bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 118: Geographic Variability in Potentially Discretionary Red Blood Cell Transfusions After Coronary Artery Bypass Grafting Surgery
Authors: Likosky Donald , Malenka David , Kommareddi Mallika , Furnary Anthony , Helm Robert , Bryson Christopher , Paone Gaetano , Jin Ruyun , Maynard Chuck , Mackenzie Todd , Zhang Min , Hanson Eric , Surgenor Stephen ,   Cardiac Surgery Quality IMPROVEment (IMPROVE) Network
Published: July 2021

Introduction:
Recently 5 established regional quality improvement collaboratives agreed to partner on assessing and improving care across their regions under the umbrella of the IMPROVE Network. The IMPROVE Network has chosen to begin by assessing regional signatures for potentially discretionary [<3 red blood cell (RBC)] transfusions.

Hypothesis:
Adjusted rates of potentially discretionary RBC transfusions differ across regional collaboratives.

Methods:
We enrolled patients who between 1/1/2008 through 6/30/2012 underwent isolated non-emergent coronary artery bypass (CABG) surgery across 58 medical centers and 4 IMPROVE Network regions. The study dataset of 11,600 consists of the most recent 200 patients from each of the 58 centers who received 0, 1 or 2 units of RBC transfusion during the index admission. We collected patient and disease characteristics, and percent of cases receiving intra- or post-operative RBC transfusions. Logistic regression models were constructed to model transfusion rates and adjust for variation in case mix across centers within each region, including: age, sex, body surface area, pre-operative hematocrit, vascular disease, diabetes, creatinine, and number of diseased vessels. We calculated crude and risk-adjusted transfusion rates across centers, and then stratified by regions.

Results:
RBC transfusions occurred among 24.8% (2,875 of 11,600) of CABG procedures. Significant variation remained across the four regions, even after adjusting for case mix (crude range: 15.3% - 29.8%; adjusted range: 18.5% - 26.6%, p<0.001), Figure.

Conclusion:
Potentially discretionary RBC transfusions were common, and varied across centers and regions, even after adjusting for differences in case mix. These data suggest that differences in regional and center practice environments, including transfusion triggers and anemia management, may be the primary drivers for variations in RBC rates.
Abstract 131: Reduction Of Inhaled Nitric Oxide Utilization And Cost While Maintaining Quality Patient Care
Authors: simsic janet , Harrison Sheilah , Evans Laura , McClead Richard , Teske Douglas
Published: July 2021

Background:
There is evidence that decreasing practice variation and following clinical guidelines improves patient outcomes and reduces cost. Inhaled nitric oxide (iNO) is an effective but expensive treatment for pulmonary hypertension and right heart failure in patients with congenital or acquired heart disease. Our primary aim was to implement standardized initiation and weaning guidelines for iNO usage in the cardiac intensive care unit (CTICU). Secondary aim was to reduce utilization and cost of iNO while maintaining quality patient care.

Methods:
Retrospective review of patients from Jan 2011-Dec 2012 who received iNO in the CTICU including outcomes, utilization and cost. Implementation of standardized initiation and weaning guidelines for iNO usage began in Jan 2012. Quality tools utilized during project development and implementation included Fishbone diagram, Key Driver diagram, Run charts and Control charts.

Results:
From Jan 2011-Dec 2011, 34 patients (6% of CTICU admissions, n=547) received iNO for an average of 177+127 hrs (range 2-661 hrs). Mortality of patient who received iNO was 50%. Total cost of iNO was $335,204; average cost per patient was $9859. Standardized initiation and weaning guidelines for iNO usage were implemented in Jan 2012. From Jan 2012-Dec 2012, 40 patients (7% of CTICU admissions, n= 554) received iNO for an average of 125+135 hrs (range 2-657 hrs). Mortality of patient who received iNO was 20%. Total cost of iNO was $380,823; average cost per patient was $9520. Initiation guideline compliance improved from 83% in 1st quarter to 86% in 4th quarter of 2012; weaning guideline compliance improved from 17% in 1st quarter to 79% in 4th quarter of 2012. There was an 8.3% increase in cost of iNO per hr from 2011 to 2012.

Conclusions:
Implementation of standardized initiation and weaning guidelines for iNO in the CTICU was successful in reducing iNO utilization (from 177+127 hrs/patient to 125+135 hrs/patient) and cost per patient (cost of iNO/hr increased) while maintaining quality patient care. However, the change was not statistically significant.
Abstract 143: Behavioral Factors as Predictors of Poor Cardiovascular Health in Middle-School Students: Results from Project Healthy Schools (PHS)
Authors: March Michelle , Stasiak Ashley , Jones Anne , Sylvester Rachel , Corriveau Nicole , Gurm Roopa , Kline-Rogers Eva , DuRussel-Weston Jean , Goldberg Caren , Jackson Elizabeth A , Eagle Kim A
Published: July 2021

Background:
Behavioral factors that contribute to CVD risk are learned and begin early in life. The present study investigates which behaviors prevent or predispose children to develop CVD risk factors.

Methods:
Middle-school students enrolled in PHS (n=2,135), with consent from both parent and child, were divided into two cohorts: (1) Low Health-Behavior Achievers, (2) Others. From self-reported surveys, Low Health-Behavior Achievers were defined as students with all of the following behaviors: ≥ 5 hours of screen time/day; 0-1 sessions of moderate (30 min) or vigorous (20 min) physical activity/week; ≥ 2 high sugar beverages/day; ≥ 2 fried, fatty, or sweet foods/day; 0-1 servings of fruits and vegetables/day. The remaining students, who did not meet these parameters, were classified as Others. Physiological measurements (lipids, BMI, Recovery Heart Rate (RHR)) and survey data were collected at baseline and one year follow-up. Pearson chi-square tests determined significance.

Results:
Of the 2,135 students, 5.6% (119 of 2135) were excluded due to missingness. The distribution between cohorts was: Low Health-Behavior Achievers (28.5%, 609 of 2135) and Others (65.9%, 1407 of 2135). Compared to Others at baseline, Low Health-Behavior Achievers were more likely to be male (p=0.003), African American or Hispanic (p≤0.001), and enrolled in a school in Detroit or Ypsilanti (p≤0.001). For all physiological characteristics except triglycerides, Low Health-Behavior Achievers were found to have less ideal values as compared to Others. Differences were found for total cholesterol (p=0.006), LDL (p=0.011), weight (p≤0.001), and RHR (p≤0.001) (Figure). Following one year of PHS intervention, the percentage of Low Health-Behavior Achievers decreased from 28.5% (609 of 2135) to 24.3% (518 of 2135) (p≤0.001).

Conclusion:
In PHS, students defined as Low Health-Behavior Achievers were more likely to be male, African American or Hispanic, and enrolled in a lower income school district. Low Health-Behavior Achievers were also found to have less ideal physiological measurements. At one year follow-up, the percentage of Low Health-Behavior Achievers decreased by 4.2%. Future studies are needed to further investigate which behaviors serve as the most effective targets for intervention among middle-school students.
Abstract 146: Medical Home Model in the management of Heart Failure
Authors: Houston-Feenstra Linda , Jutzy Kenneth , Larsen Reane
Published: July 2021

Purpose:
Heart failure (HF) continues as the most expensive diagnosis to manage in the US. Patient failure to adhere to medication regimens and fluid overload have been identified as causative factors in frequent exacerbations requiring hospitalization. This study was designed to evaluate outcomes over time of a Medical Home interdisciplinary team management and patient education design compared to standard of care in HF.

Methods:
The study was designed as a prospective case-control study. Enrollment occurred post HF hospitalization. During hospitalization all pts received education in Guideline-driven management of HF, and were discharged on evidence-based medications. Patients provided informed consent allowing review of medical records for 5 years. One group of pts agreed to participate in a Medical Home for the management of HF (MHHF) while another group chose management of HF by their own cardiologists. Data analysis was performed using case controlled pairing of pts based on age, gender and socio-economic status. Data represents results at 48 months. The Intervention group (22 pts: mean age 60.8) was followed in a MHHF which includes a HF specific clinic and a 12 week comprehensive HF management and exercise program (both clinic and HF management program have the same disease management protocols) and the Control group (48 pts: mean age 62.2) returned to standard follow up care for HF. In MHHF medications were optimized per evidence -based recommendations and education included use of medications, diet and effective sodium balance.

Results:
Functional Capacity

Results:
Medication adherence/Hospitalizations/ED visits

Note:
* baseline to 48 months. Hosp. visits = # hospitalizations/yr/ patient, ED Visits = # ED visits/yr/ patient. Medical record review of medication use for Standard of Care pts failed to provide adequate information on dose /patient. **Adherence was often self reported so true adherence may be lower than reported for this group.

Conclusions:

1. Patients participating in MHHF demonstrated long-term improvement in medication adherence and smoking cessation.

2. Patients participating in MHHF demonstrated significantly fewer HF related Hospitalizations and ED visits 48 months following their baseline hospitalization.
Abstract 162: Procedural and 1-Year Outcomes between PCI Centers with and without On-Site CT Surgery: Insights from the VA CART Program
Authors: Maddox Thomas M , Stanislawski Maggie , O’Donnell Colin , Plomondon Mary E , Bradley Steve , Ho P Michael , Tsai Thomas T , Shroff Adhir , Speiser Bernadette , Jesse Robert J , Rumsfeld John S
Published: July 2021

Background:
Clinical trials demonstrate that percutaneous coronary intervention (PCI) can be safely performed at medical centers without on-site cardiothoracic (CT) surgery, and current PCI guidelines support this practice with effective quality oversight. Translation of these trial findings and guideline recommendations into clinical practice has not been described. In 2005, the VA initiated a policy to expand PCI access by performing procedures at centers without on-site CT surgery under strict quality standards. The impact of this policy on procedural and longer-term patient outcomes has not been evaluated.

Methods:
We studied all PCIs conducted in the VA health care system between 2007-2010. We used data from the VA Clinical Assessment, Reporting, and Tracking (CART) Program, a national clinical quality program that collects real-time data on coronary procedures, procedural complications, and outcomes. Procedural complications (need for emergent CABG and in-lab death), 1-year all-cause mortality, myocardial infarction (MI), and rates of repeat revascularization procedures were compared by presence of on-site CT surgery. We used multivariate survival analysis to assess the association between the presence of on-site CT surgery and 1-year outcomes. The analyses were further stratified by procedural indication (ACS vs. elective) and cath lab PCI volume (≥ vs. <165 PCIs/year).

Results:
24,387 patients received a PCI at 59 centers in the VA health care system between 2007-2010. 6,900 (28.3%) patients underwent PCI at 19 centers without on-site CT surgery. Rates of procedural complications were similar for PCI centers with and without on-site CT surgery (emergent CABG: 13 (0.1%) at PCI centers with on-site CT surgery vs. 2 (<0.05%) at PCI centers without on-site CT surgery, p-value 0.26; deaths: 15 (0.1%) at PCI centers with on-site CT surgery vs. 5 (0.1%) at PCI centers without on-site CT surgery, p-value 0.74). Adjusted 1-year combined all-cause mortality and MI rates were similar between centers (HR 0.995, 95% CI 0.84, 1.17), but revascularization rates were higher at sites without on-site CT surgery centers (HR 1.20, 95% CI 1.05, 1.33). Neither PCI indication nor cath lab volume significantly modified these results.

Conclusions:
Our findings demonstrate that procedural and 1-year patient outcomes are similar between PCI centers with and without on-site CT surgery. These results indicate that the clinical trial evidence of PCI safety without on-site CT surgery can be effectively translated to clinical practice. The VA’s policy allowing for PCI centers without on-site CT surgery in the setting of a quality oversight program may serve as a potential model for improving PCI access in large, integrated health care systems.
Abstract 171: The Role Of A Novel Measure Of Socioeconomic Status Using Individual Housing Data In Cardiovascular Research
Authors: Bang Duk Won , McNallan Sheila M , Roger Veronique L , Christine Lohse M , Yawn Barbara P , Juhn Young J
Published: July 2021

Background:
We recently developed an index of socioeconomic status (SES) termed HOUSES (
HOU
sing-based index of
S
ocio
E
conomic
S
tatus) to overcome the absence of SES measures in common data sources. HOUSES has been associated with various childhood health outcomes to a similar extent as other measures of SES. Whether it is associated with outcomes in adults is unknown. To address this question, we assessed whether HOUSES was associated with mortality after MI.

Methods:
We conducted a population-based cohort study among all Olmsted County, MN residents with MI who were prospectively identified using predetermined criteria from November 1, 2002 to May 31, 2006. HOUSES was formulated based on a z-score for housing value, actual square footage, and numbers of bedrooms and bathrooms and categorized into quartiles. The 1-year mortality rate post MI was compared among subjects with different SES by HOUSES based on a log-rank test.

Results:
Among 696 patients with MI; 623 (90%) were successfully geo-coded to address and real property data. Of these 623 subjects, 594 (95%) were white and 263 (42%) female; the mean age was 68±15 years. Spearman correlation coefficient between HOUSES and education level was 0.23 (p<0.001). Mortality rates at 1 year following MI were 20% (95%CI: 13 - 26), 18% (11 - 24), 14% (8 - 19), and 16% (10 - 21) for patients in the first (lowest SES), second, third, and fourth quartiles (highest SES) of the HOUSES index, respectively (p=0.032). This association between HOUSES and mortality after MI was primarily explained by age and comorbid conditions which were associated with HOUSES. Cardioprotective drugs such as aspirin, beta-blocker, and statins were not associated with HOUSES nor accounted for the association between HOUSES and mortality after MI.

Conclusions:
Despite the lack of a strong correlation with other SES measure (i.e. no redundancy), HOUSES may be useful for overcoming the paucity of conventional SES measures in commonly used datasets in epidemiological research concerning cardiovascular disease among adults.
Abstract 179: The correlation between Insurance Coverage and Long-term Outcomes in patients presenting with ACS: An ACAP-PAIN Registry Analysis
Authors: Pamidimukala Chaithanya K , Aziz Emad F , Pratap Balaji , Bastawrose Joseph H , Mohamed Shuaib , Pai Urvi V , Cho Eun Sik J , Bharathi Ramya , Lizardo Ian M , Benjo Alexandre M , Herzog Eyal
Published: July 2021

BACKGROUND:
To look for the association between Insurance coverage (IC) and Long term Outcomes (O) after discharge following ACS admission from ACAP-PAIN (AP) registry.

METHODS:
The AP registry had 5526 hospitalized patients admitted with a diagnosis of ACS enrolled between 2006-2010. Long-term outcomes (composite of death, AMI, and ACS readmission) were evaluated during a Follow-up period of 4 yrs. Patients were stratified into 5 medical insurance groups: Government (Gov) (n = 2571), Managed Government (MGov) (n = 1229), HMO (n = 630), Commercial (Com) (n = 863), and other (O) (n = 233).

RESULTS:
Composite endpoint at the end of the follow up was seen in 29%, 23%, 16%, 15%, and 12%, (p <0.0001), and all-cause mortality was seen in 6.5%, 6.2%, 3.9%, 3.1%, and 1.2%, (p<0.001), of the 5 medical insurance groups, respectively. Patients with Gov and MGov care coverage were older, with higher incidence of CAD, hypertension and diabetes. After adjusting for confounding variables, the multivariable-adjusted odds for composite endpoint was 1.73 (95% confidence interval [CI], 0.56-1.36) for Gov patients, 1.07 (95% CI, 0.93-1.24) for MGov patients, 0.56 (95% CI, 0.45-0.70) for HMO patients, 0.55 (95% CI, 0.46-0.67) for Com patients, and, 0.42 (95% CI, 0.29-0.63) for O patients. (See Graph)

CONCLUSIONS:
The results of this population-based study demonstrate that ACS patients with any government insurance status have an increased long term morbidity and mortality. This may be explained at least partially by the patients’ characteristics.
Abstract 184: Patterns of Outpatient Follow-up after Acute Myocardial Infarction: Follow-up Frequency is Associated with Utilization of Evidence-based Therapies
Authors: Vigen Rebecca , Li Yan , Maddox Thomas M , Daugherty Stacie , Bradley Steven M , Ho P M
Published: July 2021

Background:
ACC/AHA guidelines recommend that patients with acute myocardial infarction (AMI) follow-up within several weeks of hospital discharge. Recommendations regarding intensity of following-up in the year following AMI are not provided. The relationship between frequency of follow-up and use of evidence-based therapies following AMI is unknown.

Methods:
6,838 patients from 2 multicenter prospective AMI registries, PREMIER and TRIUMPH registries were studied. We divided the number of patient self-reported outpatient follow-up visits with cardiologists, primary care providers, or both into tertiles: low, medium, and high. The primary outcome was use of statins, beta blockers, aspirin, ACE/ARBs, and a composite of all four medications at 12 months among eligible patients. The association between tertiles of visits following AMI among patients who had at least one visit and primary outcome was evaluated using hierarchical multivariable modified Poisson models.

Results:
Mean number of follow-up visits in the year following AMI was 6 (IQR 3 - 8) and 189 (4%) of patients had no visits. In lowest tertile, patients had 1 to < 4 visits, in the medium tertile, 4 to < 7 visits, and in highest tertile, 7 to 59 visits. Patients in medium and high intensity tertiles were older, more likely to have insurance, and had higher GRACE 6-month mortality risk scores compared to the lowest tertile. In multivariable analyses, patients in the medium tertile were more likely to use statins and ASA than those in the lowest tertile (Figure). There were no differences in use of individual medications when comparing the highest and medium tertiles although individuals in the highest tertile were less likely to use all four medications.

Conclusions:
Significant variability exists in follow-up frequency following AMI and 4% of the cohort had no follow-up. Patients who had medium intensity visits were more likely to use some evidence-based medications than those with low intensity. Higher intensity visits was not associated with greater medication use. It is possible that the observed differences may be attributed to unmeasured differences among patients rather than the actual follow-up visits. Prospective studies are needed to assess key elements of outpatient visits that may lead to better utilization of evidence-based therapies.
Abstract 198: Racial Disparity In Resuming Anticoagulation For Atrial Fibrillation After An Episode Of Major Gastrointestinal Bleeding
Authors: Qureshi Waqas , Garikapati Kiran , Patsias Iani , Cheema Gagandeep , Mittal Chetan , Alirhayim Zaid , Paje David
Published: July 2021

Background:
Racial disparities are well known in patients treated for atrial fibrillation (AF). Racial minorities are less likely to be treated and diagnosed with atrial fibrillation. However, it is not known if gastrointestinal bleeding which is common complication in anticoagulated atrial fibrillation patients leads to any racial disparities.

Methods:
Retrospective data was obtained from claims of warfarin prescriptions made to a large insurance company of South Eastern Michigan. Patients with gastrointestinal bleeding were confirmed by detailed chart review. GIB was defined as a drop of 2 gram of hemoglobin or need for blood transfusion in the setting of one of the symptoms of GIB confirmed by hospital staff. A propensity matched multivariable logistic regression analysis was performed to assess the likelihood of being resumed on warfarin. Recurrent GIB, stroke/TIA and mortality rates were also compared between Caucasians and African Americans.The analysis was adjusted for propensity score, blood transfusions, length of stay, CHADS2 and HAS - BLED scores.

Results:
Out of 118,342 initially obtained patients on warfarin, there were 1143 (mean age 75.8 ± 14.7, women 46%) patients that developed gastrointestinal bleeding while on anticoagulation for AF. There were 776 (58.38%) Caucasians and 367 (27.6%) African American (AA) patients. Out of these, 339 (43.7%) Caucasians and 189 (55.7%) AA patients were resumed on warfarin (p = 0.001). Warfarin was resumed later in Caucasians than AA (68 vs. 64 days, p = 0.03). AA were more likely to not resume warfarin due to personal preference or negative experience with warfarin and Caucasians were more likely to not resume warfarin due to doctor’s suspicion of higher risk of bleeding (p <0.01). Caucasians had less endoscopic evaluations 106 (13.6%) than AA 58 (15.8%) patients (p = 0.002). AA had non-significant higher rates of recurrent GIB 48 vs. 68 (13.1% vs. 12.8%) than Caucasians (p=0.09) but stroke risk was significantly less than Caucasians 39 vs. 112 (10.6% vs 14.4%) (p = 0.001).There were 113 (30.7%) deaths in AA and 301 (38.7%) Caucasians died (p = 0.001). The risk of stroke was lower in AA patients than Caucasians (OR 0.74; 95% CI 0.58 - 0.94, p = 0.015). AA also had decreased mortality (HR 1.45; 95% CI 1.2 - 2.1, p = 0.004). There were higher readmissions for recurrent GIB in AA patients (p= 0.04). For having one more stroke/TIA than AA, warfarin needed to be discontinued in 41 additional Caucasians than AA.

Conclusion:
In conclusion, the racial disparity in resuming warfarin after an episode of major GIB in anticoagulated patients for atrial fibrillation was more for Caucasians than African American. This may be explained by uncertainty of outcomes that frequently leads to overtreatment of minority patients. Cultural beliefs for not resuming warfarin might have also played a role.
Abstract 202: Predictors of Hospital and Long-Term Outcomes in Patients Treated with Therapeutic Temperature Manipulation
Authors: Elkharbotly Ali , Ji Yong , Waters Theresa , Torosoff Mikhail
Published: July 2021

Background:
Hospital and long-term outcomes in cardiovascular (CV) and neurological (CNS) patients treated with therapeutic temperature manipulation were compared to investigate predictors of poor prognosis.

Methods:
Hospital data and long-term outcomes were collected in 89 consecutive CV or CNS patients treated with either therapeutic normothermia or hypothermia at a single institution. The study was approved by the IRB. Analysis of variance, chi-square, and logistic regression were used (Table).

Results:
In both CNS and CV patients, increased hospital mortality were observed with advanced age (P= 0.05), tachycardia (P= 0.02), hyperglycemia (P= 0.01), increased calcium (P= 0.03), decreased hemoglobin (P= 0.02), and hyperlipidemia (P=0.05). Advanced age retained predictive significance in multivariate logistic regression (HR 1.045, p=0.034, 95%CI 1.003-1.088). Long-term mortality was increased in patients with history of renal disease (P=0.04), elevated admission creatinine (P=0.04), and hyperlipidemia (P=0.001).

Conclusions:
Hospital, but not long-term outcomes, are determined by admission metabolic derangements and age in patients undergoing therapeutic temperature manipulation. In survivors to hospital discharge renal dysfunction and dyslipidemia appear to be associated with worse outcomes. Additional studies of this important subject are needed.
Abstract 204: Efficacy of Mirror Therapy Combined with Afferent Stimulation on Motor Impairment, Motor Function, and Daily Function in Chronic Stroke: A Randomized Controlled Trial
Authors: Wu Ching-yi , Huang Pai-chuan , Lin Keh-chung , Huang Wen-ling
Published: July 2021

Background:
Studies have found that both mirror therapy (MT) and mesh-glove (MG) afferent stimulation reduce motor impairments after stroke. MT might recruit the premotor cortex or balance neural activation within the primary motor cortex toward the affected hemisphere. And MG stimulation might result in plastic changes in the primary motor cortex and induce an effect on motor cortical excitability. Adding MG to MT might further augment cortical reorganization. In addition, combining two treatment protocols has been advocated as a way to improve treatment efficacy in stroke rehabilitation. A combined protocol such as MT combined with MG (MT+MG) might broaden aspects of treatments effects. This study aimed to demonstrate the comparative efficacy of MT+MG, MT, and a conventional task-oriented training (CT).

Methods:
This study recruited forty-three participants with chronic stoke at the mild to moderate level of motor impairments. Participants were randomly assigned to one of the three groups: MT+MG, MT, or CT groups. All participants in these three groups received a 1.5-hour training session per day, 5 days/week for 4 weeks. Treatment outcomes included motor impairment measured by the Fugl-Meyer Assessment (FMA), motor functions measured by the Box and Block Test (BBT) indicating manual dexterity and 10-Meter Walk Test (10 MWT) indicating ambulation function, and daily function measured by the ABILHAND Questionnaire. Evaluations were administered before and after the 4-week treatments.

Results:
Significant effects on the FMA (p =.045), the BBT (p = .019), and the 10-MWT (velocity of self-pace: p =.011; stride of self-pace: p =.002; velocity of ASAP: p = .025) were found among the three groups. Post hoc analyses showed that MT+MG and MT groups elicited significantly better FMA total scores compared to the CT group (p = 0.0032 and 0.0031). MT+MG and CT groups performed significantly better on the BBT compared to the MT group (p = 0.007 and 0.036). MT+MG and CT groups performed significantly better on three of four 10 MWT subscales, the velocity of self-pace (p = 0.004 and 0.031), the stride of self-pace (p = 0.016 and 0.016), and the velocity of as-soon-as-possible (p = 0.014 and 0.023) than MT. There were no significant group effects on ABILHAND Questionnaire.

Conclusions:
The MT+MG group specifically demonstrated superior benefits on manual dexterity and ambulation function over the MT group. Both MT+MG and MT treatments showed significant benefits on the reduction of motor impairment. However, MT+MG and MT protocols did not yield extra benefits on daily function. Future studies might include functional task practice to enhance generalizability of the treatment effects to daily function in patients with various severities of motor impairments. The retention effect of MT + MG needs further investigation.
Abstract 207: High Blood Pressure Effects on the Outcomes of Cardiovascular Events: Teaching versus Non Teaching Hospitals
Authors: Okunji Priscilla O , Daniel Johnnie , Wutoh Anthony
Published: July 2021

Background:
The effects of blood pressure on outcomes of inpatients with cardiovascular related diseases in teaching and non teaching hospitals are not well known. In this study we are investigating the prevalence of hypertension and other co-morbidities on the length of stay and transfers of inpatients’ with heart attack in teaching and non teaching hospitals.

Method:
Patients were selected using International Classification of Diseases-9-Clinical Modification primary diagnosis codes from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database. Data were retrospectively extracted from 1,056 hospitals in 42 States with 8,158,381 samples in 2008. Multivariate statistical techniques were used to examine patient characteristics and outcomes of inpatient with heart attack, diabetes and other co-morbidities in teaching and non teaching hospitals.

Results:
The percentage of hospital length of stay for a day or less than one day was higher in non- teaching than in teaching hospitals for patients’ co-morbidities. Especially for hypertension, the percentage was higher in non-teaching hospitals, X
2
= 25.236, df = 6,
p
=.000. The percentage of longer lengths of stay (7-13 days) for congestive heart failure (CHF) was also higher in non teaching hospitals (34.9%) than teaching hospitals (25%). The results correlate with the symptomatic effects of heart attack. High blood pressure resulting into rupture, clot and necrotic tissues which limits blood circulation, hence heart attack. In addition, inpatients’ with chronic pulmonary disease (X
2
= 37.225, df = 4,
p
=.000) and hypertension (X
2
= 46.058, df = 4,
p
=.000) had higher transfer rates in non-teaching hospitals. The difference between teaching and non-teaching hospitals was statistically significant for chronic pulmonary disease and hypertension was large enough to affect clinical policy.

Conclusions:
This study has ascertained that the effect of hypertension on the length of stay and transfers of inpatients with cardiovascular events in teaching and non teaching hospitals is highly significant. Hence, it is suggested that there should be a policy in place to screen all patients for hypertension and other co-morbidities on admission to prevent cardiovascular complications.
Abstract 208: A Literature Review Of Indirect Cost Of Stroke
Authors: Joo Heesoo , George Mary G , Fang Jing , Wang Guijing
Published: July 2021

Background:
Stroke is not only a costly deadly disease, but also a leading cause of long-term disability. However, stroke associated indirect costs such as productivity loss and informal care cost have not been well studied. To better develop such studies and provide policy-relevant information, we conducted a literature review of indirect costs of stroke.

Methods:
We conducted a literature search using PubMed, MEDLINE and EconLit, complemented by Google Scholar search and cross-reference checking using key words of stroke, cerebrovascular disease, subarachnoid hemorrhage, intracerebral hemorrhage, cost of illness, productivity loss, indirect cost, economic burden, and informal caregiving. We identified original research articles published during 1990-2012 in English language peer reviewed journals for the review. Since the number of studies on indirect cost of stroke was small, we included cost-of-illness (COI) studies if they contained sufficient analyses of the indirect cost. We summarized the indirect costs by study type, cost categories, and study settings.

Results:
There were 31 original research articles investigating the indirect cost of stroke. Only 6 (19%) of these studies solely investigated the indirect cost; the other 25 (81%) studies were COI studies which included the indirect cost as a component. Of the 31 articles, six examined indirect costs in the US. Two of them focused solely on indirect costs. One study at a national level examined informal caregiving among elderly with stroke and estimated the annual cost of such care to be $6.1 billion in 1999. The other study for the State of California estimated lost productivity associated with stroke mortality in the State to be over $1 billion in 1991. The other four US studies suggested that the indirect costs will continue to increase in the coming decades, especially among African American and Hispanics, and that indirect costs might account for over 58% of the total cost of stroke. Due to diverse research methods, data, and cost definitions, the literature suggested a wide range of the indirect cost as a percentage of total stroke costs (2.6% - 71%) often with indirect cost as a significant cost component of stroke.

Conclusions:
While the literature indicated that the indirect cost accounted for a significant portion of the economic burden of stroke, there is a clear need to develop improved methods to study costs and to better use or establish relevant data sources for such studies. With the aging population and increasing survival rate of stroke, both direct and indirect costs of stroke are likely to increase greatly. Interventions for stroke prevention as well as for improving quality of life among stroke patients are needed to contain both direct and indirect costs associated with stroke. More research investigating the indirect costs will be helpful in guiding the development of such interventions to reduce the burden of stroke.
Abstract 211: Association of Patient Characteristics With the Initiation of Dabigatran Versus Warfarin Among Anticoagulant Naive Patients With Non-valvular Atrial Fibrillation
Authors: Walker David R , Ivanova Jasmina , Betts Keith A , Rao Sapna , Wu Eric Q
Published: July 2021

Background and Objective:
Dabigatran etexilate (DE) and warfarin, both oral anticoagulants used for stroke risk reduction in patients with non-valvular atrial fibrillation (NVAF), have been or are being compared in several comparative effectiveness studies. Understanding patient characteristics of those prescribed DE vs. warfarin are important for interpreting such studies. The objective of this study is to identify the characteristics that differentiate NVAF patients prescribed DE versus warfarin as first-line anticoagulation.

Methods:
An online survey was administered in October 2012 to an established panel of cardiologists and primary care physicians (PCPs) in the US. Physicians were asked to identify medical charts of their patients diagnosed with NVAF and who had at least one prescription for DE or warfarin between 1/1/2011 and 6/30/2012. Patients were further required to be anticoagulant naïve prior to the first prescription of DE or warfarin. A computer generated random dice was applied to direct the random selection of the patients. Patient characteristics, comorbidities and clinical risk measures were compared between DE and warfarin patients using Chi-square tests for categorical variables and t-tests for continuous variables. A logistic regression model was utilized to evaluate patient characteristics associated with DE vs. warfarin use among anticoagulant naïve NVAF patients.

Results:
A total of 288 physicians (144 cardiologists and 144 PCPs) completed the survey. 262 medical records for DE patients and 247 for warfarin patients were randomly selected. The mean age of the DE and warfarin patients, respectively were 61.6 and 65.8 years (p < 0.01). The proportion of females was 20.6% and 41.7% in the DE and warfarin patients respectively (p<0.01). 86.3% of DE patients vs. 68.4% of warfarin patients were Caucasian (p<0.01). Other differences between DE and warfarin patients respectively included: previous myocardial infarction (3.8%, 9.3%; p<0.05), previous transient ischemic attack (8.4%, 16.2%; p <0.01), and CHA
2
DS
2
-VASc stroke risk score (2.21, 2.98; p<0.01). The logistic regression model found age (OR = 0.96; p=0.001), female gender (OR=0.46; p = 0.002), Hispanic/Latino (OR = 0.33; p=.007), Black (OR= 0.37; p = 0.006), and
>
6 months and < 1 year for time from first NVAF diagnosis to first prescription date (OR = 0.38; p = 0.02) were associated with initiation of DE vs. warfarin. However, CHA
2
DS
2
-VASc was not found to be a significant predictor of anticoagulant prescription.

Conclusions:
Patients who are younger, male, Caucasian, and recently diagnosed with NVAF were significantly more likely to be initiated by their physician on DE vs. warfarin. These findings should be considered when doing comparative analyses of outcomes between patients on DE vs. warfarin.
Abstract 217: How well does the CHADS
2
Stroke Risk Score Predict Major Hemorrhage in Patients with Atrial Fibrillation?
Authors: Quinn Gene R , Singer Daniel E , Go Alan S , Chang Yuchiao , Borowsky Leila , Pomernacki Niela , Udaltsova Natalia , Fang Margaret C
Published: July 2021

Background:
The decision on whether or not to use anticoagulants for atrial fibrillation depends on estimating a patient’s risk of stroke compared to their risk of bleeding. The CHADS
2
risk score is widely used to predict the risk of stroke in patients with atrial fibrillation. Several of the risk factors in CHADS
2
have also been associated with hemorrhage risk, raising the possibility that CHADS
2
could also be used to predict warfarin-associated hemorrhage.

Objective:
To determine whether the CHADS
2
stroke risk scheme can be used to predict hemorrhage in patients with atrial fibrillation and to compare the predictive ability of CHADS
2
with a risk score specifically designed to predict warfarin-related hemorrhage.

Methods:
We used data from the ATRIA Study, a cohort of 13,559 adults with atrial fibrillation receiving care in a large integrated healthcare delivery system. The cohort was divided into on-warfarin and off-warfarin periods. Clinical risk factors were obtained from computerized medical databases and used to calculate a CHADS
2
risk score (congestive heart failure, hypertension, age≥75, diabetes, and prior stroke) as well as a previously developed measure of anticoagulation-associated bleeding risk, the ATRIA bleeding risk score (anemia, severe renal disease, age≥75, prior bleed, and hypertension). The primary outcome was hospitalization for major hemorrhage, validated through chart review. The performance of the CHADS
2
and ATRIA scores was compared by
c
-index and net reclassification improvement.

Results:
We identified 170 major hemorrhages during 15,300 person-years of follow-up on warfarin, and 162 hemorrhages during 15,530 person-years off warfarin. The CHADS
2
risk score predicted hemorrhage risk better than chance in both warfarin and non-warfarin exposed groups, with a
c-
index of 0.67 [95% CI = 0.64 - 0.71] and 0.65 [95% CI = 0.62-0.67], respectively. However, the ATRIA bleeding risk score predicted major hemorrhage events better than CHADS
2
, with a
c
-index of 0.74 [95% CI = 0.72-0.76] for warfarin users and 0.77 [95% CI = 0.75-0.80] for non-warfarin users. The ATRIA bleeding risk score also had better net reclassification improvement than CHADS
2,
35.6% for warfarin users and 26.8% for non-warfarin users.

Conclusions:
Although some clinical markers of stroke risk such as those included in the CHADS
2
risk score are also associated with increased hemorrhage risk, the CHADS
2
risk score should not be used instead of a validated hemorrhage risk tool to estimate hemorrhage risk.
Abstract 224: Neurological Complications Following Cardiac Catheterization During Transition From Femoral Access To Radial And Femoral Access
Authors: Patel Ankitkumar , Chaudhry Kunal , Kabadi Rajesh , Cole Robert , Patel Ankita , Martin Fern , Iliadis Elias
Published: July 2021

Background:
Prior data has shown that radial approach has been associated with increased rate of cerebral emboli. During transition from femoral access site (historical) to a combined radial and femoral access site (contemporary) for cardiac catheterization, we hypothesize that increased manipulation of equipment would be associated with greater manipulation of the aorta and result in increased embolic events to the brain. Our study investigates whether the rate of neurologic events changed from historical to contemporary time periods.

Methods:
A retrospective chart review was conducted to assess all cardiac catheterization cases performed at a large tertiary care academic center from 2007-2009 (historical n = 9776) and from 2010-2011 (contemporary n = 5294). A cerebrovascular accident (CVA) is defined as a documented central neurologic deficit persisting for at least 24 hours and a transient ischemic attack (TIA) as a neurologic event with the signs and symptoms of a CVA but which goes away within a short period of time.

Results:
The historical group had equivalent mean age (p=0.1), percentage female patients (p=0.13), history of cerebrovascular disease (p=0.62) and hyperlipidemia (p=0.08) as compared to the contemporary group. The historical group had lower rate of diabetes (37.4% vs 41.6%, p<0.01) and hypertension (82.1% vs 84.1%, p<0.01) but higher rate of renal failure (6.1% vs 4.8%, p<0.01) as compared to contemporary group. The historical group utilized femoral access significantly more than contemporary group (99.5% vs 79.6%, p<0.001). The historical group had equivalent CVA/TIA rate as contemporary group (0.02% vs 0.09%, p=0.056).

Conclusion:
Our single-center, retrospective study shows that during a period of transition to the radial artery access site for cardiac catheterization does not significantly change the rate of neurologic complications.
Abstract 230: The Impact of Hospital Closures on Outcomes for Myocardial Infarction and Stroke
Authors: Joynt Karen E , Orav E. John , Jha Ashish K
Published: July 2021

Objective:
U.S. hospitals face substantial financial challenges as policymakers try to reduce healthcare spending. As a result, it is likely that hospital closures will accelerate in the coming years. Hospital closures threaten access to care, and may negatively impact patient outcomes by lengthening travel times, particularly for illnesses for which treatment depends heavily on timely receipt of treatment. Therefore, our objective was to assess the impact of hospital closures on patient outcomes for acute myocardial infarction (AMI) and stroke over the past decade.

Methods:
We used data from Medicare files as well as the American Hospital Association from 2002 through 2010 to identify hospital closures. For each hospital that closed, we identified Medicare fee-for-service patients that sought care at that hospital for AMI or stroke in the year prior to closure. We then determined the nearest alternative hospital using geocoding for each patient in the sample, and determined the additional travel time associated with this alternative site of care. We compared the characteristics of the closing versus alternative hospitals. We then created multivariate hierarchical logistic regression models in which we reassigned each of the patients at a hospital that closed to the nearest alternative hospital, and compared mortality rates between the closed and alternative facilities.

Results:
Between 2002 and 2010, we identified 121 hospital closures. There were 1,109 patients that received AMI care and 1,104 patients that received stroke care at a hospital that closed in the subsequent year. The median age was 79 for both conditions; of the AMI patients, 45% were male, and of the stroke patients, 39% were male. Travel time increased by 2.8 minutes for AMI patients and by 1.5 minutes for stroke patients. For AMI patients, the alternative hospital to which they would have traveled was more often large (0% versus 28%, p<0.001), non-profit (63% versus 79%, p<0.001), and teaching (1.1% versus 8.2%, p<0.001) compared with hospitals that closed. Patterns were similar for patients with stroke. For AMI, there was no difference in 30-day risk-adjusted mortality rates for the closed versus alternative hospitals (19.03% versus 19.17%, difference 0.14%, p=0.90). Similarly, for stroke, there was no difference in 30-day risk-adjusted mortality rates (19.57% versus 19.96%, difference 0.39%, p=0.75).

Conclusions:
We found no evidence that hospital closure was associated with worse clinical outcomes for AMI or stroke for patients. Though there were increased travel times for both conditions, this was likely offset by an increase in hospital quality in the alternative hospitals. These findings should provide some reassurance to those concerned that hospital closures will lead to significantly worse patient outcomes, even for conditions for which timely receipt of treatment is critical.
Abstract 234: Prior Warfarin Treatment and Intracranial Hemorrhage among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator: A Meta-analysis
Authors: Li Huijuan , Xian Ying , Laskowitz Daniel , Peterson Eric
Published: July 2021

Background and Purpose:
The risk for bleeding complications after intravenous thrombolysis for ischemic stroke in patients on warfarin with international normalized ratio [INR] ≤1.7) remains unclear. The aim of the current study is to perform a meta-analysis to determine whether there is an association between warfarin and risk of symptomatic intracranial hemorrhage (sICH).

Methods:
We searched MEDLINE, Web of Science and EBSCO databases for articles published through Jul 2012. A random-effects model was used to compute the pooled risk estimate.

Results:
Overall, 11 observational studies were identified that met our study inclusion criteria. This included 29,283 stroke participants treated with tPA; of which 2129 (7.3%) patients were on home warfarin prior treatment. Warfarin pretreatment was associated with an increased crude OR for symptomatic intracranial hemorrhage (sICH) (combined OR=1.77; 95% CI, 1.07~2.93;P=0.03).Of these studies, 7 studies had conducted a multivariate adjusted analyses, which demonstrated no association between warfarin use and increased risk of sICH following tPA use (combined adjusted OR=1.73; 95% CI, 0.91-3.28; p=0.10).

Conclusions:
These data suggested that the risk of sICH after thrombolytic therapy is not increased in patients using warfarin with sub therapeutic INR levels.
Abstract 239: Rates of Atrial Fibrillation Diagnoses and Stroke Events by Combination of Risk Factors
Authors: Turakhia Mintu P , Hunter Tina D , Mollenkopf Sarah A , Reynolds Matthew R
Published: July 2021

Objectives:
To stratify individual and incremental risks for AF and stroke based on annualized rates of diagnoses in 2008-2010 by patient risk status in 2007.

Methods:
A sample of 3,007,874 patients from the Truven Health MarketScan® Commercial and Medicare Supplemental Databases was categorized by their unique combination of age (<65, 65-74, 75+), HTN, diabetes, heart failure, CAD, and renal insufficiency. Counts of patients with events in each category were divided by the sum of patient-years to first event to produce annualized event rates. Similarly, annualized event rates were calculated separately by age group alone (0-17, 18-34, 35-44, 45-54, 55-64, 65-74, and 75+).

Results:
Baseline annualized rates of AF and stroke diagnoses among patients with age <65 and no additional risk factors were 0.35% and 0.49%, respectively, while rates ranged from 0.65% to 3.34% for those with single risk factors, including older age groups. Patients age 75+ had the highest annualized rates of both AF and stroke among single risk factors (3.25% and 3.34%), while those age 75+ with heart failure had the highest rates among patients with two risk factors (10.22% and 5.88%). In some cases, an interaction among risk factors produced a supra-additive effect, such as the effect on AF rate of age 75+ combined with heart failure (10.22% >> 3.25% + 1.67%). Conversely, for those cases where the subsample of patients with a particular risk factor combination was very small, the true incidence rate may be best approximated by summing the rates for the individual risks. Rates of AF and stroke by age group alone increased approximately exponentially from 0.15% and 0.20%, respectively, among patients age 0-17 to 5.60% and 4.85% among those age 75+.

Conclusions:
Results from a very large sample of patients in a claims database confirm increased rates of AF and stroke in patients with known risk ractors, while adding to the knowledge base regarding the risk levels among many less prevalent combinations of these factors. The results suggest that patients should be monitored more vigilantly as age progresses for signs of AF, and possibly treated more aggressively for risk factors that increase the incidence of AF and stroke. In particular, patients age 75+ may be considered to be at risk based on age alone.