95% confidence interval 1.91-2.42], central venous catheter placement [1.76; 1.60-1.94], ischemic stroke [1.68; 1.54-1.84] obesity [1.58; 1.47-1.70], and prior VTE [1.57; 1.24-1.99]), model discrimination was relatively poor (c statistic = 0.61).

Conclusion:
VTE prophylaxis is under-utilized in high-risk hospitalized medically ill patients, during initial admission and following hospital discharge.
Abstract P46: Misperception of Body Size and Barriers to Weight Loss among Families
Authors: Dumas Nicole E , Sciacca Robert R , Rodriguez Juviza K , Paul Tracy K , Giardina Elsa-Grace V
Published: July 2021

Background:
Misperception of body size and barriers to weight loss are prevalent in families at risk for cardiovascular disease.

Methods:
Women (n=111) and their pre-adolescent children (n=111) at an academic medical clinic were surveyed regarding socio-demographics, anthropometrics, weight loss attitudes, and body size perception.

Results:
The majority of women self-identified as Hispanic (79.3%), age 40±7 yrs. Children's age ranged from 7-13 yrs (10.5±1.3 yrs) with 51.4% girls. Among mothers, 65.8% were overweight (OW) or obese (OB), avg BMI 27.7 ± 5.1. Children's avg BMI percentile was 72.3%; 38.9% were OW or OB. OB women (81.8%) underestimated weight more than OW (42.5%) and normal weight (NW) women (13.2%) (p < .0001). Analogous to mothers, 85.7% of OW or OB children underestimated weight vs 15.2% of NW children (p < 0.0001). OB (97.0%) and OW (77.5%) women had more body dissatisfaction, the difference between self-perceived and ideal size, than NW women (42.1%) (p < 0.0001); similarly, 77.8% of OB and 50.0% of OW children were dissatisfied vs 26.7% of NW children (p < 0.0001). Overall, 55.7% of all women were attempting weight loss by improving eating habits (67.2%), exercising (40.3%), dieting (13.5%), medications (12.6%), and surgery (4.5%). Weight loss barriers included family responsibilities (27.0%), time (25.2%), money (11.7%), and employment (11.7%). OW and OB women were more likely to cite family responsibilities (34.3% vs 13.2%, p=0.018) and employment (16.4% vs 2.6%, p=0.03) then NW women. Almost half (46.3%) used nutrition labels “always” or “most of the time,” however 37.0% did not know daily caloric consumption. Women with ≤ 8 years education (73.3%) were less likely to know their caloric consumption compared to those with 9-12 years (42.9%) and > 12 years (16.7%) (p=0.003).

Conclusion:
Misperception of body size is common among OW/OB women and children in this urban population. However, these women and children are also highly dissatisfied with their current body size, indicating some awareness and prompting more then half to attempt weight loss. Strategies to overcome the obesity epidemic should emphasize healthy body size goals and address barriers including family responsibilities, time, and lack of proper nutritional knowledge.
Abstract P73: Comparison of Hospital-Acquired Anemia and TIMI Bleeding for Mortality Prediction in Patients with Acute Myocardial Infarction
Authors: Salisbury Adam C , Amin Amit P , Alexander Karen P , Masoudi Frederick A , Li Yan , Spertus John A , Kosiborod Mikhail
Published: July 2021

Background:
In-hospital bleeding and new onset, hospital acquired anemia (HAA) are both associated with higher mortality in acute myocardial infarction (AMI). Since bleeding is variably defined and often poorly documented, HAA could be a better method to identify at-risk patients, if its prognostic ability were at least as good as documented bleeding. We directly compared the association of HAA and TIMI bleeding with 1-year mortality.

Methods:
Among 2,803 AMI patients who were not anemic at admission in the 24-center TRIUMPH registry, the presence and severity of HAA and TIMI bleeding were prospectively collected to identify their relative discrimination of 1-year mortality. Logistic regression models, accounting for clustering using generalized estimating equations, were fit for 1) no bleeding, TIMI minimal, minor and major bleeding and 2) no HAA, mild (hemoglobin (Hgb) > 11 g/dl), moderate (Hgb 9 - 11 g/dl) and severe HAA (Hgb < 9 g/dl). Discrimination was compared using c-statistics and reclassification was assessed using the integrated discrimination improvement (IDI), which measures a model's improvement in average sensitivity without sacrificing average specificity vs. another model, and the continuous net reclassification improvement (NRI), to identify the proportion of patients correctly reclassified by the HAA model.

Results:
HAA was more common (mild: 33%, moderate: 10%, severe 2%) than TIMI bleeding (minimal: 5%, minor: 3%, major 1%). Over 1-year follow-up, 111 patients (4%) died. The HAA model was superior to TIMI bleeding model for 1-year mortality prediction (c-statistic 0.60 vs. 0.51, p<0.001). The IDI of the HAA vs. the bleeding model was 0.009 (95% CI 0.005 - 0.014) and the relative IDI was 0.26 (26% better average discrimination), with a NRI of 0.32 (0.13-0.50) - 17% of patients with events were correctly reclassified to a higher risk while 14% of patients without events were correctly reclassified to a lower risk by the HAA model.

Conclusions:
HAA is better than TIMI bleeding for identifying 1-year mortality after AMI hospitalization, and may better identify patients without recognized bleeding who are also at risk for poor outcomes. HAA may be useful to identify high-risk patients and as a quality assessment tool.
Abstract 102: FOCUS: Appropriate Use of Cardiac Imaging
Authors: Johnson Thomas V , Rose Geoffrey A , Wilson B. Hadley , Fenner Deborah J
Published: July 2021

Introduction
The American College of Cardiology has created a new initiative (FOCUS) to help reduce inappropriate use of clinical imaging in cardiology. In accord with the effort, the Sanger Heart and Vascular Institute (SHVI) has designed a program to enhance appropriate use of cardiac imaging.

Hypothesis:
By implementing a quality improvement program to evaluate the appropriateness of cardiac imaging, there will be a 10% improvement in the percentage of studies ordered for appropriate indications and a corresponding decrease in the number of studies ordered for inappropriate indications.

Methods:
The initiative utilized an integrated multifaceted approach to quality improvement: 1) Staff / physician education with video teleconferences: Presentations were given at SHVI’s Grand Round, focusing on the appropriate use criteria as outlined in the ACCF/ASE/ASNC documents. An important component was interactive case studies highlighting the principles of appropriate use criteria. 2) Peer review and audits: Each practitioner and site received individual performance feedback. This was a complete analysis which included testing appropriateness as an indication. 3) System support tools: A comprehensive order sheet with check boxes for all appropriate indications was designed. All ordering physicians were asked to use this form for ordering all cardiac imaging studies. For those studies in which the form was not utilized, the imaging technologist attempted to obtain the appropriate information. All information from the forms was entered into a database designed specifically for this study. A baseline survey of 30 consecutive studies was selected for analysis from each echocardiography and cardiac nuclear imaging site within SHVI for a total of 360 studies. The ongoing post intervention survey conducts a monthly review of 25% of all studies per site.

Results:
At baseline, 77% of transthoracic echocardiographic studies were ordered for appropriate indications. Post intervention there was significant improvement: 91% (p<0.0013) of studies were categorized as appropriate and 1% of studies categorized as inappropriate (14% improvement in each). Of the remaining studies, 9% could not be categorized. With regards to stress cardiac imaging, 71% of studies were ordered for appropriate indications at baseline. Post intervention, there was significant improvement: 94% (p<0.0008) of studies categorized as appropriate (23% improvement), 16% categorized as inappropriate, and 6% could not be categorized.

Conclusion:
Although there is limited data on a national basis, published literature would suggest 70-80% appropriate use of cardiac imaging as a baseline benchmark. The results of this initiative demonstrated a statistically significant benefit in the appropriate use of cardiac imaging for SHVI from this baseline. The data gathering and database capabilities established during this initiative will allow quarterly reviews to providers, which will help ensure continued compliance with the guidelines.
Abstract 13: Advance Directives in Heart Failure Patients
Authors: Dunlay Shannon M , Mueller Paul S , Swetz Keith M , Roger Veronique L
Published: July 2021

Background:
Heart failure (HF) has an overall poor prognosis, with only half of patients surviving more than 5 years after diagnosis. Although it is recommended that all patients with HF have advance directives (ADs) in place before the end of life is imminent, the use of ADs in these patients has not been well studied.

Methods:
We prospectively enrolled all Olmsted County residents presenting with active HF from October 2007 through October 2011 into a longitudinal community cohort study which included an echocardiogram and administration of health status questionnaires at enrollment. Information from ADs completed prior to enrollment was manually abstracted from the patient’s medical record.

Results:
A total of 608 patients were enrolled during the study period (mean age 74.0 years, 54.9% male, 49.9% with preserved EF [EF≥50%], 65.3% NYHA functional class 3 or 4). Mortality was high; 164 (27.0%) patients died after a mean follow-up of 1.8 years with estimated 1-year mortality of 14.3%. At the time of enrollment, only 249 (41.0%) patients had ADs, and they were completed an average of 3.3 years prior. Although most ADs appointed a proxy decision-maker (91.1%), less than half addressed patient wishes regarding use of cardiopulmonary resuscitation (41.4%), mechanical ventilation (38.7%), administration of artificial nutrition (38.6%), or hemodialysis (10.0%) at the end of life. AD use was more common in older individuals (p<0.001); 60.7% of those ≥80 years had an AD vs. 13.6% of those who were <60 years old. While ADs were more common in women than men (46.7% vs. 36.2%, respectively) and in those with preserved EF (47.2% vs. 34.0% in those with reduced EF), differences were not significant after adjustment for age. AD use was no more common in patients with worse NYHA functional class or health status as measured by the Kansas City Cardiomyopathy Questionnaire.

Conclusions:
Despite a high mortality rate, over half of community patients with HF do not have ADs, and existing AD fail to address important medical decisions common at the end of life. Further work is needed to identify potential barriers to AD use in HF patients, and to determine whether their use has any impact on patient outcomes, including end of life resource utilization.
Abstract 155: Treatment Outcomes After Regionalization of Acute Stroke Care
Authors: Govindarajan Prasanthi , Shiboski Steve , Cook Larry , Grimes Barbara , Johnston S Claiborne
Published: July 2021

Objective:
To determine if regionalization of stroke care is associated with improved treatment rates.

Methods:
This is an observational study of all patients with a discharge diagnosis of stroke admitted to hospitals located in a Northern California county during a three year period. Patient and hospital demographic data, stroke center designation status, teaching status of the hospital, hospital discharge diagnosis and treatment with intravenous thrombolysis (IV t-PA) for the pre and post phase of regionalization were obtained from the statewide discharge database. We included patients ≥18 years of age with validated ICD- 9 code for stroke and excluded inter-facility transports and direct admissions. Logistic regression was performed to study the independent association of regionalization with IV t-PA treatment rates. Data analysis was performed using SAS 9.2

Results:
Number of patients with a discharge diagnosis of stroke in the pre-regionalization phase was 2149 and in the post regionalization phase was 4261. In the regionalized phase, mean age at time of admission was 73 (+/-15) years; 54% of patients (n=2280) were females and 62% (n=2649) of the patients were whites. Majority of patients were transported from home (3647, 86%); 2847 (67%) were treated at stroke centers and 4133 (97%) were treated at community hospitals. After controlling for patient and hospital demographics, teaching status and stroke center status, regionalization was not associated with increase in IV t-PA use (OR 0.8, p <0.001)

Conclusions:
While county-wide treatment rates for stroke did not improve after regionalization of care, similar relationship in those transported by emergency medical services in a regionalized system should be explored.
Abstract 158: Exposure to Warfarin and the Risks of Stroke and Bleeding Events among Patients with Non-Valvular Atrial Fibrillation: Real-World vs. Clinical Trial
Authors: Amin Alpesh , Boulanger Luke , Gatt Elyse , Makenbaeva Dinara , Stokes Michael , Wiederkehr Daniel , Wu Ning , Graham John
Published: July 2021

INTRODUCTION:
While recent randomized controlled trials (RCTs) have examined safety and efficacy of apixaban versus warfarin in stroke prevention among patients with nonvalvular atrial fibrillation (NVAF), real-world (RW) event rates may differ from the RCT setting.

HYPOTHESIS:
In a managed care, NVAF population exposure to warfarin is associated with a decreased risk of stroke and increased risk of bleed relative to non-exposure, but both stroke and bleed rates remain higher than those observed in RCT settings.

METHODS:
Using a retrospective cohort design, we selected patients aged ≥18 years with diagnosis of NVAF during 2007- 2009 from a Medco population of both U.S. commercial and Medicare health plans. The first claim with an AF diagnosis was defined as the study index date. Pharmacy claims were used to define periods of warfarin exposure following the study index date. Stroke and bleed events occurring during follow-up were identified using diagnosis codes on the medical claims and categorized according to occurrence during warfarin exposure or no exposure and according to patient baseline CHADS2 risk to address differences in population risk.

RESULTS:
Of the 37,878 patients meeting the study criteria, the mean age was 75 years (SD=8.6), and 53% were male. Among the 66% of patients with at least one prescription for warfarin, the total person-time of warfarin exposure was 41,515 years. Compared to rates occurring in two recent RCTs of warfarin exposed (ARISTOTLE) and warfarin unexposed (AVERROES; aspirin treated) patients, stroke and bleed event rates for NVAF patients in the real-world were higher overall and within each CHADS2 group.

CONCLUSIONS:
While in the real world warfarin use was associated with a reduction in stroke rates and an increase in bleed rates, the rate of events in real world patients relative to their RCT counterparts were higher. The absolute impact of novel agents, such as apixaban, in the real world may be greater than in RCT setting if the relative risk reductions versus alternatives from RCTs persist in the real world.
Abstract 16: Society of Chest Pain Centers accreditation is associated with improved cardiac service line outcomes in Virginia hospitals
Authors: Ghaemmaghami Chris
Published: July 2021

Introduction:
Hospitals in Virginia publicly report mortality outcomes on cardiac patients voluntarily. The Society of Chest Pain Centers (SCPC) is a process improvement organization that uses a standardized system of accreditation to recognize hospitals meeting specific process and organizational standards in acute cardiac care.

Hypothesis:
An association may exist between a hospital’s SCPC accreditation status and the reported mortality index for cardiology patients who do not undergo percutaneous or surgical coronary intervention.

Methods:
Self-reported data on non-interventional cardiac service line mortality for acute care hospitals in Virginia for calendar year 2009 were obtained from the Virginia Health Information website (
www.VHI.org
). Expected mortality rates were calculated by quality personnel at each hospital using standardized methodologies. Actual to expected (A:E) mortality ratios were compared between SCPC accredited an d non-accredited hospitals. Two-tailed t tests were used for comparisons.

Results:
Data were available from 77 acute care hospitals representing a total of 57,976 non-interventional cardiology patient cases in Virginia for 2009. 17 SCPC-accredited hospitals accounted for 19,246 cases and 60 non-accredited hospitals accounted for 38,730 cases. Using volume-weighted averages, the mean A:E mortality ratio was 0.91 at SCPC-accredited hospitals vs. 1.14 at non-accredited hospitals. (p <0.0001, 95% CI for difference in means: -0.24 to -0.22). In high-volume centers (>500 cases/yr), there was a significantly decreased A:E mortality ratio in accredited centers (n=13) vs. non-accredited ones (n=29) (0.86 vs. 1.11, p <0.0001; 95% CI for difference in means: -0.26 to -0.24). In low-volume centers (<500 cases/yr), there were higher than expected A:E mortality ratios in both the accredited (n=4) and non-accredited groups (n=31) (1.54 and 1.24, respectively).

Conclusions:
SCPC accreditation was associated with a lower A:E mortality ratio in Virginia hospitals. This lower mortality ratio was more prominent in hospitals having higher volumes of non-interventional cardiac cases. Smaller volume centers had higher than expected mortality ratios regardless of accreditation status.
Abstract 161: Trends in Intracranial Stenting among Medicare Beneficiaries in the United States, 2005-2008
Authors: Gupta Aakriti , Wang Yun , Desai Mayur M , Kim Nancy , Krumholz Harlan M
Published: July 2021

Background:
Intracranial stenting (ICS) was introduced to improve outcomes for stroke patients, but practice guidelines advocating its use have been based on limited evidence and a recent trial suggested no benefit and a mortality hazard. We sought to determine trends in ICS use, mortality, and associated costs of the procedure during the period of uncertain benefit.

Methods:
Inpatient Medicare standard analytic files were used to identify 100% of fee-for-service (FFS) patients aged ≥65 years who underwent ICS (ICD-9-CM code 00.65) from 2005 to 2008, a period chosen based on the emergence of a specific code for ICS in 2004. We linked the inpatient data with the Medicare denominator file to report operative rates per 1,000,000 person-years. Thirty-day and one-year mortality were ascertained through corresponding vital status files. Costs were defined as hospital payments made by Medicare.

Results:
A total of 783 ICS procedures were performed during 2005-2008 among Medicare FFS beneficiaries. The overall procedure rate for ICS quadrupled from 3 per million person-years ( n=94 procedures) in 2005 to 12 per million person-years (n=344 procedures) in 2008. Across years, women received ICS more frequently than men, and ICS procedure rates were highest among patients aged 65-74 years and lowest among those ≥85 years. One-year mortality rates increased from 10.6% (95% CI: 5.2% - 18.7%) in 2005 to 15.7% (95% CI: 12% - 20%) in 2008, with one-third of patients aged ≥85 years undergoing ICS in 2008 dying within one year. Procedure-related hospital costs increased from $1,381,142 ($14,693/patient) in 2005 to $8,736,912 ($25,398/patient) in 2008, with a total expenditure of nearly $17 million incurred by the federal government during 2005-2008.

Conclusion:
From 2005 to 2008, use of ICS increased, at a considerable cost to Medicare. Although the total number of people treated was small, many patients were exposed to risk for a technology that now has been shown to provide no benefit and may be hazardous. The health system cannot afford even modest expenditures that provide no return for patients.
Abstract 163: Telestroke Consultations Are Executed Quickly and Efficiently
Authors: Yang Julian P , Grujovski Andre , Wu Tzu-Ching , Tegeler Charles H , Xian Ying , Olson DaiWai M , Kolls Brad J
Published: July 2021

Introduction:
Telestroke systems have demonstrated the ability of technology to provide high quality acute stroke care to previously underserved populations. Although hospital systems across the U.S. are rapidly implementing these systems, little data exists to define the time commitment required by stroke specialists to complete a telestroke consultation.

Objective:
To describe the length of time physicians spend responding to and completing a telestroke consultation and to examine associated factors that may impact these times.

Methods:
This is a retrospective review of data logs generated between 7/2010 and 2/2011 using StrokeRESPOND telestroke software (InTouch Technologies, Inc.). Demographics and clinical data were abstracted from 846 consecutive consultations at eight hub hospitals and were linked to time metadata generated by clinician interaction with the software. Complete time-stamped logs were available for 203 cases. Response time was defined as patient arrival to physician log-on. Consult length was defined as time logged on to the robot and was exclusive of any telephone interaction or documentation time. Statistical analysis relating clinical variables’ effect on mean times was performed with ANOVA and paired t-test using SAS-JMP and SASv9.4 software (Cary, NC).

Results:
Patients had a mean age of 69.3 years and were male 41.9% (85/203). Mean consult length was 14.5 min (IQR 9.2-18.4). There was no independent association between consult length and age, diagnosis, time of arrival from symptom onset, neurological exam findings, known tPA contraindications, and absence of vascular risk factors. Mean consult length was statistically longer in tPA-recommended cases (20.0 vs 15.3 min; p= 0.04). Mean time from ED arrival to consult was 76.3 min (IQR 39.4 - 94.0) with a non-significant trend (p= 0.82) towards longer mean times (91.9 min) at night from 12:01 am to 6:00 am.

Conclusions:
The mean consult length of 14.5 min suggests that specialists are not using telestroke to run stroke codes remotely from start to finish and that work-up is largely completed prior to telestroke initiation. In this model, the utility of the telestroke is to have a specialist efficiently render an expert opinion on a gathered set of data (e.g. make the clinical diagnosis of stroke vs. mimic). The considerable range in response time suggests an area of improvement for telestroke. These findings will need to be validated, but this initial experience highlights the profound value of clinical metadata and the ongoing importance of thoughtful software design for accurate data abstraction with minimal data loss.
Abstract 164: Treatment Differences in Acute Stroke By Mode of Transport
Authors: Govindarajan Prasanthi , Chandra Anisha , Ghilarducci David , Shiboski Steve , Grimes Barbara , Johnston S Claiborne
Published: July 2021

Background:
EMS (Emergency Medical Services) is an important component of the stroke chain of survival. While in hospital stroke time targets have shown to be better when prehospital providers provide advance notification, population-wide studies on thrombolysis rates (IV t-PA) for those who arrive by EMS is sparse.

Objective:
To examine differences in treatment rates for acute stroke by mode of transport.

Methods:
This is a cross-sectional study of all patients who were transported to hospitals in two Northern California counties by providers of a single EMS agency during a three year period. Patient demographic data, prehospital provider clinical assessment was obtained from the computerized prehospital transport records and patient location, hospital demographics, physician diagnosis and treatment rates were obtained from statewide administrative patient discharge data. The data sources were linked using probabilistic linkage methodology. Patients ≥18 years of age with validated ICD- 9 code for stroke were included. We excluded inter-facility transports and direct admissions.

Results:
Of 10,456 patients who had a hospital based discharge diagnosis of stroke, 3787 (36%) were transported by EMS. Mean age at the time of admission was 75 years (+/- 14); 55% (2093) were females, 65% (2471) were whites and 86% (3247) were Hispanics. Most of the patients had Medicare (72%, 2737) and 92% (3471) were transported from home. Majority of the patients were treated at stroke centers [n=3014, (80%)]) and at community hospitals [n=3664, (97%)]. Of 3757 patients with a primary diagnosis of stroke, 4% (150) were treated with IV t-PA. After controlling for covariates, patients transported by EMS had higher odds of treatment with IV t-PA (OR 2.6, 95 CI 1.9-3.3). Treatment at stroke centers (OR 1.5, 95 CI 1-2.2) and academic centers were independently associated with treatment rates (OR 2.4, 95 CI 1.6-3.6).

Conclusions:
Arrival by EMS to emergency department is associated with higher treatment rates with thrombolytics for acute stroke patients and efforts should be targeted to improve use of EMS for stroke.
Abstract 190: Evaluation of Total Medical Costs with the Use of Apixaban and Rivaroxaban vs. Warfarin Among Atrial Fibrillation Patients
Authors: Deitelzweig Steve , Amin Alpesh , Jing Yonghua , Makenbaeva Dinara , Wiederkehr Daniel , Lin Jay , Graham John
Published: July 2021

Introduction:
While clinical trials have demonstrated that apixaban and rivaroxaban are effective and safe alternatives to warfarin, little is known regarding the total medical costs associated with such usage of the new anticoagulants (NOACs).

Hypothesis:
This study assessed the hypothesis that apixaban and rivaroxaban use among the general and elderly AF patients avoids medical costs when compared to warfarin, based on the results of the ARISTOTLE and ROCKET-AF trials.

Methods:
Event rates in patients receiving warfarin, apixaban, and rivaroxaban were estimated for the general and elderly (age ≥ 75 years) AF patient populations. Event rates associated with warfarin were calculated as weighted averages from NOAC trials among AF patients; NOAC rates were estimated by adjusting trial hazard ratios to these weighted averages. Annual incremental costs among patients with clinical events from the US payer perspective were obtained from published literature and inflation adjusted to 2010 cost levels. Total medical costs were compared for each NOAC vs. warfarin.

Results:
Apixaban use was associated with medical cost reductions (Table) in both the general and elderly populations compared to warfarin; cost avoidance was driven by reductions in major bleeding excluding hemorrhagic stroke (MBEHS) and stroke or systemic embolism (SSE). Rivaroxaban-mediated cost reductions among the both the general and elderly population came from reduced SSE which was offset by increased MBEHS costs; Myocardial infarction, pulmonary embolism or deep vein thrombosis and non-major bleeding each made smaller contributions to the medical cost differences among both populations.

Conclusions:
Apixaban and rivaroxaban use may be associated with reduced total medical cost among the general AF patient population when compared to warfarin. Apixaban vs. warfarin usage among elderly AF patients may be associated with a substantial medical cost reduction due to reductions in both stroke and major bleeding events.
Abstract 192: Impact of Altering Definitions of Hypertension “Control” on Patient and Provider Performance Assessments
Authors: Navar-Boggan Ann M , Stafford Judith , Peterson Eric
Published: July 2021

Background:
Given that hypertension is one of our nations most important modifiable risk factors, many have focused on comparing provider performance based on hypertension control. However, there are multiple definitions of ‘blood pressure (BP) control’ and the impact of these alternative definitions on provider performance rankings is unclear.

Methods:
We evaluated rates of hypertension control among a cohort of patients with hypertension followed routinely by a cardiologist. Patients were eligible who saw the same cardiologist at least twice in a year-long assessment period. Three definitions of failure to control BP were evaluated: 1) Systolic BP (SBP ≥140) or diastolic (DBP ≥90) at the final visit, 2) Average SBP≥140 or average DBP≥90 across all visits, and 3) SBP ≥140 or DBP≥90 at over half of visits during the assessment period. Provider-specific performance was evaluated using each definition, and correlation of provider performance between definitions evaluated using linear regression.

Results:
A total of 5558 patients followed by 54 cardiologists were included. Overall failure to control BP rates were 30.1% using the last visit definition, 27.3% using the average BP, and 24.5% when using elevated BP during at least half of visits. For 4495 patients (81%), there was no difference in overall classification of hypertension control between the varying definitions. However, provider-specific rates of hypertension control were only modestly correlated between definitions (see table 1). Classification of outliers with respect to highest and lowest performing providers remained unchanged between definitions.

Discussion:
While varying the definition of BP control does not affect patient classification for the majority of patients, assesements of provider performance with respect to hypertension change as definitions of BP control vary.
Abstract 222: Administration of Intravenous Fluids in Patients Hospitalized with Heart Failure
Authors: Mody Purav , Li Shu-Xia , Dharmarajan Kumar , Kim Nancy , Strait Kelly , Horwitz Leora , Krumholz Harlan
Published: July 2021

Administration of Intravenous Fluids in Patients Hospitalized with Heart Failure

Background:
Administration of intravenous (IV) fluids to patients with acute decompensated heart failure (HF) may worsen pulmonary congestion or hemodynamic status. However, little is known about the use of IV fluids in clinical practice. We examined the frequency and volume with which commonly used IV fluid preparations are used among inpatients with HF as well as the association of these treatment patterns with diuretic use and length of stay (LOS).

Methods:
We identified all hospitalizations in 2009-2010 with a principal discharge diagnosis of heart failure from the Premier, Inc. hospitals. In order to capture inappropriate therapy with intravenous fluids, we limited our study period to the initial two days, a period during which most HF patients undergo diuresis for fluid overload. We excluded patients with a potential indication for fluid resuscitation (concomitant therapy with vasopressors or inotropes, undergoing invasive procedures, or having secondary diagnosis of bleeding, sepsis or anaphylaxis). We also excluded hospitalizations with age < 18 yrs, < 3 day LOS, transfer-ins, and hospitals with < 25 HF cases. We calculated the administration frequency and volume of commonly used IV fluids (normal saline, half normal saline, 5% dextrose, and Lactated Ringer’s), the percentage of patients receiving concomitant therapy with loop diuretics, and the average LOS associated with administration of each of the four fluids.

Results:
Among 195,652 hospitalizations, 25% (48,611) were administered at least one of the four IV fluids. Normal saline was the most commonly administered fluid (19.4% of hospitalizations), followed by 5% dextrose (6%), half normal saline (2.2%), and Lactated Ringer’s (0.2%). The median volume of fluid administration over the first two days was 1,000 ml (IQR: 250, 1250). Eighty-nine percent of patients receiving fluid therapy received concomitant loop diuretics. Increasing median LOS was noted with increasing fluid volumes across all four individual IV fluid categories (see Table).

Conclusion:
A substantial proportion of patients hospitalized with HF receive a considerable volume of intravenous fluid during their first 2 hospital days; normal saline was the most commonly administered formulation. Loop diuretic use was very common in those receiving IV fluids. Greater understanding of the concomitant use of intravenous fluids and diuretics and their relation to length of stay may provide an opportunity to improve quality of care.
Abstract 259: Myocardial Perfusion Imaging has Markedly Lower Sensitivity after Accounting for Verification Bias
Authors: Elashoff Michael , Ladapo Joseph A , Phelps Charles E , Douglas Pamela S
Published: July 2021

Introduction
Estimates of myocardial perfusion imaging (MPI) performance are often derived from convenience cohorts of patients undergoing coronary angiography, who are selectively referred for this invasive test because of high-risk clinical characteristics, high-risk test results, or both. While clinically appropriate, this approach distorts estimates of MPI's test performance, since sensitivity and specificity are only assessed in patients who are referred for angiography. This verification bias, sometimes called “work-up” or “referral” bias, compromises physicians' ability to appropriately use noninvasive testing since test performance data may be inaccurate. We sought to examine the impact of verification bias on MPI's performance, to provide clinicians with a more accurate assessment of its diagnostic characteristics.

Hypothesis
We hypothesized that the bias-adjusted performance of MPI will show significantly lower sensitivity and significantly higher specificity compared to published estimates derived from convenience cohorts undergoing invasive angiography.

Methods
We used a comprehensive meta-analysis of MPI performance (14 studies totaling 3,500 patients based on angiographic referral) to assess the reported (biased) sensitivity and specificity of MPI. We then computed unbiased sensitivity and specificity rates using published methods, combining the meta-analysis estimates with other published data giving angiography referral rates for patients with both positive and negative MPI results (48% and 6%, respectively). Finally, we validated the unbiased performance estimates using a recent multi-center study (Coronary Obstruction Detection by Molecular Personalized Gene Expression [COMPASS]) of MPI that was not subject to verification bias, since all subjects had angiographic referral to use as the gold standard.

Results
The meta-analysis reported (biased) MPI sensitivity was 81% and specificity was 65%. After appropriate correction for verification bias, the unbiased estimate of sensitivity was 35% (95% CI = 27% to 45%) and specificity was 94% (95% CI = 91% to 96%). These estimates were very similar to the observed values in the unbiased COMPASS trial (N=431 patients): core laboratory MPI sensitivity was 36% (95% CI = 24% to 50%) and specificity was 90% (95% CI = 87% to 93%).

Conclusions
In conclusion, after correction for verification bias or when estimated in a population without bias, MPI is markedly less sensitive and more specific than most published estimates would indicate. The biased estimates of test performance would tend to encourage referral to angiography compared to corrected estimates. Future studies of non-invasive imaging modalities in patients with suspected or diagnosed CHD should report performance estimates that are either corrected for verification bias or use unbiased cohorts, to provide an accurate assessment of test performance for clinical decision making.