bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 104: Mortality Risk Across Chronic Kidney Disease Stages With Fibrate or Niacin Use Compared With No Fibrate or Niacin Therapy in Male US Veterans
Authors: Soohoo Melissa , Jackevicius Cynthia , Streja Elani
Published: May 2020

Background:
Chronic kidney disease (CKD) patients have a higher cardiovascular (CV) disease and mortality risk, elevated triglycerides (TG), and decreased high density lipoproteins (HDL). Post-hoc analysis of trials examining use of fibrate (Fib) or niacin (Nia) therapy in lowering CV outcome risk have failed to show benefit in mild to moderate kidney disease. These analyses were criticized for their study design or small sample size. We sought to examine if Fib or Nia use is associated with lower mortality risk in US veterans across CKD stages.

Methods:
In a retrospective cohort analysis, we identified male veterans who initiated Fib or Nia, with a high TG ≥150 mg/dL or low HDL ≤40 mg/dL between 2004-2014, and matched them on CKD stage and TG and HDL levels to unexposed men. We examined the association of Fib or Nia use (ref: unexposed) with 12-month all-cause mortality risk across CKD stage strata using an adjusted Cox proportional hazards model. Propensity scores (PS) included baseline demographics, comorbidities and lab measures and high-dimensional propensity scores (HDPS) included over 100 covariates for each drug and stage analysis. PS and HDPS analyses included score adjustment and matching.

Results:
The cohort had a mean±SD age of 64±12 years, and 30% had CKD stage 3A and higher. There were 69,295 Fib, 87,727 Nia, and 114,411 unexposed patients, respectively. Patient characteristics were similar across drug groups within each CKD stage. With covariate adjustment, both Fib and Nia were associated with a lower death risk compared to unexposed men in lower CKD stages (Figure A and B). Among those with CKD stage 4/5, Fib and Nia were associated with a higher death risk (HR[95%CI]: 1.43[1.15, 1.78] and 1.17[0.97,1.40], respectively). Those on Fib or Nia and in end-stage renal disease had a null association with mortality. Associations were similar for each CKD stage in PS and HDPS analyses, yet Fib and Nia were no longer associated with a lower death risk for CKD stage 3A and 3B patients.

Conclusion:
Mortality associations of Fib and Nia among male veterans with high TG and low HDL varied across CKD stage, where CKD stage 4/5 patients had a higher mortality risk, even in PS and HDPS analyses. While covariate balance was met, further studies are needed to examine the mechanisms for this higher observed risk in late-stage CKD patients.
Abstract 105: Rehospitalization After Admission With Myocardial Infarction and Spontaneous Coronary Artery Dissection
Authors: Elkaryoni Ahmed , Kennedy Kevin F , Grodzinsky Anna , Naderi Sahar , Wood Malissa J , Kim Esther Sh S , Stevens Tracy , Arnold Suzanne V
Published: May 2020

Introduction:
Spontaneous coronary artery dissection (SCAD) is one of the most common non-atherosclerotic causes of myocardial infarction (MI) in young patients, yet little is known about post-discharge outcomes. Given the high psychological stress of a SCAD diagnosis, we sought to understand the rehospitalization burden after SCAD so as to provide more prognostic data to SCAD patients.

Methods:
Using data from the Nationwide Readmission Database 2010-16, we identified patients 18-55 years of age hospitalized with MI with and without SCAD. We compared readmission over 1 year after index hospitalization for all-cause, MI, chest pain without MI, and heart failure. Cox proportional regression was used to examine factors associated with readmission, and we explored interactions of patient factors*SCAD to identify factors associated with differential risk of readmission in patients with SCAD.

Results:
Among 327,227 young patients admitted with an MI, 3704 (1.1%) had a diagnosis of SCAD. Patients with SCAD were more likely to be younger, women, have a higher burden of anxiety or depression, and longer length of stay compared with those without SCAD. While the risk of all-cause rehospitalization over 1 year was similar in those with versus without SCAD (KM-estimated rates: 22.3% vs. 24.1%; log-rank p=0.596, Figure), patients with SCAD were more likely to be rehospitalized for MI (4.9% vs. 4.2%, log-rank p=0.012) and chest pain without MI (3.6% vs. 2.8%, log-rank p=0.060) but less likely to be rehospitalized for heart failure (1.0 % vs. 1.8%, log-rank p=0.005). In the multivariable model, a diagnosis of SCAD was not associated with risk of rehospitalization (HR 1.00, 95% CI 0.92-1.08) nor was a diagnosis of SCAD associated with a differential effect of any of the patient factors on the risk of rehospitalization (all interaction p-values >0.05).

Conclusion:
Although patients with SCAD had a similar risk of rehospitalization compared with young patients with MI but without SCAD, we identified different patterns of hospitalization, which may be explained by the different underlying conditions. Further studies are needed to investigate possible interventions to reduce the high burden of post-SCAD rehospitalizations.
Abstract 108: Contemporary Timing and Etiology of Mortality in ST-Elevation Myocardial Infarction
Authors: Il'Giovine Zachary J , Kumar Anirudh , Huded Chetan , Menon Venu , Krishnaswamy Amar , Lincoff A Michael M , Kapadia Samir R , Khot Umesh
Published: May 2020

Background:
Acute treatment of ST-elevation myocardial infarction (STEMI) has focused on early reperfusion, prompt defibrillation, and appropriate mechanical support to mitigate short-term mortality. Long-term patterns of death in a contemporary population are not well described.

Methods:
We reviewed consecutive cases of STEMI treated with percutaneous coronary intervention (PCI) at our center between January 1, 2011, and December 31, 2016, and divided patients into two groups: uncomplicated STEMI (US) and complicated STEMI (CS). CS was defined by presence of cardiac arrest or cardiogenic shock, ascertained from first-medical-contact to device time for PCI. We assessed for differences in characteristics and short- and long-term mortality between the groups.

Results:
We identified 1,272 patients with STEMI; 214 of which were CS (16.8%). Those with CS were significantly more likely to have heart failure (22.9% vs 11.3%, p<0.001), kidney disease (38.2% vs. 21.0%, p<0.001), cerebrovascular disease (18.7% vs 11.0%, p=0.003), peripheral vascular disease (16.8% vs 7.9%, p<0.001), and left main or left anterior descending culprit vessel (51.9% vs. 40.3%, p<0.002). Total in-hospital mortality was 5.0% (63 patients), with 19.6% (42/214) and 2.0% (21/1058) of those with CS and US respectively (p<0.001). Among 1209 of patients that survived to hospital discharge, total long-term mortality was 10% (121 patients) of which 18.0% (31/172) had CS and 8.7% (90/1037) had US (p=0.001) over mean follow-up of 3.1±1.9 years. Of those, 52% and 50%, respectively, were from non-cardiovascular etiologies (Figure) including malignancy (13% vs. 22%), infection (22% vs. 19%), or other causes (17% vs. 9.0%).

Conclusion:
Despite advances in the in-hospital care of patients with STEMI, there remains a significant risk of long-term mortality for both patients with uncomplicated and complicated STEMI. A substantial proportion of overall STEMI mortality now occurs after hospital discharge predominantly due to non-cardiovascular causes. Systems of care to mitigate this long-term risk are needed.
Abstract 206: Descriptive Analysis of Patients Undergoing Percutaneous Coronary Interventions in India
Authors: Gupta Kashvi , Nallamothu Brahmajee K , Duggal Mona , Anupindi Ravi , Duggal Bhanu
Published: May 2020

Background:
Patterns of percutaneous coronary intervention (PCI) use in economically disadvantaged patients are largely unknown in India. Yet it is important to understand PCI use given its increasing availability and the growth of social insurance programs. Leveraging a unique registry in Maharashtra from 2015 and 2016, we set out to evaluate how to collect data on PCI use in patients within a state-wide government funded health insurance scheme, the Rajiv Gandhi Jeevandayee Aarogya Yojana (RGJAY). RGJAY covers full costs for the procedure for eligible patients with an annual household income less than 100,000 rupees.

Methods:
Our registry collected detailed patient and procedural information on patients 18 years and older undergoing a PCI at one of 473 empaneled hospitals. Research coordinators obtained telephonic consent from the patients to participate in the study. Standardized forms were used to abstract data from electronic medical records that were uploaded onto a centralized database managed by the Department of Health and Family Welfare of the Government of Maharashtra. The coordinators followed up with participants at one-year with an additional telephonic survey. Patients with missing demographic and clinical data were excluded from this analysis (n=52). We report descriptive statistics, focusing on risk factors as well as the indication for PCI.

Results:
We included a total of 1829 PCI procedures from 34 public and 175 private hospitals that provided cardiology services. Mean age was 57.5 (SD, 10.5) and 28% were women. Nearly half of patients had no or primary school education only, and fewer than 40% were employed. Table 1 lists full descriptive statistics including risk factors. Importantly, 30% of PCIs were for chronic stable angina (in contrast to ~20% in US registries). Limited data were available on symptom burden, additional anti-anginal therapies, and ischemia evaluations prior to PCI. Overall mortality at 1-year follow-up was 4.3%.

Conclusion:
Data on PCI use in patients from lower income-backgrounds covered by social insurance programs can be collected but with limitations that make it challenging to assess quality and appropriateness. Our findings have implications for the recent roll-out of Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).
Abstract 222: Changing Practice of Thrombolytic Therapy for Acute Ischemic Stroke in a Community Hospital After Implementation of Vascular Neurology Program
Authors: Passarello Sabena , Kim Benny S , Roland Niama , Sverha John , Silverman Michael , Nadareishvili Zurab
Published: May 2020

Introduction:
Despite significant increase in intravenous tissue plasminogen activator (IV tPA) treatment rates in the US, only 9.0% of patients with acute ischemic stroke (AIS) receive IV tPA in certified Primary Stroke Centers (PSC). The goal of this study is to analyze the effects of the implementation of a vascular neurology program in a PSC certified community hospital on IV tPA treatment rates and related stroke metrics.

Methods:
This quality improvement project (QIP) was undertaken at a community hospital, in Arlington, VA, which is 380 bed hospital, with The Joint Commission certification as a PSC. Intervention included implementation of evidence-based ischemic stroke IV tPA pathways with extensive hospital-wide medical and nursing staff training (25 lectures for nurses and 6 for MDs) by two newly appointed board certified vascular neurologists from Department of Neurology, George Washington University, Washington, DC. Study outcome measures were: IV tPA utilization rate (IV tPA/total AIS = %), proportion of patients with door to needle time (DTN) < 60 minutes (%), discharge home (%), and symptomatic intracerebral hemorrhage (SICH). We compared one year outcomes, pre- (August 1, 2017-18) and post-intervention (August 1, 2018-19). No IRB approval was required, as this was a QIP.

Results:
There were n=752 AIS admissions: n=337 pre- and n=415 post-intervention. There was a significant increase in stroke patient volume after intervention (1.4% vs. 1.8%, p=0.0006). There was significant increase from 28.0% (7/25) to 66.7% (24/36) in proportion of patients with DTN < 60 minutes pre- versus post-intervention (p=0.0032). Although IV tPA utilization rate [7.4 % (25/337) vs. 8.7% (36/415), p=0.52] and proportion of patients discharged home were higher after intervention (52% vs. 61%, p=0.48), they did not reach statistical significance. There was no difference in the rate of symptomatic hemorrhagic transformation between two cohorts (8.0% pre vs. 8.3% post, p=0.96).

Conclusions:
Implementation of an evidence-based vascular neurology program in a PSC community hospital resulted in a significant increase in proportion of patients with DTN less than 60 minutes, an increase in stroke patient volume, and a trend towards higher IV tPA utilization rate and better AIS outcome.
Abstract 23: Income Disparity and Utilization of Cardiovascular Preventive Care Services in the Medical Expenditure Panel Survey (MEPS)
Authors: Shahu Andi , Okunrintemi Victor , Tibuakuu Martin , Khan Safi U , Gulati Martha , Marvel Francoise A , Blumenthal Roger S , Michos Erin D
Published: May 2020

Background:
Socioeconomic markers such as income level are associated with cardiovascular disease (CVD). However, the associations between income and utilization of CVD preventive services, such as receipt of lifestyle advice and screening for CVD risk factors in populations with and without established CVD are less well understood.

Methods:
We used data from the nationally representative Medical Expenditure Panel Survey (2006-2015). We included adults (≥18 years old) and divided the sample population into 2 groups: those with CVD (defined by self-reported and/or ICD9 diagnosis of CVD [coronary artery disease, stroke, heart failure, cardiac dysrhythmias and/or peripheral arterial disease]) and those without CVD. Participant responses were recorded by telephone survey. Additional information on health care utilization was collected from physicians, hospitals, and pharmacies. We categorized participants as high income (400% of federal poverty level [FPL]), middle income (200-400% of FPL), low income (125-200% of FPL) and poor/very low income (<125% of FPL). We used logistic regression to compare likelihood of utilizing or receiving certain CVD risk preventive services among participants in different income groups, adjusting for demographics, comorbidities and other socioeconomic factors.

Results:
We included 185,081 participants without CVD (representing 194.6 million US adults without CVD, 48% female) and 32,862 participants with CVD (representing 37 million U.S. adults with CVD); 36% of individuals with CVD were in the high income category, 29% were middle income, 16% and 19% were in the low and poor/very low income group, respectively. Compared with high income adults, adults with low and poor/very low income were less likely to have cholesterol levels or blood pressure checked and receive counseling about diet modifications, exercise, or smoking cessation, regardless of CVD status (
Table
).

Conclusion:
Poor/very low income adults were much less likely to be screened for CVD risk factors or receive counseling for prevention of CVD than high income adults. More work must be done to reduce disparities in access to and utilization of CVD preventive services among adults in different income groups.
Abstract 232: Initiating Empagliflozin vs. Glucagon-like Peptide 1 Receptor Agonists is Associated With Lower Healthcare Cost of Care Among Patients With Type 2 Diabetes and Cardiovascular Disease
Authors: Pimple Pratik , Raju Aditya , Stafkey-Mailey Dana , Shetty Sharash
Published: May 2020

Background:
The 2019 ADA’s Standards of Medical Care in Diabetes recommend use of SGLT-2 inhibitor (SGLT-2i) or GLP-1 receptor agonist (GLP-1RA) as one of the six drug classes after metformin (MET) in type 2 diabetes (T2D) patients, and is recommended as the treatment of choice among patients with cardiovascular disease (CVD; empagliflozin [EMPA] and liraglutide showing stronger evidence). CVD benefits of empagliflozin and GLP-1 RAs have been demonstrated in clinical trials; however, the impact on all-cause (AC) healthcare costs has not been studied.

Methods:
This retrospective cohort study utilized an US based, commercial claims database (IQVIA Pharmetrics Plus) to identify patients with T2D and CVD who initiated empagliflozin or a GLP-1 RA between 08/01/2014 - 12/31/2016. First prescription date (index date) for empagliflozin or a GLP-1 RA was used to classify patients into study cohorts. During a post-index period of up to 1 year, AC costs were computed on a per patient per month (PPPM) basis; and evaluated using generalized linear models that controlled for pre-index covariates. A sub-analysis comparing AC costs among patients who initiated second-line treatment with empagliflozin or a GLP-1 RA after metformin monotherapy, was also conducted.

Results:
As compared to the GLP-1 RA cohort (N = 1376), patients in the empagliflozin cohort (N= 441) were more likely to be males, had a lower Charlson comorbidity score, higher rates of dyslipidemia, and lower rates of obesity in the 1-year pre-index period; all other measured pre-index characteristics were similar. After covariate adjustment, compared to GLP-1 RA cohort, the empagliflozin cohort had lower total AC PPPM (($1,766 vs. $2,096; difference (Δ) = $330,
p<0.001
), medical (Δ = $97,
p=0.28
), and pharmacy (Δ = $228,
p<0.001
) costs. In patients who initiated 2
nd
line empagliflozin or GLP-1 RA treatment, the empagliflozin cohort (N = 160) had lower total AC PPPM (($1,432 vs. $1,969; Δ = $536,
p<0.001
), medical (Δ = $275,
p=0.02
), and pharmacy (Δ = $225,
p=0.12
) costs, compared to the GLP-1 RA cohort (N = 477).

Conclusions:
In patients diagnosed with T2D & CVD, initiating empagliflozin compared to GLP-1 RA was associated with lower all-cause healthcare costs. Together with ADA guidelines, these findings can provide critical insights for health care decision makers for reducing the clinical and economic burden for patients with T2D & CVD.
Abstract 242: Evaluating the Impact and Barriers to a Collaborative Physician-pharmacist Care Model to Control Hypertension in a Low-income Population
Authors: Hennessey Kerrilynn C , Hickman Carolyn , Krawczyk Brianne , Opare Michelle , Churchwell Leslie , Tucker Katherine , Do Tina , Renauer Marie , Churchwell Keith , Spatz Erica S
Published: May 2020

Objectives:
Physician-pharmacist collaborative practice models have emerged as an effective model for managing hypertension (HTN). We implemented this model in a low-income, hospital-based cardiology clinic and sought to identify programmatic features necessary to control HTN in this vulnerable population.

Methods:
Patients with persistently elevated blood pressure (>130/80) were referred by their primary cardiologist. Patients were excluded if they were pregnant, had acute kidney injury, or acute cardiovascular complaints including anginal chest pain, decompensated heart failure, or unstable arrhythmia. The initial pharmacist appointment occurred within 2 weeks of referral, with the goal of bi-weekly visits for 6 weeks or until blood pressure was controlled. Patients were prescribed home blood pressure cuffs and given specific instructions for home-based monitoring. Telehealth visits were made available to interested patients. During each encounter, pharmacists assessed response and side effects to medication, adherence, lifestyle behaviors, stressors, and social barriers to blood pressure control. Clinical management and barriers to HTN control were reviewed at standing weekly staff meetings that included cardiologists and pharmacists.

Early results:
Among 35 people referred, 22 patients attended at least one pharmacist visit. A total of 139 reminder or follow-up calls were made for these 22 patients. Among the first 35 referrals (mean age 58; 57% male; 65% African American or Latinx), 26% have documented substance use disorders, 34% have a mental health comorbidity, 20% were not taking their medications as prescribed on intake, and 17% had side effects from 2 or more prior antihypertensive medications. Medications adjustments were made in 21/43 patient visits (49% of visits). In 8/43 visits more than 1 medication change was made. The most common patient reported barriers to care include transportation (20%) and language barriers (11%).

Discussion and Future Direction:
Managing HTN in a low-income population requires attention to the social and contextual factors impacting blood pressure control. We plan to: 1) support the uptake of telehealth to address issues of transportation and access; 2) pilot blue-tooth connected blood pressure cuffs to facilitate home monitoring and management; and 3) partner with community health workers to assess best practices for capturing and addressing social determinants of health in the clinical setting.
Abstract 245: Risk of Readmission With Recurrent Myocardial Infarction After Index Myocardial Infarction
Authors: Nair Raunak , Johnson Michael , Kravitz Kathleen A , Anabila Moses , Rajeswaran Jeevanantham , Blackstone Eugene H , Menon Venu , Lincoff A Michael M , Kapadia Samir R , Khot Umesh
Published: May 2020

Background:
Recurrent Myocardial Infarction (MI) after an index MI is a cause for considerable morbidity and mortality. However, the underlying factors that precipitate patients for a recurrent MI remain unclear. We aimed to assess the effect of index MI treatment strategy on the risk of developing a recurrent MI.

Methods:
We reviewed all cases of MI at a single quaternary care medical center from January 1
st
, 2010 to January 1
st
, 2017 and identified all cases of recurrent MI within 90 days after index MI. Readmissions were further stratified depending on the treatment strategy undertaken during index MI into medically managed and revascularized patients. The instantaneous risk of readmission following each of these treatment strategies was estimated by the parametric method.

Results:
We identified 6,626 patients admitted with an index MI, of which 168 patients were readmitted with a recurrent MI within 90 days. Among the index admissions, 4354 (66%) patients underwent revascularization and 2272 (34%) patients underwent medical management. Time-varying instantaneous risk of readmission analysis showed an early peaking risk followed by a late increasing risk in the revascularization group whereas, in the medically managed group, the analysis yielded an early peaking followed by a late almost constant risk of readmission for MI.

Conclusion:
Patients with acute MI who are medically treated are at a higher risk of developing a recurrent MI than patients who undergo revascularization. Defining the characteristics and underlying factors contributing to these readmissions can be pivotal in improving patient outcomes.
Abstract 248: Recurrence Burden in Recurrent Pericarditis: A US-based Retrospective Study of Administrative Healthcare Claims
Authors: Lin David , Laliberté François , Magestro Matt , Paolini John F , Majeski Christine , Lejeune Dominique , DerSarkissian Maral , Mahendran Malena , Duh Mei Sheng
Published: May 2020

Background:
Up to 30% of incident pericarditis patients (pts) recur within 18 months. Recurrences can be debilitating and typically last several weeks despite conventional treatments (Tx). Recurrence burden (likelihood and frequency) is poorly defined. Improved understanding of recurrence burden can inform Tx decisions and the introduction of novel therapies.

Method:
Adults with idiopathic recurrent pericarditis (RP) were identified in the OptumHealth Reporting and Insights dataset (2007-2017). RP was defined as ≥2 episodes separated by >4 weeks. Disease duration (time from first episode to end of last recurrence, confirmed by a 1.5-year recurrence-free period) was evaluated using Kaplan-Meier analysis. Recurrence frequency and time between recurrences were evaluated among pts with 4+ years of observation.

Result:
Of the 1,604 RP pts, mean age was 50.7 years and 51.6% were female. Median RP duration was 2.1 and 3.1 years for pts with ≥1 and ≥2 recurrences, respectively (
Figure
). Over 4 years with RP, 15% of pts with ≥1 recurrence and 22% of pts with ≥2 recurrences had more than one episode/year. Mean ± SD time from first episode to first recurrence was 14.5 ± 17.9 months and 10.7 ± 12.1 months between subsequent recurrences.

Conclusion:
Recurrent pericarditis can span many years. Over half of pts with ≥2 recurrences have RP persisting over 3 years. Subsequent recurrences are more frequent but highly variable, making RP unpredictable. Tx to reduce recurrences could benefit pts with ≥2 recurrences.
Abstract 25: Patient-reported Outcomes, Resource Utilization, and Healthcare Expenditures Across the 3 Major Atherosclerotic Diseases: The Medical Expenditure Panel Survey (meps)
Authors: Tibuakuu Martin , Okunrintemi Victor , Shahu Andi , Ratchford Ratchford V , Savji Nazir , Blumenthal Roger S , Thamman Ritu , Mahtta Dhruv , Virani Salim S , Michos Erin D
Published: May 2020

Background:
Public health campaigns aimed at reducing the morbidity, mortality and economic burden of atherosclerotic cardiovascular disease (ASCVD) have mainly targeted coronary artery disease (CAD). Stroke and peripheral artery disease (PAD) are associated with substantial medical and financial burden for patients and the US healthcare system.

Objective:
We sought to compare the associations of patient-reported outcomes, resource utilization, and healthcare expenditures across the 3 major ASCVD types (CAD, stroke, or PAD).

Methods:
We used data from the Medical Expenditure Panel Survey (MEPS) conducted between 2006-2015 and included adults aged ≥18 yrs. MEPS is a nationally representative US sample and provides information on patient-reported outcomes (PROs), medical conditions, healthcare utilization and expenditures. The ASCVD types were ascertained by ICD-9 codes and/or self-reported data. Participants with more than 1 ASCVD type were not included. The associations of PROs and health utilization were quantified and contrasted across the 3 ASCVD types using multivariable adjusted regression models. A 2-part econometric model was used to assess healthcare expenditures.

Results:
The study sample included 14,262 MEPS participants with 1 type of ASCVD, translating into 15.9 million US adults. The mean age (SD) was 65 (±14) yrs; 48% were women, 59.6% had the diagnosis of CAD only, 37.5% stroke only, and 2.9% PAD only. Participants with stroke were more likely to report poor patient-provider communication [OR 1.37 (95% CI 1.18-1.59)], poor healthcare satisfaction, and more ED visits, and were less likely to be on a statin and aspirin, compared to CAD (
Table
). Participants with PAD also had higher odds of not being on aspirin [3.10 (2.31-4.16)] and statin [2.01 (1.37-2.95)], compared to CAD. PAD was associated with the highest annual total and out-of-pocket expenditures among the 3 ASCVDs.

Conclusion:
Both stroke and PAD were associated with low uptake of guideline-directed preventive therapies, compared to CAD, with PAD having the highest healthcare expenditures among the 3 ASCVD types. Our results highlight a missed opportunity for secondary ASCVD prevention among patients with PAD and stroke, and the need for public health campaigns to direct equal attention to all 3 major ASCVDs.
Abstract 260: Coping and Health Related Quality of Life in Patients With Heart Failure: A Scoping Review
Authors: Alanazi Mohammed O , Wyatt Gwen , Annis Ann , Lehto Rebecca
Published: May 2020

Purpose:
Heart failure (HF) is associated with poor health-related quality of life (HRQoL) secondary to decrements in functional status. Patients’ adoption of coping strategies may affect their HRQoL. The review purpose was to characterize what is known about factors that impact selection of coping strategies that contribute to HRQoL among HF patients.

Research Question/Hypothesis:
What is known about: 1) the impact of coping strategies on HRQoL among patients with HF; and 2) factors affecting the adoption of coping strategies?

Theoretical framework/rationale:
This review was guided by Lazarus and Folkman’s stress and coping theory.

Methods:
A scoping review was conducted using the Arksey and O’Malley framework and a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Databases searched included PubMed, Web of Science, Cochrane, CINAHL, and PsycINFO. Keywords included: cope, coping, HF, congestive HF, HRQoL, coping strategies. Two investigators came to consensus on publications meeting eligibility criteria.

Results:
674 articles were identified of which 471 articles were screened by title and abstract after duplicates were removed, with 27 meeting eligibility. 25 studies were quantitative and 2 qualitative. Six studies were randomized controlled trials, 18 were cross-sectional, and one was longitudinal. Participants’ ages ranged in age from 49-79. Most studies (n=18) reported a significant impact of coping strategies on HRQoL in HF patients, and six studies reported minimum to no impact. Factors that influenced the adoption of coping strategies were reported (n=7 studies): age, gender, religious belief, culture, depression and illness severity. Four of the seven studies reported depression as a significant factor in adopting coping strategies.

Conclusion:
Most studies found a significant impact on HRQoL through coping among HF patients. However, the majority of studies were cross-sectional in design, highlighting difficulties in determining causal relationships and changes over time. While only seven studies addressed factors that led to the use of coping strategies in HF, the leading contributors were sociodemographics along with depression. This review provides an overview of the state of science; lack of experimental studies suggests a gap in the literature and a need to explore this area of research.
Abstract 267: National Comparison of Prior Authorization and Utilization of Sacubitril/valsartan in Medicare and Commercial Plans in Patients With Heart Failure With Reduced Ejection Fraction
Authors: Ozaki Aya , Krumholz Harlan M , Tran Tien , Le Quan , Yokota Mai , Mody Freny V , Jackevicius Cynthia
Published: May 2020

Background:
Sacubitril/valsartan (Entresto
®
) reduces mortality and heart failure (HF) admissions in NYHA Class II/III HF with reduced ejection fraction (HFrEF). However, uptake in practice has been lower than expected. Prior authorization (PA) is a common barrier that may reduce drug access, which may impact clinical outcomes. Our study characterizes PA requirement burden and use of sacubitril/valsartan by insurance plan type.

Methods:
We conducted a cross-sectional study using insurance plan information directly from a managed care organization-approved insurance coverage website accessed in Mar/2019 to characterize sacubitril/valsartan PA criteria in Medicare and commercial plans. We also used IQVIA National Prescription Audit data from Aug/2018 to Jul/2019 to estimate the number of prescriptions (Rx) dispensed and patient copayment for sacubitril/valsartan. Primary outcomes were proportion of plans requiring PA, frequency of specific PA criteria, number of sacubitril/valsartan Rx, and copayments. Data analysis was descriptive or used Chi-square.

Results:
For Medicare, 27.7% of plans required PA for sacubitril/valsartan, a significantly lower rate than 57.2% for commercial plans (p<0.001). For both plans, most frequently required PA criteria were ejection fraction (71.6%, 90.9%) and NYHA class (60.4%, 90.8% for Medicare and commercial plans, respectively). There were 814,437 sacubitril/valsartan Rx dispensed over the year for Medicare and 822,292 for commercial plans. Based on estimated HFrEF populations for each plan type, 4-fold more sacubitril/valsartan Rx were dispensed in commercial than in Medicare plans (820 Rx vs. 215 Rx/1,000 HFrEF population). Copay amounts varied by plan type, with significantly more sacubitril/valsartan Rx having no patient copayment required in commercial (32.4%) than Medicare plans (19.3%) (p<0.001).

Conclusions:
Despite commercial plans having greater PA requirements than Medicare, use of sacubitril/valsartan was higher in commercial plans. Thus, PA policies may not represent a major barrier to sacubitril/valsartan use. Given that commercial plans had more Rx with no or low copays than Medicare, copay amounts may be more influential on sacubitril/valsartan use.
Abstract 268: Trends and Predictors of Novel Oral Anticoagulant versus Warfarin Use in Patients With Non-valvular Atrial Fibrillation: Opportunities for Improving Care
Authors: Brownell K. Brian , Sezer Ahmet , Jain Sandeep , Thoma Floyd W , Kancharla Krishna , Bhonsale Aditya , Saba Samir , Mulukutla Suresh R
Published: May 2020

Objectives:
While NOACs are known to have an excellent safety profile, providers have historically been cautious when prescribing this medication class to specific patient populations, including those with a low GFR, advanced age, elevated bleeding risk, and a history of CAD. This study aims to examine the role of patient demographics, comorbid conditions, and health indices on anticoagulant prescribing practices with hopes to identify patient populations for which we have not yet maximized the use of NOACs in clinical practice.

Methods:
We performed a retrospective analysis looking specifically at a cohort of all outpatients in a large health system from 2010 to 2019 who were newly diagnosed with NVAF. The data was then split into an early versus contemporary NOAC era defined as when the incidence of NOAC prescriptions surpassed that of Warfarin. Patient demographics, comorbid conditions, and health indices were then analyzed to elucidate which of these factors most influence anticoagulant selection. Finally, we examined how the influence of these factors had changed over time.

Results:
Our sample consisted of 19,989 patients; 7606 on Warfarin and 12,383 on a NOAC. The early-NOAC cohort consisted of 6041 patients; 4143 on Warfarin and 1458 on a NOAC. The contemporary-NOAC cohort consisted of 13,948 patients; 3463 on Warfarin and 10,925 on a NOAC. Table 1 illustrates the adjusted odds ratios for NOAC versus Warfarin selection. Overall, the most significant predictors of AC selection were patient age, income, insurance type, and history of coronary artery disease, diabetes, and systolic heart failure.

Conclusions:
We have identified changes over time in anticoagulant prescribing practices for NVAF. Factors such as advanced age and a history of major bleeding have shown a shift towards NOACs, which is consistent with the evidence in the literature supporting NOACs’ safety in these populations. On the other hand, irrespective of mounting evidence that NOACs are safe in patients with a low GFR or a history of CAD, our findings indicate that providers still favor Warfarin in these populations, suggesting that there is still an opportunity to improve our prescribing practices to provide the best high-quality, evidence-based care.
Abstract 274: Primary Care Physician Status is an Important Factor in Addressing Healthcare Disparities in Patients With Cardiovascular Disease
Authors: King Ryan , Giedrimiene Dalia
Published: May 2020

Recent improvements in survival and management of patients with cardiovascular disease (CVD) have resulted from timely use of medications such as beta blockers according to established guidelines. Without medical care provided by a primary care physician (PCP), patients may experience a significant healthcare disparity leading to CVD risk factors not being addressed or not receiving effective preventative therapies. If patients do not have a PCP, then their risk of experiencing CVD complications including an acute myocardial infarction (AMI) may be increased without access to appropriate treatment. We hypothesized that the utilization of preventative therapy depends on patient’s ability to have a PCP. Patients who do not have a PCP are less likely to receive a timely prescription of a beta blocker. Data for this study was collected through a retrospective chart review for 250 patients who presented to the Hartford Hospital Emergency Department for an AMI and were subsequently admitted between August 1, 2016 and April 30, 2018. A Chi square, independent t-test, and logistic regression were used for statistical analysis. A total of 17 patients were excluded due to incomplete documentation. The mean age of 233 patients was 64.64 ± 14.03 years old (range 26-89, males-144, females-89). There were 179 (76.8%) of these patients who had a documented PCP. Out of those with a PCP there were 104 (72.2%, of 144) males as compared to 75 (84.3%, of 89) females, p<0.034. Of the 223 with confirmed information about a beta blocker prescription there were 116 (52.0%) using a beta blocker before this admission for AMI and 99 (85.3%, of 116) of them had a PCP. There were 69 (59.5%, of 116) men and 47 (40.5%, of 116) women using a beta blocker. The mean age of patients using a beta blocker was 69.38 ± 12.9 years vs. 58.99 ± 13.08 years for those without a prescription (p < 0.001). A significant association was also found using logistic regression between PCP status and age groups (> 55 y vs < 55 y), p=0.032, gender, p=0.047, and beta blocker use, p=0.018. Our study shows that being prescribed a beta blocker significantly depends on the patient’s ability to have a PCP. Our study shows that among subjects with AMI, having access to a PCP is an important factor in being prescribed a beta blocker. Identifying barriers to PCP access may improve prevention measures and help bridge disparities resulting in major cardiac events such as myocardial infarction.
Abstract 279: Outcomes From Integrating Stroke Survivors Into Cardiac Rehabilitation
Authors: Regan Elizabeth W , Handlery Reed , Wilcox Sara , Stewart Jill , Pearson Joseph L , Fritz Stacy L
Published: May 2020

Purpose:
Lack of physical activity after stroke results in increased risk of stroke recurrence and other health problems. While some survivors receive physical therapy (PT), it is often discontinued within a year. Cardiac Rehabilitation (CR) is a community exercise program for people with cardiac dysfunction; however, stroke is not a covered diagnosis despite high cardiovascular risk. CR for stroke survivors is an opportunity to bridge the gap between PT and community physical activity. The study evaluated the impact of CR participation on stroke survivors.

Materials and Methods:
A pilot study was completed at a phase 3 CR facility. Participants were screened for eligibility and entered the CR program (3 x per week for 12 weeks) with an aerobic fitness focus. Individual outcomes were taken pre- and post-program, and 6-months follow up. Program impact was measured by paired t-tests (24 participants) and repeated measures ANOVA (18 participants) for 6-month follow up.

Results:
Twenty-four participants completed the study. Participants were 79% (19/24) male with an average age of 62.2 years old (range 33.5 -81.5) with a time since stroke of 29.7 months (range 3-123). Most participants (20/24) were community ambulators at the start of the study (six-minute walk test (6MWT) > 288 m).

Pre-Post Program:
The six-minute walk test (6MWT) (endurance) improved by 62 ± 66 m (p<0.005). The five times sit to stand test (5xSS) (strength) improved by 3.8 ± 5.8 sec (P=0.004). The Stroke Impact Scale Mobility Subscale improved by 7.3% ± 11.8%, (p=0.006), the Activities of Daily Living Subscale improved by 6.2% ± 9.9%, (p=0.006) and the Memory Subscale by 6.4% ± 14.7%, (p=0.043). Fast Walking Speed, Self-Efficacy and Exercise Outcome Expectation Scales improved with statistical significance but lacked clinical significance. No other outcomes had statistically significant changes.

Six-month Follow up:
At 6-month follow up, 89.5% (16/18) of participants were still exercising at least once a week. The CR program elicited statistically significant participant improvements over time in the 6MWT (p=0.001) and 5xSS (p<0.001). Post-hoc analysis revealed a statistically significant improvement from pre-program to 6-month follow up in 6MWT distance (66.52 ± 53.73m, p=0.013), 5xSS (-3.44 ± 2.20s, p=0.003) but not post-program to 6 months follow up 6MWT (-5.2 ± 26.4m, p=1.00) and 5xSS (-0.24 ± 1.69s, p=1.00) demonstrating maintenance of gains, but no additional gains.

Conclusions:
CR elicited meaningful improvements for stroke survivors (exceeding minimal clinically important differences) in walking endurance, strength, perceived memory and perceived mobility with gains maintained for endurance and strength at 6-month follow up. CR enhances exercise habits and physical activity through structured exercise after discharge from PT and may improve community participation.
Abstract 285: Association Of Patient Out-of-pocket Costs And Financial Assistance With Prescription Abandonment: The Case Of PCSK9 Inhibitors
Authors: Doshi Jalpa A , Li Pengxiang , Puckett Justin , Pettit Amy , Parmacek Michael S , Rader Daniel
Published: May 2020

Background:
Specialty drugs are typically subject to high out-of-pocket (OOP) costs, especially for Medicare Part D patients and commercially insured patients facing high deductibles and/or coinsurance. Financial assistance offered by charities or manufacturers often helps reduce OOP burden. Studies in several disease areas have shown that high OOP costs are associated with prescription abandonment, defined as failure to purchase an insurer-approved prescription at the pharmacy. We examined how OOP costs and financial assistance were associated with abandonment of PCSK9i prescriptions.

Methods:
This retrospective study utilized 2015-2017 claims data from Decision Resources Group for Medicare and commercially insured patients. We defined PCSK9i abandonment rate as the percentage of patients with no evidence of a dispensed PCSK9i in the 90 days after their first PCSK9i prescription was approved by the insurer. Logistic regressions controlling for demographic, clinical, and treatment characteristics were used to estimate risk-adjusted rates of abandonment across different OOP cost levels. We conducted simulations to predict abandonment rates if a patient’s OOP cost level changed and/or they did not receive financial assistance, while holding all other covariates constant. Analyses were conducted separately in the Medicare and commercially insured patients.

Result:
Our final sample included 8,024 Medicare beneficiaries and 3,865 commercially-insured patients. We found that higher OOP cost was associated with higher risk-adjusted PCSK9i abandonment rates in both groups. For instance, Medicare beneficiaries with $0 OOP cost had a 7.4% risk-adjusted abandonment rate, compared to 9.8% for the $1-$9 group (odds ratio [OR]:1.37; 95% CI:1.04-1.81), 19.6% for the $10-$99 group (OR: 3.12; 95% CI: 2.62-3.72), 42.6% for the $100-$199 group (OR: 9.99; 95% CI: 7.60-13.14), 51.9% for the $200-$299 group (OR: 14.48; 95% CI: 11.14-19.76), 58.5% for $300-$399 group (OR: 19.7; 95% CI: 15.01-25.86), and 59% for the ≥$400 group (OR: 20.13; 95% CI: 14.96-27.09). All comparisons were significant at P<0.05. About 4% of Medicare beneficiaries (n=288) and 32% of commercially insured patients (n=1,243) received financial assistance. Without it, their mean OOP costs would have increased from $31 to $386 for Medicare and $7 to $534 for commercial insurance and abandonment rates would have increased from 9.7% to 46.4% (change: 36.7% [95% CI: 31.4% -41.9%]) for Medicare and 4.4% to 27.4% (change: 23% [95% CI: 19.1% -26.9%] for commercial insurance.

Conclusions:
Higher OOP costs were associated with higher rates of PCSK9i abandonment. Lack of financial assistance was associated with increased abandonment. Our findings help inform current policy efforts to protect patients from high cost sharing, such as current bills in Congress aiming to reduce patient OOP burden under Medicare Part D.
Abstract 287: Vendor-neutral Clinic Management Software Use Is Associated With Time Savings For Remote Monitoring
Authors: Biundo Eliana , Lanctin David , Rosemas Sarah C , Nicolle Emmanuelle , Burke Alan
Published: May 2020

Background:
As cardiac implantable electronic devices (CIEDs) have increased in complexity and sophistication, a transition from in-person follow-up to remote device management has taken place. The amount of information collected via cardiac devices has also increased, making the development of efficient workflows necessary for operational sustainability. Vendor-neutral clinic management software organizes patient, device, and programmer information, and thus has potential to improve remote monitoring workflow and data management. This study sought to examine whether management software use is associated with reduced time to review manage remote transmissions.

Methods:
A time and motion workflow analysis was performed in 6 U.S. cardiac device clinics, 3 of which use management software (Medtronic Paceart Optima™). Participating sites had an average size of 4,217 (range of 870 to 10,336) CIED patients managed. Each step involved in remote transmission review (including all clinical and administrative tasks, such as chart documentation and billing) was repeatedly timed, for all device models/manufacturers, during one business week (5 days) of observation at each clinic. The time to review an average remote transmission was calculated based on the mean time to perform each step as well as published literature, and stratified by sites with or without management software. Annual staff time required for remote monitoring was modeled by multiplying the average remote transmission review time by the average number of annual transmissions per patient across the 6 sites: 16.1 transmissions/year, representing a weighted average of therapeutic cardiac devices (4.2 transmissions/year) and insertable cardiac monitors (38.9 transmissions/year).

Results:
A total of 1,290 remote transmission review activities (725 with management software; 565 without management software) were observed and measured during 6 weeks of data collection. On average, the total staff time to review a remote transmission was 2.1 minutes lower at sites with management software (13.6 vs. 11.5 minutes). Extrapolated to the average clinic size of 4,217 patients, this translates into a potential annual time savings of 2,329 hours for sites with management software (13,026 vs. 15,355 hours of total transmission review time). This represents collective time savings across all clinical and administrative staff, and equates to 1.24 annual full-time equivalents (6.9 vs. 8.2 full-time equivalents).

Conclusion:
Remote monitoring of CIED patients requires significant staff time in cardiac device clinics. Management software is an effective tool in optimizing management of remotely monitored patients, and these benefits may translate into time savings for cardiac device clinics.