A validation study: how effective is the Hospital Morbidity Data as a surveillance tool for heart failure in Western Australia?

Accuracy of heart failure ascertainment using routinely collected healthcare data: a systematic review and meta-analysis

BACKGROUND

Ascertainment of heart failure (HF) hospitalizations in cardiovascular trials is costly and complex, involving processes that could be streamlined by using routinely collected healthcare data (RCD). The utility of coded RCD for HF outcome ascertainment in randomized trials requires assessment. We systematically reviewed studies assessing RCD-based HF outcome ascertainment against "gold standard" (GS) methods to study the feasibility of using such methods in clinical trials.

METHODS

Studies assessing International Classification of Disease (ICD) coded RCD-based HF outcome ascertainment against GS methods and reporting at least one agreement statistic were identified by searching MEDLINE and Embase from inception to May 2021. Data on study characteristics, details of RCD and GS data sources and definitions, and test statistics were reviewed. Summary sensitivities and specificities for studies ascertaining acute and prevalent HF were estimated using a bivariate random effects meta-analysis. Heterogeneity was evaluated using I2 statistics and hierarchical summary receiver operating characteristic (HSROC) curves.

RESULTS

A total of 58 studies of 48,643 GS-adjudicated HF events were included in this review. Strategies used to improve case identification included the use of broader coding definitions, combining multiple data sources, and using machine learning algorithms to search free text data, but these methods were not always successful and at times reduced specificity in individual studies. Meta-analysis of 17 acute HF studies showed that RCD algorithms have high specificity (96.2%, 95% confidence interval [CI] 91.5-98.3), but lacked sensitivity (63.5%, 95% CI 51.3-74.1) with similar results for 21 prevalent HF studies. There was considerable heterogeneity between studies.

CONCLUSIONS

RCD can correctly identify HF outcomes but may miss approximately one-third of events. Methods used to improve case identification should also focus on minimizing false positives.

Temporal trends in chronic complications of diabetes by sex in community-based people with type 2 diabetes: the Fremantle Diabetes Study

BACKGROUND

Whether recent reductions in cardiovascular disease (CVD) events and mortality in type 2 diabetes apply equally to both sexes is largely unknown. The aim of this study was to characterize temporal changes in CVD events and related outcomes in community-based male and female Australian adults with type 2 diabetes or without known diabetes.

METHODS

Participants from the longitudinal observational Fremantle Diabetes Study Phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) and four age-, sex- and postcode-matched individuals without diabetes (FDS1 n = 5159; FDS2 n = 6036) were followed for first myocardial infarction, stroke, heart failure hospitalization, lower extremity amputation, CVD death and all-cause mortality. Five-year incidence rates (IRs) for males versus females in FDS1 and FDS2 were calculated, and IR ratios (IRRs) derived.

RESULTS

The FD1 and FDS2 participants were of mean age 64.0 and 65.4 years, respectively, and 48.7% and 51.8% were males. For type 2 diabetes, IRRs for all endpoints were 11-62% lower in FDS2 than FDS1 for both sexes. For participants without diabetes, IRRs were 8-56% lower in FDS2 versus FDS1 apart from stroke in females (non-significantly 41% higher). IRRs for males versus females across FDS phases were not significantly different for participants with type 2 diabetes or those without diabetes (P-values for male * FDS2 interaction ≥ 0.0.083 adjusted for age). For risk factors in participants with type 2 diabetes, greater improvements between FDS1 and FDS2 in smoking rates in males were offset by a greater reduction in systolic blood pressure in females.

CONCLUSIONS

The incidence of chronic complications in Australians with type 2 diabetes and without diabetes has fallen similarly in both sexes over recent decades, consistent with comparably improved overall CVD risk factor management.

Unplanned Readmissions and Long-Term Mortality Risk After Incident Heart Failure Hospitalisation in Western Australia, 2001-2015

AIMS

To investigate the frequency and predictors of unplanned readmissions after incident heart failure (HF) hospitalisation and the association between readmissions and mortality over two years.

METHODS

We performed a retrospective cohort study using Western Australian morbidity and mortality data to identify all patients, aged 25-94 years, who survived an incident (first-ever) HF hospitalisation (principal diagnosis) between 2001-2015. Ordinal logistic regression models determined the covariates independently associated with unplanned readmission(s). Cox proportional hazards models with time-varying exposures determined the hazard ratios (HR) of one or more readmissions for mortality over two years after incident HF.

RESULTS

Of 18,693 patients, 53.4% male, mean age 74.4 (standard deviation [SD] 13.6) years, 61.3% experienced 32,431 unplanned readmissions (39.7% cardiovascular-related) within two years. Leading readmission causes were HF (19.1%), respiratory diseases (12.6%), and ischaemic heart disease (9.6%). All-cause death occurred in 27.2% of the cohort, and the multivariable-adjusted mortality HR of 1 (versus 0) readmission was 2.5 (95% confidence interval [CI], 2.3-2.7) increasing to 5.0 (95% CI, 4.7-5.4) for 2+ readmissions. The adjusted mortality HR of 1 and 2+ (versus 0) HF-specific readmission was 2.0 (95% CI, 1.8-2.1) and 3.6 (95% CI, 3.2-3.9), respectively. Coexistent cardiovascular and other comorbidities were independently associated with increased readmission and mortality risk.

CONCLUSION

This study underlines the high burden of recurrent unplanned cardiovascular and other readmissions within two years after incident HF hospitalisation, and their additive adverse impact on mortality. Integrated multidisciplinary management of concomitant comorbidities, in addition to HF-targeted treatments, is necessary to improve long-term prognosis in HF patients.

Evidence-based medication adherence among seniors in the first year after heart failure hospitalisation and subsequent long-term outcomes: a restricted cubic spline analysis of adherence-outcome relationships

PURPOSE

Non-adherence to heart failure (HF) medications is associated with poor outcomes. We used restricted cubic splines (RCS) to assess the continuous relationship between adherence to renin-angiotensin system inhibitors (RASI) and β-blockers and long-term outcomes in senior HF patients.

METHODS

We identified a population-based cohort of 4234 patients, aged 65-84 years, 56% male, who were hospitalised for HF in Western Australia between 2003 and 2008 and survived to 1-year post-discharge (landmark date). Adherence was calculated using the proportion of days covered (PDC) in the first year post-discharge. RCS Cox proportional-hazards models were applied to determine the relationship between adherence and all-cause death and death/HF readmission at 1 and 3 years after the landmark date.

RESULTS

RCS analysis showed a curvilinear adherence-outcome relationship for both RASI and β-blockers which was linear above PDC 60%. For each 10% increase in RASI and β-blocker adherence above this level, the adjusted hazard ratio for 1-year all-cause death fell by an average of 6.6% and 4.8% respectively (trend p < 0.05) and risk of all-cause death/HF readmission fell by 5.4% and 5.8% respectively (trend p < 0.005). Linear reductions in adjusted risk for these outcomes at PDC ≥ 60% were also seen at 3 years after landmark date (all trend p < 0.05).

CONCLUSION

RCS analysis showed that for RASI and β-blockers, there was no upper adherence level (threshold) above 60% where risk reduction did not continue to occur. Therefore, interventions should maximise adherence to these disease-modifying HF pharmacotherapies to improve long-term outcomes after hospitalised HF.

Long-term survival and life expectancy following an acute heart failure hospitalization in Australia and New Zealand

AIMS

Contemporary long-term survival following a heart failure (HF) hospitalization is uncertain. We evaluated survival up to 10 years after a HF hospitalization using national data from Australia and New Zealand, identified predictors of survival, and estimated the attributable loss in life expectancy.

METHODS AND RESULTS

Patients hospitalized with a primary diagnosis of HF from 2008-2017 were identified and all-cause mortality assessed by linking with Death Registries. Flexible parametric survival models were used to estimate survival, predictors of survival and loss in life expectancy. A total of 283 048 patients with HF were included (mean age 78.2 ± 12.3 years, 50.8% male). Of these, 48.3% (48.1-48.5) were surviving by 3 years, 34.1% (33.9-34.3) by 5 years and 17.1% (16.8-17.4) by 10 years (median survival 2.8 years). Survival declined with age with 53.4% of patients aged 18-54 years and 6.2% aged ≥85 years alive by 10 years (adjusted hazard ratio [aHR] for mortality 4.84, 95% confidence interval [CI] 4.65-5.04 for ≥85 years vs. 18-54 years) and was worse in male patients (aHR 1.14, 95% CI 1.13-1.15). Prior HF (aHR 1.20, 95% CI 1.18-1.22), valvular and rheumatic heart disease (aHR 1.11, 95% CI 1.10-1.13) and vascular disease (aHR 1.07, 95% CI 1.04-1.09) were cardiovascular comorbidities most strongly associated with long-term death. Non-cardiovascular comorbidities and geriatric syndromes were common and associated with higher mortality. Compared with the general population, HF was associated with a loss of 7.3 years in life expectancy (or 56.6% of the expected life expectancy) and reached 20.5 years for those aged 18-54 years.

CONCLUSION

Less than one in five patients hospitalized for HF were surviving by 10 years with patients experiencing almost 60% loss in life expectancy compared with the general population, highlighting the considerable persisting societal burden of HF. Concerted multidisciplinary efforts are needed to improve post-hospitalization outcomes of HF.

Patient characteristics, short-term and long-term outcomes after incident heart failure admissions in a regional Australian setting

AIMS

This study aims to (1) define the characteristics of patients with a first admission for heart failure (HF), stratified by type (reduced (HFrEF) vs preserved (HFpEF) ejection fraction) in a regional Australian setting; (2) compare the outcomes in terms of mortality and rehospitalisation and (3) assess adherence to the treatment guidelines.

METHODS

We identified all index hospitalisations with HF to John Hunter Hospital and Tamworth Rural Referral Hospital in the Hunter New England Local Health District over a 12 months. We used the recent Australian HF guidelines to classify HFrEF and HFpEF and assess adherence to guideline-directed therapy. The primary outcome of the study was to compare short-term (1 year) and long-term all-cause mortality and the composite of all-cause hospitalisation or all-cause mortality of patients with HFrEF and HFpEF.

RESULTS

There were 664 patients who had an index HF admission to John Hunter and Tamworth hospitals in 2014. The median age was 80 years, 47% were female and 22 (3%) were Aboriginal. In terms of HF type, 29% had HFrEF, 37% had HFpEF, while the remainder (34%) did not have an echocardiogram within 1 year of admission and could not be classified. The median follow-up was 3.3 years. HFrEF patients were predominantly male (64%) and in 48% the aetiology was ischaemic heart disease. The 1-year all-cause mortality was 23% in HFpEF subgroup and 29% in HFrEF subgroup (p=0.15). Five-year mortality was 61% in HFpEF and HFrEF patients. Of the HFrEF patients, only 61% were on renin-angiotensin-aldosterone blockers, 74% were on β-blockers and 39% were on aldosterone antagonist.

CONCLUSION

HF patients are elderly and about evenly split between HFrEF and HFpEF. In this regional cohort, both HF types are associated with similar 1-year and 5-year mortality following incident HF hospitalisation. Echocardiography and guideline-directed therapies were underused.

Changing age-specific trends in incidence, comorbidities and mortality of hospitalised heart failure in Western Australia between 2001 and 2016

BACKGROUND

Incident heart failure (HF) hospitalisation rates in most high-income countries are stable or declining. However, HF incidence may be increasing in younger people linked to changing risk factor profiles in the general population. We examined age and sex-specific patterns of incidence, comorbidities and mortality of hospitalised HF in Western Australia (WA) between 2001 and 2016.

METHODS AND RESULTS

All WA residents aged 25-94 years, with an incident (first-ever) principal HF discharge diagnosis between 2001 and 2016 were included (n = 22,476). Poisson regression derived annual age and sex-standardised rates of incident HF and 1-year mortality overall, and by age groups (25-54, 55-74, 75-94), across the study period. Overall, the age and sex-standardised rates of incident HF increased marginally by 0.6% per year (95% confidence interval (CI), 0.3, 0.8) whereas incidence increased by 3.1% per year (95% CI, 2.2, 4.0) in the 25-54 year age-group (trend p < 0.0001). There was a high prevalence (≥15%) of obesity, diabetes mellitus, cardiomyopathy, hypertension, ischemic heart disease, atrial fibrillation, and chronic kidney disease in younger HF patients. Overall standardised 1-year mortality declined by -1.0% per year (95%CI, -0.4, -1.6), driven largely by the mortality decline in the 55-74 year age group.

CONCLUSION

Incident HF hospitalisation rates have been rising in WA since 2006, notably in individuals under 55 years. The underlying reasons require further investigation, particularly the population-attributable risk related to increasing obesity and diabetes mellitus in the general population. Rising HF incidence along with declining mortality rates portends to an increasing HF burden in the community.

Incidence, predictors and mortality risk of new heart failure in patients hospitalised with atrial fibrillation

OBJECTIVE

To determine the incidence, risk predictors and relative mortality risk of incident heart failure (HF) in patients following atrial fibrillation (AF) hospitalisation.

METHODS

The Western Australian Hospitalisation Morbidity Data Collection was used to identify patients aged 25-94 years with index (first-in-period) AF hospitalisation, but without a prior HF admission, between 2000 and 2013. We evaluated the risk of incident HF hospitalisation within 3 years after AF admission, and the impact of HF hospitalisation on all-cause mortality.

RESULTS

The cohort comprised 52 447 patients, 57.5% men, with a median age of 73.1 (IQR 63.2-80.8) years. At 3 years after AF discharge, the cumulative incidence of HF (n=6153) was 11.7% (95% CI 11.5% to 12.0%) and all-cause death (n=9702) was 18.5% (95% CI 18.2% to 18.8%). Independent predictors of incident HF included advancing age, any history of myocardial infarction (MI), peripheral vascular disease, valvular heart disease, chronic kidney disease, chronic obstructive pulmonary disease, hypertension, diabetes, obesity and excessive alcohol use (all p<0.001). Patients hospitalised for first-ever HF compared with those without HF hospitalisation had an adjusted HR of 3.3 (95% CI 3.1 to 3.4) for all-cause mortality (p<0.001). Independent predictors of HF were also shared with those for mortality, with the exception of hypertension.

CONCLUSION

Hospitalisation for new HF is common in patients with AF and independently associated with a 3-fold hazard for death. The clinical predictors of incident HF emphasise the importance of integrated management of common comorbid conditions and lifestyle risk factors in patients with AF to reduce their morbidity and mortality.

Frequency, trends and institutional variation in 30-day all-cause mortality and unplanned readmissions following hospitalisation for heart failure in Australia and New Zealand

AIMS

National 30-day mortality and readmission rates after heart failure (HF) hospitalisations are a focus of US policy intervention and yet have rarely been assessed in other comparable countries. We examined the frequency, trends and institutional variation in 30-day mortality and unplanned readmission rates after HF hospitalisations in Australia and New Zealand.

METHODS AND RESULTS

We included patients >18 years hospitalised with HF at all public and most private hospitals from 2010-15. The primary outcomes were the frequencies of 30-day mortality and unplanned readmissions, and the institutional risk-standardised mortality rate (RSMR) and readmission rate (RSRR) evaluated using separate cohorts. The mortality cohort included 153 592 patients (mean age 78.9 ± 11.8 years, 51.5% male) with 16 442 (10.7%) deaths within 30 days. The readmission cohort included 148 704 patients (mean age 78.6 ± 11.9 years, 51.7% male) with 33 158 (22.3%) unplanned readmission within 30 days. In 392 hospitals with at least 25 HF hospitalisations, the median RSMR was 10.7% (range 6.1-17.3%) with 59 hospitals significantly different from the national average. Similarly, in 391 hospitals with at least 25 HF hospitalisations, the median RSRR was 22.3% (range 17.7-27.1%) with 24 hospitals significantly different from the average. From 2010-15, the adjusted 30-day mortality [odds ratio (OR) 0.991/month, 95% confidence interval (CI) 0.990-0.992, P < 0.01] and unplanned readmission (OR 0.998/month, 95% CI 0.998-0.999, P < 0.01) rates declined.

CONCLUSION

Within 30 days of a HF hospitalisation, one in 10 patients died and almost a quarter of those surviving experienced an unplanned readmission. The risk of these outcomes varied widely among hospitals suggesting disparities in HF care quality. Nevertheless, a substantial decline in 30-day mortality and a modest decline in readmissions occurred over the study period.

Temporal Trends in Cardiovascular Complications in People With or Without Type 2 Diabetes: The Fremantle Diabetes Study

CONTEXT

There is evidence that diabetes-related complications are declining but most data sources have limitations.

OBJECTIVE

To characterize temporal changes in incidence rates (IRs) of chronic complications and mortality in well-characterized, community-based Australians.

DESIGN

Longitudinal observational study.

SETTING

Urban population.

PARTICIPANTS

Participants with type 2 diabetes from the Fremantle Diabetes Study phases I (FDS1; n = 1291 recruited 1993-1996) and II (FDS2; n = 1509 recruited 2008-2011) age-, sex,- and ZIP code-matched 1:4 to people without diabetes.

MAIN OUTCOME MEASURES

First hospitalizations for/with myocardial infarction (MI), stroke, heart failure (HF), lower extremity amputation, and cardiovascular disease (CVD) and all-cause mortality. Five-year IRs, IR ratios for those with versus without diabetes in FDS1 and FDS2, and IR differences (IRDs), were calculated.

RESULTS

The 13,995 participants had a mean age of 64.8 years and 50.4% were males. There were lower IR ratios for MI, stroke, HF, and CVD death in FDS2 versus FDS1. IRDs for people with versus without type 2 diabetes had reduced by >50% between phases for MI, stroke, HF, lower extremity amputation, and CVD death, with no change in IRD for all-cause mortality. Within the pooled type 2 diabetes cohort, FDS2 versus FDS1 participation was an independent inverse predictor of stroke, HF, CVD death, and all-cause mortality after adjustment in Cox proportional hazards models.

CONCLUSIONS

Cardiovascular outcomes in Australians have improved since the 1990s, especially in type 2 diabetes. The difference in all-cause mortality between those with and without type 2 diabetes has persisted despite longer survival.

Long-Term Adherence to Renin-Angiotensin System Inhibitors and β-Blockers After Heart Failure Hospitalization in Senior Patients

AIMS

We investigated long-term adherence to renin-angiotensin system inhibitors (RASIs) and β-blockers, and associated predictors, in senior patients after hospitalization for heart failure (HF).

METHODS

A population-based data set identified 4488 patients who survived 60 days following their index hospitalization for HF in Western Australia from 2003 to 2008 with a 3-year follow-up. Their person-linked Pharmaceutical Benefits Scheme records identified medications dispensed during follow-up. Drug discontinuation was defined as the first break ≥90 days following the previous supply. Medication adherence was calculated using the proportion of days covered (PDC), with PDC ≥ 80% defined as being adherent. Multivariable logistic regression models were used to identify predictors of PDC < 80%.

RESULTS

In the cohort (57% male, mean age: 76.6 years), 77.4% were dispensed a RASI and 52.7% a β-blocker within 60 days postdischarge. Over the 3-year follow-up, 28% and 42% of patients discontinued RASI and β-blockers, respectively. Only 64.6% and 47.5% of RASI and β-blocker users, respectively, were adherent to their treatment over 3 years, with adherence decreasing over time (trend P < .0001 for RASI and trend P = .02 for β-blockers). Older age, increasing Charlson comorbidity score, chronic kidney disease, and chronic obstructive pulmonary disease were independent predictors of PDC < 80% for both drug groups.

CONCLUSION

Among seniors hospitalized for HF, discontinuation gaps were common for RASI and β-blockers postdischarge, and long-term adherence to these medications was suboptimal. Where appropriate, strategies to improve long-term medication adherence are indicated in HF patients, particularly in elderly patients with comorbidities.

Field Implementation of Remote Ischemic Conditioning in ST-Segment-Elevation Myocardial Infarction: The FIRST Study

BACKGROUND

Remote ischemic conditioning (RIC) is a noninvasive therapeutic strategy that uses brief cycles of blood pressure cuff inflation and deflation to protect the myocardium against ischemia-reperfusion injury. We sought to compare major adverse cardiovascular events (MACE) for patients who received RIC before PCI for ST-segment-elevation myocardial infarction (STEMI) compared with standard care.

METHODS

We conducted a pre- and postimplementation study. In the preimplementation phase, STEMI patients were taken directly to the PCI lab. After implementation, STEMI patients received 4 cycles of RIC by paramedics or emergency department staff before PCI. The primary outcome was MACE at 90 days. Secondary outcomes included MACE at 30, 60, and 180 days. Inverse probability of treatment weighting using propensity scores estimated causal effects independent from baseline covariables.

RESULTS

A total of 1667 (866 preimplementation, 801 postimplementation) patients were included. In the preimplementation phase, 13.4% had MACE at 90 days compared with 11.8% in the postimplementation phase (odds ratio [OR] 0.86, 95% CI 0.62-1.21). There were no significant differences in MACE at 30, 60, and 180 days. Patients presenting with cardiogenic shock or cardiac arrest before PCI were less likely to have MACE at 90 days (42.7% pre vs 27.8% post) if they received RIC before PCI (OR 0.52, 95% CI 0.27-0.98).

CONCLUSIONS

A strategy of RIC before PCI for STEMI did not reduce 90-day MACE. Future research should explore the impact of RIC before PCI for longer-term clinical outcomes and for patients presenting with cardiogenic shock or cardiac arrest.

Incidence and Predictors of Sudden Cardiac Death After a Major Non-Fatal Cardiovascular Event

BACKGROUND

Sudden cardiac death (SCD) still accounts for the majority of deaths from the four major cardiovascular events (myocardial infarction (MI), heart failure (HF), atrial fibrillation (AF), and stroke) despite substantial progress on prevention.

METHODS

Four separate cohorts (one for each of the four major cardiovascular conditions) were captured through person-linked hospital morbidity and mortality data collections between 2000 and 2009 and followed-up for 11.5 years. The incidence rate for each cohort was total SCD cases divided by sum of follow-up time for each individual alive. Kaplan-Meier survival curve was used to calculate unadjusted risk of SCD. Predictors of SCD were identified by fitting multivariable adjusted Cox regression models in each of the cohorts.

RESULTS

There were 1,174 cases of SCD from 53,614 total CVD events across the cohorts (35.6% for MI, 15.6% for HF, 22.4% for AF, 26.4% for stroke). The incidence rate and unadjusted risk of SCD were both highest after incident hospitalisation for HF, followed by MI, stroke and AF. The elevated risk of SCD was independently associated with MI, HF, arrhythmias, peripheral artery disease, diabetes, chronic kidney disease, and prior coronary heart disease (hazard ratios ranging from 1.1 to 2.8). Early revascularisation is protective in 28-day survivors after an incident MI event.

CONCLUSIONS

An appreciable incidence of SCD following an incident event of MI, HF, AF and stroke deserves greater prevention efforts. Major medical conditions such as MI, HF, peripheral artery disease, and arrhythmias are risk markers of SCD and coronary revascularisation is protective.

Outcomes following heart failure hospitalization in a regional Australian setting between 2005 and 2014

AIMS

The aim of the current study is to examine 10 year trends in mortality and readmission following heart failure (HF) hospitalization in metropolitan and regional Australian settings.

METHODS AND RESULTS

We identified all index HF hospitalizations in the Hunter New England region from 2005 to 2014, using a 10 year 'look back' period. The primary endpoint was a composite of all-cause mortality or all-cause readmission at 1 year. Secondary endpoints included all-cause mortality, all-cause readmission, and HF readmission at 30 days and 1 year. We used logistic regression to explore the predictors of the composite outcome of either all-cause death or readmission at 1 year. There were 12 114 patients admitted with a first episode of HF between 2005 and 2014, followed up until death or the end of 2015. The mean age was 78 ± 12 years and 49% (n = 5906) were male. A total of 4831 (40%) resided in regional areas and the remainder in metropolitan areas. One hundred sixty-eight patients (1.4%) were Aboriginal. Approximately 69% of patients had either died or been readmitted for any cause within 12 months of their index event. The 30 day and 1 year all-cause mortality rates were 13% and 32%, respectively, with no change in the trend over the study period. Age, socio-economic disadvantage, ischaemic heart disease, renal failure, and chronic lower respiratory disease were predictors of the primary endpoint.

CONCLUSIONS

Heart failure hospitalizations are followed by high rates of death or readmission. There was no change in this composite endpoint over the 10 year study period.

High-sensitivity cardiac troponin I and risk of cardiovascular disease in an Australianpopulation-based cohort

Objective

High-sensitivity cardiac troponin I (hs-cTnI) is an emerging biomarker for cardiovascular risk. We examined hs-cTnI as a predictor of mortality and cardiovascular outcomes in an Australian population-based cohort and evaluated if a sex difference exists.

Methods

Serum hs-cTnI was measured in the Busselton Health Study 1994/1995 Cohort (n=3939). Outcome measures were total and cardiovascular mortality, cardiovascular disease (CVD) and coronary heart disease (CHD) events, heart failure and stroke.

Results

Hs-cTnI was detectable (>1.2 ng/L) in 66.1% of participants (males 81.8%, females 54.4%) at baseline. There were 886 deaths (including 361 from CVD) and 940 CVD events during 20-year follow-up. Adjusting for Framingham Risk Score variables, hs-cTnI was a significant predictor of total mortality (HR (95% CI): 1.16 (1.09 to 1.24)), CVD mortality (1.33 (1.23 to 1.44)), CVD events (1.18 (1.11 to 1.25)), CHD events (1.11 (1.03 to 1.20)), heart failure (1.44 (1.31 to 1.58)) and stroke (1.13 (1.03 to 1.24)) per doubling of hs-cTnI at baseline. HRs remained significant in CVD-free individuals at baseline (n=3215), except for CHD events. There were no significant interactions between sex and hs-cTnI as a predictor of outcomes. Compared with individuals with hs-cTnI ≤1.2 ng/L, men with hs-cTnI ≥6.0 ng/L and women with hs-cTnI ≥4.0 ng/L had an HR of 2.18 (1.42 to 3.37) and 1.84 (1.30 to 2.62), respectively, for any CVD event, which persisted in the CVD-free subgroup.

Conclusions

Cardiac troponin I, measured with a high-sensitive assay, is an independent predictor of fatal and non-fatal CVD events and may help identify at-risk individuals in a general population.

Decreasing Risk of Fatal Subarachnoid Hemorrhage and Other Epidemiological Trends in the Era of Coiling Implementation in Australia

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) is associated with a high risk of mortality and disability in survivors. We examined the epidemiology and burden of SAH in our population during a time services were re-organized to facilitate access to evidence-based endovascular coiling and neurosurgical care.

METHODS

SAH hospitalizations from 2001 to 2009, in New South Wales, Australia, were linked to death registrations to June 30, 2010. We assessed the variability of admission rates, fatal SAH rates and case fatality over time and according to patient demographic characteristics.

RESULTS

There were 4,945 eligible patients admitted to hospital with SAH. The risk of fatal SAH significantly decreased by 2.7% on average per year (95% CI = 0.3-4.9%). Case fatality at 2, 30, 90, and 365 days significantly declined over time. The average annual percentage reduction in mortality ranged from 4.4% for 30-day mortality (95% CI -6.1 to -2.7) (P < 0.001) to 4.7% for mortality within 2 days (-7.1 to -2.2) (P < 0.001) (Table 3). Three percent of patients received coiling at the start of the study period, increasing to 28% at the end (P-value for trend <0.001). Females were significantly more likely to be hospitalized for a SAH compared to males [incident rate ratio (IRR) = 1.33, 95% CI = 1.23-1.44] (P < 0.001) and to die from SAH (IRR = 1.40, 95% CI = 1.24-1.59) (P < 0.001). People born in South-East Asia and the Oceania region had a significantly increased risk of SAH, while the risk of fatal SAH was greater in South-East and North-East Asian born residents. People residing in areas of least disadvantage had the lowest risk of hospitalization (IRR = 0.83, 95% CI = 0.74-0.92) and also the lowest risk of fatal SAH (0.81, 95% CI = 0.66-1.00) (P < 0.001 and P = 0.003, respectively). For every 100 SAH admissions, 20 and 15 might be avoided in males and females, respectively, if the risk of SAH in our population equated to that of the most socio-economically advantaged.

CONCLUSION

Our study reports reductions in mortality risk in SAH corresponding to identifiable changes in health service delivery and evolving treatments such as coiling. Addressing inequities in SAH risk and mortality may require the targeting of prevalent and modifiable risk factors to improve population outcomes.

Association Between High-Sensitivity Cardiac Troponin I and Cardiac Events in Elderly Women

Background

Elderly women are at high risk of coronary heart disease (CHD) and heart failure. High‐sensitivity assays allow detection of cardiac troponin I (hsTnI) well below diagnostic cutoffs for acute coronary syndrome. We investigated the association between these levels with future cardiac events in community‐based ambulant white women aged over 70 years initially recruited for a 5‐year randomized, controlled trial of calcium supplements.

Methods and Results

This was a prospective study of 1081 elderly women without clinical CHD at baseline (1998) or hsTnI above the diagnostic cutoffs for acute coronary syndrome with 14.5‐year follow‐up hospitalization and mortality (events). Two hundred forty‐three (22%) women had CHD events, 163 (15%) myocardial infarction or CHD death (hard CHD), and 109 (10%) heart failure. In 99.6% of available serum samples, hsTnI was above the level of detection (median, 4.5 ng/L; interquartile range, 3.6–5.8). After adjusting for Framingham risk factors, each SD natural log‐transformed hsTnI increase was associated with an increased hazard for CHD (hazard ratio, 1.34; 95% CI, 1.18–1.53; P<0.001) hard CHD (hazard ratio, 1.51; 95% CI, 1.29–1.76; P<0.001), and heart failure (hazard ratio, 1.65; 95% CI, 1.36–1.99; P<0.001). Step‐wise increases in relative hazards were observed with increasing quartiles of hsTnI (P for trend, <0.001), whereas the addition of hsTnI to conventional risk factors modestly improved discrimination indices: Harrell's c‐statistic, net reclassification, and integrated discrimination (P<0.05).

Conclusions

Cardiac troponin I is independently associated with future cardiac events in elderly women without apparent clinical manifestations. The addition of cardiac troponin I to conventional risk factors may modestly improve risk prediction in this setting.

Phase 4 Studies in Heart Failure - What is Done and What is Needed?

Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.

Long-term use of secondary prevention medications for heart failure in Western Australia: a protocol for a population-based cohort study

INTRODUCTION

Heart failure (HF) is a chronic, debilitating and progressive disease associated with high morbidity and mortality. Evidence-based medications (EBMs) are the cornerstone of management of patients with HF. In Australia, these EBMs are subsidised by the Commonwealth Government under the Pharmaceutical Benefits Scheme. Suboptimal dispensing and non-adherence to these EBMs have been observed in patients with HF. Our study will investigate trends in dispensing patterns, as well as adherence and persistence of EBMs for HF. We will also identify factors influencing these patterns and their impact on long-term clinical outcomes.

METHODS AND ANALYSIS

This whole population-based cohort study will use longitudinal data for people aged 65-84 years who were hospitalised for HF in Western Australia between 2003 and 2008. Linked state-wide and national data will provide patient-level information on medication dispensing, medical visits, hospitalisations and death. Drug dispensing trends will be described, drug adherence and persistence estimated and the association with all-cause/cardiovascular death and hospitalisations reported.

ETHICS AND DISSEMINATION

This project has received approvals from the Western Australian Department of Health Human Research Ethics Committee and the Western Australian Aboriginal Health Ethics Committee. Results will be published in relevant cardiology journals and presented at national and international conferences.

Is poor oral health a risk marker for incident cardiovascular disease hospitalisation and all-cause mortality? Findings from 172 630 participants from the prospective 45 and Up Study

OBJECTIVE

To investigate the relationship between oral health and incident hospitalisation for ischaemic heart disease (IHD), heart failure (HF), ischaemic stroke and peripheral vascular disease (PVD) and all-cause mortality.

DESIGN

Prospective population-based study of Australian men and women aged 45 years or older, who were recruited to the 45 and Up Study between January 2006 and April 2009; baseline questionnaire data were linked to hospitalisations and deaths up to December 2011. Study exposures include tooth loss and self-rated health of teeth and gums at baseline.

SETTING

New South Wales, Australia.

PARTICIPANTS

Individuals aged 45-75 years, excluding those with a history of cancer/cardiovascular disease (CVD) at baseline; n=172 630.

PRIMARY OUTCOMES

Incident hospitalisation for IHD, HF, ischaemic stroke and PVD and all-cause mortality.

RESULTS

During a median follow-up of 3.9 years, 3239 incident hospitalisations for IHD, 212 for HF, 283 for ischaemic stroke and 359 for PVD, and 1908 deaths, were observed. Cox proportional hazards models examined the relationship between oral health indicators and incident hospitalisation for CVD and all-cause mortality, adjusting for potential confounding factors. All-cause mortality and incident CVD hospitalisation risk increased significantly with increasing tooth loss for all outcomes except ischaemic stroke (ptrend<0.05). In those reporting no teeth versus ≥20 teeth left, risks were increased for HF (HR, 95% CI 1.97, 1.27 to 3.07), PVD (2.53, 1.81 to 3.52) and all-cause mortality (1.60, 1.37 to 1.87). The risk of IHD, PVD and all-cause mortality (but not HF or ischaemic stroke) increased significantly with worsening self-rated health of teeth and gums (ptrend<0.05). In those reporting poor versus very good health of teeth and gums, risks were increased for IHD (1.19, 1.03 to 1.38), PVD (1.66, 1.13 to 2.43) and all-cause mortality (1.76, 1.50 to 2.08).

CONCLUSIONS

Tooth loss and, to a lesser extent, self-rated health of teeth and gums, are markers for increased risk of IHD, PVD and all-cause mortality. Tooth loss is also a marker for increased risk of HF.

A cohort study: temporal trends in prevalence of antecedents, comorbidities and mortality in Aboriginal and non-Aboriginal Australians with first heart failure hospitalization, 2000-2009

BACKGROUND/OBJECTIVES

Little is known about trends in risk factors and mortality for Aboriginal Australians with heart failure (HF). This population-based study evaluated trends in prevalence of risk factors, 30-day and 1-year all-cause mortality following first HF hospitalization among Aboriginal and non-Aboriginal Western Australians in the decade 2000-2009.

METHODS

Linked-health data were used to identify patients (20-84 years), with a first-ever HF hospitalization. Trends in demographics, comorbidities, interventions and risk factors were evaluated. Logistic and Cox regression models were fitted to test and compare trends over time in 30-day and 1-year mortality.

RESULTS

Of 17,379 HF patients, 1,013 (5.8%) were Aboriginal. Compared with 2000-2002, the prevalence (as history) of myocardial infarction and hypertension increased more markedly in 2006-2009 in Aboriginal (versus non-Aboriginal) patients, while diabetes and chronic kidney disease remained disproportionately higher in Aboriginal patients. Risk factor trends, including the Charlson comorbidity index, increased over time in younger Aboriginal patients. Risk-adjusted 30-day mortality did not change over the decade in either group. Risk-adjusted 1-year mortality (in 30-day survivors) was non-significantly higher in Aboriginal patients in 2006-2008 compared with 2000-2002 (hazard ratio (HR) 1.44; 95% CI 0.85-2.41; p-trend = 0.47) whereas it decreased in non-Aboriginal patients (HR 0.87; 95% CI 0.78-0.97; p-trend = 0.01).

CONCLUSIONS

Between 2000 and 2009, the prevalence of HF antecedents increased and remained disproportionately higher in Aboriginal (versus non-Aboriginal) HF patients. Risk-adjusted 1-year mortality did not improve in Aboriginal patients over the period in contrast with non-Aboriginal patients. These findings highlight the need for better prevention and post-HF care in Aboriginal Australians.

Using quality indicators to compare outcomes of permanent cardiac pacemaker implantation among publicly and privately funded patients

BACKGROUND

Funding source/insurance status has been associated with disparity in the management and outcomes of cardiovascular disease, with poorer outcomes among disadvantaged groups.

AIM

Using proposed quality indicators for permanent pacemaker (PPM) implantation and administrative data, this study aimed to determine whether quality indicator-based outcomes of PPM implantation were comparable for publicly and privately funded patients within Australia's two-tier health system.

METHODS

A population-based cohort study of adults implanted with a PPM between 1995 and 2009 in Western Australia. The association of funding outcomes derived from linked administrative data was tested in multivariate logistic regression models.

RESULTS

There were 9748 PPMs implanted, 48% being among privately funded patients. The mean age was 75 years for both public and private patients. Private patients had better health status (fewer with cardiac conditions and lower non-cardiac comorbidity scores), were less likely to be an emergency admission (33% vs 60%, P < 0.001) and more likely to have dual- or triple-chamber pacing. Mean length of stay was significantly greater for private patients (4.3 (standard deviation 6.3) vs 5.1 (6.8) days <0.001), related to longer elective admissions. Crude mortality was lower for private patients in-hospital (0.7 vs 1.3%), 30-day post-procedure (1.3 vs 2.1%) and at 1 year (7.3 vs 9.5%). Emergency admission, comorbidity and other demographic and clinical factors, not funding source, were significant predictors of these outcomes.

CONCLUSIONS

There was no difference between publicly and privately funded patients in study outcomes, after adjustment for demographic and clinical factors. The exception was longer hospital stay for elective PPM among privately funded patients.

Trends in the incidence and prevalence of cardiac pacemaker insertions in an ageing population

OBJECTIVES

To determine contemporary population estimates of the prevalence of cardiac permanent pacemaker (PPM) insertions.

METHODS

A population-based observational study using linked hospital morbidity and death registry data from Western Australia (WA) to identify all incident cases of PPM insertion for adults aged 18 years or older. Prevalence rates were calculated by age and sex for the years 1995-2009 for the WA population.

RESULTS

There were 9782 PPMs inserted during 1995-2009. Prevalence rose across the study period, exceeding 1 in 50 among people aged 75 or older from 2005. This was underpinned by incidence rates which rose with age, being highest in those 85 years or older; over 500/100 000 for men throughout, and over 200/100 000 for women. Rates for patients over 75 were more than double the rates for those aged 65-74 years. Women were around 40% of cases overall. The use of dual-chamber and triple-chamber pacing increased across the study period. A cardiac resynchronisation defibrillator was implanted for 58% of patients treated with cardiac resynchronisation therapy.

CONCLUSIONS

Rates of insertion and prevalence of PPM continue to rise with the ageing population in WA. As equilibrium has probably not been reached, the demand for pacing services in similarly well-developed economies is likely to continue to grow.

Declining rates of fatal and nonfatal intracerebral hemorrhage: epidemiological trends in Australia

Background

A recent systematic review of epidemiological studies reported intracerebral hemorrhage (ICH) incidence and mortality as unchanged over time; however, comparisons between studies conducted in different health services obscure assessment of trends. We explored trends in ICH rates in a large, representative population in New South Wales, Australia's most populous state (≈7.3 million).

Methods and Results

Adult hospitalizations with a principal ICH diagnosis from 2001 to 2009 were linked to death registrations through to June 30, 2010. Trends for overall, fatal, and nonfatal ICH rates within 30 days and fatal rates for 30‐day survivors at 365 days were calculated. There were 11 332 ICH patient admissions meeting eligibility criteria, yielding a crude hospitalization rate of 25.2 per 100 000 (age‐standardized rate: 17.2). Age‐ and sex‐adjusted overall rates significantly declined by an average of 1.6% per year (P=0.03). Fatal ICH declined by an average of 2.6% per year (P=0.004). For 30‐day survivors, a nonsignificant decline of 2.3% per year in fatal ICH at 365 days was estimated (P=0.17). Male sex and birth in the Oceania region and Asia were associated with an increased ICH risk, although this depended on age. Approximately 12% of ICH admissions would be prevented if the socioeconomic circumstances of the population equated with those of the least disadvantaged.

Conclusions

Overall and fatal ICH rates have fallen in this large Australian population. Improvements in cardiovascular prevention and acute care may explain declining rates. There was no evidence of an increase in devastated survivors because the longer term mortality of 30‐day survivors has not increased over time.

The relationship between nurse staffing and inpatient complications

AIM

To compare characteristics of hospitalizations with and without complications and examine the impact of nurse staffing on inpatient complications across different unit types.

BACKGROUND

Studies investigating the relationship between nurse staffing and inpatient complications have not shown consistent results. Methodological limitations have been cited as the basis for this lack of uniformity. Our study was designed to address some of these limitations.

DESIGN

Retrospective longitudinal hospitalization-level study.

METHOD

Adult hospitalizations to high intensity, general medical and general surgical units at three metropolitan tertiary hospitals were included. Data were sourced from Western Australian Department of Health administrative data collections from 2004-2008. We estimated the impact of nurse staffing on inpatient complications adjusted for patient and hospital characteristics and accounted for patients with multiple hospitalizations.

RESULTS

The study included 256,984 hospitalizations across 58 inpatient units. Hospitalizations with complications had significantly different demographic characteristics compared with those without. The direction of the association between nurse staffing and inpatient complications was not consistent for different inpatient complications, nurse skill mix groups or for hospitalizations with different unit movement patterns.

CONCLUSION

Our study design addressed limitations noted in the field, but our results did not support the widely held assumption that improved nurse staffing levels are associated with decreased patient complication rates. Despite a strong international focus on improving nurse staffing to reduce inpatient complications, our results suggest that adding more nurses is not a panacea for reducing inpatient complications to zero.

Disparities experienced by Aboriginal compared to non-Aboriginal metropolitan Western Australians in receiving coronary angiography following acute ischaemic heart disease: the impact of age and comorbidities

INTRODUCTION

Aboriginal Australians have a substantially higher frequency of ischaemic heart disease (IHD) events than their non-Aboriginal counterparts, together with a higher prevalence of comorbidities. The pattern of health service provision for IHD suggests inequitable delivery of important diagnostic procedures. Published data on disparities in IHD management among Aboriginal Australians are conflicting, and the role of comorbidities has not been adequately delineated. We compared the profiles of Aboriginal and non-Aboriginal patients in the metropolitan area undergoing emergency IHD admissions at Western Australian metropolitan hospitals, and investigated the determinants of receiving coronary angiography.

METHODS

Person-linked administrative hospital and mortality records were used to identify 28-day survivors of IHD emergency admission events (n =20,816) commencing at metropolitan hospitals in 2005-09. The outcome measure was receipt of angiography. The Aboriginal to non-Aboriginal risk ratio (RR) was estimated from a multivariable Poisson log-linear regression model with allowance for multiple IHD events in individuals. The subgroup of myocardial infarction (MI) events was modelled separately.

RESULTS

Compared with their non-Aboriginal counterparts, Aboriginal IHD patients were younger and more likely to have comorbidities. In the age- and sex-adjusted model, Aboriginal patients were less likely than others to receive angiography (RRIHD 0.77, 95% CI 0.72-0.83; RRMI 0.81, 95% CI 0.75-0.87) but in the full multivariable model this disparity was accounted for by comorbidities as well as IHD category and MI subtype, and private health insurance (RRIHD 0.95, 95% CI 0.89-1.01; RRMI 0.94, 95% CI 0.88-1.01). When stratified by age groups, this disparity was not significant in the 25-54 year age group (RRMI 0.95, 95% CI 0.88-1.02) but was significant in the 55-84 year age group (RRMI 0.88, 95% CI 0.77-0.99).

CONCLUSIONS

The disproportionate under-management of older Aboriginal IHD patients is of particular concern. Regardless of age, the disparity between Aboriginal and non-Aboriginal Australians in receiving angiography for acute IHD in a metropolitan setting is mediated substantially by comorbidities. This constellation of health problems is a 'double-whammy' for Aboriginal people, predisposing them to IHD and also adversely impacting on their receipt of angiography. Further research should investigate how older age and comorbidities influence clinical decision making in this context.

Outcomes after first percutaneous coronary intervention for acute myocardial infarction according to patient funding source

Background

Disparities in the use of invasive coronary artery revascularisation procedures to manage acute myocardial infarction (AMI) have been found in several developed economies. Factors such as socio-economic status, income and funding source may influence the use of invasive procedures and have also been associated with ongoing care. The objectives of this study were to determine whether outcomes for patients at one and five years after AMI treated with first-ever percutaneous coronary intervention (PCI) were the same for public and privately funded patients.

Methods

Retrospective, population-based cohort study using linked data to identify 30-day survivors of AMI treated with PCI in the index admission between 1995 and 2008 in Western Australian hospitals. The main outcome measures were admission for another PCI, re-AMI, and all-cause and cardiac mortality at one and five years.

Results

At one year, private patients were at greater adjusted risk for another PCI (HR 1.62 [1.36 – 1.94]; p < 0.001) than public patients, and more likely to have an additional revascularisation procedure from 90 days to 5 years (HR 1.33 [1.11 – 1.58]; p < 0.001). They were at less risk for all-cause death within five years (HR 0.69 [0.62–0.91]; p = 0.01) with a trend to reduced risk for cardiac death and re-AMI.

Conclusions

Treatment as a private patient for AMI with first PCI is associated with an increased likelihood of additional coronary revascularisation procedure within 12 months and to five years, and a reduced risk for all-cause mortality to 5 years. While additional procedures were not associated with poorer outcomes, there was no clear relationship between better outcomes and additional procedures. Other lifestyle and health care factors may contribute to the significant reduction in all-cause mortality and the trends to reduced hazard for AMI and cardiac death among private patients.

Impact and costs of home-based trial of void compared with the day care setting

AIMS

This paper presents the relative merits and comparative costs of conducting trial of void using Hospital-In-The-Home vs. the Day Procedure Unit.

BACKGROUND

Hospitals increasingly discharge patients with acute urinary retention with indwelling urinary catheters. For these to be removed and patients supported to return to normal urinary function, outpatient or in-home services are used. To date, the relative effectiveness and costs of Hospital-In-The-Home care and Day Procedure Unit care for trial of void have not been examined.

DESIGN

This retrospective study used a static-group comparison design.

METHODS

Hospital administrative data from 1 February 2009-30 March 2011 for patients having trial of void in the Day Procedure Unit (n = 107) and Hospital-In-The-Home (n = 163) of a tertiary hospital in Western Australia were compared in terms of patient outcomes and costs.

RESULTS

Day Procedure Unit patients had longer wait times than Hospital-In-The-Home patients; there was no difference between the two groups for average per patient days of service or successful first trials. Hospital-In-The-Home care did not increase the overall period of care. Per patient average ward-equivalent cost in the Day Procedure Unit was A$396 higher than the Hospital-In-The-Home ward-equivalent cost. The average cost saving per patient for Hospital-In-The-Home care including trial of void cost and emergency department visits was A$117.

CONCLUSION

Patient outcomes from Hospital-In-The-Home trial of void in low-risk patients were comparable to those of Day Procedure Unit care and less costly. Hospital-In-The-Home care for this well-defined procedure could permit more efficient management of patient throughput.

Rural-urban differentials in 30-day and 1-year mortality following first-ever heart failure hospitalisation in Western Australia: a population-based study using data linkage

OBJECTIVES

We examined differentials in short-term (30-day mortality) and 1-year mortality (in 30-day survivors) following index (first-ever) hospitalisation for heart failure (HF), between rural and metropolitan patients resident in Western Australia.

DESIGN

A population-based cohort study.

SETTING

Hospitalised patients in Western Australia, Australia.

PARTICIPANTS

Index patients aged 20-84 years with a first-ever hospitalisation for HF between 2000 and 2009 (with no prior admissions for HF in previous 10 years), identified using the Western Australia linked health data.

MAIN OUTCOME MEASURES

30-day and 1-year all-cause mortality (in 30-day survivors) following index admission for HF.

RESULTS

Of 17 379 index patients with HF identified, 25.9% (4499) were from rural areas. Rural patients were significantly younger at first HF hospitalisation than metropolitan patients. Aboriginal patients comprised 1.9% of metropolitan and 17.2% of rural patients. Despite some statistical differences, the prevalence of antecedents including ischaemic heart disease, hypertension, diabetes and chronic kidney disease was high (>20%) in both subpopulations. After adjusting for age only, patients from rural areas had a higher risk of 30-day death (OR 1.16 (95% CI 1.01 to 1.33)) and 1-year death in 30-day survivors (HR 1.11 (95% CI 1.01 to 1.23)). These relative risk estimates increased and remained significant after further progressive adjustments for Aboriginality, socioeconomic status, insurance status, emergency presentation, individual comorbidities and revascularisation with OR 1.25 (1.06 to 1.48) for 30-day mortality and HR 1.13 (1.02 to 1.27) for 1-year mortality. The addition of the weighted Charlson index to the 30-day model improved the 'c' statistic (under the receiver operating characteristic curve) from 0.656 (using a variation of administrative claims model) to 0.714.

CONCLUSIONS

Remoteness and variable access to healthcare can cause important disparities in health outcomes. Rural patients with HF in Western Australia have poorer risk-adjusted outcomes compared with metropolitan patients. This finding has important implications for chronic disease management and provision of health services in rural Australia.

The effects of 3 years of calcium supplementation on common carotid artery intimal medial thickness and carotid atherosclerosis in older women: an ancillary study of the CAIFOS randomized controlled trial

Calcium is an essential nutrient for skeletal health; however, it has been suggested that supplemental calcium may be associated with adverse cardiovascular effects, raising widespread concern about their use. One suggested mechanism is via increasing carotid atherosclerosis, however few randomized controlled trials (RCT) of calcium supplements have assessed these mechanisms. The calcium intake fracture outcome study (CAIFOS) was a 5-year RCT (1998 to 2003) of 1.2 g of elemental calcium in the form of calcium carbonate in 1460 elderly women. An ancillary study of 1103 women assessed common carotid artery intimal medial thickness (CCA-IMT) and carotid atherosclerosis at year 3 (2001). The effects of supplementation were studied in intention-to-treat (ITT) and per-protocol (PP) analyses before and after adjustment for baseline cardiovascular risk factors. The mean age of participants at baseline was 75.2 ± 2.7 years. In ITT analyses, women randomized to calcium supplementation had no difference in multivariable-adjusted mean CCA-IMT (calcium 0.778 ± 0.006 mm, placebo 0.783 ± 0.006 mm, p = 0.491) and maximum CCA-IMT (calcium 0.921 ± 0.007 mm, placebo 0.929 ± 0.006 mm, p = 0.404). Women randomized to calcium did not have increased carotid atherosclerosis (calcium 47.2%, placebo 52.7%, p = 0.066). However, in women taking at least 80% of the supplements, a significant reduction in carotid atherosclerosis was observed in unadjusted but not in multivariate-adjusted models (p = 0.033 and p = 0.064, respectively). Participants in the highest tertile of total calcium (diet and supplements) had reduced carotid atherosclerosis in unadjusted and multivariable-adjusted analyses compared with participants in the lowest tertile (odds ratio [OR] = 0.67 [95% confidence interval (CI) 0.50-0.90], p = 0.008, and OR = 0.70 [95% CI 0.51-0.96], p = 0.028, respectively). In conclusion, these findings do not support the hypothesis that calcium supplementation increases carotid artery intimal medial thickness or carotid atherosclerosis, and high calcium intake may reduce this surrogate cardiovascular risk factor.

Body mass index and incident hospitalisation for cardiovascular disease in 158 546 participants from the 45 and Up Study

Objective:

To investigate the relationship between fine gradations in body mass index (BMI) and risk of hospitalisation for different types of cardiovascular disease (CVD).

Design, Subjects and Methods:

The 45 and Up Study is a large-scale Australian cohort study initiated in 2006. Self-reported data from 158 546 individuals with no history of CVD were linked prospectively to hospitalisation and mortality data. Hazard ratios (HRs) of incident hospitalisation for specific CVD diagnoses in relation to baseline BMI categories were estimated using Cox regression, adjusting for age, sex, region of residence, income, education, smoking, alcohol intake and health insurance status.

Results:

There were 9594 incident CVD admissions over 583 100 person-years among people with BMI⩾20 kg m⁻², including 3096 for ischaemic heart disease (IHD), 1373 for stroke, 411 for peripheral vascular disease (PVD) and 320 for heart failure. The adjusted HR of hospitalisation for all CVD diagnoses combined increased significantly with increasing BMI (P(trend) <0.0001)). The HR of IHD hospitalisation increased by 23% (95% confidence interval (95% CI): 18–27%) per 5 kg m⁻² increase in BMI (compared to BMI 20.0–22.49 kg m⁻², HR (95% CI) for BMI categories were: 22.5–24.99=1.25 (1.08–1.44); 25–27.49=1.43 (1.24–1.65); 27.5–29.99=1.64 (1.42–1.90); 30–32.49=1.63 (1.39–1.91) and 32.5–50=2.10 (1.79–2.45)). The risk of hospitalisation for heart failure showed a significant, but nonlinear, increase with increasing BMI. No significant increase was seen with above-normal BMI for stroke or PVD. For other specific classifications of CVD, HRs of hospitalisation increased significantly with increasing BMI for: hypertension; angina; acute myocardial infarction; chronic IHD; pulmonary embolism; non-rheumatic aortic valve disorders; atrioventricular and left bundle-branch block; atrial fibrillation and flutter; aortic aneurysm; and phlebitis and thrombophlebitis.

Conclusion:

The risk of hospitalisation for a wide range of CVD subtypes increases with relatively fine increments in BMI. Obesity prevention strategies are likely to benefit from focusing on bringing down the mean BMI at the population level, in addition to targeting those with a high BMI.

Trends from 1996 to 2007 in incidence and mortality outcomes of heart failure after acute myocardial infarction: a population-based study of 20,812 patients with first acute myocardial infarction in Western Australia

Background

Advances in treatment for acute myocardial infarction (AMI) are likely to have had a beneficial impact on the incidence of and deaths attributable to heart failure (HF) complicating AMI, although limited data are available to support this contention.

Methods and Results

Western Australian linked administrative health data were used to identify 20 812 consecutive patients, aged 40 to 84 years, without prior HF hospitalized with an index (first) AMI between 1996 and 2007. We assessed the temporal incidence of and adjusted odds ratio/hazard ratio for death associated with HF concurrent with AMI admission and within 1 year after discharge. Concurrent HF comprised 75% of incident HF cases. Between the periods 1996–1998 and 2005–2007, the prevalence of HF after AMI declined from 28.1% to 16.5%, with an adjusted odds ratio of 0.50 (95% CI, 0.44 to 0.55). The crude 28‐day case‐fatality rate for patients with concurrent HF declined marginally from 20.5% to 15.9% (P<0.05) compared with those without concurrent HF, in whom the case‐fatality rate declined from 11.0% to 4.8% (P<0.001). Concurrent HF was associated with a multivariate‐adjusted odds ratio of 2.2 for 28‐day mortality and a hazard ratio of 2.2 for 1‐year mortality in 28‐day survivors. Occurrence of HF within 90 days of the index AMI was associated with an adjusted hazard ratio of 2.7 for 1‐year mortality in 90‐day survivors.

Conclusions

Despite encouraging declines in the incidence of HF complicating AMI, it remains a common problem with high mortality. Increased attention to these high‐risk patients is needed given the lack of improvement in their long‐term prognosis.

Effect of private insurance incentive policy reforms on trends in coronary revascularisation procedures in the private and public health sectors in Western Australia: a cohort study

Background

The Australian federal government introduced private health insurance incentive policy reforms in 2000 that increased the uptake of private health insurance in Australia. There is currently a lack of evidence on the effect of the policy reforms on access to cardiovascular interventions in public and private hospitals in Australia. The aim was to investigate whether the increased private health insurance uptake influenced trends in emergency and elective coronary artery revascularisation procedures (CARPs) for private and public patients.

Methods

We included 34,423 incident CARPs from Western Australia during 1995-2008 in this study. Rates of emergency and elective CARPs were stratified for publicly and privately funded patients. The average annual percent change (AAPC) in trend was calculated before and after 2000 using joinpoint regression.

Results

The rate of emergency CARPs, which were predominantly percutaneous coronary interventions (PCIs) with stenting, increased throughout the study period for both public and private patients (AAPC=12.9%, 95% CI=5.0,22.0 and 14.1%, 95% CI=9.8,18.6, respectively) with no significant difference in trends before and after policy implementation. The rate of elective PCIs with stenting from 2000 onwards remained relatively stable for public patients (AAPC=−6.0, 95% C= −16.9,6.4), but increased by 4.1% on average annually (95% CI=1.8,6.3) for private patients (p_difference=0.04 between groups). This rate increase for private patients was only seen in people aged over 65 years and people residing in high socioeconomic areas.

Conclusions

The private health insurance incentive policy reforms are a likely contributing factor in the shift in 2000 from public to privately-funded elective PCIs with stenting. These reforms as well as the increasing number of private hospitals may have been successful in increasing the availability of publicly-funded beds since 2000.

The economic benefits of increased levels of nursing care in the hospital setting

AIM

To assess the economic impact of increased nursing hours of care on health outcomes in adult teaching hospitals in Perth, Western Australia.

BACKGROUND

Advancing technology and increased availability of treatment interventions are increasing demand for health care while the downturn in world economies has increased demand for greater efficiency. Nurse managers must balance nurse staffing to optimize care and provide efficiencies.

DESIGN

This longitudinal study involved the retrospective analysis of a cohort of multi-day stay patients admitted to adult teaching hospitals.

METHODS

Hospital morbidity and staffing data from September 2000 until June 2004, obtained in 2010 from a previous study, were used to analyse nursing-sensitive outcomes pre- and post-implementation of the Nurse Hours per Patient Day staffing method, which remains in place today. The cost of the intervention comprised increased nursing hours following implementation of the staffing method.

RESULTS

The number of nursing-sensitive outcomes was 1357 less than expected post-implementation and included 155 fewer 'failure to rescue' events. The 1202 other nursing-sensitive outcomes prevented were 'surgical wound infection', 'pulmonary failure', 'ulcer, gastritis', 'upper gastrointestinal bleed', and 'cardiac arrest'. One outcome, pneumonia, showed an increase of 493. Analysis of life years gained was based on the failure to rescue events prevented and the total life years gained was 1088. The cost per life year gained was AUD$8907.

CONCLUSION

The implementation of the Nurse Hours per Patient Day staffing method was cost-effective when compared with thresholds of interventions commonly accepted in Australia.

Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality: a prospective cohort study

BACKGROUND

Erectile dysfunction is an emerging risk marker for future cardiovascular disease (CVD) events; however, evidence on dose response and specific CVD outcomes is limited. This study investigates the relationship between severity of erectile dysfunction and specific CVD outcomes.

METHODS AND FINDINGS

We conducted a prospective population-based Australian study (the 45 and Up Study) linking questionnaire data from 2006-2009 with hospitalisation and death data to 30 June and 31 Dec 2010 respectively for 95,038 men aged ≥45 y. Cox proportional hazards models were used to examine the relationship of reported severity of erectile dysfunction to all-cause mortality and first CVD-related hospitalisation since baseline in men with and without previous CVD, adjusting for age, smoking, alcohol consumption, marital status, income, education, physical activity, body mass index, diabetes, and hypertension and/or hypercholesterolaemia treatment. There were 7,855 incident admissions for CVD and 2,304 deaths during follow-up (mean time from recruitment, 2.2 y for CVD admission and 2.8 y for mortality). Risks of CVD and death increased steadily with severity of erectile dysfunction. Among men without previous CVD, those with severe versus no erectile dysfunction had significantly increased risks of ischaemic heart disease (adjusted relative risk [RR] = 1.60, 95% CI 1.31-1.95), heart failure (8.00, 2.64-24.2), peripheral vascular disease (1.92, 1.12-3.29), "other" CVD (1.26, 1.05-1.51), all CVD combined (1.35, 1.19-1.53), and all-cause mortality (1.93, 1.52-2.44). For men with previous CVD, corresponding RRs (95% CI) were 1.70 (1.46-1.98), 4.40 (2.64-7.33), 2.46 (1.63-3.70), 1.40 (1.21-1.63), 1.64 (1.48-1.81), and 2.37 (1.87-3.01), respectively. Among men without previous CVD, RRs of more specific CVDs increased significantly with severe versus no erectile dysfunction, including acute myocardial infarction (1.66, 1.22-2.26), atrioventricular and left bundle branch block (6.62, 1.86-23.56), and (peripheral) atherosclerosis (2.47, 1.18-5.15), with no significant difference in risk for conditions such as primary hypertension (0.61, 0.16-2.35) and intracerebral haemorrhage (0.78, 0.20-2.97).

CONCLUSIONS

These findings give support for CVD risk assessment in men with erectile dysfunction who have not already undergone assessment. The utility of erectile dysfunction as a clinical risk prediction tool requires specific testing.

Heart failure among Indigenous Australians: a systematic review

Background

Cardiovascular diseases contribute substantially to the poor health and reduced life expectancy of Indigenous Australians. Heart failure is a common, disabling, progressive and costly complication of these disorders. The epidemiology of heart failure and the adequacy of relevant health service provision in Indigenous Australians are not well delineated.

Methods

A systematic search of the electronic databases PubMed, Embase, Web of Science, Cinahl Plus, Informit and Google Scholar was undertaken in April 2012 for peer-reviewed journal articles relevant to the topic of heart failure in Indigenous Australians. Additionally, a website search was done to identify other pertinent publications, particularly government reports.

Results

There was a paucity of relevant peer-reviewed research, and government reports dominated the results. Ten journal articles, 1 published conference abstract and 10 reports were eligible for inclusion. Indigenous Australians reportedly have higher morbidity and mortality from heart failure than their non-Indigenous counterparts (age-standardised prevalence ratio 1.7; age-standardised hospital separation ratio ≥3; crude per capita hospital expenditure ratio 1.58; age-adjusted mortality ratio >2). Despite the evident disproportionate burden of heart failure in Indigenous Australians, the accuracy of estimation from administrative data is limited by poor indigenous identification, inadequate case ascertainment and exclusion of younger subjects from mortality statistics. A recent journal article specifically documented a high prevalence of heart failure in Central Australian Aboriginal adults (5.3%), noting frequent undiagnosed disease. One study examined barriers to health service provision for Indigenous Australians in the context of heart failure.

Conclusions

Despite the shortcomings of available published data, it is clear that Indigenous Australians have an excess burden of heart failure. Emerging data suggest that undiagnosed cases may be common in this population. In order to optimise management and to inform policy, high quality research on heart failure in Indigenous Australians is required to delineate accurate epidemiological indicators and to appraise health service provision.

The health services burden of heart failure: an analysis using linked population health data-sets

BACKGROUND

The burden of patients with heart failure on health care systems is widely recognised, although there have been few attempts to quantify individual patterns of care and differences in health service utilisation related to age, socio-economic factors and the presence of co-morbidities. The aim of this study was to assess the typical profile, trajectory and resource use of a cohort of Australian patients with heart failure using linked population-based, patient-level data.

METHODS

Using hospital separations (Admitted Patient Data Collection) with death registrations (Registry of Births, Deaths and Marriages) for the period 2000-2007 we estimated age- and gender-specific rates of index admissions and readmissions, risk factors for hospital readmission, mean length of stay (LOS), median survival and bed-days occupied by patients with heart failure in New South Wales, Australia.

RESULTS

We identified 29,161 index admissions for heart failure. Admission rates increased with age, and were higher for males than females for all age groups. Age-standardised rates decreased over time (256.7 to 237.7/100,000 for males and 235.3 to 217.1/100,000 for females from 2002-3 to 2006-7; p = 0.0073 adjusted for gender). Readmission rates (any cause) were 27% and 73% at 28-days and one year respectively; readmission rates for heart failure were 11% and 32% respectively. All cause mortality was 10% and 28% at 28 days and one year. Increasing age was associated with more heart failure readmissions, longer LOS and shorter median survival. Increasing age, increasing Charlson comorbidity score and male gender were risk factors for hospital readmission. Cohort members occupied 954,888 hospital bed-days during the study period (any cause); 383,646 bed-days were attributed to heart failure admissions.

CONCLUSIONS

The rates of index admissions for heart failure decreased significantly in both males and females over the study period. However, the impact on acute care hospital beds was substantial, with heart failure patients occupying almost 200,000 bed-days per year in NSW over the five year study period. The strong age-related trends highlight the importance of stabilising elderly patients before discharge and community-based outreach programs to better manage heart failure and reduce readmissions.

Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study

AIMS

This article is a report of a study of the association between skill mix and 14 nursing-sensitive outcomes following implementation of the nursing hours per patient day staffing method in Western Australian public hospitals in 2002, which determined nursing hours by ward category but not skill mix.

BACKGROUND

Findings from previous studies indicate that higher nurse staffing levels and a richer skill mix are associated with improved patient outcomes. Measuring skill mix at a hospital level for specific staffing methods and associated nursing-sensitive patient outcomes are important in providing staffing for optimal patient care.

DESIGN

The research design for the larger study was retrospectively analysing patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over 4 years.

METHODS

A subset of data was used to determine the impact of skill mix on nursing-sensitive outcomes following implementation of the staffing method. All patient records (N=103,330) and nurse staffing records (N=73,770) from nursing hours per patient day wards from October 2002-June 2004 following implementation were included.

RESULTS

Increases in Registered Nurse hours were associated with important decreases in eight nursing-sensitive outcomes at hospital level and increases in three nursing-sensitive outcomes. The lowest skill mix saw the greatest reduction in nursing-sensitive outcome rates.

CONCLUSIONS

The skill mix of nurses providing care could impact patient outcomes and is an important consideration in strategies to improve nurse staffing. Levels of hospital nurse staffing and skill mix are important organizational characteristics when predicting patient outcomes.

Chronic heart failure: we are fighting the battle, but are we winning the war?

Heart failure represents an end-stage phenotype of a number of cardiovascular diseases and is generally associated with a poor prognosis. A number of organized battles fought over the last two to three decades have resulted in considerable advances in treatment including the use of drugs that interfere with neurohormonal activation and device-based therapies such as implantable cardioverter defibrillators and cardiac resynchronization therapy. Despite this, the prevalence of heart failure continues to rise related to both the aging population and better survival in patients with cardiovascular disease. Registries have identified treatment gaps and variation in the application of evidenced-based practice, including the use of echocardiography and prescribing of disease-modifying drugs. Quality initiatives often coupled with multidisciplinary, heart failure disease management promote self-care and minimize variation in the application of evidenced-based practice leading to better long-term clinical outcomes. However, to address the rising prevalence of heart failure and win the war, we must also turn our attention to disease prevention. A combined approach is required that includes public health measures applied at a population level and screening strategies to identify individuals at high risk of developing heart failure in the future.

Regular primary care plays a significant role in secondary prevention of ischemic heart disease in a Western Australian cohort

BACKGROUND

Secondary prevention for established ischaemic heart disease (IHD) involves medication therapy and a healthier lifestyle, but adherence is suboptimal. Simply having scheduled regular appointments with a primary care physician could confer a benefit for IHD patients possibly through increased motivation and awareness, but this has not previously been investigated in the literature.

OBJECTIVE

To estimate the association between regular general practitioner (GP) visitation and rates of all-cause death, IHD death or repeat hospitalisation for IHD in older patients in Western Australia (WA).

DESIGN

A retrospective cohort design.

PARTICIPANTS

Patients aged  ≥  65 years (n  = 31,841) with a history of hospitalisation for IHD from 1992-2006 were ascertained through routine health data collected on the entire WA population and included in the analysis.

MAIN MEASURES

Frequency and regularity of GP visits was determined during a three-year exposure period at commencement of follow-up. A regularity score (range 0-1) measured the regularity of intervals between the GP visits and was divided into quartiles. Patients were then followed for a maximum of 11.5 years for outcome determination. Hazard ratios and 95% confidence intervals were calculated using Cox proportional hazards models.

KEY RESULTS

Compared with the least regular quartile, patients with greater GP visit regularity had significantly decreased risks of all-cause death (2(nd) least, 2(nd) most and most regular: HR = 0.76, 0.71 and 0.71); and IHD death (2(nd) least, 2(nd) most and most regular: HR = 0.70, 0.68 and 0.65). Patients in the 2(nd) least regular quartile also appeared to experience decreased risk of any repeat IHD hospitalisation (HR =  0.83, 95%CI 0.71-0.96) as well as emergency hospitalisation (HR = 0.81, 95%CI 0.67-0.98), compared with the least regular quartile.

CONCLUSIONS

Some degree of regular GP visitation offers a small but significant protection against morbidity and mortality in older people with established IHD. The findings indicate the importance of scheduled, regular GP visits for the secondary prevention of IHD.

Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study

AIM

To determine the prevalence of potentially suboptimal medication use and association with adverse outcomes.

METHODS

A prospective, observational cohort study of 4260 community-dwelling older men from Perth, Western Australia (mean age of 77 ± 3.6 years) was conducted. Follow-up was for 4.5 years (or until death, if sooner). Cox proportional hazard models were used to explore associations between suboptimal medication use and prospective clinical outcomes. Logistic regression analyses were used to explore predictors of a fall in the previous 12 months.

RESULTS

Use of potentially inappropriate medicines (48.7%), polypharmacy (≥5 medications, 35.8%) and potential under-utilization (56.7%) were highly prevalent, and overall 82.3% of participants reported some form of potentially suboptimal medication use. A self-reported history of falls in the previous 12 months was independently associated with the number of medicines taken (odds ratio [OR]= 1.06, 95% confidence interval [CI] 1.02, 1.09) and use of one or more potentially inappropriate medicines (OR = 1.23, 95% CI 1.04, 1.45). After adjusting for age, co-morbidity, smoking status, body mass index, hypertension and educational attainment, the number of medicines reported was associated with admission to hospital (hazard ratio [HR]= 1.04, 95% CI 1.03, 1.06), cardiovascular events (HR = 1.09, 95% CI 1.06, 1.12) and all cause mortality (HR = 1.04, 95% CI 1.00, 1.07). Use of one or more potentially inappropriate medicines was associated with admission to hospital (HR = 1.16, 95% CI 1.08, 1.24). Potential under-utilization was associated with cardiovascular events (HR = 1.20, 95% CI 1.03, 1.40).

CONCLUSIONS

These data suggest that both medication over-use and under-use occur frequently among older men and may be harmful.