bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 111: Independence in Activities of Daily Living and Death in Patients wtih Heart Failure
Authors: Dunlay Shannon M , Manemann Sheila M , Jiang Ruoxiang , Weston Susan A , Chamberlain Alanna , Roger Veronique
Published: July 2021

Background:
Several chronic diseases can contribute to functional disability. However, little is known about functional disability and its progression overtime in chronic heart failure (HF). We aimed to investigate the prevalence and progression of difficulty with activities of daily living (ADLs) and its association with mortality in patients with HF.

Methods:
We enrolled Southeastern Minnesota residents with HF into a longitudinal study from September 2, 2003 through January 31, 2012. A patient’s difficulty with 9 ADLs (feeding themselves, dressing, toileting, housekeeping, climbing stairs, bathing, walking, using transportation, managing medications) was assessed by questionnaire. Patients were followed for all-cause mortality. Using Rasch analysis to determine the order of ADL difficulty, patients were divided into 3 categories (minimal, moderate, severe difficulty). Predictors of ADL difficulty were assessed using negative binomial regression and the association between ADL difficulty and death with Cox proportional hazard regression.

Results:
Among 1128 patients (mean age 74.7 years, 49.2% female), most (59.4%) reported difficulty with one or more ADLs at enrollment, with 272 (24.1%) and 146 (12.9%) reporting moderate and severe difficulty, respectively. The independent predictors of difficulty with ADLs were older age, female sex, diabetes, morbid obesity, cerebrovascular disease, dementia, anemia, and unmarried status. After a mean (SD) follow-up of 3.2 (2.4) years, 615 (54.5%) patients had died. There was a stepwise increase in the risk of death as difficulty with ADLs increased (
Figure
). After adjusting for age, sex, and comorbidity, the HR (95% CI) for mortality was 1.52 (1.25-1.83, p<0.001) for patients with moderate and 2.28 (1.82-2.85, p<0.001) for those with severe difficulty with ADLs compared to those with minimal difficulty (p for trend<0.001). In most patients (73.5%), difficulty with ADLs was stable over time. However, survivors reporting persistently severe or worsening ADL difficulty in a second assessment (median 9 months later) were at an increased risk of subsequent mortality (adjusted HR 2.08, 95% CI 1.70-2.55, p<0.001).

Conclusions:
Functional disability is common in patients with HF, can progress over time, and is independently associated with adverse prognosis.
Abstract 112: Depression Does Not Predict Longitudinal Medication Adherence in an Acute Coronary Syndrome Population
Authors: Fagan Katherine M , Lambert-Kerzner Anne , Carey Evan P , Del Giacco Eric J , Mihalko-Corbitt Renee , Fahdi Ibrahim E , Bosworth Hayden B , Melnyk Dee , Bryson Chris L , Rumsfeld John S , Ho Michael
Published: July 2021

Background:
Prior studies have shown that depression may be associated with longitudinal medication non-adherence for patients with chronic cardiovascular disease. However, little is known about depression and medication adherence following acute coronary syndrome (ACS) hospitalization. Our objective was to assess whether depression was associated with longitudinal medication adherence following ACS among Veterans enrolled in a clinical trial designed to improve medication adherence.

Methods:
Patients included in the current analysis were enrolled in the MEDICATION study, which tested a multifaceted intervention versus usual care to improve medication adherence in the year following ACS hospitalization at 4 VA Medical Centers. Depression was assessed using the Patient Health Questionnaire (PHQ-9) prior to hospital discharge based on a score of ≥10. Medication adherence was assessed for 4 classes of cardioprotective medications (Statins, ACEI/ARBs, Clopidogrel, and Beta Blockers) in the 12-months following hospital discharge using pharmacy refill data. A proportion of days covered (PDC) was calculated based on the 4 classes of medications, and adherent patients were categorized based on a PDC ≥0.80. Then, we assessed the association between depression and medication adherence in the year after ACS hospitalization.

Results:
Of the 241 patients, the average age was 63.9 years, mean BMI was 30.9 kg/m
2
, and they had a number of comorbidities: 45.2% had diabetes and 65.6% had a history of coronary artery disease. The mean PHQ-9 score was 8.2 and 35.4% had depression (PHQ≥10) prior to discharge, with no difference in the prevalence of depression between treatment groups. In the year after ACS hospitalization, the mean PDC was 0.90 for all patients and there was no difference between depressed (PDC=0.91) and non-depressed patients (PDC=0.90). Among patients in the usual care group, there was also no difference in adherence between depressed (PDC=0.88) and non-depressed (PDC=0.86) patients.

Conclusions:
In this cohort of patients enrolled in a clinical trial, depression was present in 1 out of 3 patients during ACS hospitalization but not associated with medication adherence in the year after hospital discharge. A potential explanation for the lack of association between depression and adherence may be related to the overall high adherence rates found in the MEDICATION study. It will be important to assess whether depression is a marker of medication non-adherence in other ACS cohorts.
Abstract 118: Right Bundle Branch Block and Clinical Outcomes in Patients with Heart Failure: A Systematic Review and Meta-analysis
Authors: Hazem Ahmad , Sharma Sunita , Sharma Amit , Leitch Cameron , Sharadanant Roopalakshmi , Uriell Matthew , Neutzling Kari , Barrionuevo Moreno Patricia , LeBlanc Annie , Wang Zhen , Sorita Atsushi , Vilenski Leonid , Prokop Larry , Makkuni Premraj , Ting Henry H , Murad Mohammad H
Published: July 2021

Importance:
Right bundle branch block (RBBB) is observed in approximately 5-14% of patients with heart failure (HF). Multiple observational studies have reported the association of RBBB with clinical outcomes in patients with HF. We performed a systematic review and meta-analysis to determine the prognostic significance of RBBB for patients with HF.

Data Sources:
We have systematically searched MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science and Scopus through January 2014.

Study Selection:
Reviewers working independently and in duplicate screened all eligible abstracts that described all cause or cardiovascular mortality in patients with RBBB and HF. We excluded studies that reported unadjusted outcome, i.e.: unadjusted event rates.

Knowledge synthesis:
We pooled reported risk ratio and hazard ratio.

Main Outcomes:
All-cause mortality and cardiovascular mortality (death).

Results:
We found 12 relevant observational studies enrolling over 38,000 patients. Risk of bias was assessed using the Newcastle-Ottawa Scale. Included studies had at least a moderate quality. Seven of those evaluated prognosis of patients with RBBB and heart failure. After a mean follow up period of 2.5 years (range: 1-5 years), RBBB was associated with a statistically significant increased risk of all-cause mortality compared to patients with heart failure but no BBB, RR 1.27, 95% CI (1.08-1.50), Figure 1. The other 5 studies evaluated CHF patients receiving cardiac resynchronization therapy (CRT), comparing outcomes of patients with RBBB to those with LBBB. After a mean f/u period of 3 years, patients with RBBB were once again found to have an increased risk of all-cause mortality, RR 1.45, 95% CI 1.12-1.89.

Conclusion and Relevance:
RBBB in patients with HF is associated with higher all-cause mortality in comparison to patients without inter-ventricular conduction defects, as well as LBBB patients in patients undergoing CRT setting.
Abstract 125: Clinical Outcomes Following Continuous-Flow Left Ventricular Assist Device: A Systematic Review
Authors: McIlvennan Colleen K , Magid Kate H , Ambardekar Amrut V , Thompson Jocelyn S , Matlock Daniel D , Allen Larry A
Published: July 2021

Objectives:
We aimed to summarize the current evidence on outcomes of continuous-flow left ventricular assist devices (CF LVAD).

Background:
Conveying the complex trade-offs of LVAD is challenging, and made more difficult by absence of an evidence summary for the full range of possible outcomes. This absence of accurate and easily accessible information from which to anchor risk-benefit communication leads to a potentially non-standardized and variable informed consent and decision-making process around LVADs that may be incomplete, confusing, or biased.

Methods:
PubMed and Cochrane Library were searched from January 2007-December 2013, supplemented with manual review. Three reviewers independently assessed each study for saliency regarding patient-centered outcomes. Data were summarized in tabular form. Overall study characteristics encouraged inclusion of all indications (destination therapy and bridge to transplant) and prevented meta-analysis.

Results:
The electronic search identified 465 abstracts, of which 50 met inclusion criteria; manual review added 2 articles in press and 3 focused on medical therapy. Evidence was generally of low-strength, with 10 industry-funded trials and registries, 10 multi-center reports, and the remainder single-center observational experiences. Estimated actuarial survival after CF LVAD ranged from 56-87% at 1-year, 43-84% at 2-years, and 47% at 4-years (see Table 1). Improvements in functional class and quality of life were reported, but missing data complicated interpretation. Adverse events were experienced by the majority of patients, but estimates for bleeding, stroke, infection, right heart failure, arrhythmias, and rehospitalizations varied greatly.

Conclusion:
The totality of data for CF LVADs show consistent improvements in survival and quality of life counterbalanced by a range of common complications. While this summary should provide a practical resource for health care provider-led discussions with patients, it highlights the critical need for high-quality patient-centered data collected with standard definitions.
Abstract 145: Rates of Transfusion and Progression to End-Stage Renal Disease in Chronic Kidney Disease Patients Undergoing Transradial Versus Transfemoral Cardiac Catheterization - An Analysis from the VA CART Program
Authors: Vora Amit N , Stanislawski Maggie A , Rumsfeld John S , Maddox Thomas M , Vidovich Mladen , Woody Walter , Nallamothu Brahmajee K , Rao Sunil V
Published: July 2021

Background:
Patients with chronic kidney disease (CKD) are at increased risk of bleeding and transfusion after cardiac catheterization. Whether rates of these complications or progression to new dialysis are increased in this high-risk population undergoing transradial (TR) access compared to transfemoral (TF) access is unknown.

Methods:
From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program between 10/2007-09/2012 we identified 40,160 CKD patients undergoing cardiac catheterization with baseline glomerular filtration rate (GFR) ≤ 60 ml/min. We used multivariable Cox modeling to determine the independent association between TR access and post-procedure transfusion as well as progression to new dialysis using TF as the reference.

Results:
Overall, 3,828 (9.5%) of CKD patients underwent TR access and tended to be slightly younger but overall had similar rates of CKD severity compared with TF patients (GFR 45-60 ml/min: 77.0% vs. 77.0%; GFR 30-44 ml/min: 19.7% vs. 19.3%; GFR 15-29 ml/min: 3.3% vs. 3.7%, p=0.35). TR patients had longer fluoroscopy times (8.1 vs 6.9 minutes, p=<0.0001) but decreased contrast use (90.0 vs 100.0 ml, p=<0.0001). Among the 31,692 patients with a full year of follow-up, 42 (1.7%) of TR patients and 545 (1.9%) of TF patients progressed to new dialysis within 1 year (p=0.64). However, only 33 (0.9%) of TR patients compared with 570 TF patients (1.6%) needed post-procedure blood transfusion (p=0.0006). After multivariable adjustment, there was no significant difference in progression to ESRD between TR and TF patients but TR was associated with a significant decrease in transfusion (Figure).

Conclusion:
Among CKD patients undergoing cardiac catheterization in the VA health system, TR access is associated with a decreased risk for post-procedure transfusion compared with TF access. There was no significant difference between the two approaches with respect to progression to ESRD. These data suggest that TR is a reasonable option for patients with any level of CKD undergoing cardiac catheterization.
Abstract 169: The Role Of Clinical Prediction Factors On Anticoagulant Selection In Atrial Fibrillation
Authors: Lauffenburger Julie
Published: July 2021

Background:
Atrial fibrillation (AF) often benefits from the use of anticoagulants for prevention of stroke or systemic embolism. While novel oral anticoagulants have emerged as possible alternatives to warfarin, it is unknown how treatment selection is determined in practice with clinical guidelines still evolving. This study examined whether and to what extent anticoagulant selection has been driven by clinical predictions of stroke risk (treatment benefit) and bleeding risk (treatment harm) in real-world practice in the US.

Methods:
A nationwide database of commercial and Medicare Part D supplement claims from 2009-2011 was used to extract a cohort of non-valvular AF patients who were newly-initiating therapy after dabigatran availability in Oct 2010. Patients were excluded if they had claims associated with a reversible AF condition. Risk scores of ischemic stroke (CHADS2 and CHA2DS2-VASc) and bleeding (ATRIA) were used to examine associations with either warfarin or dabigatran use, calculated via claims in the outpatient pharmaceutical, inpatient medical, outpatient, and provider claims files. Baseline demographic and clinical characteristics were also measured as covariates, including concomitant diseases and medications. Multivariable log-binomial regression models assessed the association between each risk score and anticoagulant use, adjusting for the measured covariates. C-statistics were also used to examine the variation in treatment selection explained by inclusion of the risk scores.

Results:
In total, 37,401 patients were identified with 31% initiating dabigatran. New users of dabigatran were more likely to be younger, male, and have comorbidities. Patients at intermediate stroke risk (CHADS2 or CHA2DS2-VASc =1) were equally likely to receive warfarin and dabigatran (RR, 95% CI: 0.98, 0.93-1.02), while selection for warfarin was significantly associated with high ischemic stroke risk (CHADS2 or CHA2DS2-VASc ≥2) (RR, 95% CI: 0.87, 0.83-0.92). New users of dabigatran were significantly less likely to have high bleeding risk (ATRIA≥5) versus warfarin (RR, 95%: 0.70, 0.66-0.74). The c-statistic of the base model, which included the other measured covariates, was only marginally increased with the addition of any of the risk scores.

Conclusions:
Despite controlling for other patient characteristics, bleeding risk was strongly associated with the selection of a specific anticoagulant. However, the extent of selection explained by predictions of treatment harm was minimal. Providers appear to base anticoagulant selection on factors other than predictions of treatment benefit, which has implications for studying the anticoagulants’ comparative effectiveness.
Abstract 17: Hospital Variation in Thrombolysis Times in Acute Ischemic Stroke Patients: the Contributions of Door-to-Imaging Time and Imaging-to-Needle Time
Authors: Sauser Kori , Levine Deborah A , Nickles Adrienne V , Reeves Mathew J
Published: July 2021

Background:
Given the limited time window available for treatment with tPA in acute ischemic stroke patients, guidelines recommend door-to-imaging time within 25 minutes of hospital arrival and a door-to-needle time (DTN) within 60 minutes. Despite temporal improvements in door-to-image and DTN, tPA treatment times remain suboptimal.

Objectives:
To examine the contributions of door-to-image and imaging-to-needle times to delays in timely delivery of tPA to ischemic stroke patients, and to examine between-hospital variation in DTN.

Methods:
A cohort analysis of 1,193 ischemic stroke patients treated with intravenous tPA from 2009-2012 at 25 Michigan hospitals participating in the Paul Coverdell National Acute Stroke Registry. The primary outcome was DTN (time in minutes from emergency department arrival to tPA delivery). Multi-level linear regression models included hospital-specific random effects.

Results:
Mean patient age was 68 years, median NIHSS score was 11 (IQR 6-17), 51% were female, and 37% were nonwhite. Mean DTN was 82.9 ±35.4 minutes, mean door-to-imaging time was 22.8 ±15.9 minutes and mean imaging-to-needle time was 60.1 ±32.3 minutes. A majority of patients had door-to-imaging within 25 minutes (68.4%) but only a minority had DTN within 60 minutes (28.7%). At the patient level door-to-imaging time was only modestly correlated with DTN (r= 0.41), conversely image-to-needle time was strongly correlated with DTN (r= 0.89) (figure). In the multi-level model the hospital random effect accounted for only 12.7% of variability in door-to-needle time. Neither annual stroke volume nor primary stroke center designation was a significant predictor of better DTN. Patient factors (age, race, sex, arrival mode, onset-to-arrival time, and stroke severity) explained 15.4% of the between-hospital variation in DTN. After adjustment for patient factors, door-to-imaging time explained only 10.8% of the variation in hospital risk-adjusted DTN, while imaging-to-needle time explained 64.6%.

Conclusion:
Compared to door-to-imaging time, imaging-to-needle time was more closely correlated with DTN and a much greater contributor to variability in hospital door-to-needle times. More attention to systems changes that can decrease imaging-to-needle time for acute ischemic stroke patients is now needed.
Abstract 171: Impact of Institutional Culture on Rates of Transfusions During Cardiovascular Procedures: The Michigan Experience
Authors: Likosky Donald S , Zhang Min , Paone Gaetano , Collins John , DeLucia Alphonse , Schreiber Theodore , Theurer Patricia F , Kazziha Samer , Leffler Dale , Wunderly Douglas J , Gurm Hitinder S , Prager Richard L
Published: July 2021

Objectives:
Red blood cell (RBC) transfusions have been associated with morbidity and mortality in both coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI). As a mechanism for identifying determinants of RBC practice, we quantified the relationship between a center’s PCI and CABG transfusion rate.

Methods:
We identified all patients undergoing CABG (n= 16568) or PCI (n=94634) at each of 33 centers from 2010 through 2012 in the state of Michigan and compared perioperative RBC transfusion rates for CABG and PCI at each center. Crude and adjusted transfusion rates were modeled separately. We adjusted for common pre-procedural risk factors (12 for CABG, and 23 for PCI) and report Pearson correlation coefficients based on the crude and risk-adjusted rates.

Results:
RBC transfusion was more common after CABG (mean 46.5%) than PCI (mean 3.3%), with wide variation across centers for both (CABG min:max, 26.5:71.3; PCI min:max, 1.6:6.0). RBC rates were significantly correlated between CABG and PCI in both crude (r=0.47, p=0.005) and adjusted (r=0.53, p=0.002) analyses, Figure. These findings were consistent when restricting to non-emergent cases (r
adj
=0.44, p=0.001).

Conclusions:
RBC transfusion rates were significantly correlated between the CABG and PCI at individual hospitals in Michigan, independent of patient case mix. Future work should explore institutional determinants of RBC transfusions.
Abstract 173: A Comparison of Administrative Claims Discharge Diagnosis with Electronic Medical Record Problem List in the Diagnosis of Acute Myocardial Infarction
Authors: McCulloch Michael D , Sobol Tim , Yuhas Joy , Ahern Bill , Hixson Eric D , Khot Umesh N
Published: July 2021

Background:
Administrative claims data are commonly used for measurement of mortality and readmissions in Acute Myocardial Infarction (AMI). With advent of the Electronic Medical Record (EMR), the electronic problem list offers new ways to capture diagnosis data. However, no data comparing the accuracy of administrative claims data and the EMR problem list exists.

Methods:
Two years of admissions at a single, quaternary medical center were analyzed to compare the presence of AMI diagnosis in administrative claims and EMR problem list data using a 2x2 matrix. To gain insights into this novel method, 25 patient admissions were randomly selected from each group to undergo physician chart review to adjudicate a clinical diagnosis of myocardial infarction based on the universal definition.

Results:
A total of 105,929 admissions from January 1, 2010 to December 31, 2011 were included. Where EMR problem list and administrative claims data were in agreement for or against AMI diagnosis they were highly accurate. Where administrative claims data, but not EMR problem list, reported AMI the most common explanation was true AMI with missing EMR problem list diagnoses (60%). Less common reasons for discordance in this category include: (1) administrative coding error (20%), (2) computer algorithm error (8%), (3) patient death before EMR problem list created (4%), (4) EMR problem list not used (4%) and (5) AMI diagnosis was removed from EMR problem list (4%). Where EMR problem list, but not administrative claims data, reported AMI the most common explanation was no AMI with historical diagnosis of AMI from a previous admission (60%). Less common reasons for discordance in this category include: (1) AMI present but not the principal diagnosis (32%), (2) administrative coding error (4%) and (3) erroneous EMR problem list entry (4%).

Conclusion:
Compared to administrative and chart review diagnoses, we found that using the EMR problem list to identify patient admissions with a principal diagnosis of AMI will overlook a subset of patients primarily due to inadequate clinical documentation. Additionally, the EMR problem list does not discriminate the admission principal diagnosis from the secondary diagnoses.
Abstract 182: Medication Adherence Based on Part D Claims for Heart Failure Patients after Hospitalization in the Atherosclerosis Risk in Communities Study
Authors: Sueta Carla A , Zhou Lei , Rodgers Jo Ellen , Thudium Emily M , Chang Patricia P , Kucharska-Newton Anna M , Stearns Sally C
Published: July 2021

Purpose:
Recent analyses of national data have focused on long-term adherence in heart failure (HF) patients. Little is known about adherence of HF patients immediately following hospitalization.

Methods:
Hospitalized patients with an adjudicated HF diagnosis were identified from the Atherosclerosis Risk in the Communities (ARIC) study, which has followed a biracial cohort of 15,792 participants from 4 US communities since 1987. Participants with an adjudicated hospitalization diagnosis of acute or chronic HF during March 2006 - December 2009 who were also enrolled in Medicare Part D for at least 3 months prior to hospitalization were included. Part D prescriptions filled were identified using National Drug Codes and analyzed by sub-groups of patients discharged on ACE inhibitors/angiotensin receptor blockers (ACEI/ARB), beta-blockers (BB), or diuretics. Proportion days covered (PDC) was calculated for up to twelve 30-day periods after discharge. PDC was based on days outside of a hospital or skilled nursing facility. Observations were censored by death or end of study period.

Results:
The study sample included 431 HF patients with mean age of 75 years (range 63 to 86), 36% male, and 41% African-American. Of the total patients, 67% were discharged on ACEI/ARB, 79% on BB, and 83% on a diuretic. Among those with discharge medications, some persons never filed Part D claims during the 12 periods (29/287 for ACEI/ARB, 25/340 for BB and 32/357 for diuretics). ACEI/ARB PDC after discharge declined from 74% to 57% over time (Figure 1); BB and diuretics had similar results. Patients with ACEI/ARB PDC>0 during the first 30 day period after discharge had higher PDC for subsequent periods, declining from 92% to 65%. The greatest decline in PDC occurred during the first 2-4 months after discharge for all medications.

Conclusions:
This study has many advantages over some prior studies. HF diagnosis was not defined simply by ICD9 codes. Discharge medications were documented, so Part D claims were not used to identify patients. Part D claims may be missing for some medications taken (e.g., $4 generic plans, provider samples), but ACEI/ARB PDC still declined 27 percentage points among patients with Part D PDC>0 immediately post-discharge. Interventions should be developed to assure early and sustained medication adherence.
Abstract 183: Optimal Medical Therapy for Cardiovascular Disease in the Obese Undergoing Elective Percutaneous Coronary Intervention: Insights from the VA CART Program
Authors: Valle Javier A , O'Donnell Colin I , Klein Andrew J , Armstrong Ehrin J , Maddox Thomas M , Ho P M
Published: July 2021

Background:
Stigma against obese patients is well described in primary care settings and may contribute to bias in therapeutic decision-making. It is unknown if similar stigma exists in obese patients referred for elective PCI. Accordingly, we evaluated the association between body mass index (BMI) and pre-procedural guideline-recommended medication use in patients undergoing elective PCI. The presence of lower medication use in overweight and obese patients may suggest the presence of a treatment bias.

Methods:
Using data from the VA Clinical Assessment, Reporting, and Tracking System (CART) Program, we identified patients undergoing elective PCI from 2007-2012. We classified patients by BMI into normal (19-25), overweight (25-30), obese (>30). Rates of guideline-indicated medication use by BMI were assessed among eligible patients: beta-blockers (BB) for HF or prior MI, statins for CAD or equivalent (DM, CVD, PAD), anticoagulation for AFib and CHADS2> 1, and ACEI/ARB for HF. We also assessed composite rates of BB and statin in eligible MI patients and BB and ACEI/ARB use in eligible HF patients, respectively. Multivariable logistic regression analyses assessed the association between BMI class and use of indicated medications.

Results:
Among 9,630 patients undergoing elective PCI from 2007-2012, 13.9% of patients had normal BMI, 35.6% overweight, and 50.6% obese. Overweight and obese patients were more likely to have sleep apnea, HTN and DM, while normal BMI patients were more likely to smoke, have lung disease, and CVD. Rates of medication use ranged from 45% to 69% depending on the class of medication assessed. After adjustment for CV risk factors, overweight and obese patients were more likely to receive statins and ACE/ARBs and equally likely to receive the other classes of medications compared to normal BMI patients (Table).

Conclusions:
Over 85% of patients undergoing elective PCI in the VA are overweight or obese. Rates of indicated medication use remained low across BMI categories (<70%). There was an association between overweight and obese patients with greater use of some guideline-indicated medications, suggesting that a treatment bias against obesity prior to elective PCI does not exist. Future studies should assess for any impact of BMI on treatment of patients during and following elective PCI.
Abstract 187: Ethics of Codes: Provider Perspectives on Cardiopulmonary Resuscitation Duration
Authors: Young Tiffany J , Perman Sarah , Daeschler Margaret , Kolansky Daniel , Gaieski David , Kirkpatrick James N
Published: July 2021

Background:
Code success can be influenced by many factors such as location of arrest, length of code, patient comorbidities, but also bias. Current recommendations for code duration range from ten to thirty minutes. Recent data suggests that longer resuscitation efforts may result in favorable outcomes. We sought to examine provider attitudes toward code duration and appropriateness.

Methods:
Email invitations were sent to residents in internal medicine and emergency medicine, nurses, midlevel providers, rapid response team members, and attending physicians in emergency medicine and cardiology at a single academic institution. The survey evaluated experience with codes as well as knowledge of recommendations and literature concerning code duration and outcomes. Email invitations were sent to 605 providers in 2 waves; 162 (26.8%) completed the survey.

Results:
Of respondents, 82 (51%) were female. A majority (n=59, 36%) were age 26-30 and were Caucasian (n=117, 75%). The sample included 47 (29%) attendings, 44 (28%) residents, 37 (23%) nurses, 19 (12%) fellows, 11 (7%) interns, and 2 (1%) physician assistants/nurse practitioners. Only 34% of respondents indicated they were familiar or very familiar with literature on code duration and outcomes (range: 56% of attendings, 21% of residents). A substantial minority, 32%, believed a “slow code” to be appropriate or very appropriate, when the team believes resuscitation is futile and the patient/family disagrees, including 35% of nurses and 50% of interns, 28% of women and 34% of men. On the 5 point scale, respondents rated the importance of each of the following factors in deciding when to stop CPR: code duration (average score=4.11), patient comorbidities (3.95), patient’s age (3.68), initial rhythm (3.55), end tidal CO2 measurement (2.94), and location of arrest (2.75). Every respondent over age 50 (100%) agreed or strongly agreed that comorbid conditions were important when deciding to end a code vs. 70% under age 50 (p=0.003).

Conclusions:
This preliminary study suggests that a variety of factors may influence decisions about code termination which may not be in line with emerging evidence. A substantial minority of respondents considered slow codes to be appropriate in the setting of futility. Future research is needed to determine the knowledge base and decision-making processes of providers who participate in decisions about CPR duration.
Abstract 2: Facility-level Variation in 30-day PCI Mortality, Readmission, and Costs in the VA Health Care System: Insights About Short-term Healthcare Value From The VA CART Program
Authors: Bradley Steven M , O'Donnell Colin I , Grunwald Gary K , Maddox Thomas M , Fihn Stephan D , Jesse Robert L , Rumsfeld John S , Ho P. Michael
Published: July 2021

Background:
Value in health care, defined as the health outcomes achieved per dollar spent, is emerging as a framework for improvement in health care delivery. We sought to describe facility-level variation in 30-day PCI mortality, readmission and costs.

Methods:
Using national data from the VA CART Program, we evaluated all patients who had PCI from 2008 to 2010. 30-day total patient costs, readmission, and mortality were attributed to the hospital where the PCI was performed. Risk standardized costs and outcomes were calculated using standardized covariates, adjusting for cardiac and non-cardiac comorbidities.

Results:
There were 60 hospitals (21,173 patients) that performed more than 20 PCIs during the study period with a mean of 353 PCIs. The unadjusted mean mortality rate was 2.5%, with no significant variation in facility-level risk standardized mortality. The unadjusted mean readmission rate was 10.6%. The risk standardized readmission rate ranged from 0.8 to 1.58 times the average, with 2 hospitals significantly below and 8 hospitals significantly above the risk standardized average. The facility-level median per patient total costs was $26,491 (IQR $20,943 to $31,866). The index hospitalization accounted for 42.4% of 30-day total costs, and readmission accounted for 5.6% of the 30-day total costs at the facility-level. Comparison of risk standardized costs identified 17 hospitals with lower than expected costs and 15 hospitals with higher than expected costs. Facilities with low readmission rates were not overrepresented among low cost facilities, suggesting readmissions are not a major contributor to facility-level 30-day cost (Figure).

Conclusion:
We observed no variation in facility-level 30-day PCI mortality despite large variation in cost. Although readmission rates varied, readmission accounted for less than 6% of 30-day cost and was not related to facility-level costs. Further studies are needed to determine factors associated with high-value PCI care, defined by low morbidity and mortality despite similar or lower costs.
Abstract 201: Gemfibrozil In Combination With Statin Is Associated With Reduction In All Cause Mortality: A Retrospective Cohort Study
Authors: Aryal Sudeep R , Newman William
Published: July 2021

Objective:
Statins and gemfibrozil as individual monotherapy have shown to reduce major cardiovascular events with statins alone reducing all cause mortality. However, it is uncertain whether the combination of statins with gemfibrozil is associated with further reduction in all cause mortality compared to mortality reduction by statins alone. We will examine the hypothesis that combination of gemfibrozil with statin is associated with greater reduction in all cause mortality compared to statin alone.

Methods:
We performed a retrospective cohort chart review of the VistA database between January 1, 2003 and January 1, 2013 at the Veterans Affairs Healthcare System in Fargo, North Dakota. All veterans greater than or equal to 18 years of age taking either the combination of statin and gemfibrozil or statin alone for a minimum of 12 months were included in the study. The subjects in either group were selected randomly from the pharmacy database, which divided the subjects into statin or combination group. The total sample size was 1800 with 900 subjects in each group. Our primary outcome variable was all cause mortality. The Kaplan Meier Survival curve was drawn for the combination group versus statin alone group. The adjustment for mortality covariates was by the Cox proportional hazard regression.

Findings:
Statin versus the combination group differed demographically by age (73 ± 11.5 vs 68 ± 11.8), BMI (29.9 ± 50 vs 31.7 ± 5.4), hypertension (72.1% vs 80.9%), diabetes mellitus (33.0% vs 47%), smoking (22% vs 28.2%) and stroke (8.3% vs 5.2%); all P<0.01. The two groups were similar for myocardial infarction, transient ischemic attack, peripheral vascular disease, coronary artery disease, and coronary artery bypass graft outcomes. The all cause mortality difference was 10.2% between statin and the combination group at 10 years (25% vs 14.8%, P<0.0001). The unadjusted Kaplan-Meier analysis over 10 years subsequent to lipid therapy initiation showed a highly significant group difference. Cox proportional hazard adjustment for age, BMI, hypertension, and diabetes revealed persistence of the group difference (P <0.0001).

Conclusion:
Combination of gemfibrozil with statin is associated with greater reduction in all cause mortality compared to statins alone.

Keywords:
gemfibrozil, mortality
Abstract 202: Association Between Implantable Ventricular Assist Device Receipt at Medicare Destination Therapy Centers and Mortality: An Instrumental Variable Analysis
Authors: Baras Shreibati Jacqueline , Baker Laurence C , Banerjee Dipanjan , Hlatky Mark A
Published: July 2021

Background:
Comparing the effectiveness of contemporary implantable ventricular assist devices (VAD) with medical therapy using observational data is challenging because of treatment selection bias.

Objective:
To use instrumental variable analysis to examine 1-year mortality of elderly Medicare beneficiaries with advanced heart failure receiving contemporary implantable VADs compared with conservative management.

Methods:
We identified the first hospitalization for heart failure for at least 14 days between January 1, 2009, and December 31, 2011, among all Medicare beneficiaries 65 to 80 years of age, as well as receipt of an implantable VAD during that hospitalization. We estimated risk-adjusted differences in 1-year mortality for VAD versus medical therapy using a 2-stage least squares instrumental variable analysis method. The date that a hospital was certified by Medicare to implant VADs as permanent circulatory support (“destination therapy facility”) was used as an instrument for VAD receipt, since this variable directly influences the use of VAD therapy. Patients were censored at the date of heart transplantation or death, or at the end of the study period.

Results:
Of 33,483 beneficiaries hospitalized, 827 (2.5%) underwent VAD implantation at 104 hospitals, 30 of which became destination therapy centers between 2009 and 2011. Among VAD recipients, 71 (8.5%) proceeded to heart transplantation. Unadjusted 1-year mortality rates were 26.5% for VAD versus 51.9% for medical therapy (risk difference,-25.4%; P < 0.001). The adjusted risk difference was -23.6% (95% CI -27.0% to -20.1%, P < 0.001). Using instrumental variable analysis, VAD receipt was associated with a significantly larger decrease in 1-year mortality (risk difference, -40.6%, 95% CI -52.2% to -29.0%; P < 0.001).

Conclusions:
When confounding was controlled with instrumental variable analysis, VAD implantation among elderly Medicare beneficiaries, on the margin, was associated with a 41% reduction in 1-year mortality compared with medical therapy, consistent with randomized trial results. Use of a hospital’s “destination therapy” certification date as an instrumental variable may facilitate future comparative effectiveness analyses of VAD therapy.
Abstract 212: Temporal Trends of SPECT Myocardial Perfusion Imaging in Patients with Coronary Heart Disease: A 22-Year Experience from a Tertiary Academic Medical Center
Authors: Jouni Hayan , Askew J. W , Crusan Daniel J , Miller Todd D , Gibbons Raymond J
Published: July 2021

Background:
Over the past 20 years, there has been an increasing decline in the prevalence of abnormal stress single-photon emission computed tomography myocardial perfusion imaging (SPECT) studies among patients with no history of coronary artery disease (CAD). The trend of SPECT studies among patients with known CAD has not been evaluated before.

Methods:
Using the Mayo Clinic nuclear cardiology database, we examined all stress SPECT tests performed between 1/1991-12/2012 in patients with prior history of CAD defined as having prior myocardial infarction, percutaneous coronary intervention, and/or coronary artery bypass grafting. Patients with left bundle branch block, paced rhythm, bicycle or rest-only tests, cardiomyopathy, valvular heart disease, and technically unsatisfactory studies were excluded. The study cohort was divided into 5 time periods: 1991-5, 1996-2000, 2001-5, 2006-10, and 2011-12.

Results:
There were 19373 eligible SPECT tests (mean age 66.2 ± 10.9y, 75.4% men). Annual utilization of SPECT studies in patients with history of CAD increased from an average of 495 tests per year between 1991-1995 to a peak of 1425 in 2003; and then decreased to 552 tests in 2012. Asymptomatic patients comprised 33% in 1991-1995, peaked at 48% in 2006, and then decreased back to 31% in 2012. Over time, patients with typical angina decreased while patients with dyspnea increased,
P
<0.001 (Fig 1). The percentage of high risk SPECT tests significantly decreased, and the percentage of low-risk SPECT tests significantly increased despite the overall decline of SPECT utilization between 2003 and 2012. Almost 80% of all tests performed in 2012 had a low risk summed stress score compared to 29% in 1991,
P
<0.001 (Fig 2).

Conclusions:
In Mayo Clinic Rochester, annual SPECT utilization in patients with prior CAD increased between 1992 and 2003, but then decreased significantly after 2003. Fewer patients had typical angina while patients with dyspnea increased over time. High risk SPECT tests declined while low risk tests increased dramatically. These data suggest that stress SPECT was being increasingly utilized in CAD patients without typical angina who are at low risk.
Abstract 216: Describing Geographically High-Risk Areas for PAD in the Netherlands: Socio-Economic Profile, Treatment Rates and Cardiovascular Prognosis
Authors: Koëter Tijmen , Vriens Patrick W , van Zitteren Moniek , Heyligers Jan M , Burger Desiree H , Lijkwan Maarten , van Hees Koen , Nooren Maria , Smolderen Kim G
Published: July 2021

Introduction:
Geospatial mapping technology has been previously successfully used in cardiac disease to identify geographical areas where at-risk patients live in terms of their socio-economic background and cardiovascular outcomes. This methodology has not been applied for peripheral arterial disease (PAD). By doing so, we could identify vulnerable subpopulations that may benefit from more aggressive secondary prevention and follow-up.

Methods:
We are introducing the Geographically High-Risk Areas for PAD (GAP) study in the Netherlands as a pilot project to leverage the use of geospatial mapping technology in a national outpatient database focusing on patients with PAD. The pilot project reports on 816 patients with newly identified PAD (>Rutherford 1) identified at the regional vascular clinics between March 2006 and November 2011 in the city of Tilburg, The Netherlands. Using the ESRI ArcGIS software, we will address the following specific aims: 1) to geo-map patients’ residential location based on their zip code;2) to describe patients’ socioeconomic characteristics based on data obtained from the Central Bureau for Statistics in the Netherlands and patient interviews;3) to geo-map their interventional procedures (endovascular and/or surgical); and 4) to geo-map patients’ cardiovascular outcomes. As an exploratory aim, we will evaluate the association between having a more vulnerable socioeconomic profile, and undergoing more interventional procedures, and having an adverse prognosis, respectively.

Results:
As an example and to test feasibility, we created a density map with the occurrence of newly identified PAD in the Tilburg area (Figure a), as well as several overviews of maps containing socioeconomic variables (e.g. Figure b - number of patients with PAD on welfare) and cardiovascular risk factors (e.g. Figure c - BMI categories distribution among patients with PAD).

Conclusion:
Using the geospatial mapping methodology in the GAP pilot project in Tilburg, The Netherlands, we will be able to leverage the use of this technology in larger national databases to better identify patients with PAD who are at risk of increased health care utilization and adverse outcomes. This information will be instrumental to help improve prevention and care for PAD in collaboration with local care providers.
Abstract 219: The Impact of Handheld devices on Healthy Lifestyles among School Age Children: A Report from Project Healthy Schools
Authors: Lee Alexander , Jiang Qingmei , Rogers Robert , Vuong Belinda , Wei Wen-Ching , Pew Alexandra , Foti Alisa , Corriveau Nicole , Kline-Rogers Eva , Goldberg Caren , DuRussel-Weston Jean , Jackson Elizabeth A , Eagle Kim A
Published: July 2021

BACKGROUND:
Project Healthy Schools (PHS) is an initiative designed to promote healthy lifestyles in middle school-age children in Michigan. Following the introduction of smartphones and portable video game platforms such as the Play Station Portable more children are using these devices. This trend has led to an increase in screen time in preteens resulting in less time being spent on more active, health-promoting activities. This study aims to analyze the relationship between the increase in technology and handheld/gaming devices and the impact on student’s lifestyle behaviors participating in PHS.

METHODS:
Data on sedentary behaviors were collected from 4,021 middle school students by a self-reported questionnaire. The questionnaire is completed by all participants of PHS at baseline and after completion of the program. The questionnaire focuses on dietary habits, physical activity and sedentary behaviors. Sedentary behavior (screen time) questions included amount of time spent watching TV, playing video games or playing on the computer. In order to determine if technology use was impacting this cohort, baseline survey results were analyzed over a 6 year period. Because the exposure to technology could be associated to socioeconomic status (SE) of the schools, we balanced the sample in SE (based on median household income) through stratified simple random sampling without replacement. Screen times were categorized into high screen time (> 120 min /day) and low screen time (≤ 120 min/day).

RESULTS:
The trends of different types of screen time were plotted from 2008 to 2013 (2010 data were excluded to avoid the bias caused by the extremely small sample size of this year). A consistent trend of a high percentage of TV viewers was present each year. However, the percentage of students categorized as high computer game users and high video game users increased with each year (Table 1).

CONCLUSIONS:
There was a significant increase in both time spent playing on the computer and time spent playing video games between the years 2008 - 2013. It’s possible the introduction of smartphones and portable video games has contributed to this trend. It is essential for wellness programs such as PHS to focus on the importance of limiting the amount of time spent playing screen games while promoting increased physical activity to this age group.
Abstract 223: Patients With Cardiac Comorbidities Carry Worse Outcome as Identified by Our SELF Risk Stratification Pathway: An ACAP-SELF Syncope Dataset Analysis
Authors: Pratap Balaji , Bastawrose Joseph , Pamidimukala Chaithanya K , Patel Dipen , Kalamkar Prachi , Lingannan Archana , Panneerselvam Narmadha , Gurram Adilaxmi , Patel Suketu , Pierce Matthew , Ghosh Himagna , Herzog Eyal , Aziz Emad
Published: July 2021

Background:
According to the design of published and validated SELF pathway, patients with syncope are stratified according to the SELF-1 criteria (Short period, Early-rapid onset, Loss of consciousness, Full recovery) and SELF-2 Criteria (Structural heart disease, abnormal electrocardiogram, and arrhythmia/AFib/AFl).

Methods:
3044 patients were prospectively followed after presenting to our emergency department for the evaluation of syncope. Patients were divided into four groups: Group A (SELF +/+) who met both SELF-1 and 2 criteria, Group B (SELF +/-) who met SELF-1 criteria but not SELF-2, Group C (SELF -/+) who met SELF-2 criteria but not SELF-1 and Group D (SELF -/-) who met neither SELF criteria. The primary endpoint was a composite of readmission for syncope, myocardial infarction (MI), stroke or death. Follow-up was 5 years.

Results:
Group A included 1001 patients (33%), Group B included 359 patients (12%), Group C had 880 patients (29%) and Group D had 804 patients (26%). Patients who met SELF-2 criteria, i.e., patients in Groups A and C, had significantly worse outcome (Group A: HR 1.85; 95% CI: 1.47-2.36; p<0.0001; Group C: HR 2.0; 95% CI: 1.54-2.52; p<0.0001). Presence of Diabetes (HR: 1.3; 95% CI: 1.1-1.5; p=0.003), Coronary Artery Disease (HR: 1.44; 95%CI: 1.2-1.7; p=0.0001) and Congestive Heart Failure (HR 2.0; 95% CI: 1.6-2.4; p<0.0001) were also important predictors of poor outcome.

Conclusions:
Using the SELF-pathway for patients presenting with syncope effectively identifies high risk patients who merit hospitalization and close follow-up post-discharge. These include patients with structural heart disease, abnormal EKG and abnormal telemetry, as well as patients with diabetes, CAD and CHF. This has important implications for the evaluation of a common disease that poses a significant economic burden on healthcare systems.