bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 116: Improvements in the Medical Management and Survival of Patients Hospitalized with Heart Failure
Authors: Joffe Samuel W , McManus David D , DeWolf Matthew , Shih Jeffrey , Kiernan Michael , Spencer Frederick , Lessard Darleen , Gore Joel , Goldberg Robert
Published: March 2022

Background:
Despite the availability of effective therapies, heart failure (HF) remains a highly prevalent, morbid and costly disease. Few data are available, however, describing long-term trends in the medical management and outcomes of patients hospitalized with acute decompensated heart failure (ADHF).

Methods:
We reviewed the medical records of 9,748 patients hospitalized with ADHF at all 11 central Massachusetts medical centers from 1995 to 2004, and abstracted information on patient’s demographic, clinical, and treatment characteristics. Mortality was calculated in-hospital and at 30 days and 1, 2, and 5 years after discharge.

Results:
Between 1995 and 2004 respectively, the use of recommended discharge medications including beta-blockers (26%; 74%), angiotensin pathway inhibitors (50%; 61%), statins (6%; 45%), and aspirin (40%; 63%) increased markedly, while the use of digoxin (55%; 33%), nitrates (68%; 47%), and calcium channel blockers (40%; 30%) declined significantly; nearly all patients received diuretics. Females, the elderly, and patients with chronic lung disease, anemia, incident HF, and multiple comorbidities were less likely to receive recommended medications than respective comparison groups. Between 1995 and 2004, in-hospital mortality decreased from 8.5% to 6.8%; 5-year survival increased from 19% to 28%, a relative improvement of 47%.

Conclusion:
The use of effective HF therapies increased markedly following the issuance of ACC-AHA guidelines for HF in 1995, with a concomitant increase in survival. Nonetheless, the prognosis for patients hospitalized with HF remains poor, as fewer than 1 in 3 patients survives 5 years. Opportunities exist to further improve the use of HF therapeutics.
Abstract 13: Risks of Death and Hospital Readmission by Time Following Hospitalization for Heart Failure and Acute Myocardial Infarction
Authors: Dharmarajan Kumar , Hsieh Angela F , Lin Zhenqiu , Kim Nancy , Ross Joseph S , Horwitz Leora I , Kulkarni Vivek , Suter Lisa G , Bernheim Susannah M , Drye Elizabeth E , Normand Sharon-Lise , Krumholz Harlan M
Published: March 2022

Background:
After hospitalization for heart failure (HF) and acute myocardial infarction (AMI), patients experience increased risk of death and hospital readmission. Defining the trajectory and timing of this period of risk may help guide interventions to improve post-discharge outcomes.

Methods:
We used 2008-10 Medicare data to identify patients ≥65 years discharged alive after HF or AMI hospitalization. Using hazard rates, we characterized the risks of death and first readmission on each day after discharge to describe (1) the maximum daily risks of death and readmission after discharge; (2) risks of death and readmission 1 year after discharge; (3) the time in days after discharge for the risks of death and readmission to reach their maximum daily rates and 50% of their maximum daily rates to characterize the rapidity of decline in risk. We created separate survival models for death and first readmission. Data were censored after 1 year follow up. The readmission model also censored for death prior to readmission.

Results:
Of 878,963 HF hospitalizations, 367,542 (41.8%) died and 618,283 (70.3%) were readmitted in 1 year. Of 350,509 AMI hospitalizations, 90,623 (25.9%) died and 177,031(50.5%) were readmitted in 1 year. The Figure shows hazard rates by time after discharge. For HF, daily risk of death was 0.0056 maximally and 0.0011 at 1 year (19% of maximum). Daily risk of readmission was 0.013 maximally and 0.002 at 1 year (16% of maximum). Daily risk of death was highest 1 day after discharge and 50% less 11 days after discharge. Daily risk of readmission was highest 4 days after discharge and 50% less 49 days after discharge. For AMI, daily risk of death was 0.010 maximally and 0.0004 at 1 year (4% of maximum). Daily risk of readmission was 0.015 maximally and 0.0011 at 1 year (7% of maximum). Daily risk of death was highest 1 day after discharge and 50% less 6 days after discharge. Daily risk of readmission was highest 2 days after discharge and 50% less 13 days after discharge.

Conclusions:
After hospitalization for HF and AMI, risk of death is highest on day 1 after discharge and then declines rapidly. In contrast, risk of readmission peaks later and declines more slowly. This extended period of risk for readmission may justify continued vigilance beyond the 30-day period used by Medicare to evaluate hospital readmission performance.
Abstract 144: Breakfast Habits and Cardiovascular Disease Risk Factors in Middle School Children
Authors: Jones Anne , Corriveau Nicole , Sylvester Rachel , March Michelle , Stasiak Ashley , Gurm Roopa , DuRussel-Weston Jean , Aaronson Susan , Kline-Rogers Eva , Goldberg Caren , Eagle Kim A , Jackson Elizabeth A
Published: March 2022

Background:
Previous studies have found that children and adolescents who skip breakfast are at greater risk of developing obesity and other chronic diseases. This study seeks to examine the relationship between breakfast consumption and cardiovascular disease risk factors in middle school children involved in Project Healthy Schools (PHS), a school-based wellness program.

Methods:
Data was collected from 1,651 sixth-grade students who consented to a health screening which collected physiologic data including blood pressure (BP), heart rate, lipids, and body mass index (BMI). Students also completed a survey evaluating their diet and other health behaviors. This study used data from the follow-up screening post-PHS intervention. Though PHS does not encourage students to fast on the day of the health screening, some students reported to be fasting. Based on this question, students were divided into two cohorts: breakfast eaters (non-fasting) and non-breakfast eaters (fasting).

Results:
Of the students in the study, 85.4% (1410 of 1651) had eaten breakfast on the day of the screening. Students who ate breakfast had lower BMIs than non-breakfast eaters (20.87 vs. 22.24) (p≤0.001). Breakfast eaters reported healthier diet choices, consuming less regular soda (p≤0.001) and high-fat meat (p=0.003), while eating more servings of fruits (p=0.010), vegetables (p≤0.001), and milk (p≤0.001). These students also reported higher levels of various physical activity sessions (p<0.05), and less time in front of the television (p≤0.001) and computer (p=0.016) screen. Students who ate breakfast also had significantly lower BP and LDL-cholesterol (Figure).

Conclusions:
Students who ate breakfast had lower BMIs, were more active, and made better diet choices. These students also had lower BP and LDL-cholesterol. These results suggest that students who eat breakfast may be at lower risk of developing cardiovascular disease, and the importance of breakfast as part of a healthy lifestyle should be emphasized among children and adolescents.
Abstract 147: End of Life Publications in the Cardiovascular Literature
Authors: Lee Joy , Umscheid Craig A , Morgan Sherry , Hanish Asaf , French Benjamin , Kirkpatrick James N
Published: March 2022

Background:
Studies from past decades demonstrate that few articles on end of life issues are published in cardiology journals, compared with other medical specialties.

Methods:
We searched OvidMEDLINE from January 2001 - August 2012 for end of life articles published in cardiology, critical care, respiratory, geriatrics, general medicine, and oncology journals with impact factor (IF) > 1 according to Journal Citation Reports. To test reliability of defining end of life articles, a separate reviewer re-examined a subset of articles from a randomly selected journal for each specialty. Reviewers were compared using a kappa statistic. To estimate rate ratios for publishing end of life articles, a Poisson regression model was used with indicator variables for journal specialty, and IF as an adjustment covariate.

Results:
3741 end of life articles were identified from 391 journals, including 89 cardiology journals. Agreement was good between reviewers (k=0.75). Critical care, general medicine and geriatrics published a higher percentage of end of life articles than cardiology (Rate Ratio [RR] 3.6, 2.5 and 3.7 respectively, p<0.01 for each comparison). Pulmonary and oncology published lower percentages (RR 0.46, p=0.02 and RR 0.68, p=0.08 respectively).

Conclusion:
Cardiology journals no longer published the lowest percentage of end of life articles among medical specialties. These findings suggest a growing, though still suboptimal, recognition of the importance of end of life care in cardiology.
Abstract 15: Decisional Needs in Patients Considering Left Ventricular Assist Device as Destination Therapy: Contrast Between Acceptors and Decliners
Authors: McIlvennan Colleen K , Allen Larry A , Nowels Carolyn , Cleveland Joseph C , Brieke Andreas , Matlock Daniel D
Published: March 2022

Background:
Left ventricular assist device as destination therapy (DT LVAD) is an option for some transplant ineligible patients who are actively dying of heart failure. Essentially, patients are faced with the decision to undergo major surgery to implant a partial artificial heart or transition to end-of-life care. While LVADs can extend life, they are also associated with significant risks including infection, stroke, and caregiver burden. How patients make this decision is poorly understood.

Methods:
We performed semi-structured, in-depth interviews based on the Ottawa Decision Support Framework to understand patients’ decisional needs in accepting or declining DT LVAD. All patients who had DT LVAD in place and patients who declined DT LVAD at an academic medical center between October-December 2012 were interviewed. Interviews were audio-recorded and transcribed. Data were analyzed using a mixed inductive and deductive approach. Additionally, we measured decision regret using the validated, 5-item decision regret scale.

Results:
All 17 eligible patients were interviewed, 13 with DT LVADs and 4 who had declined. Their mean age was 68. Patients accepting DT LVADs often did not perceive a decision. “I had to do it if I wanted to exist anymore.” This perception appeared to come from a belief that choosing end-of-life medical care was not an option, “This [LVAD] was the only option I had..that or push up daisies...so I automatically took this.” They also noted that the risks of the LVAD were not that important as they had “nothing to lose.” Those who declined an LVAD stated they were not afraid of death, asserted that their life lived had meaning, and recognized the potential burdens to both themselves and their family, “There are worse things than death.” For both accepters and decliners, this was an emotionally and spiritually driven decision. Both groups felt highly involved and informed. They also endorsed little decision regret (mean 5/100 for acceptors, 0/100 for decliners).

Conclusions:
There is a fundamental difference in values surrounding death among patients who either accept or decline a DT LVAD. Decision support interventions around this complex medical decision need to consider patient values first before getting into more cognitive aspects of the decision making process.
Abstract 151: Association Between Glycated Hemoglobin A1c And SYNTAX Score In Non-Diabetic Patients Undergoing Coronary Artery Bypass Grafting
Authors: Bhat Tariq M , Chauhan Dhaval , Shah Neeraj , Wahba Joseph , Shariff Masood A , Nabagiez John P , Silverman Robert , Tamburrino Frank V , McGinn Joseph T
Published: March 2022

Objective:
SYNTAX score is now increasingly used as an index to guide further revascularization measures in patients with coronary artery disease. This study is aimed at finding association of glycated hemoglobin (HbA1c) and coronary artery disease severity and lesion complexity as assessed by SYNTAX score in non-diabetic patients who ultimately underwent coronary artery bypass grafting (CABG).

Methods:
A total of 587 non-diabetic patients who underwent CABG after coronary angiography from January 2007 to March 2010 were included in the study. Each patient’s SYNTAX score was calculated based on the coronary angiography. They were divided into four groups based on quartiles of HbA1c. Multivariate logistic regression analysis was performed to evaluate association of HbA1c to SYNTAX score and areas of lesions in individual coronary arteries.

Results:
The mean age of our population was 65 years with 77.3% males. The 4 quartiles of HBA1c were: HbA1c>=5.6%, HbA1c 5.7%-5.8%, HbA1c 5.9%-6.1% & HbA1c>=6.2%. There was no statistically significant association between HbA1c quartiles and SYNTAX score (p=0.54 for 4th vs. 1st quartile of HbA1c). Similarly, there was no statistically significant association between HbA1c and total number of diseased vessels (p=0.72) or total number of grafts used during CABG (p=0.40). We also found no statistically significant association between HbA1c levels and lesions at different anatomical sites: left main coronary artery (p=0.47), proximal left anterior descending (LAD) artery (p=0.92), mid-LAD artery (p=0.89), left circumflex artery (p=0.52) and right coronary &/or posterior descending artery (p=0.44).

Conclusion:
In non-diabetic patients undergoing CABG, there is no statistically significant association between HbA1c and location of coronary artery disease, number of diseased vessels or SYNTAX score.
Abstract 165: What Risk Factors are Associated with Heart Failure Readmission?
Authors: Safi Lucy , Patel Ankitkumar , Cha Christine , Skaf Jad , Cha Rido
Published: March 2022

Background:
In the recent years, there has been a focus on decreasing heart failure readmission rates with many hospital initiatives directed towards implementation of heart failure discharge protocols. We hypothesize that identifying those patients at risk for readmissions may help prevent future readmissions.

Methods:
All patients with heart failure who presented to a tertiary urban medical center from July 2008 to December 2011 were included. Readmission was defined as being admitted to the hospital within one month of a previous heart failure admission. A multivariate analysis was performed on patients readmitted with goal to identify risk factors.

Results:
The study period had 3790 admissions for heart failure where 476 (12.7%) of which were readmissions. It was found that for every unit increase in body mass index (BMI) and hemoglobin, there was a significant decrease in odds of readmission. Antiarrhythmic medication, lipid medication, or angiotensin II receptor blockers (ARBs) also have a significant protective effect. Isosorbide, warfarin, cardiac resynchronization therapy (CRT), and for every unit increase in blood urea nitrogen (BUN) there was a significant increase in the patient’s risk of readmission (Table 1).

Conclusions:
Our single center, retrospective study shows an obesity paradox and a protective effect seen with heart failure medications as well as lipid lowering medications. This information may be used to target at risk patients in order to decrease readmission by establishing close follow-up and maximizing medical therapies.
Abstract 176: Have VA Hospitals Improved their Discharge Policies for Hospitalized Heart Failure Patients?
Authors: Sahay Anju , Heidenreich Paul
Published: March 2022

Objective:
Over the past few years the VA Chronic Heart Failure (CHF) QUERI has been facilitating national initiatives like the Save 5 Million Lives Campaign and Hospital To Home (H2) with specific focus on inpatients, discharge process and follow up HF care. Survival following discharge has improved though it is not clear if discharge policies have changed.

Method:
Using a longitudinal approach in 2008 the CHF QUERI identified facility-level best practices related to discharge processes for hospitalized HF Veterans. In 2008 and then again in 2011 cross-sectional surveys were completed by the Chiefs of Medicine or Chiefs of Cardiology at each VA facility. For both waves of data collection we had a response rate of 100% from 140 facilities.

Results:
Comparative findings over the 3 years show that VA facilities have markedly improved their discharge policies for hospitalized HF patients. Among the facilities reporting none of the following discharge policies in 2008, in 2011 53% of those facilities routinely scheduled a follow-up phone call after discharge within
<
1 week (59%) and >1 week (41%); and 100% of those facilities routinely scheduled a follow-up visit with provider at the time of discharge within
<
1 week (83%) and >1 week (17%).

In 2008 facilities reported that during the first follow up visit after discharge, all the time the patient was seen in the HF clinic (15%), cardiology, not HF clinic (10%)and by primary care provider (59%). On a separate note, in 2011 facilities reported that during the first follow-up visit with provider after discharge the HF patient was usually seen in HF clinic (41%), by cardiology provider not in HF clinic (19%), by primary care provider (37%) and other (3%).

Conclusions:
Significant improvements in the discharge policies of hospitalized HF patients at VA facilities have occurred from 2008 to 2011.

Implications:
Improved discharge HF care may have contributed to the reduction in 30-day mortality.
Abstract 206: Expansion Of Emergency Medical Services Routing For Stroke In The United States
Authors: Sanossian Nerses , Hanks Natalie , He Shuhan , Wen Ge , Krug Aaron M , Kim-Tenser May , Cen Steven , Song Sarah , Saver Jeffrey L , Adamczyk Peter , Mack William J
Published: March 2022

Background:
Organized stroke systems of care include preferential emergency medical services (EMS) routing to deliver suspected stroke patients to designated hospitals. EMS transport of stroke patients is regulated at the State and County level in the United States (US). We aimed to characterize the growth of EMS regional systems of acute stroke care by describing the number and proportion of nationwide stroke hospitalizations in areas with EMS systems of care over a 10-year period.

Methods:
Data on ischemic stroke using ICD-9 coding was collected from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database from the years 2000-2010. The NIS contains all discharge data from 1,051 hospitals located in 45 States, approximating a 20-percent stratified sample. Data on EMS systems of care was obtained from a review of archives, reports, and interviews with state EMS officials. NIS hospital data is not reported at the county level in the state of Texas. Thus although Harris county began EMS routing in 2000, all Texas data were analyzed using the date of state EMS diversion policy in 2005

Results:
Nationwide stroke hospitalizations held steady: 583,000 in 2000 and 573,000 in 2010. From 2000-2003 there were no states and/or counties with EMS systems of care. The proportion of US stroke hospitalizations occurring in jurisdictions with established EMS regional systems of acute stroke care increased steadily from 2004 to 2010 (1%, 13%, 28%, 30%, 30%, 34%, 49%). In 2010, 278,538 stroke hospitalizations, 49% of all US stroke hospitalizations, occurred in areas with established EMS routing, with an additional 18,979 (3%) patients in regions undergoing a transition to EMS routing.

Conclusions:
In 2010 a majority of stroke patients in the United States were hospitalized in an area with established or transitioning to EMS diversion. This milestone coverage of half the US population is a major advance in systematic stroke care, and emphasizes the need for novel approaches, such as telemedicine, to further extend access to stroke center care to all patients.
Abstract 210: Association of Emergency Medical Services Stroke Protocols with Minimizing On-Scene Time for Stroke Patients
Authors: Patel Mehul D , Brice Jane H , Moss Chailee , Suchindran Chirayath M , Evenson Kelly R , Rose Kathryn M , Rosamond Wayne D
Published: March 2022

Background:
Acute stroke patients require immediate medical attention. Therefore, American Stroke Association guidelines recommend that for suspected stroke cases, emergency medical services (EMS) personnel spend less than 15 minutes (min) on-scene at least 90% of the time. However, not all EMS providers include specific scene time limits in their stroke patient care protocols. We sought to determine whether a protocol with a specific time goal was associated with less time spent at the scene.

Methods:
Stroke protocols from each of the 100 EMS systems in North Carolina (NC) were collected and abstracted for scene time instructions. Suspected stroke events occurring in 2009 were analyzed using data from the NC Prehospital Medical Information System, a statewide electronic healthcare record used for evaluation of EMS patient care and system performance. Scene time was defined as the time from EMS arrival at the scene to departure with the patient. Quantile regression was used to estimate how the 90th percentile of the scene time distribution varied by the presence of protocol instructions limiting scene time. Models adjusted for system annual patient volume and metropolitan status.

Results:
In 2009, NC EMS systems varied in their stroke protocols: 23 had no instructions regarding scene time; 73 had general instructions to minimize scene time; and 4 had a specific limit for scene time (i.e. 10 or 15 min). Among 9,723 eligible suspected stroke events, mean scene time was 15.9 min (standard deviation 6.9 min) and median scene time was 15.0 min (interquartile range 11.0-19.5 min). We observed significantly lower 90th percentile scene times in EMS systems with specific time limit instructions (22.0 min) compared to systems without any instructions on scene time (24.6 min). There was no significant difference between 90th percentile scene times in EMS systems with general instructions compared to systems without instructions (25.0 versus 24.6 min). In adjusted quantile regression models, the estimated reduction in the 90th percentile scene time, comparing specific to no instructions, was 2.2 min (95% confidence interval 1.3, 3.1 min). The adjusted difference in 90th percentile scene time between general and absent instructions was not statistically different (0.7 min (95% confidence interval -0.1, 1.4 min)).

Conclusion:
Specific scene time limits were associated with EMS crews spending less time at the scene while general instructions were not. These findings suggest that EMS stroke protocols that include specific scene time limits are more likely to reduce on-scene times than those with no or only general instructions.
Abstract 219: What factors influence the decision to refer patients to a stroke center in an Emergency Medical Service Dispatch Center?
Authors: FREDERIC Muriel , Ozguler Anna , Loeb Thomas , Baer Michel
Published: March 2022

Introduction:
Recent findings recommend fibrinolysis for ischemic stroke patients with no age limit and when onset of symptoms is less than 6 hours before treatment. The aim of this study was to identify the factors that influence the decision to refer to a stroke center (SC) in an Emergency Medical Service Dispatch Center (EMS).

Methods:
A prospective study was implemented in an EMS located in Paris area, from 10/02/2011 to 01/06/2013. Dispatchers initiated 1319 calls with a suspicion of stroke, and transferred them to a Medical Doctor (MD) that took the final decision to refer or not to a SC. Age, gender, socio-economic status of residential area, delay from onset of symptoms to call were first compared at bivariate level. The final analysis was based on backward stepwise logistic regression model with the referral to SC as dependent variable. The [[Unable to Display Character: ﬁ]]nal model included factors associated with referral to a SC at a p level of 0.10. A p value of less than 0.05 was accepted as significant.

Results:
bivariate comparisons showed younger age, call location and short delay from onset to call as significantly associated with referral to a SC (table 1). In the logistic regression model only age and short delay from onset to call remained associated with the referral to a SC. Women tended to less benefit from SC, but with no statistical significance (table 2).

Conclusion:
in our study 26% of callers were referred to a SC, age and delay influenced this decision. Enforced implementation of recent recommendations and standard training in stroke recognition will improve EMS pathways to SC.
Abstract 227: Prescribing Warfarin at Discharge for Heart Failure Patients without Atrial Fibrillation Findings from the Get With The Guidelines-Heart Failure Registry
Authors: Eapen Zubin , Grau-Sepulveda Maria , Fonarow Gregg , Heidenreich Paul , Peterson Eric , Hernandez Adrian
Published: March 2022

Background:
The benefits of anticoagulation in heart failure (HF) without other known indications has not been established. Contemporary use of anticoagulation in HF patients is not well described.

Methods:
We identified patients with HF without contraindications to warfarin therapy who were discharged home from hospitals in the GWTG[[Unable to Display Character: –]]HF Registry from 01/01/2005[[Unable to Display Character: –]]09/30/2011. We excluded patients with a history of atrial fibrillation (AF), stroke, valvular heart disease or inhospital valve surgery. Using multivariable models, we determined patient characteristics independently associated with warfarin prescription.

Results:
A total of 66,140 HF patients from 283 hospitals were identified. Of these, 7,404 (11.2%) were prescribed warfarin at discharge; these patients were more likely to have a left ventricular ejection fraction
<
35% (58.6% vs. 49.0%, p<0.001), coronary artery disease (48.8% vs. 45.3%, p<0.001), or prior myocardial infarction (19.6% vs. 17.4%, p<0.001). After multivariable adjustment, prior implantable cardioverter defibrillator or cardiac resynchronization therapy with defibrillation device implantation was the most strongly associated factor with warfarin prescription independent of the severity of left ventricular systolic dysfunction. Prescription of warfarin in this setting varied widely among hospitals; from 0% to 45.4% (median: 10.7%, 25
th
[[Unable to Display Character: –]]75
th
: 7.5[[Unable to Display Character: –]]14.7) (Figure).

Conclusions:
Approximately 1 in 10 HF patients without AF or other documented indications are prescribed warfarin at discharge, and prescription rates vary widely across hospitals. Further research is needed to understand why anticoagulation is prescribed to patients with HF in the absence of documented indications.
Abstract 23: Impact of Massachusetts Health Reform on Hospitalizations, Length of Stay and Costs of Inpatient Care: Does Safety-Net Status Matter?
Authors: Hanchate Amresh D , McCormick Danny , Feng Chen , Lasser Karen E , Kressin Nancy R
Published: March 2022

Objective:
There is widespread concern that large-scale insurance expansion - such as that anticipated from the Affordable Care Act - has the potential to cause sharp increases in health care utilization and costs. In the setting of Massachusetts’ landmark 2006 health care reform, we estimated pre-reform to post-reform changes in inpatient care volumes and costs, contrasting the experience of safety-net hospitals (SNH) as the predominant providers of care for targeted reform beneficiaries, with that of non-SNH.

Study Design:
We analyzed MA inpatient discharge on all discharges from 2004-2010 for 2,636,326 non-elderly patients (age 18-64) across all 66 short-term acute care hospitals. Safety-net hospitals were identified as those in the top quartile of hospitals in the proportion of hospital admissions with Medicaid, Free Care and self-pay as the primary payer. Using linear regression models we estimated hospital-level post-reform changes in (a) # admissions, (b) length of stay (LOS; days), (c) charge per day ($) and (d) charge per stay ($), separately for SNH and non-SNH, adjusting for patient demographics and comorbidities. We also examined changes for subpopulations by race/ethnicity and socioeconomic status (SES; defined using patient zip code median income). To isolate the impact of reform from secular trends, we treated the elderly as the “control” population.

Findings:
There was no significant post-reform change in the number of admissions; average quarterly number of admissions per hospital were 1,480 pre-reform and 1,520 post-reform (p=0.68). A similar pattern was found for admissions by SNH status, and for minority and low-income subpopulations. Average LOS increased by a smaller amount among SNH (0.20 days; 95% CI=[0.15, 0.25]) than among non-SNH (0.30 days; 95% CI=[0.27, 0.33]). Average charges per day decreased among SNH ($-198; 95%=[$-251, $-145]) and increased among non-SNH ($249; 95%=[$215, $284]). A similar trend with a larger difference was found for average charges per stay (SNH=$-477; 95%CI=[$-768, $-187] and non-SNH=$1,442; 95%CI=[$1,248, $1,635]). Similar trends were found for both acute and non-acute admissions. Among blacks, Hispanics and low-income patients, none of the measures indicated larger increase in SNH compared to that in non-SNH.

Conclusion:
Following MA health reform, utilization of inpatient care did not increase at SNH, the predominant providers of inpatient care for populations targeted by the reform, compared to non-SNH. A similar trend was found for acute and non-acute admissions, and for minority and low-income subpopulations. Future analyses in the coming months will test robustness of these findings using the non-elderly patients from comparison states as the control population.

Implications:
Insurance coverage expansion in MA may not have increased overall use of inpatient use and costs.
Abstract 242: Long-term Outcome Of Quality Of Life Related To Treatment And Observation In Unruptured Intracranial Aneurysms
Authors: Holcombe Andrea , Meissner Irene , Torner James , Piepgras David , Huston John , Zhang Jie , Brown Robert ,   ISUIA Investigators
Published: March 2022

Introduction:
Quality of life changes can occur following procedural interventions and subarachnoid hemorrhage in unruptured intracranial aneurysms (UIA). The International Study of Unruptured Intracranial Aneurysms conducted quality of life assessment using the Mini-Mental State Exam, Rankin Score, and Barthel Index at baseline and the Telephone Interview Cognitive Status Exam (TICS), Rankin Score, and Barthel Index at follow-up.

Hypothesis:
The purpose of this analysis was to compare the 1 year and 5 year outcome in the treatment cohorts (surgery and endovascular) with those of the untreated subgroup.

Methods:
Patients were subdivided into the initial treated and untreated cohorts based upon observation or treatment practices in 61 centers from 1991-1998. 1691 patients were in the observational cohort and 2388 in the treated cohort. The cohorts were followed annually with measures of neurological status, Rankin Scale, Barthel Index and cognition (TICS). Outcomes were determined prospectively. Comparison of outcomes was done using continuous and categorical data. Covariate adjustment was done using general linear models. Stratified analysis was done by Rankin Score at the time of follow-up.

Results:
The percent of patients with a Barthel Index score of less than 60 at 1 year in the cohort was 9.4% (treated patients, 9.7%; untreated patients, 9.2%). The percent of patients at year 1 with a score of greater than 90 was 87.6%, 87.4% for treated patients and 87.8% for untreated patients. The percent of patients with a Barthel Index score of less than 60 at 5 years in the cohort was 41.4% (treated patients, 41.4%; untreated patients, 41.4%). The percent of patients at year 5 with a score of greater than 90 was 56.3%, 56.1% for treated patients and 56.5% for untreated patients.

TICS and Barthel Index scores were significantly associated with each other for patients with Rankin Scores 0-2 (P<0.0001). This was seen at both year 1 and year 5 follow-up, but not for patients with Rankin Score 3-5. At both 1 year and 5 year follow-up, after controlling for Rankin Score, the distribution of Barthel Index scores of untreated patients and treated patients did not significantly differ. At both the 1 year follow-up, baseline Rankin Score, TICS and follow-up Rankin Score were significant predictors of Barthel Score (P<0.0001). At 5 years, only the follow-up Rankin Score was associated with Barthel Score (P<0.0001).

Conclusions:
Barthel Index Score decreased over time, but does not differ with treatment. The Rankin Score was the main predictor at follow-up of Barthel Index Score distribution.
Abstract 26: Durability Of Blood Pressure Control In A Randomized Trial Of Home Telemonitoring With Pharmacist Case Management (Hyperlink)
Authors: Margolis Karen L , Asche Stephen E , Bergdall Anna R , Sperl-Hillen Joann M , O’Connor Patrick J , Maciosek Michael V , Trower Nicole K , Kerby Tessa J , Pritchard Rachel A , Sekenski Jaime L
Published: March 2022

Background:
Patients with high blood pressure (BP) visit a physician on average 4 times per year, but fewer than half have controlled BP. Practical, effective, and sustainable models are needed to improve BP management. Accumulating evidence supports the effectiveness of team-based models for care and home telemonitoring, but few studies have examined whether effects persist after intervention completion.

Aims:
Hyperlink is a clinic-randomized trial testing an intervention combining home BP telemonitoring with pharmacist case management in patients with uncontrolled hypertension.

Methods:
We enrolled 450 patients with uncontrolled BP from 16 primary care clinics, 8 randomized to usual care (UC, 222 patients) and 8 to telemonitoring intervention (TI, 228 patients). TI patients received home telemonitors that transmit BP data to a secure database. Pharmacists met with TI patients by phone and adjusted drug therapy based on home BP data. The intervention had an ‘intensive’ phase for the first 6 months and a ‘maintenance’ phase with less frequent pharmacist support through 12 months. Patients were followed through 18 months to observe durability of effects on BP control (<140/90 mm Hg, <130/80 mm Hg if diabetes or kidney disease). General and generalized linear mixed models were used to accommodate the cluster-randomization.

Results:
Enrollees were 45% female, 82% white, and 12% black, with mean age of 61 years. Mean BP at baseline was 148/85 mm Hg in both groups. Results indicate a significant effect on BP control in the TI group. Around 71% of TI patients achieved BP control at each time point, while UC BP control was 45.2% at 6 months, 52.8% at 12 months and 57.1% at 18 months. The mean difference in BP change (mm Hg) between groups from baseline was -10.7/-6.0 at 6 months, -9.7/-5.1 at 12 months, and -6.6/-3.0 at 18 months (Table 1, attached). Mean number of drugs per patient increased in TI from 1.5 at baseline to 2.2 at 6 months, persisting through 18 months. A small increase was observed in UC, with 1.4 at baseline, 1.6 at 6 and 12 months, and 1.7 at 18 months.

Conclusions:
Home telemonitoring with pharmacist case management was effective at reducing BP for 12 months, with a persistent effect 6 months later. Further long-term follow-up of study participants is planned.
Abstract 291: Impact of an Outpatient Cardiology Heart Failure Discharge Clinic on 30-day Readmission Rates for Patients with a Recent Admission for Heart Failure.
Authors: Marar Devan , Shaw Richard E , Gupta Prabhas , Kersh Edward
Published: March 2022

Introduction:
Heart failure (HF) is a frequent cause of hospitalization in the USA with readmission rates as high as 25%. Given the focus on healthcare costs, healthcare systems are investigating ways to lower readmission rates. Dedicated HF clinics have been shown to improve mortality and decrease hospitalizations. This study was designed to evaluate the impact of a HF clinic staffed by cardiology fellows at an urban institution with an ethnically diverse and economically disadvantaged patient population on institutional readmission rates for heart failure.

Methods:
Using a system wide discharge database and electronic health record (EHR), patients admitted with a primary diagnosis of HF were identified between January 1
st
2011 and March 2012. Using the EHR, patients who were followed up after their hospitalization in our HF discharge clinic were identified. In clinic, patients’ weights and volume status were clinically assessed, medications were optimized, HF education was reinforced to patients and caretakers and further outpatient follow up was arranged. The study group was comprised of those who were readmitted within 30 days for any cause and had been followed in the clinic. The 30-day all cause readmission rates following a HF hospitalization in the year prior to the initiation of the HF clinic and in the year after its creation were compared.

Results:
From January 2011 through March 2012, 154 patients were admitted with the diagnosis of HF; 61 of the 154 (39.6%) hospitalized were seen in the HF clinic following their hospitalization, with an average appointment time of 9.5 days after discharge; 23 of the 154 patients (14.9%) were readmitted within 30 days of their index HF hospitalization. Of the 23 patients readmitted, 4 were seen in the HF clinic following their index HF hospitalization; the average time to follow up in clinic of these 4 patients was 5 days. Accordingly, the 30-day readmission rate for patients seen in the HF clinic was 6.5% versus 20.4% for those not evaluated in the clinic (p = 0.018). In the year preceding the creation of the HF discharge clinic, the 30-day hospital readmission rate for an index HF admission was 20.6%, which decreased to 14.1% in the year after the founding of the clinic (p= 0.01).

Conclusion:
A HF clinic operated by Cardiology Fellows at an urban medical center with a diverse patient population where patients were seen in follow up shortly after a HF hospital discharge was associated with a 13.9% reduction in 30-day all cause rehospitalization. This study suggests that a dedicated heart failure clinic may be a factor in reducing heart failure readmissions.
Abstract 311: Differences in Resting Heart Rate among Trained Collegiate Athletes
Authors: Hatch Jason , Austin Bethany , Magee Lawrence , Zabel Michael , McCoy Marcia , Bunten Linda , Gosch Kensey , Magalski Anthony
Published: March 2022

Background:
While the incidence of sudden death in athletes is low, a number of clinically unsuspected cardiovascular diseases have been linked to sudden death in young well-trained athletes. Athlete-specific ECG criteria have been proposed to facilitate identification of athletes at risk via pre-participation screening; however, normal values for resting heart rate in this population have not been previously described. We sought to determine normative values across various subsets of competitive athletes and to ascertain any differences evident by gender, race and ECG abnormality.

Methods:
1,540 competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Each athlete was resting 3 minutes prior to ECG being performed. ECGs were classified as normal or abnormal according to previously published criteria. Resting heart rate was not a criterion for an abnormal ECG. Resting heart rate difference between genders and sports was done using t-test. ANOVA with follow up t-test was used for difference in resting heart rate between races.

Results:
In 740 consecutively screened male collegiate athletes, resting heart rate was 62.6 (±11) beats per minute (bpm) (min 38 - max 109) versus 800 female athletes with a resting heart rate of 64.5 (±12) bpm (min 35 - max 110). This difference was statistically significant (p= <.001). It was noted that as age increased by 1 year, heart rate on average dropped by 0.7 bpm (mean age was 19.3 ±1.3). Heart rate was on average 2.4 bpm higher in white (n= 1113) than black (n= 302) athletes (64.1 vs. 61.8, p= <.0001). Heart rate was on average 5.5 bpm lower in those who participated in track/cross country vs. other sports (58.2 vs. 63.7, p= <.001).

Conclusion:
Among competitive collegiate athletes, there is a small but statistically significant difference in resting heart rate with slower rates in men and blacks as compared with women and white athletes. Further work needs to be done to elucidate the potential physiologic determinants of these differences and whether they relate to relative risk of incidence of cardiovascular disease.
Abstract 323: Regional Variation in Patient Selection for Endovascular vs. Open Abdominal Aortic Aneurysm Repair
Authors: De Martino Randall , Nolan Brian W , Schanzer Andres , Indes Jeffrey , Kalish Jeffrey , Bertges Daniel , Powell Richard J , Cronenwett Jack L , Goodney Philip P
Published: March 2022

Objective:
The purpose of this study was to analyze the factors that influence the choice of endovascular (EVAR) vs. open (OAAA) strategies for AAA repair, and examine how this decision varies between centers performing AAA repair in New England.

Methods:
We examined prospectively collected data from 2,940 elective infrarenal AAA repairs (985 OAAAs and 1,955 EVARs) performed in 18 centers (2003-2011). All patients were anatomically acceptable candidates for either EVAR or OAAA. We identified pre-operative patient characteristics associated with treatment with EVAR (vs. OAAA repair), adjusting for year. The observed to expected ratio for EVAR utilization was compared across centers.

Results:
Overall, EVAR utilization increased from 51% of all repairs in 2003 to 84% of all repairs in 2011 (p<0.001). EVAR utilization varied across centers, from 25 % of all repairs in one center , to 100% of all repairs in other centers (p<0.001). In multivariable analysis, factors associated with choosing EVAR for were increasing age over 65 (HR 1.6, p<0.01), male gender (HR 1.6, p<0.01), diabetes (HR 1.5, p=0.02), CAD (HR 1.5, p=0.01), CHF (HR 2.6, p<0.01), and COPD (HR 1.5, p<0.01). Even after adjustment for these factors, three centers performed EVAR at rates lower than expected (based on patient characteristics alone), and two centers performed EVAR at rates higher than expected ( p<0.05, Figure). In chi-pie analysis, 53 % of the observed variability in EVAR utilization was attributable to center variation and year of repair, while 47% was attributable to differences in patient characteristics.

Conclusion:
Hospital practice patterns and adaption to technology influence the decision to perform EVAR more than patient characteristics, and many patients eligible for EVAR still undergo open repair in certain centers. Patients and providers interested in EVAR, irrespective of their anatomy, should seek out repair at centers most likely to perform these procedures.
Abstract 335: Cardiac Rehabilitation Referral After Acute Myocardial Infarction: Variation in Referral Rates and Association with Core Components of Risk Factor Management
Authors: Buchanan Donna M , Bennett Kymberley K , Reid Kimberly , Spertus John A
Published: March 2022

Background:
Although currently an endorsed performance measure of quality, cardiac rehabilitation (CR) referral rates remain quite low. Established guidelines describe recommended core components of CR programs for risk factor management: nutritional counseling; physical activity counseling; exercise training; smoking cessation; and weight, hypertension, lipid, diabetes, and psychosocial management. We sought to determine the variability in hospital referral rates for CR and assess whether patients are more likely to be referred who have risk factors that are intervention targets of the core components of CR.

Methods:
We assessed referral to outpatient CR among 3632 MI patients from 22 US hospitals in the TRIUMPH study who were discharged home with risk factor data available. Variation in CR referral rates across hospitals was quantified by the median rate ratio (MRR). The prediction of CR referral by 8 individual risk factors that are intervention targets of CR was assessed using hierarchical modified Poisson regression, adjusting for study site and 16 demographic and clinical patient characteristics.

Results:
Upon hospital discharge, only 39.1% (n=1420) of patients were referred to CR. Referral rates varied greatly across sites, ranging from 2.6% to 88.2%. After adjusting for potentially confounding patient factors, the MRR was 2.47 (95% CI 1.67, 3.23), indicating an average 2.5 times greater likelihood of 2 hypothetically identical patients being referred to CR upon discharge from 1 random hospital as compared with another. Only 1 of 8 risk factors modifiable by CR core components was associated with increased referral (see figure), with overweight patients (BMI > 25 or waist circumference > 40 in. for men, > 35 in. for women) being more likely to be referred than non-overweight patients (RR 1.09; 95% CI 1.03, 1.15; p<0.01).

Conclusion:
Among patients discharged home after MI hospitalization, there are marked differences in outpatient CR referral rates by study site, but relatively little association with patient risk factors that the core components of CR programs are specifically designed to modify. This suggests that site-specific factors strongly influence CR referral and site-level interventions to improve referral are likely to most effectively improve compliance with this performance measure.