bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 143: Pearls and Pitfalls of Performance-linked Reimbursement Plans for Novel Drugs: The Case of Sacubitril-Valsartan
Authors: Sandhu Alexander T , Heidenreich Paul A
Published: March 2022

Introduction:
Rising drug costs have sparked interest in tying payments to outcomes to reduce payer risk of adopting low-value interventions. However, performance-linked reimbursement (PLR) plans are poorly understood. We modeled the effects of PLR plans on the distribution of therapy value obtained using sacubitril-valsartan as an illustrative case.

Methods:
We modeled PLR plans that issued refunds/discounts based on reductions in cardiovascular mortality or heart failure hospitalization. We used probabilistic sensitivity analyses from a published cost-effectiveness model of sacubitril-valsartan to model real-world uncertainty. We compared the distribution of value obtained (net monetary benefit [NMB]) with PLR plans and conventional payment across 10,000 paired simulations. Price premiums were set so average reimbursement was equal with both schemes. We varied plan structure and treatment/population uncertainty. With successful plans, payment would decrease in simulations with less benefit and increase with more benefit - decreasing the NMB standard deviation. We also calculated incremental NMBs as valuations of the change in NMB variability using a risk-averse utility curve.

Results:
A plan that adjusted drug reimbursement based on the ratio of observed to expected reduction of cardiovascular mortality reduced the standard deviation of NMB by 16.6% (Table 1). The incremental NMB - an estimate of per-patient value of implementing the PLR plan - was only $35, 3.3% of the NMB with conventional payment. Cardiovascular mortality plans were more successful than heart failure hospitalization plans. With rare outcomes, refunds based on cohort event rates were larger than refunds for individual adverse events. Plans improved with greater treatment effect uncertainty, larger refunds, and more payer risk-aversion. Their value decreased with more natural history uncertainty. Plans unraveled if the payer asymmetrically selected higher risk patients.

Conclusion:
PLR plans require outcomes tightly associated with treatment value and minimally influenced by unrelated uncertainty. Both sides must agree on a predictable population and limit asymmetric selection. For rare outcomes, plans should evaluate population event rates or surrogate measures that consistently reflect the clinical benefit.
Abstract 160: Impact of ECG to Decision Time and Sex Differences on False Positive STEMI Diagnosis Rate in a Large Rural Healthcare Center
Authors: Mullvain Richard , Saman Daniel M , Benziger Catherine
Published: March 2022

Objectives:
A false positive diagnosis of STEMI may lead to unnecessary treatments and increased costs. Little data are published on the unique care performance metric of electrocardiogram-to-decision time (E2Decide) for the diagnosis of STEMI. The objective of this quality improvement analysis was to determine the association between E2Decide time and sex differences on false positive diagnosis rates for STEMI

Methods:
A retrospective analysis was conducted of consecutive STEMI diagnoses treated at a rural tertiary care hospital, located in Duluth, Minnesota, USA, between May 2013 to December 2017, originating from 4 different settings: (1) non-PCI facilities, (2) in the field by emergency medical services, (3) tertiary hospital emergency department, or (4) tertiary hospital in-patient. A false positive STEMI diagnosis was defined as no culprit lesion or multi-vessel disease found during angiography, or if the cardiologist rejected the initial diagnosis of STEMI and cancelled angiography. Multivariate logistic regression modeling was used for parameter estimates.

Results:
There were 1278 consecutive STEMI diagnoses in our analysis, of which there were 429 (33.6%) females. A total of 215 (16.8%) were false positives. Females had a 45.2% increased odds of a false positive diagnosis compared to males [estimated odds ratio (OR) 1.452 (95% CI: 1.062- 1.984)]. E2Decide time was positively associated with an increase in odds of a false positive (OR 1.007; 95% CI: 1.001-1.012). For every 5 minutes of increase in E2Decide time, there was a 3.6% increase in the odds of a false positive STEMI diagnosis.

Conclusions:
We observed a higher false positive STEMI diagnosis rate with females compared to males. Longer E2Decide times were significantly associated with higher false positive STEMI diagnosis rates. In addition to demonstrating the impact of sex differences on false positive STEMI diagnosis rate, this analysis demonstrates the potential value of the metric E2Decide time.
Abstract 17: Association Between Pre-stroke Depression and Patient Reported Outcomes After Acute Ischemic Stroke
Authors: Shah Shreyansh , Xu Haolin , Xian Ying , Maisch Lesley , Hannah Deidre , Lindholm Brianna , Lytle Barbara L , Pencina Michael J , Olson DaiWai M , Smith Eric E , Fonarow Gregg C , Schwamm Lee H , Bhatt Deepak L , Hernandez Adrian F , O’Brien Emily C
Published: March 2022

Background:
Post-stroke depression has been shown to have a negative impact on patients’ quality of life but data regarding the relationship between pre-stroke depression and post-stroke outcomes are lacking.

Methods:
Patient reported outcome measures (PROMS) were prospectively collected (January 2014 – December 2014) as a part of PROSPER, a PCORI-funded study designed by researchers and stroke survivors to evaluate the effectiveness of therapies post-stroke. PROMS evaluated in the study included modified Rankin Scale (mRS) assessed at discharge, 3 months and 6 months post-discharge. EuroQual-5D-3L (EQ-5D-3L), EuroQual Visual Analog Scale (EQ-VAS), Patient Health Questionnaire-2 (PHQ-2), Stroke Impact Scale-16 (SIS-16), and Fatigue Severity Scale (FSS) were assessed at 3 months and 6 months post-discharge. Pre-stroke depression was identified from patient medical history. Validated dichotomized endpoints were used to create regression models to examine association of pre-stroke depression with PROMS.

Results:
Of 1,617 enrolled patients at 60 hospitals, 185 (11.4%) had pre-stroke depression. Patients with documented pre-stroke depression were more likely to be white, female and have a higher prevalence of cardiovascular risk factors than those without pre-stroke depression. While both cohorts had similar stroke severity and functional status at discharge, patients with pre-stroke depression had significantly worse PROMS at 3 months and 6 months post-discharge. Pre-stroke depression was associated with 56% higher odds of functional decline between 3 months and 6 months post-discharge with greater negative impact of stroke on patient’s health and life, and with increased likelihood of reporting severe fatigue during stroke recovery (Table 1).

Conclusions:
Pre-stroke depression is associated with worse patient reported outcomes and greater odds of functional decline after ischemic stroke discharge. Strategies to more effectively manage comorbid depression and improve outcomes in these patients are needed.
Abstract 189: Electronic Consults and Active Referral Management for Improving Access to Specialty Care Within the Veterans Health Administration
Authors: Winchester David E , Wokhlu Anita , Vilaro Juan , Bavry Anthony A , Park Ki , Choi Calvin , Panna Mark , Kaufmann Michael , McKillop Matthew , Schmalfuss Carsten
Published: March 2022

Background:
Electronic consultations (e-consults) are a novel approach to patient care that may improve access to specialty care by reducing the burden on outpatient clinics. We adopted e-consults within an active referral management (ARM) process for our Veterans Health Administration (VHA) outpatient cardiology clinic to reduce clinic wait times.

Methods:
Our ARM process consisted of reviewing all incoming consult requests for our outpatient clinic and triaging the requests to either an e-consult or a clinic visit. This occurred in two phases, triaged by physician alone in the first phase (11/1/15 to 10/30/16) and by a non-physician provider/provider dyad (11/1/16 to 3/1/17) in the second phase.

Results:
The primary outcome was wait time for an appointment in our clinic. A secondary analysis of consult requests was reviewed to determine the proportions of ordering specialties, reasons for consults, and the result of the ARM triage. The median wait time for our clinic prior to adopting e-consults and the ARM process was 24 days. In phase 1, we observed 20 weeks of wait times below the median and the wait time was calculated to be 13 days (46% reduction). In phase 2, we observed a significant increase in both overall consult volume and in wait times. Approximately 60% of incoming consults could be triaged into e-consults, predominantly by managing stable diseases or minor symptoms.

Conclusions:
E-consults and ARM of clinical referrals were effective at reducing wait times for outpatient VHA cardiology clinic. The majority of clinical referrals could be handled through e-consult and did not require an in-person clinic visit.
Abstract 212: Left Ventricular Hypertrophy by Electrocardiogram Criteria is Associated With Post-Transcatheter Aortic Valve Replacement High-Degree Atrioventricular Block and Left Bundle Branch Block
Authors: Zhang Robert , Jou Stephanie , de la Rosa Angelo , El-Hajjar Mohammad , Nappi Anthony , Delago Augustin , Steckman David , Torosoff Mikhail
Published: March 2022

Background and Hypothesis:
Severe aortic valve stenosis is associated with LVH, which has been shown to increase all-cause mortality and lead to conduction abnormalities. Patients undergoing trans-catheter aortic valve replacement (TAVR) have an increased risk for conduction abnormalities and subsequent permanent pacemaker (PPM) implantation. We investigated an association between pre-TAVR LVH by ECG criteria and post-TAVR conduction abnormalities and need for a permanent pacemaker. This relationship has not been studied before.

Methods:
A retrospective chart review was conducted in 388 consecutive TAVR patients (57.7% females, transfemoral approach in 59.3%, 77.9% with Sapien valve) without pre-TAVR pacemaker. Analyses of variation, chi-square, multi-variate, and logistic regression were used. The study was approved by the institutional IRB.

Results:
Post-TAVR pacemaker was more commonly needed in patients with baseline QRS >120 msec (35 vs. 11%, p<0.003), baseline RBBB (35 vs. 20%, p<0.02), post-TAVR LBBB (39 vs. 17%, p<0.0001), or post-TAVR high-degree AV block (69 vs. 12%, p<0.0001). All 388 patients had LVH by echocardiographic criteria, but only 50% of the patients had LVH by ECG criteria. Patients with LVH by ECG criteria were more likely to develop post-TAVR LBBB (27 vs. 13%, p=0.001) or high grade AV block (26% vs. 14%, p=0.005). Overall, there was a trend for increased pacemaker need in patients with pre-TAVR LVH by ECG criteria (20% vs. 17%, p=0.385).

Conclusion:
LVH by voltage criteria in TAVR patients is associated with post-TAVR LBBB and post-TAVR high degree AV blocks, which lead to post-TAVR pacemaker placement. Pre-TAVR LVH by ECG criteria may be used to identify high-risk patients in whom extended telemetry monitoring may be warranted. Additional studies investigating this important subject are needed.
Abstract 222: Age-Related Practice and Outcome Patterns in Infective Endocarditis in the National Readmissions Database, 2010-2015
Authors: Migotsky Sean , Kazi Dhruv S , Spivak Emily S , Shah Sonia U , Shah Rashmee U
Published: March 2022

Background:
The epidemiology and outcomes of infective endocarditis (IE) may be changing due to increasing transcatheter valve replacements and intravenous drug use. Our goal was to evaluate the demographics and outcomes of patients with IE using the largest sample of IE patients published to date.

Methods:
We used the Nationwide Readmissions Database, which compiles all-payer hospital inpatient stays across 22 states - a sample size of 13 to 15 million discharges per year. We identified hospitalization for IE from 2010 to 2015 using International Classification of Diseases (ICD) codes. The primary outcomes of interest were annual IE incidence, and in-hospital death rates, valve replacement, and 30-day readmission rates.

Results:
We identified 164,542 hospitalized IE cases from 2010 to 2015. Incidence ranged from 6 to 121 cases per 100,000 adults, with incidence increasing with age. Overall, 10.6% (17,420 of 164,542) of patients died during the index hospitalization, with lowest mortality amongst youngest patients, 4.7% (449 of 9,600) in 18-29 age group compared with 10.8% (4,449 of 41,255) amongst patients aged 80 and older. Among index hospitalization survivors, 9.6% (14,165 of 147,122) were re-hospitalized within 30 days. In contrast to mortality, re-hospitalization was 14% (1,285 of 9,151) among 18-29 year olds vs. 6.4% (2,365 of 36,806) in the 80+ age group. Valve replacement occurred during the index hospitalization for 7.9% (12,950 of 164,542) of IE patients. Valve replacement was least common in older age groups; 13.6% (4,881 of 35,678) of those 18-49 years old received valve replacements compared with only 1.3% (524 of 41,255) of patients age 80 and older.

Conclusion:
Infective endocarditis incidence increases with age, with an incidence more than twenty-fold higher in those age 80 and older compared with 18-29 year olds. Moreover, older age is associated with higher rates of IE-related mortality, but lower rates of surgery and readmission.
Abstract 227: Inter-hospital Variation in Costs of Pediatric Cardiac Catheterization: An Analysis of the PHIS Database
Authors: O’Byrne Michael L , Shinohara Russell T , Mi Lanyu , Dori Yoav , Gillespie Matthew J , Rome Jonathan J , Kawut Steve M , Glatz Andrew C , Groeneveld Peter W
Published: March 2022

Background:
No previous studies have studied the variation in costs between hospitals for catheterization procedures performed in children. Variation in cost not explained by differences in case-mix can indicate opportunities to improve efficiency and quality of care.

Methods:
A multicenter observational study was performed, studying total hospital costs of 9 common transcatheter procedures (diagnostic procedures in 2 populations and 7 interventional procedures) performed between 2007-2015 at hospitals contributing data to the Pediatric Health Information Systems database. Mixed effects models were used to adjust costs for case mix and to assess inter-hospital variation. Bayesian methods were used to calculate risk-standardized costs for each hospital.

Results:
The study included 35,637 procedures from 43 hospitals. Median costs (US 2015 dollars) increased roughly with technical complexity, from $8,249 (heart transplant diagnostic catheterization) to $38,909 (transcatheter pulmonary valve replacement). There was significant inter-hospital variation in cost for each procedure (
p
<0.0001). After case mix-adjustment, the range of standardized costs remained broad (Table). These differences were not explained by differences in hospital catheterization volume.

Conclusion:
There is significant inter-hospital variation in costs of transcatheter procedures after case-mix adjustment. Exploring the etiology of these differences is an opportunity to improve care of children with heart disease.
Abstract 248: Gold Star Pilot Program Expedites Early Discharges From Inpatient Cardiology Unit
Authors: Chen John H , Vazquez John R , Hummel Christina , Kumarasamy Mathu , Yam Alison , Esper Gregory J , Goyal Abhinav , Wells Bryan J
Published: March 2022

Background:
Benefits of early hospital discharge include decreased length of stay, improved patient satisfaction, and more efficient resource utilization. Patients admitted to inpatient cardiology units are excellent candidates for targeting early discharge, particularly after uncomplicated procedures.

Aim:
We planned to increase the rate of pre-11:00 AM discharges from 7% to 14% within 12 weeks on the inpatient cardiology unit of a single university hospital.

Methods:
The Gold Star pilot program was initiated in the cardiology unit at Emory University Hospital. Potential next-day discharges were designated Gold Star status if the patient had no procedural complications, complex discharge needs, pending consults, or incomplete tests. Providers notified nurses and social workers by placing a Gold Star communication order in the patient’s EMR. Day and night shift nurses completed a checklist for patient education and transportation planning. In the morning, the provider completed a discharge order by 9:00 AM and the patient was discharged by 11:00 AM. We measured the proportion of patients with a discharge order in EMR by 9 AM, and who were discharged by 11 AM, during a 4-week “baseline” period (n=146 patients); a 3-week period of implementing Gold Star discharges from the interventional cardiology service (n=133); and 9 more weeks after “full implementation” i.e. expanding the program to the general cardiology, heart failure, and electrophysiology services (n=352).

Results:
The proportion of discharge orders placed before 9 AM was 8.9% (13 of 146) at baseline versus 12.2% (43 of 352) after full implementation (p=0.35 by Fisher’s exact test). The proportion of discharges occurring before 11 AM rose from 6.8% (10 of 146) at baseline to 14.5% (51 of 352) after full implementation (p=0.0166, Figure). Mean (median) length of stay was 4.1 (3) days at baseline and 4.0 (3) days after full implementation (p=0.88 by Student’s t-test).

Conclusions:
The Gold Star program facilitated pre-11 AM discharges from an inpatient cardiology unit. Barriers to early discharge include wait time for diagnostic studies, failure to identify Gold Star eligible patients, and delays in transportation. We continue to address these barriers and plan to replicate our program at other hospitals within our health system.
Abstract 266: Preoperative Vancomycin and the Risk of Cardiovascular Implantable Electronic Device Infection: A Cohort Study in a Veteran Population
Authors: Alzahrani Talal , Baddour Larry M , Karasik Pamela E
Published: March 2022

Background:
The rate of cardiovascular implantable electronic device infection (CIEDI) has increased, despite the use of preoperative antibiotics at the time of device placement or revision. Cefazolin, a beta-lactam antibiotic, is used as standard preoperative prophylaxis in the bulk of patients. Vancomycin is used in the small minority of patients who have IgE-mediated allergies to beta-lactams or have a history of colonization/infection with MRSA. As compared to cefazolin, vancomycin is less effective against methicillin-susceptible Staphylococcus aureus, has no gram-negative coverage, and has nephrotoxicity risk.

Methods:
A retrospective cohort study was performed to assess whether vancomycin use increased the risk of CIEDI in comparison to the standard preoperative prophylaxis. The VA Informatics and Computing Infrastructure (VINCI) database, which includes all veterans who underwent CIED placement or revision between 2008 and 2015, was used. A logistic regression model was constructed to estimate the adjusted risk of CIEDI among patients who received vancomycin after adjusting for confounding factors.

Results:
Overall, 10,454 CIED procedures were included, and 98% of them were performed in men with a mean age of 71 ± 12 years. Vancomycin was given in 40.6% of these procedures. The rate of diabetes mellitus, heart failure, and advanced chronic kidney diseases were 20.5%, 13.5%, and 2.3%, respectively. The logistic regression analysis showed that vancomycin increased the risk of CIEDI three-fold (OR 2.99 [1.76-5.06], P-value <0.001) as compared to the standard preoperative prophylaxis, after controlling for other effects including MRSA colonization.

Conclusions:
Our study revealed that among patients who received vancomycin as preoperative for CIED placement or revision, there was a three-fold increase in the risk of subsequent CIEDI.
Abstract 280: Strength of Clinical Trial Evidence for High-Risk Cardiovascular Devices Approved Through Food and Drug Administration (FDA) Priority Review
Authors: Jones Camille , Dhruva Sanket S , Redberg Rita F
Published: March 2022

Importance:
There is increasing emphasis on getting medical devices to market more quickly by use of priority review pathways, promoted in recent US Food & Drug Administration (FDA) guidance documents and the 21
st
Century Cures Act of 2016.

Objective:
To evaluate the impact of priority review pathways for high-risk cardiovascular devices by analyzing the quality and characteristics of premarket clinical studies in support of their approval and the frequency of postmarket recalls.

Design and Setting:
Descriptive study of premarket clinical studies supporting all high-risk cardiovascular devices approved via the priority review premarket approval (PMA) pathway between January 1, 2005 and June 15, 2017.

Exposure:
Priority Review PMA
Main Outcome(s) and Measure(s):
For all clinical studies which supported priority review PMAs we analyzed: number of patients enrolled, number of patients analyzed for each primary endpoint, demographic information, randomization, blinding, use and type of controls, use of training patients, number and location of study sites, and time of FDA review to approval. We also determined if a post hoc analysis was conducted. We counted all Class 1 and Class 2 recalls and examined FDA expert device panel recommendations.

Results:
There were 16 priority review cardiovascular devices approved, with mean 1.4 (SD 0.6, range 1-3) pivotal studies per device. Eleven of 16 (69%) were approved based on a single pivotal study. Of 23 pivotal studies, ten (43%) were randomized, 3 (13%) were single-blinded, and none were double-blinded. Twelve (52%) used a noninferiority primary endpoint hypothesis for at least one endpoint and 18 (78%) used a surrogate endpoint. Of the 11 votes on device effectiveness by FDA expert panels, 6 (55%) voted devices were effective. There were a total of 18 Class 1 and 2 recalls for 7 of these devices.

Conclusions and Relevance:
Most priority review pathway high-risk cardiovascular devices are approved without a randomized or blinded trial. Noninferiority design and use of surrogate endpoints are common. These devices are frequently subject to recalls.
Abstract 35: Trends in Statin Use and Adherence and the Impact of the 2013 Cholesterol Guidelines
Authors: Gilstrap Lauren , Chernew Michael , Nguyen Christina , Alam Sartaj , Bai Barbara , Landrum Mary Beth
Published: March 2022

Background:
In 2013, the ACC/AHA updated the cholesterol treatment guidelines. At the time, it was estimated that an additional 13 million Americans would quality for statin therapy. To date, the real-world implications of this guideline change have not been well studied. This study aims to better understand trends in statin use and adherence, by gender, and the impact of guideline change.

Methods:
This is a retrospective, observational study using medical and pharmacy claims from 2009 to 2014 from a large, national, commercial insurer. Considering all beneficiaries aged 18-65 with ≥1 year of continuous enrollment, we created annual cross sectional populations of statin-eligible patients and divided them into 3 statin benefit groups (SBG). In descending order of risk, the groups were: (1) atherosclerotic cardiovascular disease (ASCVD); (2) diabetes and (3) hyperlipidemia. Patients were assigned to the highest risk group that they qualified for.

Results:
Statin use rates among those with ASCVD increased until 2012 and then plateaued
(Figure 1a
). Use rates among those with diabetes, were flat until 2011 and then increased. Use rates among those with hyperlipidemia steadily rose from 2009-2014. Statin adherence rates among those with ASCVD increased from 2009-2014 (
Figure 1b
). Adherence rates among those with diabetes, decreased from 2009-2011 and then rose significantly from 2011-2014. Adherence rates among those with hyperlipidemia also rose steadily from 2009-2014. The most significant gender gap in treatment, for both use and adherence, was between men and women with ASCVD. There was with little change in this treatment gap, in any risk group, over the time period observed.

Conclusion:
The 2013 cholesterol guidelines have not yet had a significant effect on statin use or adherence. Recently improving trends in statin use and adherence, especially among patients with diabetes, appear to predate the 2013 guideline change. A significant gender gap in statin treatment remains, especially among those in the highest risk group.
Abstract 5: Optimizing Emergency Room Throughput for Cardiac Telemetry Patients: A Queuing Theory Approach
Authors: Rosenblatt Anna , Gravenor Stephanie , Gurvich Itai , Van Mieghem Jan , Mutharasan R. Kannan
Published: March 2022

Background:
The capacity of telemetry monitoring in hospitalized patients is constrained due to limited equipment and personnel. Electing for telemetry monitoring may pose a bottleneck for patients admitted through the Emergency Department (ED). This can result in increased length of stays in the ED, a parameter that is correlated with decreased quality of care due to crowding and delay in treatment. Queuing theory is the mathematical study of waiting times. We opted to use queuing theory to analyze system performance before and after an expansion of telemetry capacity.

Objective:
To retrospectively analyze the impact of telemetry capacity on ED wait times using enterprise data warehouse (EDW) data and queuing theory.

Methods:
Unused telemetry boxes were used as a proxy metric for available cardiac telemetry monitoring. The number of telemetry boxes in use at a large urban academic medical center was determined by daily manual count. The number of telemetry admissions, average length of telemetry use, and length of stay in the ED were obtained from EDW data. Using queuing theory, system parameters including expected wait time and percent of patients who will wait were calculated for scenarios to simulate before and after the expansion of telemetry capacity. These modeled system behaviors were compared to observed data from before and after the intervention to understand the utility of the mathematical model.

Results:
Over the study period of 365 days, a total of 13,515 inpatient non-critical care hospital encounters had orders for telemetry monitoring. Prior to the increase in telemetry capacity, there were 144 telemetry boxes, which were utilized at 96.7% of capacity. Using these parameters, the model predicts a 5.8-hour average wait time and a 42.1% chance that a patient will have to wait for a telemetry box. Increasing telemetry capacity modestly by 10 boxes (144 to154 boxes) results in a dramatic system improvement, reducing utilization to 88.6%, average wait time for a telemetry bed to 34 minutes, and percent of patients waiting for a telemetry slot to 9.4%. These predicted results compared well to the observed data. After the intervention, there was a decrease in utilization to 86.9%, and a statistically significant reduction in time waiting in the ED for an inpatient bed by 1.24 (p<0.05) hours per telemetry patient, representing a total savings of ED boarding time of 11.2 bed-days per week.

Conclusions:
Queuing theory allows for modeling of healthcare system behavior to predict needed clinical capacity for achieving system goals. Our simplified model demonstrates that a modest increase in capacity can drive significant system improvements. Utilizing queuing theory and understanding the behavior of the healthcare system can improve the predicted impact of interventions on cost-effectiveness and quality of care.
Abstract 14: Gender Differences in Loss of Sexual Activity 1-Year After an Acute Myocardial Infarction (AMI)
Authors: Lindau Stacy , Gosch Kensey , Abramsohn Emily , Chan Paul , Krumholz Harlan , Spatz Erica , Wroblewski Kristen , Spertus John
Published: March 2022

Objectives:
Little is known about sexual activity after an AMI and the extent to which physicians discuss this with their patients. We compared sexual activity, predictors of change in activity, and patterns of communication with physicians about sexual activity among men and women following an AMI.

Methods:
Between 2005-08, the TRIUMPH Study enrolled 4340 AMI patients and surveyed them at baseline, 1, 6, and 12 months. In 9/07, a sexual health module to assess pre- and post-MI sexual activity and communication was added and administered at months 1 and 12; a total of 1184 men and 576 women received the module at their one year follow-up. Multivariable hierarchical models (separate for men and women), within site, were used to predict loss of sexual activity 1 year after an AMI. Loss of sexual activity was defined as less frequent or no sexual activity in those who were sexually active prior to an MI. Item non-response for the sexuality module ranged from 4.4%-5.9%.

Findings:
Participants were 58.6 ± 11.0 years (males) and 61.0 ± 12.9 years (females) old. Women were less likely than men to be married (40.6% of 574 vs 64.6% of 1182, p<0.001), and less likely to be sexually active prior to the MI (43.1% of 504 vs 73.5% of 1095, p<0.001). At 1 year, men were more likely than women to report having received discharge instructions about resuming sexual activity (46.3% of 1163 and 34.5% of 556, p<0.001, respectively). Men were more than twice as likely as women to report having discussed sex with a physician in the year following MI (38.8% of 896 vs 17.5% of 325, p<0.001). The majority of men (67.7% of 1100) but less than half of women (40.6% of 505) reported some sexual activity in the year following an MI. Controlling for age, partner status, GRACE 6-month mortality risk score, depression (PHQ-9), and physical health (SF-12) (all at baseline), those who did not receive discharge instructions about sexual activity were significantly more likely to report loss of sexual activity at one year (RR 1.32, 1.14-1.54 for men and RR 1.41, 1.16-1.72 for women).

Conclusions:
Discussion with a physician about sex occurs much less often for women than men. Lack of physician-patient communication about sex prior to hospital discharge after an MI is independently associated with loss of sexual activity at one year.
Abstract P112: End-of-Life Care in Heart Failure: Differences Between the U.S. and Canada
Authors: Curtis Lesley H , Greiner Melissa A , Unroe Kathleen T , Hernandez Adrian F , McAlister Finlay A , Ezekowitz Justin A , Quan Hude , Armstrong Paul W , Kaul Padma
Published: March 2022

Background:
Heart failure (HF) is a debilitating and chronic condition with high mortality, yet little is known about costs of care at the end of life and how they differ between the US and Canada. The objective was to compare health care resource use during the last six months of life between the US and Canada among elderly patients with HF.

Methods:
We used a 5% national sample of Medicare beneficiaries with HF (age 65+) who died from 2000-2006 and patients in the Alberta Cardiac Access Collaborative Heart Failure cohort (age 65+) who died from 2000-2006. We tallied all-cause hospitalizations, intensive care unit (ICU) days, outpatient physician visits, and the use of tests and procedures in the 180 days preceding death. We examined the level of care at the time of death. We assessed trends over time within each country and, among patients who died in 2006, we directly compared end of life care between countries.

Results:
The cohort included 204,520 Medicare beneficiaries and 33,144 patients in the province of Alberta, Canada. The average age at death was 83 in both countries. The proportion of US patients hospitalized in the last six months of life was constant at 81% over the study period. In Canada, by contrast, the proportion hospitalized decreased from 84% in 2000 to 76% in 2006 (p<.001). Resource use at the end of life differed between the countries (
Table
). The mean number of inpatient days was higher in Canada, but mean ICU days were higher in the US. The use of most tests and procedures was higher in the US. Patients in Canada were more likely to die in the hospital, but US. patients were more likely to be in the ICU during the terminal hospitalization.

Conclusion:
There are substantial differences in the management of heart failure patients in the US and Canada in the last six months of life. Further research is needed to understand the role of patient and provider preferences in the observed cross-country differences.

End of Life Resource Use among HF Patients in the US and Canada, 2006

US (n=26 550)
Canada (n = 4857)
p-value

Resource use in the 180 days preceding death

Any hospitalization
21 540 (81)
3703 (76)
<.001

Inpatient days, mean (SD)
21 (22)
34 (35)
<.001

ICU days, mean (SD)
4.4 (9.3)
1.5 (7.0)
<.001

Stress test, no. (%)
1568 (5.9)
70 (1.4)
<.001

Cardiac catheterization no. (%)
1536 (5.8)
167 (3.4)
<.001

CABG no. (%)
348 (1.3)
39 (0.8)
0.003

Inpatient at time of death, no. (%)
9491 (35.7)
2622 (54.0)
<.001

ICU, no. (%)
4563 (48.1)
546 (12.1)
<.001
Abstract P117: Longer Hospital Length of Stay in Non-ST-Elevation Myocardial Infarction Associated With Higher Risk but Less Evidenced-Based Treatment: Results From ACTION Registry
Authors: Lopes Renato D , Chen Anita Y , Shah Bimal R , Wang Tracy Y , Newby L. Kristin , Ho P. Michael , Wiviott Stephen D , Peterson Eric D , Roe Matthew T , Granger Christopher B
Published: March 2022

Background:
There is substantial heterogeneity in hospital length of stay (LOS) among patients with non-ST elevation myocardial infarction (NSTEMI). Little is known about factors associated with LOS, related treatment patterns, and outcomes.

Methods:
We examined 43,440 NSTEMI patients from 332 ACTION registry hospitals from January 1, 2007, to March 31, 2009. Patients who died during the hospitalization were excluded from these analyses. LOS was categorized into 4 groups, such as ≤2, 3-4, 5-7, and ≥8 days, where prolonged LOS was defined as >4 days and short LOS was defined ≤2 days.

Results:
The median (IQR) LOS was 4 (2, 6) days. In general, patients with shorter LOS were older, had fewer comorbidities, and less hemodynamic instability such as acute heart failure. Patients with LOS of ≤2 days were more likely to receive evidence-based therapies within the first 24 hours than those with LOS >2 days (
Table
). Compared to patients with prolonged LOS (>4 days), patients with short LOS (≤2 days) were paradoxically more likely to receive PCI - although when they underwent revascularization, patients with prolonged LOS had longer time from arrival to PCI and coronary artery bypass surgery.

Conclusions:
Patients with longer LOS, as expected, have more comorbidities and in-hospital complications, but paradoxically are less often treated with evidence-based medications. Better understanding of the heterogeneity of LOS and exploring approaches to lead to safe early discharge for patients with NSTEMI are needed.

Evidence-based medication within 24 hours and in-hospital outcomes according to LOS

≤2 days (N=10,932)
3-4 days (N=15,333)
5-7 days (N=8,824)
≥8 days (N=8,351)
P-Value

Acute medications

Aspirin (%)
97.97
97.35
95.27
94.92
<0.0001

Clopidogrel (%)
73.04
61.90
49.25
42.65
<0.0001

Beta-blocker (%)
93.36
93.15
91.01
90.53
<0.0001

ACE-inhibitor (%)
46.92
47.46
45.13
41.49
<0.0001

Statin (%)
65.94
60.78
55.06
52.11
<0.0001

In-hospital complications

Cardiogenic shock (%)
0.18
0.40
1.33
5.33
<0.0001

Heart failure (%)
2.11
4.75
9.81
16.08
<0.0001

Stroke (%)
0.07
0.18
0.52
2.16
<0.0001

Major bleeding (%)
1.67
5.35
14.62
25.40
<0.0001

Non-CABG transfusion (%)
1.44
4.43
14.59
30.68
<0.0001
Abstract P121: Comparison of the Utilization of Evidence-Based Therapies and Clinical Outcomes Between Teaching and Non-Teaching Medical Services After the Implementation of Novel Clinical Pathways for the Management of Cardiac Patients
Authors: Aziz Emad F , Pratap Balaji , Wever-pinzon Omar , Javed Fahad , Yang Yoon K , Kalal Kiran K , Rao Venkat , Premji Resmi , patel Putun , Tojino Andre , Huaman Jeannette , Chodakiewitz Yosef , Herzog Eyal
Published: March 2022

PURPOSE
To compare the utilization of evidence-based (EB) cardiac therapies and clinical outcomes of cardiac care on general medicine inpatient services under teaching and nonteaching services at an academic hospital.

METHODS
In 2005 we implemented the Advanced Cardiac Admission Protocol (ACAP) for all cardiac patients admitted to our hospital. 4170 patients were admitted with ACS or HF were assigned to a resident-staffed teaching service (
n
= 3890) or to a hospitalist-nonteaching service (
n
= 280). We compared utilization of EB therapies, hospital readmission rate at 30 days, length of hospital stay (LOS), and all-cause mortality at 90 days.

RESULTS
The cohort mean age was 63 ± 15 years, 55% males. 34% had diabetes, 74% were hypertensive and 41% had hyperlipidemia. Mean LVEF was 50 ± 22% and mean TIMI risk score was 2.7 ± 1.5. There were no difference between both services in regards to the utilization of all EB therapies, BB (62 vs. 63%), ACEi (56 vs. 57%), ASA (83 vs. 80%), anticoagulation (58 vs. 63) and Statins (68 vs. 67%). Clinical outcomes including LOS (4.95 days vs. 5.14 days;
P
= .24), readmission rate (10.5% vs. 11%;
P
= .21), and all-cause mortality (4.0% vs. 3.4%;
P
= .64) were similar.

CONCLUSIONS
At our academic hospital, implementation of a standardized novel pathway for cardiac patients led to comparable outcomes between teaching and nonteaching services.
Abstract P135: An Independent Initiative to Improve Door-to-Balloon Times: Results From the Aurora 24x7 STEMI Program
Authors: Jan M. Fuad , Tajik A. Jamil , Mori Naoyo , Schlemm Angela , Gupta Anjan , Bajwa Tanvir , Allaqaband Suhail
Published: March 2022

BACKGROUND:
To improve hospital performance in door-to-balloon (D2B) times, an independent initiative - the Aurora St. Luke's 24x7 STEMI (ST-segment elevation myocardial infarction) program - was launched on April 1, 2004, as part of a system-wide quality improvement effort. We evaluated recent changes in D2B times within the program.

METHODS:
The program involves 24 hours a day, 7 days a week in-hospital call for the interventional cardiologist and the cardiac catheterization laboratory (CCL) staff and includes the following strategies: 1) rapid electrocardiogram acquisition and emergency department (ED) physician interpretation in ≤10 min of hospital arrival; 2) ED physician activation of the 24x7 team with a single call; 3) calibration of the clocks in the ED and the CCL checked monthly; and 4) feedback provided to staff within 24-72 hours. We studied D2B times in non-transferred patients with STEMI treated with primary PCI (PPCI) from July 2007 to June 2009.

RESULTS:
A total of 251 consecutive non-transfer patients (median age 60, women 30.7% [77 of 251]) underwent PPCI for acute STEMI. Median D2B was 52 min (interquartile range 41-64) with a 93.6% (n=235 of 251) rate of D2B <90 min. Secondary analyses of this cohort demonstrated a 69.3% rate (175 of 251) of D2B <60 min.

CONCLUSION:
An innovative in-hospital 24x7 interventional STEMI program has dramatically increased the percentage of patients reperfused within 90 min and consistently exceeds the American College of Cardiology Door-to-Balloon (D2B) Alliance benchmark (93.6% vs. 75% rate of D2B <90 min). The 24x7 STEMI program is an important demonstration model in systems improvement for care of patients with STEMI.
Abstract P142: A Statistically Significant Reduction in Heart Failure Length of Stay: Moving the Mean Through Process Improvement
Authors: Moffa Carolyn M , Weintraub William , DeMaio Rocco A , Saltzberg Mitchell T
Published: March 2022

Background:
The burden of acute heart failure (HF) remains formidable. Length of stay (LOS) must be minimized to control costs, while still maintaining positive outcomes. Inappropriate diagnoses and the lack of coordinated care remain impediments to achieving a target LOS. Care process redesign affords an opportunity to improve LOS.

Method:
The HF program at Christiana Care Health System implemented a process improvement (PI) project in June 2009 on our 31 bed heart failure unit (HFU) to identify and correct barriers to timely discharge. Markers for increased LOS were identified based on historical data and included: O2 use, skilled nursing facility referral, IV vasoactive therapy use, absence of ACC/AHA guideline-based HF therapy, multiple co-morbidities, poor social support and depression. The HFU multi-disciplinary team engaged the nursing staff in twice daily case review rounds to identify and remedy outstanding care issues. The HFU team was proactive and developed individual care plans. Social Work and Case Management addressed options for the transition to home (+/- home healthcare), rehabilitation, or extended care. A HF Clinical Psychologist was consulted for patients with depression and/or poor social support. Providers were engaged where ACC/AHA HF guideline and HF Core measure compliance was lacking or when prolonged O2, IV diuretics, or IV vasoactive drug use was identified.

Results:
LOS on the HFU (6 months Pre and Post project initiation) was compared via Student's t-Test for unpaired data. PI Project implementation resulted in LOS reduction of 0.86 days. Pre vs post project initiation: p= 0.028. (See
Table
).

Conclusion:
A dedicated multi-disciplinary team, rounding twice daily on HF patients in a dedicated HFU, was able to significantly reduce LOS through the systematic identification of barriers to a timely discharge, and application of targeted interventions in a large volume medical center.

Christiana Care Health System Heart Failure Unit

Time Period
HF Admissions
Male
Female
Mean Age
LOS
LOS Range

Pre- PI Project Intervention

Dec ’08 - May ’09
358
45.00%
55.00%
73.3 yrs
6.24 ± 0.49
5.42 - 6.90

PI Project Intervention

Jun ’09 - Nov ’09
346
51.00%
49.00%
72.9 yrs
5.38 ± 0.66
4.55 - 6.20

Pre versus Post PI Project Intervention LOS: p= 0.028
Abstract P144: The Adoption of Prospective ECG Gating in Cardiac Computed Tomography Angiography Reduces Radiation Exposure
Authors: Qureshi Waqas T , Swadia Tanmay , Khalid Fatima , Al-Mallah Mouaz H
Published: March 2022

INTRODUCTION
The mean effective radiation dose values of a conventional cardiac computed tomography angiography (CCTA) can reach 41 millisieverts (mSv). Radiation doses above 10 mSv can cause 1 additional cancer in 1000 patients. Prospective gating reduces radiation exposure during CCTA since the radiation exposure occurs only during a portion of diastole as compared to whole cardiac cycle in conventional CCTA. Effective radiation dose value is a quality measure used across the CCTA centers to determine radiation dose exposure. This aim of this analysis evaluates the impact of this method in reducing radiation dose in real life setting.

METHODS
This is a non randomized, controlled, prospective study which included 663 consecutive patients that underwent CCTA during 2.5 years at a single center. Prospective ECG gating was employed after June 2008.

The main outcome measure

was the total effective radiation dose. Image quality was assessed as excellent, good, adequate and non-diagnostic.

RESULTS
For maintaining homogeniety and comparison of data, patients were divided into 5 cohorts based on 6-month periods in which they were exposed to radiation. The patients did not differ regarding sex, age, BMI, race, Framingham score, diabetes, hyperlipidemia or hypertension (p>0.1) across the cohorts. The image quality did not differ before and afer June 2008 (p>0.3). Radiation dose reduced by 55% after June 2008 with 36% (90 of 251) patients having <8 mSv exposure (Figure).

CONCLUSION
The study demonstrated that the quality improvement initiative of employing prospective ECG gating in CCTA reduced the radiation dose exposure without compromising the image quality.
Abstract P187: Assessing Gender Bias in the Treatment of Cardiovascular Disease in Canada
Authors: Eaton Emily L , Parfrey Patrick , Mendelssohn David , McFarlane Phil , Camacho Fernando , Curtis Bryan M
Published: March 2022

The objective of this study was to determine the presence of gender bias in the treatment of CVD in Canada. Gender bias has been explored extensively in the treatment of CVD, particularly AMI. Previous research is inconsistent in suggesting that women who suffer an AMI are treated less optimally than men. To date, gender bias has not been well addressed in other CVD's, specifically CVA, CABG, or RRT. In an attempt to get a clearer grasp of the problem, CAP was also studied and served as a control. Retrospective chart reviews for all AMI's, CVA's, CABG's, and CAP's in 1995/6, 1998/9, and 2000/1 in two locations of Newfoundland (St. John's and central) were reviewed. Outcomes were analyzed for differences between men and women. Adjusting for baseline differences, regression models were used to assess the following: AMI - time to thrombolytics, admission to CCU, death, discharge beta blockers, ACE/ARB, anti-lipids, ASA; CVA - LOS, transfer to and time to rehabilitation center, death; CABG - time to CABG; CAP - appropriateness of antibiotics (AB), death. RRT was analyzed from the results of the STARRT (Study To Assess Renal Replacement Therapy) study, a Canadian multicentre retrospective chart review of incident dialysis patients followed for six months. Outcomes were explored for differences in care between men and women. Optimal care was based on 1) length of pre-dialysis care; 2) modality choice; 3) access; 4) laboratory parameters at dialysis start; 5) clinical outcomes. Women who had suffered an AMI had a significantly longer time to thrombolytics and were less likely to be admitted to the CCU but did not differ significantly from men in other modes of treatment. Women who were RRT patients began dialysis at a lower eGFR level after receiving less pre-dialysis care than men. Women who received treatment for CAP were less likely than men to receive the appropriate AB's according to the 1993 guidelines for AB treatment of CAP. There were no significant treatment differences between men and women who had suffered a CVA or who had had a CABG. There were no gender differences in death for any of the diseases. There is little evidence of a significant gender bias in cardiovascular disease in Canada. A potential gender bias in the treatment of CVD patients needs to be explored further.