Cardiometabolic Risk and Dietary Behaviors in Middle-School Children Consuming School-Sourced Lunch

OBJECTIVE

Childhood obesity remains a major public health issue. This study assessed the association between school-sourced lunches and cardiometabolic risk factors in middle-school students.

METHODS

Data from health behavior surveys and physiologic screenings in a Michigan middle-school wellness program between 2005 and 2019 were used to analyze the association of school lunch consumption with cardiometabolic risk factors (overweight/obesity, non-fasting lipids/glucose, blood pressure) and dietary behaviors (fruit/vegetable consumption, intake of sugar-sweetened beverages/foods). Students were divided into three groups based on their responses to the survey item if they 1) always, 2) sometimes, or 3) never consumed school-sourced lunches. Groups were compared using descriptive statistics and chi-squared tests.

RESULTS

Students consuming school-sourced lunches were more likely to have overweight or obesity, without significant differences in total, HDL, or LDL cholesterol. There was no difference in non-fasting glucose levels, blood pressure, or resting heart rate. Students consuming school sourced lunch were more likely to have increased sugary and fatty food or beverage consumption. Students consuming school sourced lunch were more likely to attend school in a low or middle socioeconomic status region.

CONCLUSIONS

In this large cohort of middle-school children, consuming school-sourced lunches was associated with a greater prevalence of overweight and obesity and consumption of fatty foods and sugary beverages. School-based interventions should target methods to reduce consumption of sugary beverages and unhealthy snacks and promote consumption of fruits and vegetables, particularly among high-risk individuals.

Lifestyle Behaviors and Cardiometabolic Health in Middle-School Children

Background: Lifestyle behaviors (LB), defined by diet and physical activity, are associated with cardiometabolic health among adults. The association of LB with cardiometabolic health among middle-school children is uncertain. Methods: An abbreviated version of the School Physical Activity and Nutrition survey was used to examine LB among students participating in a wellness program between 2004 and 2018. Students were incorporated into three groups determined by self-reported healthy LB (≥6, 4-5, ≤3 behaviors), including; ≤1 serving/day sugary foods/beverages; ≤1 serving/day fried/fatty foods; ≥1 serving/day fruits and vegetables; ≤2 hours of screen time/day; ≥1 day/week of physical education; ≥1 team sport/year; and ≥1 session/week of moderate to vigorous activity. Baseline cardiometabolic parameters [BMI, lipids, glucose, and blood pressure (BP)], resting heart rate (HR), and HR recovery were examined in association with LB groups. Results: Of 2538 children, 488 (19.2%) reported ≥6, 1219 (48.0%) reported 4-5, and 831 (32.7%) reported ≤3 LB. White or Asian race and higher socioeconomic status were associated with ≥6 LB (p < 0.001). Students performing ≤3 LB exhibited higher BMI (p < 0.001), BP (p = 0.001), resting HR (p < 0.001), and HR recovery (p < 0.001). Students performing ≥6 LB were less likely to be overweight (p < 0.001), obese (p < 0.001), or have low high-density lipoprotein (p = 0.05); however, more likely to have elevated triglycerides (p < 0.01). Conclusions: Among middle-school students, baseline BMI, BP, resting, and recovery HR were higher among children reporting fewer healthy LB. Students performing more healthy LB were less likely to be overweight or obese. Efforts to improve LB among middle-school children may be important for primordial cardiovascular prevention efforts.

Predictors of Early (0-7 Days) and Late (8-30 Days) Readmission in a Cohort of Acute Coronary Syndrome Patients

Background:

Readmissions following acute coronary syndrome are unevenly distributed across the 30-day post-discharge period. There is limited data on predictors of all-cause readmission in early (0–7 day) and late (8–30 day) post-discharge periods for this population; the purpose of this retrospective cohort study was to identify predictors of early and late readmission.

Methods:

Patients at Michigan Medicine (Ann Arbor, Michigan, United States) with a principal discharge diagnosis of unstable angina, ST-segment elevation myocardial infarction, or non-ST segment elevation myocardial infarction between April 2008 and November 2017 were identified. Predictors of early and late readmission were analyzed with multivariable logistic regression models.

Results:

Of 1120 patients hospitalized following acute coronary syndrome, 198 (17.68%) were readmitted within 30 days while 70 (6.25%) were readmitted within 7 days of discharge. Of 30-day readmissions, early readmissions were more likely in females [OR 2.26, 95% confidence interval (CI) 1.23, 4.16], non-white individuals (p=0.05), or patients requiring intensive care unit admission during hospitalization (OR 2.20, 95% CI 1.14, 4.24). Relative to patients not readmitted within 7 days, patients who were female, had history of atrial fibrillation, principal discharge diagnosis of non-ST segment elevation myocardial infarction, or required intensive care unit admission were more likely readmitted early. History of congestive heart failure was a predictor of late readmission when compared to patients not readmitted in 30 days.

Conclusion:

Following acute coronary syndrome, predictors of readmission varied between early and late readmission groups. Readmission predictors provides healthcare providers with information useful in minimizing readmissions and concomitant financial penalties.

Cardiac Transitional Care Effectiveness: Does Overall Comorbidity Burden Matter?

BACKGROUND

Cardiovascular disease is the most common cause of mortality and hospitalization in the United States. Transitional care initiatives can improve outcomes for cardiac patients, but it is unclear whether patients with different baseline comorbidity burden benefit equally. We evaluated the effectiveness of the Bridging the Discharge Gap Effectively (BRIDGE) program, a nurse-practitioner-led transitional care clinic, in mitigating adverse clinical outcomes in cardiac patients with varying Charlson comorbidity index (CCI).

METHODS

We studied patients referred to BRIDGE between 2008 and 2017 postdischarge for a cardiac condition. Using proportional hazards regression models, we evaluated associations between attendance at BRIDGE and hospital readmission, emergency department (ED) visit, and a composite outcome consisting of readmission, ED visit, or mortality, and assessed interaction between BRIDGE attendance and CCI.

RESULTS

Of 4559 patients, 3256 (71.4%) attended BRIDGE. In patients with low CCI, attendance at BRIDGE was inversely associated with hospital readmission (adjusted hazard ratio = 0.82, 95% confidence interval [CI]: 0.69, 0.97, P = .02) and the composite endpoint (adjusted hazard ratio = 0.84, 95% CI: 0.72, 0.98, P = .02). Associations of BRIDGE attendance with both readmission and ED visit were significantly weaker in patients with high CCI (adjusted P, interaction = .007 and .03, respectively). Overall, BRIDGE attendance was associated with an 11% lower hazard of developing the composite endpoint (95% CI: 2%, 19%, P = .01).

CONCLUSIONS

Attendance at a transitional care clinic is inversely associated with risk of readmission and a composite endpoint in cardiac patients with low CCI. Future research should investigate modified transitional care programs in patients with varying comorbidity burden.

Trends in Calcium Channel Blocker Use in Patients with Heart Failure with Reduced Ejection Fraction and Comorbid Atrial Fibrillation

BACKGROUND

Heart failure with reduced ejection fraction and atrial fibrillation commonly coexist. Most calcium channel blockers are not recommended in heart failure with reduced ejection fraction, but their use has been seldom evaluated. For patients with heart failure with reduced ejection fraction and comorbid atrial fibrillation, we sought to 1) determine the proportion discharged on contraindicated calcium channel blockers, 2) describe how clinicians' use of these medications at discharge have changed over time, and 3) identify predictors for contraindicated calcium channel blocker prescription at discharge.

METHODS

We analyzed 395 patients discharged with heart failure with reduced ejection fraction and atrial fibrillation between 2008 and 2018. Discharge on a contraindicated calcium channel blocker (any calcium channel blocker except amlodipine) was the primary outcome. Changes in calcium channel blocker prescription over time were evaluated with a Cochran-Armitage trend test. Multivariable logistic regression was used to identify predictors of calcium channel blocker prescription at discharge.

RESULTS

Twenty-nine (7.3%) patients were discharged on a contraindicated calcium channel blocker without change over time (P_trend = .38). Of these, 26 (86.7%) were discharged on multiple atrioventricular nodal blocking medications. Hypertension (odds ratio [OR] 7.87; 95% confidence interval [CI], 1.04-59.40) and female sex (OR 3.01; 95% CI, 1.36-6.67) were both associated with contraindicated calcium channel blocker prescription at discharge while diabetes mellitus was negatively associated with this outcome (OR 0.34; 95% CI, 0.14-0.88).

CONCLUSION

One in 14 patients with heart failure with reduced ejection fraction and comorbid atrial fibrillation were discharged on a contraindicated calcium channel blocker, without change over time. Most patients were discharged on multiple atrioventricular nodal blockers, highlighting potential need for greater coordination between discharging physicians, pharmacists, and electrophysiology.

Early (0-7 day) and late (8-30 day) readmission predictors in acute coronary syndrome, atrial fibrillation, and congestive heart failure patients

OBJECTIVES

Thirty-day readmission following hospitalization for acute coronary syndrome (ACS), atrial fibrillation (AF), or congestive heart failure (CHF) is common, and many occur within one week of discharge. Using a cohort of patients hospitalized for ACS, AF, or CHF, we sought to identify predictors of 30-day, early (0-7 day), and late (8-30 day) all-cause readmission.

METHODS

We identified 3531 hospitalizations for ACS, AF, or CHF at a large academic medical center between 2008 and 2018. Multivariable logistic regression models were created to identify predictors of 30-day, early, and late unplanned, all-cause readmission, adjusting for discharge diagnosis and other demographics and comorbidities.

RESULTS

Of 3531 patients hospitalized for ACS, AF, or CHF, 700 (19.8%) were readmitted within 30 days, and 205 (29.3%) readmissions were early. Of all 30-day readmissions, 34.8% of ACS, 16.8% of AF, and 26.0% of the CHF cohorts' readmissions occurred early. Higher hemoglobin was associated with lower 30-day readmission [adjusted (adj) OR 0.92, 95% CI 0.88-0.97] while patients requiring intensive care unit (ICU) admission were more likely readmitted within 30 days (adj OR 1.31, 95% CI 1.03-1.67). Among patients with a 30-day readmission, females (adj OR 1.73, 95% CI 1.22, 2.47) and patients requiring ICU admission (adj OR 2.03, 95% CI 1.27, 3.26) were more likely readmitted early than late. Readmission predictors did not vary substantively by discharge diagnosis.

CONCLUSION

Patients admitted to the ICU were more likely readmitted in the early and 30-day periods. Other predictors varied between readmission groups. Since outpatient follow-up often occurs beyond 1 week of discharge, early readmission predictors can help healthcare providers identify patients who may benefit from particular post-discharge services.

Physiological and Lifestyle Factors Associated With Abnormal Blood Pressure in Adolescents Before and After a School-Based Wellness Program in Michigan: A Report From Project Healthy Schools

PURPOSE

Hypertension (HTN) is associated with increased cardiovascular risk and unhealthy lifestyles in adults. However, data on both physiological and lifestyle factors associated with abnormal blood pressure (BP) in adolescents, as well as the effectiveness of interventions in improving these factors among adolescents with abnormal BP, is scarce.

METHODS

Students enrolled in a middle-school-based wellness program, Project Healthy Schools (PHS), between 2005-2016 were eligible. Three systolic (SBP) and diastolic (DBP) BP measurements were taken pre-PHS and post-PHS; averages of the final two were analyzed. Students were grouped by baseline BP: abnormal BP (≥90th percentile for SBP and/or DBP, or ≥120/80 mmHg) or normal BP (<90th percentile for SBP and/or DBP, or <120/80 mmHg). Demographics, physiologic measures, and health behaviors were compared between groups pre- and post-PHS.

RESULTS

Of 2,865 students, 812 (28.3%) had abnormal BP. Median SBP was 119 mmHg in abnormal BP students and 103 mmHg in normal BP students (p < .001). Females were less likely to have abnormal BP than males (48.4% vs. 51.6%, p < .01). Pre-PHS, abnormal BP students were more likely to be overweight (62.3% vs. 28.2%, p < .001) or obese (38.9% vs. 11.3%, p < .001) than normal BP students. Their total cholesterol, triglycerides, random glucose, resting, and recovery heart rates were also higher, and they had worse dietary and sedentary habits. Post-PHS, abnormal BP students demonstrated greater reduction in SBP (-4.0 vs. 2.8 mmHg, p < .001) and DBP (-3.3 vs. .8 mmHg, p < .001) than normal BP students.

CONCLUSIONS

Abnormal BP was prevalent and associated with worse cardiometabolic health parameters and behaviors at baseline. Abnormal BP students demonstrated significant improvements in BP post-PHS, suggesting school-based programs may be effective as nonpharmacological lifestyle interventions in this population.

The Relationship Between Patient Satisfaction With Hospitalization and Outcomes Up to 6 Months Post-Discharge in Cardiac Patients

Little is known about the relationship between patient satisfaction with inpatient care and post-discharge outcomes. This study examined inpatient hospital satisfaction after a cardiac event and outcomes through 6 months post-discharge. We examined 327 cardiac patients from the Bridging the Discharge Gap Effectively database who completed a patient satisfaction survey about their hospital admission and had post-discharge outcomes data. Higher patient satisfaction with the discharge process correlated with fewer readmissions at 90 days post-discharge. Higher patient satisfaction with hospital staff management of personal issues correlated with fewer emergency department visits at 6 months post-discharge. Higher patient satisfaction with overall assessment of care and hospitalization correlated with lower mortality rate at 6 months post-discharge. Being nonwhite correlated with lower nursing care satisfaction. Associations between cardiac patient satisfaction and outcomes exist. In this population, higher patient satisfaction correlated with better outcomes. Patient satisfaction data may be able to inform areas for health system improvement.

Insights into hospital readmission patterns of atrial fibrillation patients

INTRODUCTION

Patients admitted to the hospital with atrial fibrillation have associated morbidity and mortality and incur significant costs. Data characterizing atrial fibrillation patients at high risk for readmission are scarce. We sought to inform this area by characterizing and categorizing unplanned readmissions of atrial fibrillation patients.

METHODS

Retrospective data were abstracted from the charts of patients discharged from 2008 to 2012 after an index hospitalization for atrial fibrillation and referred to the nurse practitioner-led transitional care program, Bridging the Discharge Gap Effectively. Unplanned readmissions were dichotomized as early (⩽30 days) or late (31-180 days) and further classified as either "atrial fibrillation/atrial fibrillation-related" (AF/AF-related), "Cardiac; not AF/AF-related," or "Not cardiac-related." Case classifications were adjudicated by a senior cardiologist. Patient demographics and readmission characteristics were then compared.

RESULTS

Of 255 patients, 97 (38.0%) had unplanned readmissions within 180 days of discharge; 45 (46.4%) were early and 52 (53.6%) were late. Atrial fibrillation and cardiac causes accounted for 68.9% (n=31) of early readmissions and 65.4% (n=34) of late. Patients with late readmissions were more likely to have diabetes (32.7% vs. 17.7%, p=.022) and higher CHA₂DS₂VASc scores (3.63 vs. 2.98, p=0.026) than those not readmitted. No other differences in baseline characteristics were seen within or between groups. The 30-day all-cause readmission rate in this sample was 17.6% (n=45).

CONCLUSION

Readmissions following hospital discharge for atrial fibrillation are common; approximately 50% of these readmissions are for reasons unrelated to atrial fibrillation. In order to reduce atrial fibrillation-related readmissions, further research is needed to characterize predictors of readmission and to develop effective transitional care interventions.

Abstract 228: Comparison of the Effect of Local and Long-Distance Delivery Models for a School-Based Wellness Intervention on Health Behaviors of Middle School Students

Background: Michigan’s upper peninsula (UP) is a remote area with only 3% of the state’s population, making it difficult to reach with health interventions. Nearly half of the UP counties have higher adult obesity rates than the state average. The Project Healthy Schools (PHS) middle school-based wellness program uses local and long-distance delivery models in Michigan’s lower peninsula (LP) and UP, respectively. Schools utilizing the local model (LP schools) have routine staff visits to assist in program implementation; conversely, long-distance model schools (UP) rely on telecommunication with PHS staff to implement the program. This study sought to determine if differences exist in health behaviors of LP and UP students at baseline, as well as post-PHS intervention to determine the effectiveness of the local and long-distance PHS delivery models.

Methods: Data from 6 th grade students enrolled in PHS between 2014-2017 were analyzed. Students were divided into two groups, UP and LP students. Demographics and health behaviors at baseline and post-intervention were compared between groups.

Results: Of 21,459 students, 695 (3.2%) were from the UP. Compared to LP students, UP students were more likely to be White and from lower and middle socioeconomic status communities. Pre-PHS intervention, UP students ate more fruits, vegetables, and chocolate candy, engaged in more moderate exercise, and spent less time on TV, computers, video games, and mobile devices than LP students. No significant differences in post-intervention impact on health behaviors were seen between UP and LP students.

Conclusions: At baseline, UP students reported better health behaviors than LP students. However, the lack of differences in post-intervention impact suggest the local and long-distance delivery models were equally effective in influencing health behaviors. Future investigation of the effect of school-based interventions in remote communities, like the UP, are warranted.

Abstract 261: Gender-Specific Differences in Behavioral and Physiological Risk Factors Associated with Childhood Obesity

Background: Prior research has shown differences in physiologic and behavioral measurements of adolescent boys and girls. This study sought to determine if similar gender-specific differences exist between participants of the Project Healthy Schools (PHS) school-based wellness program, both at baseline and post-PHS intervention.

Methods: Demographics, physiological measures and health behaviors were compared between 6 th grade girls and boys enrolled in PHS between 2004-2017 at baseline and post-PHS intervention.

Results: Health behavior data were collected in 19,995 students (46.1% girls); physiological measures were collected in 2,922 students (52.7% girls). Boys within the physiological sample were older than girls (11.62 v. 11.55, p<0.001). At baseline, girls had lower HDL cholesterol and higher resting and recovery heart rates, but reported greater consumption of fruits and vegetables and less sugary beverages and fried meats than boys. Boys reported more vigorous exercise but greater hours of television and video game screen time than girls. Post-intervention, girls showed greater improvement in resting heart rate, fruit consumption and video game time.

Conclusion: Girls had better health behaviors but poorer physiological markers at baseline. Lower rates of physical activity in girls at baseline highlight a potential area of focus for the PHS intervention in this population. Future exploration of gender-specific targeted strategies to improve health behaviors is warranted.

Abstract 241: An Investigation of Sex Differences in the BRIDGE Transitional Care Clinic Population

Background: Although cardiovascular disease (CVD) is the leading cause of death in men and women, women are less likely than men to received certain evidence-based treatments for CVD or be enrolled in CVD clinical trials. This study sought to identify sex differences in outcomes among patients referred to the BRIDGE transitional care clinic following hospitalization for a cardiac event.

Methods: Retrospective data on patients referred to BRIDGE from 2008-2016 were analyzed. Demographics and outcomes (readmissions, emergency department [ED] visits, death) were compared between male and female patients in five populations: 1) the total BRIDGE population, 2) acute coronary syndrome (ACS) patients, 3) congestive heart failure (CHF) patients, 4) atrial fibrillation/flutter (AF) patients, and 5) patients who attended BRIDGE clinic.

Results: Of 4159 patients, 1710 (41.1%) were female. In the total population, women were significantly older than men (66.8 v 64.8, p=0.010), were less likely to be married (45.2% v 68.2%, p≤0.001), and had higher Charlson Comorbidity Index (CCI) scores (4.90 v 4.60, p=0.001). Women were also less likely to have ACS (20.7% v 28.6%, p≤0.001), more likely to have CHF (25.1% v 20.9%, p=0.001), and were more likely to have an ED visit within 6 months post-discharge. No significant differences were seen in outcomes between males and females in the CHF and AF populations; however, female ACS patients were more likely to have had an ED visit within 6 months of discharge than male ACS patients. In regards to transitional care, women were less likely to attend their BRIDGE appointment (68.7% v 72.4%, p=0.008). Among BRIDGE attendees, females were older (66.8 v 64.9, p=0.001), less likely to be married (45.9% v 68.8%, p=0.001), and had higher CCI scores (4.80 v 4.55, p=0.016) than males. Female attendees were more likely than male attendees to have had an ED visit both within 30 days and 6 months.

Conclusions: Among the total population, BRIDGE attendees, and ACS patients, women were more likely to visit the ED than men. Additionally, women were less likely than men to attend their BRIDGE transitional care appointment. Efforts should be made to improve BRIDGE clinic attendance among women and develop targeted strategies to improve outcomes for female patients, specifically those with a primary diagnosis of ACS.

Abstract 231: Outcome Variations Between Patients Prescribed Direct Oral Anticoagulant or Warfarin

Background: Patients with cardiovascular disease (CVD) require antithromobotic therapy to reduce risk of embolization. Direct oral anticoagulants (DOAC) were introduced to widespread clinic use in 2010. This study explores differences in demographics and outcomes (readmission, ED visit, death) between patients on a DOAC or warfarin, and the impact of attending a cardiac transitional care appointment (BRIDGE) on outcomes between groups.

Methods: Data from patients in the BRIDGE dataset from 2010-2017 were analyzed, excluding those with an adverse event prior to their BRIDGE appointment. Demographics and outcomes of patients prescribed warfarin were compared with those prescribed a DOAC. Outcomes for each group were further compared by BRIDGE clinic attendance.

Results: Prescribing of DOACs has linearly increased from 2010-2017. Of 666 anticoagulated patients, 22.5% (n=150) were prescribed a DOAC and 77.5% (n=516) were prescribed warfarin, for any indication. Warfarin patients had higher CHA2DS2-VASc scores and were more likely to visit the ED within 30 days than DOAC patients. DOAC patients were more likely to be readmitted within 6 months. Both warfarin and DOAC patients who attended BRIDGE were less likely to have a readmission within 6 months than patients who did not attend. DOAC patients who attended BRIDGE were also less likely to have an ED visit within 6 months than DOAC patients who did not attend. However, patients with a 30 day adverse event were more likely to have attended BRIDGE (readmission: DOAC 90%, 9/10; warfarin 73.8%, 31/42; ED: DOAC 100%, 5/5; warfarin 78.7, 37/47).

Conclusion: Since introduction, DOAC prescription has continuously increased. Warfarin patients had higher CHA2DS2-VASc scores and higher rates of early adverse events (ED visit) than DOAC patients. DOAC patients had higher rates of late adverse events (readmission in 6 months). The differences in early and late readmissions may be partially explained by the necessity of early follow up for those prescribed warfarin at discharge. However, early readmissions overall were more likely to have attended BRIDGE. This suggests that early follow up frequently identifies anticoagulated patients in need of hospitalization, and the importance of prompt transitional care among this population.

Abstract 236: Investigation of the Effects of the Affordable Care Act within the BRIDGE Population

Background: The U.S. Patient Protection and Affordable Care Act (ACA) aimed to provide all United States citizens access to health care and reform the way healthcare was delivered. A key provision of the ACA was the Readmission Reduction Program (RRP) that penalizes hospitals for excessive readmissions. This study sought to determine if changes exist after ACA implementation in demographics and outcomes of myocardial infarction (MI) and heart failure (CHF) patients referred for transitional care (BRIDGE).

Methods: MI and CHF patients referred to BRIDGE between 2008-2016 were divided into pre-ACA (2008-2013) and post-ACA (2014-2016) cohorts. Demographics and outcomes (ED visits, readmissions) were compared between groups. Post-hoc, a subset of patients of low socioeconomic status (SES) were analyzed. Low SES was defined as a median household income (based on the patient’s zip code) less than the 2012 household income for the state of Michigan ($46,859).

Results: Compared to pre-ACA patients, post-ACA patients had higher Charlson comorbidity scores and were more likely to be readmitted within 6-months. In addition, when examined independently, both MI and CHF patient subsets had higher Charlson scores post-ACA. Similar differences were seen in the subset of low SES patients, with post-ACA patients having higher Charlson scores, 6-month readmission rates, and 6-month ED visits rates than pre-ACA patients.

Conclusions: There were few differences in outcomes between pre-ACA and post-ACA groups in this sample. Overall, post-ACA patients were sicker. There were no differences in participation in the BRIDGE transitional care program or in early readmissions or ED visits. Notably, there were higher rates of readmission and ED visits within 6-months, potentially suggesting greater access to care. This finding was consistent both in the total MI and CHF population as well as among those of low SES. More research is needed to determine whether changes as a result of ACA implementation can in part explain these findings.

Abstract 139: Examining the Effect of Post-Hospital Syndrome on Outcomes in Patients Discharged After an Acute Coronary Syndrome

Background: Hospital readmissions are increasingly observed and reported as quality indicators. The literature is critical of studies that use all cause readmission definitions, suggesting that not every readmission is related to the index admission diagnosis. However, hospitals are not a therapeutic environment. Patients are often kept on ”nothing by mouth” (NPO) status, subjected to testing at irregular hours, placed on bed rest, and discharged on new medications. Thus, patients may be more vulnerable to adverse outcomes at discharge; some have characterized this phenomenon as “post-hospital syndrome.” This study sought to compare these inpatient stressors (NPO status, after-hours testing, new medications, and bed rest) to patient outcomes (ED visits, readmissions).

Methods: A retrospective chart review of 100 randomly selected ACS patients referred to a cardiac transitional care program (BRIDGE) between 2014-2015 was conducted. Associations between hours NPO, number of new medications, number of tests at irregular hours (11pm-5am), prescribed bed rest and outcomes at 30 and 180 days were analyzed.

Results: Of 100 patients, 72% were male with a mean age of 65.87 ± 12.33 and a mean Charlson comorbidity score of 5.42 ± 2.58. Bed rest was prescribed for 69% of patients. The average patient was prescribed 4.43 new medications at discharge, underwent 4.37 tests at irregular hours, and spent 11.40 hours NPO. Median length of stay was 3 days (range: 0-18 days). Number of tests at irregular hours was positively correlated with readmission at 30 days (r=0.272, p=0.006), and 180 day ED visits (r=0.282, p=0.004) and readmissions (r=0.363, p<0.001). No other significant correlations were observed between inpatient stressors and outcomes.

Conclusions: NPO status and tests at irregular hours were correlated with negative short and longer-term outcomes. Efforts should be made to limit these inpatient stressors or to stabilize patients prior to discharge. Future research on post hospital syndrome is warranted to better understand potential longer-term relationships and to better plan for care transitions.

Abstract 117: Presence of Mental Health Disorders, Low Socioeconomic Status, More Closely Associated With Adverse Cardiovascular Outcomes After a Recent Hospitalization

Background: BRIDGE is a cardiac transitional care program. In previous studies, lower socioeconomic status (SES) and mental health disorders (MHD) have been associated with higher readmission rates. No research has been done on the combined effects of low SES and MHD on outcomes. This study sought to describe outcomes (ED Visits, readmission, and death) of patients by SES and MHD.

Methods: All patients referred to BRIDGE between 2008-2015 were included in this study. Data were analyzed in three ways: 1) by SES and then by presence (or absence) of MHD (depression, anxiety, substance abuse), 2) by MHD and then by SES, and 3) patients of low SES without MHD compared to patients of high SES with a MHD (data not shown in Table 1). High and low SES were defined as above or below the state of Michigan median household income ($46,859), estimated by patients’ home zip code. Demographics and outcomes were compared within and between groups.

Results: Among 3051 patients divided first by SES, there were a number of significant differences in demographics and outcomes between patients with and without MHD. Regardless of SES, patients with MHD were more often younger, female, single, and had higher rates of ED visits and readmissions at 180 days post-discharge than patients without MHD. Among high SES patients, patients with MHD had higher rates of ED visits within 30 days despite lower Charlson Comorbidity scores. In contrast, when divided by presence or absence of MHD first, fewer differences existed between SES groups. Regardless of presence or absence of MHDs, patients of low SES were younger and more racially diverse than patients of high SES; however, there were no differences in outcomes between these SES groups. Among patients without a MHD, low SES patients were less likely to attend BRIDGE. Patients of low SES without MHD were more likely than patients of high SES with MHD to be male (61.4% v. 51.2%, p<0.001), married (60.8% v. 52.2%, p=0.013), and non-White (75.3% v. 89.5%, p<0.001), and were less likely to have an ED visit within 180 days (31.9% v. 43.9%, p<0.001).

Conclusions: The presence of MHDs appears to be more strongly associated with negative outcomes than low SES. Efforts to develop and improve interventional care strategies that target patients with MHDs should be made to reduce these health disparities.

Abstract 217: Smoking Cessation and Patient Outcomes in the BRIDGE Clinic Population

Background: Cigarette smoking is associated with significant morbidity and mortality among patients with cardiovascular disease. Yet, nearly 1 in 6 people in the US continue to smoke. This study sought to determine the prevalence of smoking and smoking cessation education in the BRIDGE post-discharge cardiac transitional care clinic and associated outcomes.

Methods: Chart review was conducted of 133 randomly selected patients who attended their BRIDGE appointment between 2011-2015 and were current smokers. Demographics and outcomes were compared between patients who did and did not have documentation of smoking cessation education at their BRIDGE clinic visit and between those who did and did not quit smoking at 30 and 180 days post-discharge.

Results: At 30 days post-discharge, 32 (24.1%) patients had quit smoking. At 180 days, 8 patients (6.0%) had resumed smoking, but an additional 10 (7.5%) had quit. There were no demographic differences between those who did and did not quit at 30 or 180 days. Further, there were no differences in readmission (21.9% v. 12.9%, p=0.214) or death (0.0% v. 1.0%, p=1.000) rates between patients who did and did not quit at 30 days post-discharge. However, patients who had quit at 180 days were more often readmitted compared to those who had not quit (55.9% v. 25.3%, p=0.001). Of 133 patients, smoking cessation was discussed with 55 (41.4%). Smoking cessation education was provided at similar rates to patients who did and did not quit smoking at 30 and 180 days (30 day, 28.1% v. 45.5%, p=0.081; 180 day, 32.4% v. 44.4%, p=0.217), and there were no demographic differences between these groups. However, those who discussed smoking cessation were more likely to visit the ED within 180 days post-discharge (50.9% v. 26.9%, p=0.005).

Conclusions: A quarter of patients who quit smoking at 30 days post-discharge had resumed smoking at 180 days. Surprisingly, patients who quit smoking had higher readmission rates at 180 days. This study should be repeated with a larger sample size and explore other potential factors influencing these outcomes. For example, documentation of smoking cessation education was far lower than anticipated and may not be representative of actual discussion frequency. Efforts to design better strategies to encourage smoking cessation and reduce relapse are critical.

Abstract 121: Anxiety and Depression in Patients With Fibromuscular Dysplasia: A Report From the US Registry for Fibromuscular Dysplasia

Introduction/Background: Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic arterial disease that may result in arterial stenosis, dissection, aneurysm, and tortuosity. Anxiety (A) and depression (D) are prevalent in patients with rare and uncommon diseases compared to the general population; however, there are limited data on A and D in the FMD population. This study describes characteristics of FMD patients with and without A and/or D (A/D).

Methods: Patients enrolled in the US Registry for FMD between 2009-2017 and had A/D information were analyzed (n=985). Diagnosis of A/D was ascertained from patient charts or self-reported via medical history questionnaires at time of registry enrollment. Demographics, family history, past medical history, presenting symptoms, and affected vascular beds were compared between patients with and without A/D.

Results: A total of 351 (35.6%) had A/D. Of patients with A/D, 126 (35.9%) had both. Patients with A/D were more likely to have a family history of aneurysm (33.6% v. 23.7%, p=0.001) and stroke (53.6% v. 46.1%, p=0.03), and have a medical history of hemispheric TIA (15.5% v. 10.9%, p=0.04), subarachnoid hemorrhage (4.4% v. 1.8%, p=0.015) and smoking (43% v. 28%, p<0.001). Patients with A/D were more likely to present at the time of diagnosis with headache (68.6% v. 53.8%, p<0.001), pulsatile tinnitus (42.2% v. 34%, p=0.014), dizziness (45.3% v. 29.2%, p<0.001), neck pain (40% v. 24.9%, p<0.001) and carotid/vertebral arterial dissection (21.6% v. 14.7%, p=0.007). Patients with A/D were less likely to have renal artery FMD (58.4% v. 68.9%, p=0.002). No differences in the time between symptom onset and FMD diagnosis (2.7±6.2 v. 3.1±6.9 years, p=0.89) or number of vascular beds involved (1.9±1.1 v. 1.9±1.1, p=0.77) were seen between groups.

Conclusions: More than 1/3 of patients in the FMD registry had A, D, or both, and these patients showed multiple differences compared to patients without A/D. More study is required to understand this relationship. Given the high prevalence of A/D in this population, FMD patients should be screened for the presence of A/D and offered appropriate treatment.

Abstract 099: Prevalence of Headaches in Patients with Fibromuscular Dysplasia: A Report from the US Registry for FMD

Introduction: Fibromuscular dysplasia (FMD) is a polyvasculopathy that may result in aneurysm or dissection in affected arterial beds. A common symptom of FMD is headache (HA). The purpose of this study is to describe and compare characteristics of FMD patients with (w/HA) and without headaches (wo/HA) in the current US Registry for FMD.

Method: Data regarding demographics, family history, medical history, and vascular beds affected in patients with FMD were collected from the US Registry for FMD between 2009 and 2016. Patients with complete HA data were included, and data were compared between patients w/HA and wo/HA as reported at time of registry enrollment.

Results: Of the 1,433 patients in the registry, 1,251 (87.3%) had complete HA data. Most were female (94.1%), with a mean age of 56.0±12.4. A history of HA was reported in 844 (67.5%) patients and 54.2% reported a HA at least weekly. No difference in gender distribution was seen between HA groups. Patients w/HA were younger at the time of FMD diagnosis (50.6±11.8 years v 58.0±13.8 years, p<0.001) and were less likely to have a history of HTN (66.8% v 74.8%, p=0.004), hyperlipidemia (36.9% v 47.2%, p=0.004), or renal failure (2.6% v 5.7%, p=0.009). Patients w/HA were more likely to have a history of aneurysm or dissection in the extracranial carotid, intracranial, or vertebral arteries (aneurysm: 13.0% v 7.2% p=0.003; dissection: 25.1% v 8.3%, p<0.001). No differences in extracranial carotid, intracranial, or vertebral FMD involvement between patients w/ and w/o HA were seen when those with history of aneurysm or dissection of those arteries were excluded (71.2% v 66.8%, p=0.20). Headache patients more often reported a history of depression (25.1% v 16.5%, p=0.01) and anxiety (28.3% v 18.0%, p=0.003).

Conclusion: More than half of FMD patients experience HAs, most on an at least weekly basis. FMD patients with HA tended to be younger, and more likely to have extracranial carotid, intracranial, or vertebral disease as well as aneurysm and dissection. Depression and anxiety was also more common in FMD patients with HA. Further research is needed to classify the types of headaches being experienced as well as effective management strategies.

Abstract 095: Lessons Learned from the BRIDGE Registry: Major Findings From 8 Years of BRIDGE

Background: Readmissions after cardiac hospitalizations are frequent and costly in the United States. Delays in follow-up and lack of adherence to guidelines may contribute to high unplanned readmission rates. Bridging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner (NP) led, transitional care clinic for cardiac patients, aimed at reducing readmissions. Data on patients referred to BRIDGE has been collected since 2009; herein we report a summary of significant findings from these data.

Methods: A qualitative review of results and conclusions from all published abstracts, oral presentations, and papers from the BRIDGE registry (June 2008-August 2015) was conducted. Content analysis was used to synthesize findings across studies.

Results: Data from 3982 patients referred to BRIDGE have been collected. Seven themes were identified in the analysis of BRIDGE publications. During BRIDGE, NPs focused on medical history, symptoms, medication management (in 24.8% of visits), patient education, and referrals. In addition to addressing provider priorities, addressing patient concerns (daily living and clinical questions, feelings and fears) was highly salient, resulting in a high level of patient-NP connectedness as evidenced by high patient-reported scores on the Consultation and Relational Empathy scale (mean 43.5 ± 2.8; possible range 0, 50) and the Patient-Doctor Relationship Questionnaire (mean 43.05 ± 3.1; possible range 5, 45). Readmissions within 30 days were consistently lower for acute coronary syndrome (ACS) patients who attended BRIDGE compared to those who did not (6.4% v. 13.1%; p<0.01); similar results were not seen in heart failure (HF) (15.4% v. 15.7%; p=0.944) or atrial fibrillation (AF) (8.5% v. 5.2%; p=0.343) patients. A spike in HF readmissions was seen between 8-14 days post-discharge, suggesting the need for a sooner appointment. However, follow-up within 7 days of discharge did not show reduced readmissions in HF patients. AF readmissions were also difficult to avoid; in a subset of AF patients readmitted within 30 days, 51.1% (n=23) were readmitted for non-AF diagnoses. High risk patients (i.e. those with an adverse event before BRIDGE) were older, had higher Charlson comorbidity scores, and were more likely to have depression. However, marriage was associated with fewer readmissions.

Conclusions: Data from the BRIDGE registry have shown that clinic attendance reduced ACS readmissions; has characterized older, depressed patients with higher Charlson comorbidity scores as being those most likely to be readmitted; and has identified areas for improvement in transitional care (e.g. AF and HF) where readmissions are difficult to avoid. Continuous quality improvement and real-time monitoring of patient outcomes have translated this research into more prompt transitional care, illustrating the importance of registry-based research.

Abstract 084: Avoiding Heart Failure Readmissions

Background: Heart failure (HF) has high in-hospital mortality and is associated with high readmission rates. Reasons for and ways to avoid HF readmissions are unclear. We explored readmission diagnoses and guideline adherence, as a proxy for avoidability, among patients readmitted after index hospitalization for HF.

Method: From 2008-2014, 3381 patients were referred to the BRIDGE transitional care clinic. Retrospective data was derived for 64 of the 154 HF patients who were readmitted within 30 days. Patients were assigned cohorts by readmission diagnosis: “HF or HF related,” “non-HF related other cardiac,” or “non-cardiac, non-HF related.” Patient and provider adherence to ACCF/AHA HF guidelines, including sodium and fluid restrictions, weight monitoring, outpatient follow-up, and medication, were assessed to determine readmission avoidability.

Results: Data were collected for 64 pts of whom 62 had complete data. The mean age was 70.3±10.3 years; the majority were male (n=40, 64.5%) and white (n=54, 87.1%). HF diagnoses accounted for 58.1% (n=36) of readmissions; 19.4% (n=12) were for non-HF cardiac diagnoses and 22.6% (n=14) were for non-cardiac diagnoses. Overall provider guideline adherence at discharge was high (82.3%). Providers frequently documented providing education on sodium (77.4%) and fluid restrictions (54.8%), as well as daily weights (88.7%). Patients reported compliance with sodium (94.2%) and fluid restrictions (89.2%), daily weights (96.5%), and medications (96.7%). Patients readmitted for HF had lower guideline adherence than non-HF cardiac or non-cardiac diagnoses for both provider (n=26, 72.7%; p=.046) and patient (n=28, 77.8%, p=.248). HF was also the most frequent readmission diagnoses when provider guidelines were not adhered (n=10, 90.9%).

Conclusion: Over 40% of HF readmissions within 30 days of discharge were non-HF related, half of which were also non-cardiac. Overall adherence to guidelines for both patients and providers was high, suggesting that many readmissions post-index hospitalization for HF may be unavoidable. When guidelines were not adhered to, patients were more likely to be readmitted for HF related diagnoses. Further research is needed to discern whether further reductions in readmission rates can be achieved through improved guideline adherence.

Abstract 097: Effects of BRIDGE Attendance on the Outcomes of Diabetic Patients

Background: Prior studies have shown that patients with diabetes mellitus (DM) have increased risk for developing cardiovascular disease. BRIdging the Discharge Gap Effectively (BRIDGE) is a nurse practitioner-delivered cardiac transitional care program for patients who have been recently discharged following a cardiac event. Previous research has shown BRIDGE to be effective in improving patient outcomes. This study sought to describe differences in outcomes 1) of heart failure (HF), acute coronary syndrome (ACS), and atrial fibrillation (AF) patients with and without concomitant DM, and 2) between diabetic patients who did and did not attend BRIDGE.

Methods: Retrospective data were abstracted for HF, ACS, and AF patients from 2008-2014. Patients were divided into cohorts based on presence or absence of DM and BRIDGE attendance versus non-attendance. Outcomes (readmissions, ED visits, death) within each primary diagnosis (HF, ACS, AF) were compared between DM and non-DM patients and between those who attended BRIDGE versus those who did not for all DM patients.

Results: Of 2197 patients referred to BRIDGE, 723 (32.9%) had concomitant DM. DM patients had similar outcomes to non-DM patients for most post-discharge outcomes; however, DM ACS patients had higher readmission (42.2% v 29.6%, p<0.001) and death (10.5% v. 4.5%, p=0.001) rates within 6 months, and DM AF patients had higher readmission rates within 6 months (52.1% v 37.9%, p=0.006). HF patients with DM who attended BRIDGE had lower mortality rates within 6 months of discharge than those who did not (10.3% vs. 22.1%, p=0.014). No other significant differences in outcomes were seen between BRIDGE attendees and non-attendees.

Conclusions: Though not significant, patients with DM had worse post-discharge outcomes than those without DM for all primary diagnoses. In the subset of DM patients, the 30-day readmission rate for ACS patients who attended BRIDGE was half of those who did not attend. Conversely, 30-day readmission rates for HF patients were greater if they attended. This may in part explain the significantly lower mortality rate among BRIDGE attenders with HF, where patients who needed readmission were identified during their BRIDGE appointment. Due to the high prevalence of DM, efforts to tailor transitional care for this population are needed.

Abstract 098: The Prevalence of Racial and Socioeconomic Disparities in an Outpatient Transitional Care Clinic

Background: Bridging the Discharge Gap Effectively (BRIDGE) is a cardiac transitional care clinic. BRIDGE has demonstrated improved patient outcomes for some populations. This study sought to determine if differences in outcomes (readmissions, ED visits, death) exist for Caucasian and non-Caucasian patients based on BRIDGE attendance and socioeconomic status (SES).

Methods: Data on patients referred to BRIDGE from 2008-2014 were analyzed. Patients were split into two cohorts (Caucasian and non-Caucasian) and outcomes for each were independently compared by BRIDGE attendance and SES. Non-low SES was defined as income > $48,600 (200% poverty line for a family of 4) and low SES was income ≤ $48,600. Demographics and outcomes were compared between groups.

Results: Of 2964 patients, 15.1% were non-Caucasian (n=448). Caucasians were significantly older than non-Caucasians (66.16±14.29 v 59.14±14.75, p<0.001), and were more likely to have primary diagnoses of acute coronary syndrome (28.2% v 23.5%, p=0.039) or atrial fibrillation (16.8% v 9.3%, p<0.001). Among Caucasian patients, BRIDGE attenders had significantly lower 30-day readmission rates (8.6% v 11.3%, p=0.038) and fewer ED visits within 6 months (1.80±1.3 v 2.10±2.0, p=0.049). Non-Caucasians, however, were more likely to have an ED visit within 6 months (40.9% v 33.7%, p=0.012; data not shown). Non-Caucasians of low SES were more likely to be readmitted within 6 months (40.5% v 29.5%, p=0.029) and less likely to attend BRIDGE (64.9% v 76.4%, p=0.016) than non-low SES non-Caucasians. There were no significant differences between non-low and low SES Caucasian patients. Among BRIDGE attenders, 6-month mortality rates were significantly lower for both groups (Caucasian: 5.2% v 10.8%, p<0.001; non -Caucasian: 4.3% v 10.7%, p=0.013).

Conclusions: BRIDGE attendance was associated with improved outcomes in Caucasians that were not seen in non-Caucasians, with the exception of reduced mortality. Also, SES appears to impact non-Caucasians more than Caucasians, with low SES non-Caucasians having higher readmission rates and lower BRIDGE attendance than non-low SES non-Caucasians. Differences seen may be biased due to unevenly distributed groups (i.e. age and diagnosis). Efforts to target these vulnerable populations are warranted to reduce disparities.

Abstract 231: Single Site Lifestyle Survey in FMD Patients Suggests Improvement Over Time

Background: Fibromuscular dysplasia (FMD) is a polyvascular disorder that may result in narrowing, aneurysm, or dissection of affected arteries. A recent qualitative study illuminated common themes relative to being diagnosed and living with FMD. This study sought to quantitatively explore these themes in a larger sample.

Methods: Patients from a single site in the US Registry for FMD (USRFMD) were eligible to participate. Subjects received an initial survey packet and up to two reminders between July and September 2015; surveys were returned via U.S. mail or online. Surveys were linked to the USRFMD database, from which clinical data was drawn. The survey included valid and reliable instruments including the Patient Health Questionnaire (PHQ) 9, PHQ-15, and the Generalized Anxiety Disorder Questionnaire.

Results: Of 91 surveys mailed, 72 were completed (79.1%). Most respondents were female (94.4%, n=68) and white (97.2%, n=70), with a mean age at diagnosis of 52.7 ± 11.9 years and had been living with FMD for a mean of 9.7 ± 8.1 years. Medical history did not differ significantly between participants and non-participants. Screening showed that 21.7% of patients experienced moderate depression, 40.7% experienced significant physical symptoms, and 10.4% experienced moderate generalized anxiety. Though not statistically significant, there was a trend towards reduced mental health symptoms over time (Figure 1) and higher symptomatology with treatment delays of 1-5 years (data not shown). No differences were found in mental health based on number or location of vessels affected by FMD. Patients who had experienced an adverse event (e.g. stroke, TIA, MI, dissection, renal infarction, mesenteric ischemia) reported more physical symptoms (57.1% v. 23.1%, p=.014).

Conclusion: Among patients from a single center participating in the USRFMD, rates of anxiety and depression are nearly double that of the general population. Trends indicate that depression, physical symptoms, and anxiety may decrease over time. Given the higher rates of anxiety, depression, and somatoform symptoms compared to the general population, greater efforts are needed to make earlier diagnoses and support patients, particularly in the early stages post-diagnosis.