bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 050: Improvements in Door to Groin Puncture Time for Surgical Stroke After Quality Protocol Interventions at the University of California, San Diego
Authors: Wali Arvin R , Santiago-Dieppa David R , Cheung Vincent , Steinberg Jeffrey , Hirshman Brian , Abraham Peter , Porras Kevin , Brandel Mike , Jurf Julie , Botts Emily , Pannell Scott , Khalessi Alexander
Published: June 2021

Introduction:
Delays in door to groin puncture time (DGPT) for patients with ischemic stroke caused by acute large vessel occlusion (LVO) correlate with worse clinical outcomes. Stroke centers aim to minimize DGPT to facilitate prompt intervention and limit ischemic brain injury. In this study, we present the results of a comprehensive quality assessment at the University of California, San Diego (UCSD). From 2015 to 2016, institutional implementation of a quality improvement protocol significantly reduced DGPT.

Materials and Methods:
Beginning July 2015, the UCSD interdisciplinary stroke team implemented a series of quality improvement measures to decrease DGPT, with a target of 90 minutes or less. After each case, areas of inefficiency were identified and changes were implemented based on direct feedback from neurointerventional physicians and ancillary staff. Changes included: 1) creation of a pager group notification system to activate the entire neurointerventional team simultaneously, 2) consistently involving anesthesia with each neurointervention, 3) streamlining communication between the vascular neurology and neurointervention teams, and 4) structuring parallel workflows to enhance mobilization speed. R statistical software was utilized to compare DGPT before and after implementation of these process improvements. Patients were divided into three groups based on the date of their intervention as follows: 23 patients treated from July-December 2015, 24 patients treated from January-July 2016, and 14 patients treated from July 2016-December 2016. A multivariable univariate binary logistic regression model was constructed to capture predictors of compliance with our target DGPT (<90 min). Variables analyzed included: date of intervention, mode of patient admission (i.e. transfer, direct admit from ED, inpatient), hospital location, age, and gender.

Results:
61 patients underwent mechanical thrombectomy for treatment of acute LVO from July 2015 to December 2016. In our analysis, date of intervention—as a proxy for implementation of process improvement protocols—and mode of admission were predictive of compliance with target DGPT. Patients who were treated from July 2016 to December 2016—after full implementation of process improvements— were 9.5 times more likely to meet or exceed the target DGPT compared to patients treated July 2015 to December 2015 (p=0.01). Additionally, arrival via transfer from an outside hospital was determined to be an independent predictor of meeting DGPT goals. (p=0.02).

Conclusion:
UCSD’s quality improvement process effected dramatic, statistically significant improvement in DGPT. This analysis demonstrates the utility of a formal quality improvement system at a large, academic comprehensive stroke center.
Abstract 058: Early Effect of Medicare Accountable Care Organizations on Acute Myocardial Infarction Episode Payments
Authors: Sinha Shashank S , Moloci Nicholas M , Ryan Andrew M , Nallamothu Brahmajee K , Hollingsworth John M
Published: June 2021

Objective:
Spending for acute myocardial infarction (AMI) episodes varies widely across hospitals, driven primarily by payments made more than 30 days after discharge. Through collective incentives and an emphasis on care coordination, Medicare accountable care organizations (ACOs) may help reduce this variation. To test this hypothesis, we analyzed national Medicare data.

Methods:
Using a 20% random sample, we identified Medicare beneficiaries admitted for AMI from January 2010 to December 2013. We distinguished admissions to hospitals affiliated with a Medicare ACO from those that were not. We then calculated 90-day, price-standardized, risk-adjusted episode payments made on behalf of beneficiaries, differentiating between early (index admission to 30 days post-discharge) and late payments (31 to 90 days). We also calculated component payments, including those for the index hospitalization, readmissions, physician services, and post-acute care. Finally, we used difference-in-differences estimation to measure the effect of admission to an ACO-affiliated hospital on early and late episode payments.

Results:
Over the study period, 15,219 beneficiaries were admitted to 299 eventual ACO-affiliated hospitals and 73,910 were admitted to 1,685 never ACO-affiliated hospitals (
p
<0.001). While beneficiaries admitted to eventual ACO-affiliated hospitals tended to be younger than those admitted to never ACO-affiliated hospitals (mean age: 79.2 ± 8.6 versus 80.0 ± 8.5, respectively;
p
=.003), they had similar levels of comorbidity (mean Elixhauser score: 2.7 ± 1.4 versus 2.7 ± 1.4, respectively;
p
=0.526). Mean 90-day episode payments were greater for ACO-affiliated hospitals [$24,887 versus $23,966;
p
<0.001]. In the period after ACO implementation (2012 and 2013), total payments for AMI episodes fell by $1259 (Figure;
p
<0.001). Most of this savings was attributable to decreases in early ($1118) versus late ($141) episode payments. However, none of these savings differed based on admission to an ACO-affiliated hospital (
p
=0.363 for the difference).

Conclusions:
Early Medicare ACOs have not affected 90-day episode payments for AMI admissions. Future studies should explore the possibility of heterogeneity in effect based on ACO structure.
Abstract 063: Diagnostic and Treatment Patterns of Cardiac Sarcoidosis: a Single Center Experience
Authors: Grodzinsky Anna , Fendler Timothy , Bhardwaj Bhaskar , Sharma Akshit , Lawhorn Stephanie , Taduru Siva , Saeed Ibrahim , Howell Gregory
Published: June 2021

Background:
Clinically manifest cardiac involvement occurs in approximately 5% of patients with sarcoidosis. The principal manifestations of cardiac sarcoidosis (CS) are conduction abnormalities, ventricular arrhythmias, and heart failure. In 2014, the first international guideline for the diagnosis and management of CS was published. There are emerging data to support cardiac MRI and PET imaging in the diagnosis of CS. Additionally, despite a paucity of data, immunosuppression therapy (primarily with corticosteroids) has been advocated for the treatment of clinically manifest CS. Device therapy, primarily with implantable cardioverter-defibrillators, is often recommended for patients with clinically manifest disease. There are few contemporary descriptions of treatment and outcomes related to CS. In this case series, we describe diagnostic and treatment patterns of thirty patients with CS.

Methods:
We performed a retrospective chart review of 30 patients with diagnosed CS. We used a spreadsheet with deidentified patient information to describe baseline patient characteristics including age, presenting symptoms, diagnostic modality, duration of follow up, medication regimen and follow up imaging, as well as the variables listed above concerning those who are deceased.

Results:
Of thirty patients included in this case series, age at diagnosis ranged from 28-69, the diagnostic modalities included autopsy of explanted heart, cardiac MRI in combination with mediastinal lymph node biopsy, endomyocardial biopsy, cardiac MRI, and cardiac PET. For the majority of patients, dyspnea was the presenting symptom. Most patient presented with NYHA class I or II symptoms. Half of patients underwent ICD implantation. Eleven patients had documented arrhythmias, including ventricular tachycardia, complete heart block, and atrial fibrillation. Of our cohort, eight patients have concomitant pulmonary sarcoidosis. Follow up duration has ranged between 1 and 12 years. Five patients proceeded to cardiac transplantation. Two patients are deceased, including one patient who suffered recurrence of cardiac sarcoidosis following orthotropic heart transplantation.

Conclusions:
In this case series of thirty patients with cardiac sarcoidosis, we describe that patients are commonly undergoing cardiac MR and PET imaging to support the diagnosis of CS. Tissue diagnosis remains a standard. Immunomodulators and cardiac device are frequently used, and further follow up data would be helpful in describing outcomes related to these therapies. This descriptions may prompt longer term observational studies that document diagnostic and therapeutic modalities, as well as cardiovascular outcomes, related to cardiac sarcoidosis.
Abstract 070: A Precision Medicine Test Influenced Costs of Care Among Patients Presenting With Stable Symptoms Suggestive of Obstructive Coronary Artery Disease: Economic Endpoint Analysis From the PRESET Registry
Authors: Ladapo Joseph , Budoff Matthew , Sharp David , Azarmina Pejman , Huang Lin , Maniet Bruce , Herman Lee , Monane Mark
Published: June 2021

Background:
Because of diagnostic uncertainty, patients with symptoms suggestive of obstructive coronary artery disease (CAD) are referred at high rates to cardiologists and advanced cardiac testing. This evaluation process may also expose patients to appreciable costs and health risks. A previously validated, blood-based test incorporating age, sex and genomic expression into an algorithmic score (1-40) has shown clinical validity in assessing the likelihood of obstructive CAD (≥50% luminal diameter stenosis by quantitative coronary angiography) early in the cardiac workup. This test has also shown clinical utility in association with decision making around cardiac referrals and helping clinicians determine the current likelihood of obstructive CAD in symptomatic patients.

Hypothesis:
We hypothesized that use of the age/sex/gene expression score (ASGES) test would influence cost of care in the diagnosis and management of symptomatic patients with suspected obstructive CAD.

Methods:
The prospective PRESET Registry (NCT01677156) enrolled stable, non-acute adult patients presenting with symptoms suggestive of obstructive CAD to 21 US primary care practices from September 2012 to August 2014. Primary care clinicians provided pre- and post-ASGES diagnosis and evaluation plans for each patient. Demographics, clinical factors, and ASGES results (predefined as low [ASGES ≤ 15] or elevated [ASGES > 15]) were collected, as were management plans post-ASGES testing, including referrals to cardiology or further functional/anatomic testing. The economic analysis for cost of care after ASGES testing was based on the cost of cardiovascular-related tests, invasive procedures, office visits, emergency room visits, and hospital admissions during 1-year follow-up.

Results:
This sub-analysis cohort included 560 patients, with 50% females and median age 56 years. Patients had a median ASGES score of 18, with 246 (44%) patients with ASGES
<
15. The mean cost of care for patients in the year following ASGES testing was $234 (SD ±$707) in the low ASGES versus $1,296 (SD ±$5230) in the elevated ASGES group (p=0.03 by Wilcoxon rank test). Multivariate analysis incorporating patient demographics and clinical covariates showed that low ASGES was associated with a 51% reduction in cost of follow-up care compared to elevated ASGES group (p<0.001 by log-linear regression).

Conclusion:
In this community-based cardiovascular registry, the ASGES influenced costs in the evaluation of patients with suspected obstructive CAD. Low score patients had approximately half the cardiovascular costs of elevated score patients in one year follow-up. Our work provides evidence supporting the economic value of using precision medicine in the delivery of cardiovascular care.
Abstract 072: Impact of Chronic Diabetes on Periprocedural Outcomes Among Patient With Atrial Fibrillation and Flutter Who Underwent Radiofrequency Catheter Ablation Therapy (RFA). Report From the NIS 2014.
Authors: Alliu Samson E , Adejumo Adeyinka , Durojaiye Modupeolowa , Emmanuel Akintoye , Wolf Lawrence , Lichstein Edgar , Hecht Melvyn , Stephan Kamholz , Adegbala Oluwole , Onyeakusi Nnaemeka , Ajayi Tokunbo
Published: June 2021

Background:
Diabetes has been associated with complications and poor perioperative outcomes. In Radiofrequency catheter ablation - therapy of choice for drug refractory atrial fibrillation and flutter, association between diabetes and procedural complications are less documented.

Objectives:
To examine if there is a difference in perioperative complications in patients with chronic diabetes who underwent RFA for atrial fibrillation/flutter when compared with non-diabetics.

Methods:
We selected patients > 45 years from the National Inpatient Survey data 2014. We identified 8356 patients (69.6 ± 9.1yrs) who underwent catheter ablation. Logistic regression analyses were performed to investigate the difference in perioperative complications (hemorrhage, cardiac perforation, cardiac complications, respiratory complications, peripheral vascular complications, stroke and in-hospital mortality) between diabetics and non-diabetics. All models were adjusted for age, gender, race, residential income, insurance, co-morbidities, hospital bed size, hospital location/teaching status, hospital region, length of stay and median household income.

Results:
Among our selected 8356 patients, 5777(69.1%) were non-diabetics, 2203(26.4%) had uncomplicated diabetes and 376 (4.5%) complicated diabetes. Overall there were 634 events (240 hemorrhages, 56 perforations, 163 cardiac complications, 43 respiratory complications, 12 strokes, 40 peripheral vascular complications and 80 in-hospital death. Rates of complications were the same among diabetes and non-diabetics. In the multivariate models, the odds of complications remain statistically non-significant across all the groups. However, among all the patients who underwent RFA, there is an increased odds of hemorrhage among patients with Medicare insurance versus private insurance (OR 1.73 95%CI 1.11-2.70), peripheral vascular complications among hospitals in the south (OR 3.35 95%CI 1.30-9.62), respiratory complications among patients with CHF (4.60 95%CI 1.68-12.60), death among patients with renal failure (OR 2.22 95%CI 1.32-3.73) and hospitals in the south (2.55 95% CI 1.08-6.0) and west (OR 3.23 95%CI 1.25-8.3) compared to the northeast. Odds of stroke were less among both urban non-teaching (OR 0.02 95%CI 0.01 - 0.34) and teaching hospital (OR 0.05 95%CI 0.01-0.36) when compared to rural hospital.

Conclusions:
RFA has a similar procedural safety in diabetics when compared to non-diabetic patients. It remains a safe procedure in diabetics with drug-refractory atrial fibrillation and flutter. Renal failure, CHF, type of Insurance, hospital location and teaching status are predictors of complications after RFA.
Abstract 079: Health-related Quality of Life With Routine Invasive versus Ischemia-guided Strategies for the Elderly With Non-ST Elevation Myocardial Infarction (NSTEMI)- Insights From PREMIER/TRIUMPH
Authors: Patel Krishna K , Arnold Suzanne V , Qintar Mohammed , Jones Philip G , Alexander Karen P , Spertus John A
Published: June 2021

Introduction:
In elderly patients presenting with a NSTEMI, a routine invasive strategy reduces cardiovascular events as compared with an ischemia guided approach. However, the association of invasive management on health status outcomes is unknown.

Methods:
Among patients admitted with NSTEMI from 2 multicenter US AMI registries (TRIUMPH and PREMIER), health status was assessed at baseline and at 1, 6 and 12 months after AMI using the Seattle Angina Questionnaire (SAQ), a CAD-specific health status measure (scores range 0-100, higher scores=better QoL; ~5-points is minimally clinically relevant difference). Invasive management was defined as coronary angiography within 72 hours of admission without a preceding stress test. Propensity-adjusted linear mixed effect models were used to compare health status between treatment strategies over the year after MI. Interactions of age (divided into <65, 65-74, 75-84, ≥85 years) with treatment and with time were tested.

Results:
Among 3559 patients with NSTEMI, 2455 (69.0%) were treated with a routine invasive strategy. This was more common in younger patients, with 72.4% (1610/ 2223) of patients <65 years, 66.6% (476/715) of those 65-74 years, 63.1% (316/501) of those 75-84 years, and 44.2% (53/120) of those ≥ 85 years treated with a routine invasive strategy (p<0.001). In propensity-adjusted analyses (Table), invasive strategy was associated with a clinically small but statistically significant benefit on SAQ physical limitation, angina frequency, and summary scores over the year following AMI; benefits that were greatest early on. Although patients aged ≥ 85 years had slightly worse health status when treated with an invasive strategy, there was no significant interaction between age and treatment strategy for any of the health status outcomes (p≥ 0.15 for all).

Conclusions:
In the setting of a NSTEMI, a routine invasive strategy is associated with small but significant health status benefits. These effects were most notable early during follow-up and did not significantly differ by age. While there was no significant interaction of treatment with age, the oldest old group appeared to derive slightly less health status benefit from a routine invasive strategy—results that will need to be confirmed in a larger study.
Abstract 085: Discordance in Patient-Physician Perceptions of Angina Experiences and Delivery of Care
Authors: Arnold Suzanne V , Deedwania Prakash C , Heggen-Peay Cherilyn , Greene Laurence , Carter Jeffrey D , Sapir Tamar
Published: June 2021

Background:
Recent findings from the APPEAR study indicate that physicians under-recognize angina frequency in many patients with coronary artery disease (CAD). We surveyed patients with angina and the physicians who treat them to further explore factors that may contribute to under-recognition and the impact of under-recognition on patients’ experiences.

Methods:
Surveys were completed by 29 US physicians and 122 of their patients with stable CAD. Patients reported burden of angina and satisfaction with medication. Physicians estimated the average experience of their patients with stable CAD.

Results:
As with prior studies, physicians under-estimated burden of angina as reported by the patients (physician vs. patient report: weekly of more angina: 24% vs 50%, p=0.014; CCS III/IV: 22% vs 43%, p<0.001). Physicians also over-estimated patients’ satisfaction with control of their angina (70% vs 50%, p<0.001). Over 90% of physicians reported routinely asking patients about the frequency of their angina and adherence to antianginal medications (Figure). Most physicians estimate angina using NYHA or CCS class (59% and 24%, respectively) whereas 7% used a patient-reported assessment. While lack of time was reported as the biggest barrier to accurately assessing patients’ burden of angina, most physicians reported having no challenges to conducting these assessments. Conversely, 68% of patients reported that their physicians effectively communicated with them.

Conclusions:
Using a detailed survey of patients with stable CAD and their physicians, we found that physicians believe they are communicating effectively and most patients agreed (although to a lesser degree); yet, a substantial discordance between physician and patient perceptions of angina remains. These discordances may contribute to suboptimal treatment decisions, decreased treatment satisfaction, and poor quality of life. The observed discordances may be explained partly by the fact that <10% of physicians reported using a tool to assess angina burden directly from the patients, as physicians appeared to over-estimate their ability to accurately assess angina using traditional interview techniques. Education and use of validated angina assessment tools are essential for aligning perceptions to improve patient care and outcomes.
Abstract 094: Evaluation of Readmission and Survival Rates After Heart Failure Hospitalization in the Veterans Affairs Health Care System Between 2006 and 2013
Authors: Parizo Justin , Lin Shoutzu , Sahay Anju , Heidenreich Paul
Published: June 2021

Objective:
Evaluate trends in readmission and mortality rates after heart failure (HF) hospitalization among veterans in the era of improved utilization of guideline directed therapy and nation-wide focus on decreasing hospital readmission rates.

Background:
In the past decade, a strong emphasis has been placed on decreasing HF readmissions. Concurrently, adherence to guideline directed therapy has improved. A 2002 to 2006 evaluation of the Veterans Affairs Health Care System (VAHCS) showed stagnant HF readmission rates, but declining mortality rates. It is unclear to what extent the recent focus on decreasing readmission and following guidelines has affected these outcomes.

Methods:
The 30-day mortality and 30-day readmission rates of patients admitted with a first diagnosis of HF from 2006 to 2013 in the VAHCS were assessed for temporal trends. Odds ratios for these outcomes were adjusted for patient demographics, medical history, and laboratory data.

Results:
This study included 119,261 patients admitted to VAHCS institutions between 2006 and 2013 with a new diagnosis of HF. Among these patients, 116,849 were male, the mean age was 71.1 years, 80,497 were white, 24,753 were black, and 6,548 were Hispanic. During the two years preceding admission, the incidence of renal disease, ischemic heart disease, diabetes, malignancy, hypertension, COPD, CVD, and acute myocardial infarction were 46.1% (54,984 of 119,261), 73.5% (87,640 of 119,261), 56.1% (66,883 of 119,261), 16.2% (19,257 of 119,261), 92.8% (110,687 of 119,261), 53.7% (64,064 of 119,261), 22.9% (27,268 of 119,261), and 26.5% (31,619 of 119,261), respectively. During the study period, the 30-day readmission rate declined from 19.56% (3852 of 19,694) to 13.76% (1420 of 10,317, p < 0.0001) with an adjusted odds ratio of 30-day readmission in 2013 (vs 2006) of 0.66 (95% CI: 0.66 to 0.76) (Figure 1). Conversely, the 30-day mortality rate was stable at 5.62% (1107 of 19,694) in 2006 and 5.30% (547 of 10,317) in 2013 (p = 0.45) with an adjusted odds ratio of 30-day mortality in 2013 (vs 2006) of 1.22 (95% CI: 1.09 to 1.37). This odds ratio was stable from 2007 through 2013.

Conclusions:
Despite the observed decline in 30-day readmission rates, 30-day mortality rates have been unaffected by the recent focus on preventing readmission and improved guideline adherence.
Abstract 100: Prevalence of Peripheral Vascular Disease Among Patients Using Cannabis, an Analysis of the 2014 National Inpatient Sample data
Authors: Adejumo Adeyinka C , Alliu Samson , Ajayi Tokunbo O , Oluwole Adegbala M , Onyeakusi Nnaemeka , Adejumo Kelechi , Durojaiye Modupeoluwa , Bob-manuel Tamunoinemi , Almaddah Nureddin , Lichstein Edgar
Published: June 2021

Background:
Despite being illegal in most countries, cannabis is highly utilised by a growing number of individuals for recreational purposes worldwide. With its increasing legalisation in many states across the United States, the effects of cannabis on different body systems are expected to rise. Its association with peripheral vascular disease (PVD) remains ambiguous.

Objective:
To examine if there is a difference in prevalence of PVD amongst patients who use cannabis when compared to non-users.

Methods:
Using the 2014 National Inpatient Sample database (N=7,071,762), we identified patients with and without a diagnosis of PVD. We also identified patients using cannabis (nondependent and dependent users) and non-users. We performed the univariate and bivariate analysis. After we had composed the crude models, we adjusted for every known risk factor for PVD. These factors included age, gender, tobacco, hypercholesterolemia, coronary artery disease (CAD), cerebrovascular vessel disease (CVD), hypertension, diabetes, renal failure, alcohol, obesity, race, insurance type, average income at the location of residence, and family history of PVD/CVD/CAD.

Results:
In our total 7,071,762 sample, 98.27% (6,949,339) are non-users, 1.54% (108,910) are nondependent users and 0.19% (13,513) are dependent users. About 3.75% (264,920) of the patients had a diagnosis of PVD versus 96.25% (6,806,842) without a diagnosis of PVD. The odds of PVD is 20% less among nondependent users when compared to nonusers (AOR 0.80[0.76-0.85]). Furthermore, dependent users have a 55% reduced odds of developing PVD when compared to nonusers (AOR 0.45[0.35-0.57]) showing a dose-response relationship. The in-group comparison showed that dependent users were 44% less likely to have PVD when compared to non-dependent users (AOR: 0.56[0.44-0.72]). Overall, the odds of PVD remain significantly high among patients who uses tobacco (AOR 1.97 [1.95-1.99]), diabetes (AOR 1.54 [1.53-1.55]), hypercholesterolemia (AOR 1.46 [1.45-1.47]), family history of PVD/CVD/CAD (AOR 1.03 [1.01-1.05]), personal history of CAD (AOR 2.55 [2.53-2.57]).

Conclusions:
Cannabis is an independent protective factor against PVD. Molecular biology evidence shows that cannabis contains various bioactive agents. Beta-caryophyllene (out of many) preferentially binds to CB-2 receptors on immune cells causing an anti-inflammatory response. We believe that more molecular studies targeting such receptors or isolating such anti-inflammatory compounds in cannabis might be useful in the treatment of vascular disease.
Abstract 101: Qualitative Evaluation of a State Stroke Registry
Authors: Reynen David J , Welter Christina R , Lenihan D Patrick , Pinsker Eve C , Seweryn Steven M , George Mary G
Published: June 2021

Objectives:
Set within the California Stroke Registry/California Coverdell Program (CSR/CCP) - a stroke-care-related quality improvement (QI) program, this study sought to do as follows: (1) describe the program’s previous prevention efforts (through quarter 1 [Q1], 2015); (2) explore what factors were influential in bringing about this programmatic state; and (3) investigate what changes could occur, in order to usher in a better future state for the program.

Methodology:
Starting in quarter 2, 2015, a systematic review of twenty-seven CSR/CCP documents preceded the conduct of fourteen key informant interviews. Subsequently, content and thematic analyses of the CSR/CCP documents and interview transcripts were performed in NVivo, and, using an action research approach, key stakeholders vetted the findings and translated them into recommendations for change.

Findings:
(1) In terms of the CSR/CCP’s programmatic state through Q1, 2015, it was revealed that, with respect to (a) recruitment (of registry members), (b) program infrastructure, (c) partnerships, and (d) QI activities, there was misalignment not only with the program’s original guiding vision but also with the prevailing national healthcare trends at that time. Of concern was the program’s lack of a functional data collection system to monitor stroke care - a significant and far-reaching liability. (2) With regard to factors that gave rise to this sub-par programmatic state, this study suggested that certain tangible influences (e.g., historical decisions, staffing patterns, operational constraints) and intangible factors (e.g., held beliefs, a lack of visibility, a lack of programmatic fit within the larger organization) had been important. (3) With respect to changes that could enable the CSR/CCP to achieve a more optimal future state, two key recommendations emerged: (a) that the CSR/CCP ought to adopt more explicit knowledge management practices - i.e., capturing, sharing, and using informational assets; and (b) that the CSR/CCP ought to be working cross-functionally - i.e., establishing multi-disciplinary teams, intentionally-focused on specific aspects of the program’s work.

Implications:
Out of this project came key findings related to knowledge management and cross-functional teams. Taking action in these areas could enable the use of timely, relevant data in driving the change-related efforts of dedicated human and other resources. Such change could lead to an improved programmatic state, one that (1) is more in line with the CSR/CCP’s original guiding vision; and (2) could serve as a model of clinical medicine and public health coming together to improve health at the community level. While becoming consistent with national healthcare trends, an improved programmatic state could also have immediate local benefits, as the CSR/CCP likely would be more effective in its work to improve the quality of stroke care.
Abstract 102: The Association of Sleep Duration with Healthcare Expenditure Across Cardiovascular Health Profiles: The Baptist Health South Florida Employee Study
Authors: Aneni Ehimen C , Osondu Chukwuemeka U , Valero-Elizondo Javier , Veledar Emir , Nasir Khurram
Published: June 2021

Introduction:
Despite the substantial evidence of health benefits associated with adequate sleep duration, little is known about the relationship between sleep duration and healthcare expenditure. In this study, we examined the relationship between sleep duration and healthcare expenditure in an employee population.

Methods:
Employees of Baptist Health South Florida voluntarily participated in a Health Risk Assessment in 2014 from which data for this study was obtained. Self-reported sleep duration for each participant was collected via a web-based questionnaire. In addition, participants were assessed for cardiovascular health (CVH) status using the American Heart Association’s ideal CVH construct and categorized as optimal and suboptimal CVH (5 - 7 metrics and 0 - 4 metrics at ideal levels respectively). Annual healthcare expenditure obtained from health insurance claims data was aggregated with participants’ data. Two-part regression models were used to calculate mean and marginal per-capita healthcare expenditures.

Results:
Among all participants (n=9071), after adjusting for age, sex, educational attainment and ethnicity, the mean healthcare expenditure in persons who slept for between 6-7.9 and ≥8 hours was $6,167 and $6,117, compared to $8,098 in those that slept < 6 hours (see bar chart in figure). This corresponded to about $1932 (6-7.9h) and 1982 (≥8h) less in healthcare expenditure (vs. <6h). Adjusting further for obesity (BMI≥30kg/m
2
) or CVH (2 groups, see above) did not significantly alter these results (figure).

In sub-group analyses, persons who achieved optimal CVH (n=3574) had the greater costs benefits (> $3000) from ≥ 6 hours a day while those with suboptimal CVH profiles (n=5497) showed no statistically significant cost benefits associated with ≥6 hours of sleep (see bar charts in figure).

Conclusions:
Workers who sleep ≥ 6 hours a day incur significantly lower healthcare costs compared to those who sleep < 6 hours a day independent of obesity or CVH status. The greatest reductions in healthcare expenditure were seen among persons with optimal CVH suggesting an effect modification by CVH on the association between sleep duration and healthcare costs. These findings highlight the need for promoting good sleep hygiene as well as heart healthy lifestyles among employee populations.
Abstract 106: Success in Failure: Reduction in 30-Day Readmissions in Primary and Secondary Heart Failure
Authors: Gadde Sushee , Aune Catharine , Omar Bassam , Burckhartt Barbara
Published: June 2021

Background:
Heart failure (HF) remains an epidemic with high morbidity, mortality and cost, which has been largely attributed to 30-day readmissions, with a national average of 23%.
OBJECTIVE:
To assess the impact on readmission rates of a heart failure clinic dedicated to taking care of advanced heart failure patients with limited resources and multiple readmissions.

Methods:
A multidisciplinary heart failure team was established, including a lead physician, case managers, pharmacist, social service, dietary, nurse manager, nurse practitioners and HF RN. Guideline-directed medical therapy (GDMT) was enforced through standardized inpatient and outpatient order sets and algorithms, post-discharge one week follow-up appointments, and a structured transition of patient care from the inpatient to the outpatient setting. Free medications were secured when needed. The 30-day readmission rates were analyzed over a 3-year period since the inception of the program, using the Chi-square test.

Results:
The total 30-day readmission rate prior to implementation of the heart failure team was 12.4%, with 4.9% readmitted with heart failure as a primary cause (primary), and 7.5% readmitted with heart failure as a secondary cause (secondary). In the following year, the total readmission rate was 10.5% (4.9% primary and 5.6% secondary). Two years later, the total readmission rate fell drastically to 5.7% (1.8% primary and 3.9% secondary, P < 0.05). Increased compliance with clinic visit appointments and adherence to GDMT recommendations were documented, in addition to demonstration of overall institutional cost-saving.

Discussion:
Congestive heart failure is an extremely morbid and costly epidemic associated with high mortality. The 30-day readmission rates add tremendously to the cost of caring for heart failure patients, in addition to further worsening the overall morbidity and mortality. We report the experience of a small university-based program in addressing this problem utilizing a multidisciplinary team, in addition to external resources, to enforce GDMT, and improve patient participation and compliance with treatment recommendations. The total readmission rates significantly declined, with the biggest impact observed when heart failure was the primary diagnosis. The heart failure team was awarded the American Heart Association Get With The Guidelines (GWTG) Heart Failure Gold Plus Quality Achievement Award, in recognition of the significant positive impact the team had on the overall care of heart failure patients. Our model should be applicable to other practices, with little additional resources and with increased coordination, yielding tremendous clinical improvements and overall net financial savings.
Abstract 108: Impact of a Wireless "Wearable" Device to Measure Daily Activity in Patients With Coronary Microvascular Disease Treated With Late Na Channel Inhibition (ranolazine): a Substudy of the RWISE Clinical Trial
Authors: Birkeland Kade , Khandwalla Raj M , Kedan Ilan , Shufelt Chrisandra L , Mehta Puja K , Minissian Margo B , Wei Janet , Handberg Eileen M , Thomson Louise E , Berman Daniel S , Petersen John W , Anderson R. D , Cook-Wiens Galen , Pepine Carl J , Bairey Merz C N
Published: June 2021

Background:
Since late Na channel inhibition (ranolazine) improves exercise duration in the stress laboratory among angina patients, we questioned if this benefit would translate to impact step-count during daily life assessed by a "wearable" device.

Methods:
We conducted a pilot substudy within a randomized, double-blinded, placebo-controlled, cross-over trial of subjects with angina, non-obstructive coronary artery disease and coronary microvascular dysfunction. Ranolazine was administered (500-1000mg BID for 2 weeks). The outcome of interest was difference in Fitbit Flex daily step-count during weeks 2 of ranolazine or placebo treatment. Other outcomes included angina, quality of life, ischemia, diastolic function.

Results:
30 subjects were analyzed. Overall, late Na channel inhibition reduced daily step-count vs. placebo (5757 +/- 3076 vs. 6593 +/- 3393, p=0.01) and did not improve angina. However, among those with improved angina (SAQ-7 improvement), a direct correlation with increased step-count (0.42, p=0.02) was observed, most due to typical angina (0.57, p=0.05) (Fig).

Conclusions:
We report the "first" data set from a wearable monitor to measure step-count in a controlled late Na channel inhibition trial. Our results suggest short-term late Na channel inhibition (ranolazine) does not increase step-count during daily life.
Abstract 115: Beta-blocker Therapy in Cocaine Users With Heart Failure: Insights From an Urban Academic Center
Authors: Egbuche Obiora E , Maihemuti Axiyan , Effoe Valery , Millard Heather R , Addae Leonard , Adedinsewo Demilade , Onwuanyi Anekwe
Published: June 2021

Background:
Beta-blockers are first line agents for reduction of symptoms, hospitalization and mortality in heart failure patients with reduced ejection fraction (HFrEF). The safety and efficacy of continuous beta-blocker therapy (BBT) in patients who use cocaine remain controversial and available literature is limited. We aimed to evaluate clinical outcomes of BBT among HFrEF patients who use cocaine.

Methods:
We conducted a retrospective chart review of 90 patients with a diagnosis of heart failure based on ICD9-CM codes and baseline ejection fraction (EF) <40% who tested positive for cocaine on urine toxicology test at the time of index admission. We included patients age 18 or older with at least 3 months of follow up. Baseline EF was obtained from the earliest available echocardiogram report in 2011 and repeat EF was obtained from follow up echocardiogram reports while on BBT. We described baseline patient characteristics, comorbidities and outcomes (change in EF during study period, re-hospitalizations and mortality).

Results:
In our study population (mean age = 56.1 ± 7.8 years), the mean baseline EF was 24.1% (std=9.0). The mean overall change in EF among patients on continuous BBT was 1.9% (std=14.6; p-value=0.2) over a mean follow-up time of 15.5 months (std=8.6). Thirty-nine percent (n=35, mean follow up=15.7 months) of our study population had a decrease in EF (mean change= -10.6%; std=6.8), 22% (n=20, mean follow up=17.4 months) had no change in EF and 39% (n=35, mean follow up=14.3 months) had an increase in EF (mean change= +14.3%; std=7.5). There was an average of 3.2(std=3.3) re-hospitalizations. Ninety-two percent (n=83) were alive at the end of the study period.

Conclusion:
Continuous beta-blocker therapy in HFrEF patients who abuse cocaine has variable effects on left ventricular EF. Large observational studies are needed to further elucidate the efficacy and safety of long-term beta-blocker therapy in this population.
Abstract 116: Relationship of Stroke Unit Status With Quality of Care and Outcome for Acute Stroke Patients: Results From China National Stroke Registry II
Authors: Zhang Xinmiao , Li Zixiao , Wang Chunjuan , Wang Caiyun , Yang Xin , Gu Hongqiu , Pan Yuesong , Liu Liping , Zhao Xingquan , Wang Yilong , Wang Yongjun
Published: June 2021

Introduction:
A key element in modern stroke care is dedicated stroke units. However, it is unclear whether processes of acute ischemic stroke (AIS) care and outcomes are different between hospitals with and without stroke units in China.

Methods:
We analyzed the China National Stroke Registry II data from June 2012 to January 2013. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to analysis the relationship between stroke units and clinical outcomes.

Results:
Among 19 604 AIS patients, there were 11050 (56.4%) patients in 121 hospitals with stroke units, and 8554 (43.6%) patients in 96 hospitals without stroke units. After matching, 8125 pairs of patients were analyzed. Totally, the composite score of processes was higher in hospitals with stroke units than that without(77% versus 74%, p<0.05). Hospitals with stroke units were more likely to conduct anticoagulation for atrial fibrillation, early antithrombotic treatment, smoking cessation, and stroke education (Figure 1). However, there are no differences between patients in hospitals with and without stroke units in clinical outcomes(Table 1).

Conclusions:
Our study showed that processes of care of AIS were better in patients in hospitals with stroke units. However, patients in hospitals with stroke units didn’t performance differences in clinical outcomes after discharge.
Abstract 120: A Retrospective Study on Heart-lung Transplantation Patient Utilizing United Network for Organ Sharing Database to Identify the Effect of CMV Donor Recipient Serostatus, Age, Sex, or Anti-thymocyte Immunoglobulin Therapy on Mortality
Authors: Urja Prakrity , Gujjula Nagarjuna R , Anugula Dixita , Parekh Jai , Kumar Mukund , Walters Ryan W , Anantanarayan Mahesh , Vivekanandan Renuga
Published: June 2021

Background:
Heart-lung transplant is the treatment of choice for the end-stage disease to improve the survival and the overall quality of life. One of the major causes of the morbidity and hospitalization after the heart-lung transplant is cytomegalovirus (CMV) infection. The major determinant of CMV infection includes the donor (D) and recipient (R) serological status present (+) or absent (-) at the time of transplant. Different category of serostatus include high risk (D+/R-), intermediate risk (D+/R+, D-/R+) and low risk (D-/R). The risk of CMV infection is also related to the immunosuppressive protocol. Our aim was to identify if age, sex, or anti-thymocyte immunoglobulin (ATG) immunosuppressive therapy are associated with mortality in heart-lung transplant patients.

Methods:
We retrospectively analyzed heart-lung transplant patients identified within the United Network for Organ Sharing (UNOS) database. For mortality data, differences in donor-recipient CMV serostatus were evaluated using unadjusted and adjusted logistic regression models. SAS v. 9.4 was used for statistical analysis with
p
< .05 used to indicate statistical significance.

Results:
Of the 79,015 patients who had a heart and/or lung transplant, CMV serostatus data was available for 49,294 patients (62%). All 49,294 patients had gender and age data; however, only 3,080 (6%) had ATG induction data. The overall mortality rate was 39%, with statistically significant differences in mortality rate observed between the low and intermediate risk groups (36% vs. 40%;
p
< 0.001) and between the low and high risk groups (36% vs. 39%;
p
< 0.001). After adjusting for age, sex, and ATG induction at discharge, low risk patients had 21% lower odds of dying compared to high risk patients (95% CI = 1% to 37%;
p
= 0.040). The effect of serostatus on mortality was not moderated by age, biological sex, or ATG induction at discharge. Finally, a 1% increase in the odds of dying was observed between patients who were one-year older at transplant (
p
= 0.006), and patients who received ATG induction at discharge had 54% lower odds of dying relative to patients who did not receive ATG induction (
p
< 0.001).

Conclusion:
Serostatus had the exclusive effect on mortality with higher mortality rate in high risk group compared to low risk serostatus group. Young population group had lower mortality rate and ATG induction therapy tends to lower the mortality rate.
Abstract 125: Natural Language Processing Identifies an Association Between Canadian Cardiovascular Society Angina Severity and Mortality Within the Department of Veterans Affairs
Authors: Owlia Mina , Dodson John A , DuVall Scott L , LaFleur Joanne , Patterson Olga , Shah Rashmee , Sedlis Steven P , Bress Adam
Published: June 2021

Background:
Stable angina is estimated to affect more than 10 million Americans and is the presenting symptom in half of patients diagnosed with coronary disease. Documentation of angina severity resides as unstructured data and is often unavailable in large datasets. We used natural language processing (NLP) to identify Canadian Cardiovascular Society (CCS) angina class and determine the association with all-cause mortality in an integrated health system’s electronic records (EHR).

Methods:
We performed a historic cohort study using national Veterans Health Administration data between 1/1/06 and 12/31/13. Veterans with incident stable angina were identified by ICD-9-CM codes. We developed an NLP tool to extract CCS class from free text notes. Risk ratios (RR) for all-cause mortality at one year associated with CCS class were calculated using Poisson regression.

Results:
There were 299,577 Veterans with angina, of which 14,216 had at least one CCS class extracted via NLP. Mean age was 66.6 years, 98% were male sex, and 82% were white. Diabetes increased with CCS class, but other comorbidities were stable (Table). There were 719 deaths at one year follow-up. The adjusted RR for all-cause mortality at one-year comparing Class III to Class I and Class IV to Class I was 1.40 (95% CI 1.16 - 1.68) and 1.52 (95% CI 1.13 - 2.04), respectively.

Conclusion:
NLP-derived CCS class was independently associated with one year all-cause mortality. Its application may be limited by inadequate EHR documentation of angina severity.
Abstract 126: The Association Between Medication Aherence and Time in Therapeutic Range (TTR) Among Patients with Atrial Fibrillation Treated With Warfarin: Lessons From the Parkland Health and Hospital System
Authors: Wang Joseph , Vigen Rebecca , Clark Christopher , Das Sandeep
Published: June 2021

Background:
Therapeutic anticoagulation with Warfarin among patients with atrial fibrillation reduces the risk of stroke. To achieve this risk reduction, it is important that the TTR is > 65%. Novel oral anticoagulants are noninferior or superior to Warfarin in reducing the risk of stroke and do not require maintaining a narrow therapeutic window. The goals of this study were to determine the TTR in a safety-net hospital system as well as predictors of poor TTR. Second, we set out to determine the association between medication nonadherence and TTR. If nonadherence is a significant independent predictor of TTR, this implies that a universal policy of switching to NOACs without considering patient adherence may not improve outcomes.

Methods:
We queried the Parkland Health and Hospital System electronic medical record for all patients from January 2010 to 2016 with a diagnosis of atrial fibrillation or flutter on EKG who were on warfarin and had INR results available during the study period. TTR was calculated using the Rosendaal method. Patients were grouped into TTR quartiles. Adherence to Warfarin was defined by the proportion of days covered to the medication (0 – 100%). Multivariable linear regression modeling was used to assess the associations between demographic, comorbid conditions, and adherence and TTR.

Results:
A total of 2,626 patients were included in the analysis. There was significant variability in the TTR with the median TTR of 50% and IQR of 31 - 66. Younger age, black race, alcohol and drug use history, use of antiplatelet medications, and systolic blood pressure >160 was associated with having TTR in the lowest quartile (<31%). Medicare status was associated with lower likelihood of being in the lowest quartile of TTR. Finally, lower adherence was associated with increased likelihood of having poor TTR (Table).

Conclusions:
TTR to Warfarin in this underserved population is suboptimal. Given that adherence to Warfarin is independently associated with poor TTR, in the absence of strong adherence interventions, a policy of universal NOAC adoption is unlikely to significantly improve outcomes. If patients are transitioned to NOACs, this data implies that a targeted adherence intervention will be necessary to ensure that the medication is effective in reducing the risk of stroke.