Regional variations in ambulatory care and incidence of cardiovascular events

Distribution of catheterisation laboratories in Indonesia 2017-2022: a nationwide survey

Background

Geographical terrains of Indonesia pose a major hindrance to transportation. The difficulty of transportation affects the provision of acute time-dependent therapy such as percutaneous coronary intervention (PCI). Also, Indonesia's aging population would have a significant impact on the prevalence of acute coronary syndrome in the next decade. Therefore, the analysis and enhancement of cardiovascular care are crucial. The catheterisation laboratory performs PCI procedures. In the current study, we mapped the number and distribution of catheterisation laboratories in Indonesia.

Methods

A direct survey was used to collect data related to catheterisation laboratory locations in July 2022. The population data was sourced from the Ministry of Home Affairs. The recent growth of catheterisation laboratories was examined and evaluated based on geographical areas. The main instruments for comparing regions and changes throughout time are the ratio of catheterisation laboratories per 100,000 population and the Gini index (a measure of economic and healthcare inequality. Gini index ranges from 0 to 1, with greater values indicating more significant levels of inequality). Regression analysis was carried out to see how the number of catheterisation laboratories was affected by health demand (prevalence) and economic capacity (Gross Domestic Regional Product [GDRP] per Capita).

Findings

The number of catheterisation laboratories in Indonesia significantly increased from 181 to 310 during 2017-2022, with 44 of the 119 new labs built in an area that did not have one. Java has the most catheterisation laboratories (208, 67%). The catheterisation laboratory ratio in the provinces of Indonesia ranges from 0.0 in West Papua and Maluku to 4.46 in Jakarta; the median is 1.09 (IQR 0.71-1.18). The distribution remains a problem, as shown by the high catheterisation laboratory Gini index (0.48). Regression shows that distribution of catheterisation laboratories was significantly affected by GDRP and the prevalence of heart disease.

Interpretation

The number of catheterisation laboratories in Indonesia has increased significantly recently, however, maldistribution remains a concern. To improve Indonesia's cardiovascular emergency services, future development of catheterisation laboratories must be better planned considering the facility's accessibility and density.

Funding

Airlangga Research Fund - Universitas Airlangga.

Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada

Cardiovascular disease has been the leading cause of death in the United States and Canada for decades. Although it affects millions of people across a multitude of backgrounds, notable disparities in cardiovascular health are observed among women and become more apparent when accounting for race and socioeconomic status. Although intrinsic sex-specific physiologic differences predispose women to poorer outcomes, social determinants of health (SDOH) and biases at both the individual provider and the larger health care system levels play an equal, if not greater, role. This review examines socioeconomic disparities in women compared with men regarding cardiovascular risk factors, treatments, and outcomes. Although various at-risk subpopulations exist, we highlight the impact of SDOH in specific populations, including patients with disabilities, transgender persons, and South Asian and Indigenous populations. These groups are underrepresented in studies and experience poorer health outcomes owing to structural barriers to care. These findings emphasise the significance of understanding the interplay of different socioeconomic factors and how their stacking can negatively affect women's cardiovascular health. To address these disparities, we propose a multipronged approach to augment culturally sensitive and patient-centred care. This includes increased cardiovascular workforce diversity, inclusion of underrepresented populations into analyses of cardiovascular metrics, and greater utilisation of technology and telemedicine to improve access to health care. Achieving this goal will necessitate active participation from patients, health care administrators, physicians, and policy makers, and is imperative in closing the cardiovascular health gap for women over the coming decades.

Variations and inequities in access to cardiac diagnostic services in Ontario Canada

OBJECTIVES

Echocardiography is an essential diagnostic modality known to have wide regional utilization variations. This study's objectives were to quantify regional variations and to examine the extent to which they are explained by differences in population age, sex, cardiac disease prevalence (CDP), and social determinants of health (SDH) risk.

METHODS

This is an observational study of all echocardiography exams performed in Ontario in 2019/20 (n = 695,622). We measured regional variations in echocardiography crude rates and progressively standardized rates for population age, sex, CDP, and SDH risk.

RESULTS

After controlling for differences in population age, sex, and CDP, Ontario's highest rate regions had echocardiography rates 57% higher than its lowest rate regions. Forty eight percent of total variation was not explained by differences in age, sex, and CDP. CDP increased with SDH risk. Access to most cardiac diagnostics was negatively correlated with SDH risk, while cardiac catheterization rates were positively correlated with SDH risk.

CONCLUSION

Variations analysis that adjusts for age and sex only without including clinical measures of need are likely to overestimate the unwarranted portion of total variation. Substantial variations persisted despite a mandatory provider accreditation policy aimed at curtailing them. The associations between variations and SDH risks imply a need to redress access and outcome inequities.

Regional variations in vaccination against COVID-19 in Germany

Vaccination willingness against COVID-19 is generally perceived as low. Moreover, there is large heterogeneity across and within countries. As a whole, Germany has average vaccination rates compared to other industrialized countries. However, vaccination rates in the 16 different German federal states differ by more than 20 percentage points. We describe variation in vaccination rates on the level of the 400 German counties using data on all vaccinations carried out until December 2022. Around 52-72% of that variation can be explained by regional differences in demographic characteristics, housing, education and political party preferences. We find indications that the remaining part may be due to differences in soft factors such as risk aversion, trust in the German government, trust in science, and beliefs in conspiracy theories regarding the origins of the Corona virus. We conclude that improving the trust in science and the fight against conspiracy theories may possibly be effective tools to improve vaccination rates and effectively fight pandemics.

Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors

PURPOSE

Geographic access to physicians has been shown to be unevenly distributed in the USA, with those in closer proximity having superior outcomes. The purpose of this study was to describe how geographic access to pediatric neurosurgeons varies across socioeconomic and demographic factors.

METHODS

Actively practicing neurosurgeons were identified by matching several registries and membership logs. This data was used to find their primary practice locations and the distance the average person in a county must travel to visit a surgeon. Counties were categorized into "surgeon deserts" and "surgeon clusters," which were counties where providers were significantly further or closer to its residents, respectively, compared to the national average. These groups were also compared for differences in population characteristics using data obtained from the 2020 American Community Survey.

RESULTS

A total of 439 pediatric neurosurgeons were identified. The average person in a surgeon desert and cluster was found to be 189.2 ± 78.1 miles and 39.7 ± 19.6 miles away from the nearest pediatric neurosurgeon, respectively. Multivariate analyses showed that higher Rural-Urban Continuum (RUC) codes (p < 0.001), and higher percentages of American Indian (p < 0.001) and Hispanic (p < 0.001) residents were independently associated with counties where the average person traveled significantly further to surgeons.

CONCLUSION

Patients residing in counties with greater RUC codes and higher percentages of American Indian and Hispanic residents on average need to travel significantly greater distances to access pediatric neurosurgeons.

Background incidence rates of health outcomes in populations at risk for Lyme disease using US administrative claims data

BACKGROUND

Background incidence rates (IRs) of health outcomes in Lyme disease endemic regions are useful to contextualize events reported during Lyme disease vaccine clinical trials or post-marketing. The objective of this study was to estimate and compare IRs of health outcomes in Lyme disease endemic versus non-endemic regions in the US during pre-COVID and COVID era timeframes.

METHODS

IQVIA PharMetrics® Plus commercial claims database was used to estimate IRs of 64 outcomes relevant to vaccine safety monitoring in the US during January 1, 2017-December 31, 2019 and January 1, 2020-December 31, 2021. Analyses included all individuals aged ≥ 2 years with ≥ 1 year of continuous enrollment. Outcomes were defined by International Classification of Diseases Clinical Modification, 10th Revision (ICD-10-CM) diagnosis codes. IRs and 95 % confidence intervals (CIs) were calculated for each outcome and compared between endemic vs. non-endemic regions, and pre-COVID vs. COVID era using IR ratios (IRR).

RESULTS

The study population included 8.7 million (M) in endemic and 27.8 M in non-endemic regions. Mean age and sex were similar in endemic and non-endemic regions. In both study periods, the IRs were statistically higher in endemic regions for anaphylaxis, meningoencephalitis, myocarditis/pericarditis, and rash (including erythema migrans) as compared with non-endemic regions. Conversely, significantly lower IRs were observed in endemic regions for acute kidney injury, disseminated intravascular coagulation, heart failure, myelitis, myopathies, and systemic lupus erythematosus in both study periods. Most outcomes were statistically less frequent during the COVID-era.

CONCLUSION

This study identified potential differences between Lyme endemic and non-endemic regions of the US in background IRs of health conditions during pre-COVID and COVID era timeframes to inform Lyme disease vaccine safety monitoring. These regional and temporal differences in background IRs should be considered when contextualizing possible safety signals in clinical trials and post-marketing of a vaccine targeted at Lyme disease prevention.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 7: Sex, Gender, and the Social Determinants of Health

Women vs men have major differences in terms of risk-factor profiles, social and environmental factors, clinical presentation, diagnosis, and treatment of cardiovascular disease. Women are more likely than men to experience health issues that are complex and multifactorial, often relating to disparities in access to care, risk-factor prevalence, sex-based biological differences, gender-related factors, and sociocultural factors. Furthermore, awareness of the intersectional nature and relationship of sociocultural determinants of health, including sex and gender factors, that influence access to care and health outcomes for women with cardiovascular disease remains elusive. This review summarizes literature that reports on under-recognized sex- and gender-related risk factors that intersect with psychosocial, economic, and cultural factors in the diagnosis, treatment, and outcomes of women's cardiovascular health.

Geographic Disparities in Access to Neurologists and Multiple Sclerosis Care in the United States

BACKGROUND AND OBJECTIVES

A shortage of neurology clinicians and healthcare disparities may hinder access to neurologic care. This study examined disparities in geographic access to neurologists and subspecialty multiple sclerosis (MS) care among various demographic segments of the United States.

METHODS

Neurologist practice locations from 2022 CMS Care Compare physician data and MS Center locations as defined by the Consortium of Multiple Sclerosis Centers were used to compute spatial access for all U.S. census tracts. Census tract-level community characteristics (sex, age, race, ethnicity, education, income, insurance, % with computer, % without a vehicle, % with limited English, and % with hearing, vision, cognitive, and ambulatory difficulty) were obtained from 2020 American Community Survey 5-year estimates. Rural-urban status was obtained from 2010 rural-urban commuting area codes. Logistic and linear regression models were used to examine access to a neurologist or MS Center within 60 miles and 60-mile spatial access ratios.

RESULTS

Of 70,858 census tracts, 388 had no neurologists within 60 miles and 17,837 had no MS centers within 60 miles. Geographic access to neurologists (spatial access ratio [99% CI]) was lower for rural (-80.49%; CI [-81.65 to -79.30]) and micropolitan (-60.50%; CI [-62.40 to -58.51]) areas compared with metropolitan areas. Tracts with 10% greater percentage of Hispanic individuals (-4.53%; CI [-5.23 to -3.83]), men (-6.76%; CI [-8.96 to -4.5]), uninsured (-7.99%; CI [-9.72 to -6.21]), individuals with hearing difficulty (-40.72%; CI [-44.62 to -36.54]), vision difficulty (-13.0%; [-18.72 to -6.89]), and ambulatory difficulty (-15.68%; CI [-19.25 to -11.95]) had lower access to neurologists. Census tracts with 10% greater Black individuals (3.50%; CI [2.93-10.71]), college degree holders (-7.49%; CI [6.67-8.32]), individuals with computers (16.57%, CI [13.82-19.40]), individuals without a vehicle (9.57%; CI [8.69-10.47]), individuals with cognitive difficulty (25.63%; CI [19.77-31.78]), and individuals with limited English (18.5%; CI [16.30-20.73]), and 10-year older individuals (8.85%; CI [7.03-10.71]) had higher spatial access to neurologists. Covariates for access followed similar patterns for MS centers.

DISCUSSION

Geographic access to neurologists is decreased in rural areas, in areas with higher proportions of Hispanics, populations with disabilities, and those uninsured. Access is further limited for MS subspecialty care. This study highlights disparities in geographic access to neurologic care.

Quantifying COPD as a risk factor for cardiac disease in a primary prevention cohort

BACKGROUND

Despite COPD being a risk factor for cardiovascular disease (CVD) and knowing that risk stratification for CVD primary prevention is important, little is known about the real-world risk of CVD among people with COPD with no history of CVD. This knowledge would inform CVD management for people with COPD. The current study aimed to examine the risk of major adverse cardiovascular events (MACE) (including acute myocardial infarction, stroke or cardiovascular death) in a large, complete real-world population with COPD without previous CVD.

METHODS

We conducted a retrospective population cohort study using health administrative, medication, laboratory, electronic medical record and other data from Ontario, Canada. People without a history of CVD with and without physician-diagnosed COPD were followed between 2008 and 2016, and cardiac risk factors and comorbidities compared. Sequential cause-specific hazard models adjusting for these factors determined the risk of MACE in people with COPD.

RESULTS

Among ∼5.8 million individuals in Ontario aged ≥40 years without CVD, 152 125 had COPD. After adjustment for cardiovascular risk factors, comorbidities and other variables, the rate of MACE was 25% higher in persons with COPD compared with those without COPD (hazard ratio 1.25, 95% CI 1.23-1.27).

CONCLUSIONS

In a large real-world population without CVD, people with physician-diagnosed COPD were 25% more likely to have a major CVD event, after adjustment for CVD risk and other factors. This rate is comparable to the rate in people with diabetes and calls for more aggressive CVD primary prevention in the COPD population.

Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes

BACKGROUND

It is unknown whether the annual number of primary care physician (PCP) unique outpatient assessments, which we refer to as clinical volume, translates into better cardiovascular preventive care. We examined the relationship between PCP outpatient clinical volumes and cholesterol testing and major adverse cardiovascular event rates among guideline-recommended eligible patients.

METHODS

This was a retrospective cohort study conducted as part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, a population-based cohort of almost all adult residents of Ontario, Canada, followed from 2008 to 2012. For each clinical volume quintile, we compared cholesterol testing and major adverse cardiovascular events, defined as time to first event of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke.

RESULTS

The 10,037 PCPs evaluated had an annualized median volume of 2303 clinical encounters (IQR 1292-3680). Among 4,740,380 patients, 84% underwent guideline-concordant cholesterol testing at least once over 5 years, ranging from 73% with the lowest clinical volume quintile physicians to 86% with the highest. After multivariable adjustment, there was a 10.5% relative increase in the probability of cholesterol testing for every doubling of clinical volumes (95% CI 9.7-11.4; P < 0.001). Patients treated by the lowest volume quintile physicians had the highest rate of major adverse cardiovascular outcomes (compared with the highest volume quintile physicians: adjusted HR 1.15, 95% CI 1.10-1.21; P < 0.001).

CONCLUSIONS

Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing and had the highest rate of incident cardiovascular events. Further research investigating the drivers of this relationship is warranted.

Cardiovascular risk factors in the elderly: a 10-year follow-up survival analysis

AIMS

Cardiovascular risk factors present a high prevalence and have an impact on the morbimortality of the elderly; however, studies evaluating the impact of cardiovascular risk factors in the elderly have had short follow-up times and have not allowed specific analyses of the effects of these factors in the aged population, including how they affect the survival of the elderly. This study aimed to analyse the survival of elderly individuals living in the community, considering the presence of cardiovascular risk factors.

METHODS AND RESULTS

A prospective 10-year follow-up was initiated in 2008 with a cohort of 418 elderly people living in a community in Central Brazil. The Kaplan-Meier method and the Cox proportional hazards model were used to examine the association between survival and cardiovascular risk factors. The mean age of the participants was 70.6 (±7.1) years; most participants were hypertensive (81.6%) and participated in irregular physical activity (44%), and 43.3% smoked. After a mean follow-up of 8.38 (±2.82) years, 59.3% had survived and 34.1% had died; among the deaths, 14.1% were due to cardiovascular causes. Age [hazard ratio (HR) 1.067, 95% confidence interval (CI) 1.027-1.109], hypertension (HR 3.178, 95% CI 1.144-8.826), and smoking (HR 2.235, 95% CI 1.253-3.987) were confirmed as risk factors for reduced survival, whereas physical activity was a protective factor (HR 0.456, 95% CI 0.206-1.007).

CONCLUSION

The results from this study highlight the need for educational policies towards hypertension and smoking prevention among elderly people, and participation in physical activity needs to be encouraged.

Social Determinants of Stroke Hospitalization and Mortality in United States' Counties

(1) Background: Stroke incidence and outcomes are influenced by socioeconomic status. There is a paucity of reported population-level studies regarding these determinants. The goal of this ecological analysis was to determine the county-level associations of social determinants of stroke hospitalization and death rates in the United States. (2) Methods: Publicly available data as of 9 April 2021, for the socioeconomic factors and outcomes, was extracted from the Centers for Disease Control and Prevention. The outcomes of interest were “all stroke hospitalization rates per 1000 Medicare beneficiaries” (SHR) and “all stroke death rates per 100,000 population” (SDR). We used a multivariate binomial generalized linear mixed model after converting the outcomes to binary based on their median values. (3) Results: A total of 3226 counties/county-equivalents of the states and territories in the US were analyzed. Heart disease prevalence (odds ratio, OR = 2.03, p < 0.001), blood pressure medication nonadherence (OR = 2.02, p < 0.001), age-adjusted obesity (OR = 1.24, p = 0.006), presence of hospitals with neurological services (OR = 1.9, p < 0.001), and female head of household (OR = 1.32, p = 0.021) were associated with high SHR while cost of care per capita for Medicare patients with heart disease (OR = 0.5, p < 0.01) and presence of hospitals (OR = 0.69, p < 0.025) were associated with low SHR. Median household income (OR = 0.6, p < 0.001) and park access (OR = 0.84, p = 0.016) were associated with low SDR while no college degree (OR = 1.21, p = 0.049) was associated with high SDR. (4) Conclusions: Several socioeconomic factors (e.g., education, income, female head of household) were found to be associated with stroke outcomes. Additional research is needed to investigate intermediate and potentially modifiable factors that can serve as targeted interventions.

Predicting hospitalisations related to ambulatory care sensitive conditions with machine learning for population health planning: derivation and validation cohort study

OBJECTIVE

To predict older adults' risk of avoidable hospitalisation related to ambulatory care sensitive conditions (ACSC) using machine learning applied to administrative health data of Ontario, Canada.

DESIGN, SETTING AND PARTICIPANTS

A retrospective cohort study was conducted on a large cohort of all residents covered under a single-payer system in Ontario, Canada over the period of 10 years (2008-2017). The study included 1.85 million Ontario residents between 65 and 74 years old at any time throughout the study period.

DATA SOURCES

Administrative health data from Ontario, Canada obtained from the (ICES formely known as the Institute for Clinical Evaluative Sciences Data Repository.

MAIN OUTCOME MEASURES

Risk of hospitalisations due to ACSCs 1 year after the observation period.

RESULTS

The study used a total of 1 854 116 patients, split into train, validation and test sets. The ACSC incidence rates among the data points were 1.1% for all sets. The final XGBoost model achieved an area under the receiver operating curve of 80.5% and an area under precision-recall curve of 0.093 on the test set, and the predictions were well calibrated, including in key subgroups. When ranking the model predictions, those at the top 5% of risk as predicted by the model captured 37.4% of those presented with an ACSC-related hospitalisation. A variety of features such as the previous number of ambulatory care visits, presence of ACSC-related hospitalisations during the observation window, age, rural residence and prescription of certain medications were contributors to the prediction. Our model was also able to capture the geospatial heterogeneity of ACSC risk in Ontario, and especially the elevated risk in rural and marginalised regions.

CONCLUSIONS

This study aimed to predict the 1-year risk of hospitalisation from ambulatory-care sensitive conditions in seniors aged 65-74 years old with a single, large-scale machine learning model. The model shows the potential to inform population health planning and interventions to reduce the burden of ACSC-related hospitalisations.

Patient, physician and geographic predictors of cardiac stress testing strategy in Ontario, Canada: a population-based study

OBJECTIVES

To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain.

DESIGN

Retrospective cohort study.

SETTING

Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018.

PARTICIPANTS

103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain.

PRIMARY AND SECONDARY OUTCOME MEASURES

To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo).

RESULTS

There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT.

CONCLUSIONS

We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.

Leading POCT Networks: Operating POCT Programs Across Multiple Sites Involving Vast Geographical Areas and Rural Communities

Few peer-reviewed publications provide laboratory leaders with useful strategies on which to develop and implement point of care testing (POCT) programs to support delivery of acute care services to remote rural communities, with or without trained laboratory staff on site. This mini review discusses common challenges faced by laboratory leaders poised to implement and operate POCT programs at multiple remote and rural sites. It identifies areas for consideration during the initial program planning phases and provides areas for focus during evaluation and for continued improvement of POCT services at remote locations. Finally, it discusses a potential oversight framework for governance and leadership of multisite POCT programs servicing remote and rural communities.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 2: Scope of the Problem

Background

This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status.

Methods

CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group.

Results

Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada.

Conclusions

Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.

Strategies for enhancing the initiation of cholesterol lowering medication among patients at high cardiovascular disease risk: a qualitative descriptive exploration of patient and general practitioners' perspectives on a facilitated relay intervention in Alberta, Canada

OBJECTIVE

The objective of our study was to explore the perspectives of patients and general practitioners (GPs) regarding interventions to increase initiation of cholesterol lowering medication (or statins), including a proposed laboratory-based facilitated relay intervention.

DESIGN

Qualitative descriptive study using interviews and focus groups for data collection, and thematic analysis for data analysis.

SETTING

Primary care providers and patients in Calgary, Alberta, Canada.

PARTICIPANTS

17 GPs with primarily community-based, non-academic practices with at least 1 year of practice experience participated in semistructured interviews. 14 patients at high risk of cardiovascular disease participated in focus groups.

MAIN OUTCOME MEASURES

Exploration of strategies that might be used to enhance the prescription of, and adherence to statin therapy for patients with statin-indicated conditions.

RESULTS

GPs proposed a variety of interventions to improve statin prescription, including electronic record audit solutions, GP directed education, and patient-oriented campaigns. Patients expressed that they may benefit from being provided access to their laboratory test results, as well as targeted education. Both parties provided positive feedback on the proposed laboratory-based facilitated relay intervention, while pointing out areas for improvement. Notably, GPs were concerned that the patient-directed component of the intervention might jeopardise therapeutic relationships, and patients were concerned about accidental disclosure of personal health information. Important considerations for the design of facilitated relay messaging should include brevity, simplicity and the provision of contact information for inquiries.

CONCLUSIONS

GPs and patients described several suggestions for increasing statin initiation and welcomed the proposal of a laboratory-based facilitated relay strategy. These findings support further testing of this intervention which may enhance GPs' ability to successfully engage patients in cardiovascular risk reduction through statin therapy.

Use of Cardiac Noninvasive Testing After Emergency Department Discharge: Association of Hospital Network Testing Intensity and Outcomes in Ontario, Canada

Background

The relationship between noninvasive cardiac diagnostic testing intensity and downstream clinical outcomes is unclear. Our objective was to examine the relationship between hospital network noninvasive cardiac diagnostic testing intensity and downstream clinical outcomes in patients who were discharged from the emergency department after assessment for chest pain.

Methods and Results

We employed a retrospective cohort study design of 387 809 patients evaluated for chest pain in the emergency department between April 1, 2010 and March 31, 2016. Hospital networks were divided into tertiles based on usage of noninvasive cardiac diagnostic testing. The primary outcome was a composite of acute myocardial infarction or all‐cause mortality. Adjusted Cox proportional hazards models were used to compare the hazard of the composite outcome of myocardical infarction and/or all‐cause mortality between the tertiles. After adjustment for clinically relevant covariates, patients evaluated for chest pain in intermediate noninvasive cardiac diagnostic testing usage tertile hospital networks did not have significantly different hazards of the composite outcome when compared with those evaluated in low usage tertile hospital networks >90 days (hazard ratio [HR], 1.00; 95% CI, 0.83–1.21), 6 months (HR, 1.07; 95% CI, 0.92–1.24), and 1 year (HR, 1.03; 95% CI, 0.94–1.14). Patients evaluated in the high usage tertile also did not have significantly different hazards of the composite outcome compared with those evaluated in the low usage tertile at 90 days (HR, 0.98; 95% CI, 0.80–1.19), 6 months (HR, 1.01; 95% CI, 0.87–1.17); and 1 year (HR, 0.95; 95% CI, 0.86–1.05).

Conclusions

Our population‐based study demonstrated that high noninvasive cardiac diagnostic testing use intensity was not associated with reductions in downstream myocardial infarction or all‐cause mortality.

Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario

BACKGROUND

We previously found large variation among family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation in adherence to recommendations for managing cardiovascular disease risk factors.

METHODS

We conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD) housed at ICES in Ontario. Five quality indicators based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care.

RESULTS

In all, 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in quality indicators, with 15% to 39% of the total variation attributable to nonpatient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their body mass index measured, and their blood pressure controlled, but less likely to receive antiplatelet medications and liver-enzyme testing if overweight or obese.

CONCLUSIONS

The majority of variations in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation was due to differences among physicians and clinics. This finding may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.

Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study

BACKGROUND

The care necessary to prevent amputation from diabetes and peripheral artery disease (PAD) remains disjointed in many jurisdictions. To help inform integrated regional care, this study explores the correlation between regional health care services and rates of lower extremity amputation.

METHODS

This ecological study included 14 administrative health regions in Ontario, Canada. All diabetes- or PAD-related major (above ankle) amputations (Apr. 1, 2007, to Mar. 31, 2017) were identified among residents 40 years of age and older. For each region, age-and sex-adjusted amputation rates were calculated as well as per capita counts of key health providers (podiatrists and chiropodists, as well as surgeons) and health care utilization among study patients in the year before the first major amputation (physician visits, publicly funded podiatry visits, emergency department visits, hospital admissions, home care nursing, minor amputation, limb revascularization).

RESULTS

A total of 11 658 patients with major amputation were identified (of whom 79.2% had diabetes and 96.5% had PAD). There was wide regional variation in amputation rates: 2.53 to 11.77 per 100 000 person-quarters. At a regional level, the proportion of study patients who received revascularization showed the strongest negative correlation with amputation rates. The regional proportion of study patients who saw a vascular surgeon showed the strongest negative correlation with amputation rates, relative to other health provider visits. Other measures of health care utilization among patients correlated poorly with regional amputation rates, as did the regional provider counts. The results were similar when we restricted the analysis to diabetes-related amputations.

INTERPRETATION

Amputation rates related to diabetes and PAD vary widely across Ontario. Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts.

Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Outpatients Evaluated for Stable Coronary Artery Disease

Background

Despite more than 4 million cardiac noninvasive diagnostic tests (NIT) being performed annually for stable coronary artery disease in the United States, it is unclear whether they are associated with downstream improvements in outcomes when compared with no testing. We sought to determine whether NIT was associated with reduced downstream major adverse cardiovascular events when compared with not testing.

Methods and Results

We conducted a population‐based study of ≈1.5 million patients undergoing chest pain evaluation in Ontario, Canada. Patients were categorized into NIT and no‐testing groups. Cause‐specific proportional hazards models were used to compare the rate of major adverse cardiovascular events (composite outcome of unstable angina, acute myocardial infarction or cardiovascular mortality and each constituent) between the 2 groups after adjusting for clinically relevant covariates. The rate of the composite outcome was ≈25% lower for patients undergoing noninvasive testing (hazard ratio [HR], 0.77; 95% CI, 0.75–0.79). The benefits of testing were consistent for all 3 constituents of the composite; unstable angina (HR, 0.87; 95% CI, 0.82–0.93 for the NIT versus the no‐testing group), myocardial infarction (HR, 0.83; 95% CI, 0.79–0.86 for the NIT versus the no‐testing group) and cardiovascular mortality (HR, 0.68; 95% CI, 0.65–0.72 for the NIT versus the no‐testing group).

Conclusions

Our large population‐based study reports an ≈25% reduction in major adverse cardiovascular events that was independently associated with NIT in outpatients being evaluated for stable angina. This study demonstrates the prognostic importance of NIT versus no testing on the health of contemporary populations.

Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease

BACKGROUND

It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA.

METHODS

The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup.

RESULTS

Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast.

CONCLUSIONS

In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.

Patterns in Geographic Access to Health Care Facilities Across Neighborhoods in the United States Based on Data From the National Establishment Time-Series Between 2000 and 2014

IMPORTANCE

The association between proximity to health care facilities and improved disease management and population health has been documented, but little is known about small-area health care environments and how the presence of health care facilities has changed over time during recent health system and policy change.

OBJECTIVE

To examine geographic access to health care facilities across neighborhoods in the United States over a 15-year period.

DESIGN, SETTING, AND PARTICIPANTS

Using longitudinal business data from the National Establishment Time-Series, this cross-sectional study examined the presence of and change in ambulatory care facilities and pharmacies and drugstores in census tracts (CTs) throughout the continental United States between 2000 and 2014. Between January and April 2019, multinomial logistic regression was used to estimate associations between health care facility presence and neighborhood sociodemographic characteristics over time.

MAIN OUTCOMES AND MEASURES

Change in health care facility presence was measured as never present, lost, gained, or always present between 2000 and 2014. Neighborhood sociodemographic characteristics (ie, CTs) and their change over time were measured from US Census reports (2000 and 2010) and the American Community Survey (2008-2012).

RESULTS

Among 72 246 included CTs, the percentage of non-US-born residents, residents 75 years or older, poverty status, and population density increased, and 8.1% of CTs showed a change in the racial/ethnic composition of an area from predominantly non-Hispanic (NH) white to other racial/ethnic composition categories between 2000 and 2010. The presence of ambulatory care facilities increased from a mean (SD) of 7.7 (15.9) per CT in 2000 to 13.0 (22.9) per CT in 2014, and the presence of pharmacies and drugstores increased from a mean (SD) of 0.6 (1.0) per CT in 2000 to 0.9 (1.4) per CT in 2014. Census tracts with predominantly NH black individuals (adjusted odds ratio [aOR], 2.37; 95% CI, 2.03-2.77), Hispanic/Latino individuals (aOR 1.30; 95% CI, 1.00-1.69), and racially/ethnically mixed individuals (aOR, 1.53; 95% CI, 1.33-1.77) in 2000 had higher odds of losing health care facilities between 2000 and 2014 compared with CTs with predominantly NH white individuals, after controlling for other neighborhood characteristics. Census tracts of geographic areas with higher levels of poverty in 2000 also had higher odds of losing health care facilities between 2000 and 2014 (aOR, 1.12; 95% CI, 1.05-1.19).

CONCLUSIONS AND RELEVANCE

Differential change was found in the presence of health care facilities across neighborhoods over time, indicating the need to monitor and address the spatial distribution of health care resources within the context of population health disparities.

Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Patients Discharged From the Emergency Department for Chest Pain

Background

More than 4 million cardiac noninvasive diagnostic tests are performed annually in the United States. However, questions remain regarding their effectiveness in improving clinical outcomes. We sought to evaluate whether noninvasive diagnostic tests were associated with lower rates of myocardial infarction or cardiovascular death when compared with no testing.

Methods and Results

We performed a retrospective, population‐based cohort study of adults evaluated for chest pain and discharged home from an emergency department in Ontario, Canada. Propensity score matching was employed to reduce confounding between the testing and nontesting groups. There were 370 863 patients evaluated in our cohort. Rates of the composite outcome were low for both groups after propensity‐score matching (0.29% and 0.78% for the nontesting group at 90 days and 1 year, respectively, and 0.34% and 0.68% for the noninvasive diagnostic test group at 90 days and 1 year respectively). Over 1 year, patients undergoing noninvasive diagnostic testing had a small but statistically significant lower hazard of developing the composite outcome of myocardial infarction or cardiovascular mortality (hazard ratio, 0.87; 95% CI, 0.78–0.96 [P<0.01]), which appears to be driven by the high‐risk subgroup (hazard ratio, 0.75; 95% CI, 0.61–0.92 [P<0.01]).

Conclusions

We report a lower observed rate of the composite outcome of cardiovascular death or myocardial infarction associated with noninvasive diagnostic testing following evaluation for chest pain in the emergency department. This lower rate was driven by the high‐risk subgroup. These results suggest that risk‐based testing should be considered for patients discharged from the emergency department for chest pain.

Cardiovascular Diseases in India Compared With the United States

This review describes trends in the burden of cardiovascular diseases (CVDs) and risk factors in India compared with the United States; provides potential explanations for these differences; and describes strategies to improve cardiovascular health behaviors, systems, and policies in India. The prevalence of CVD in India has risen over the past 2 decades due to population growth, aging, and a stable age-adjusted CVD mortality rate. Over the same time period, the United States has experienced an overall decline in age-adjusted CVD mortality, although the trend has begun to plateau. These improvements in CVD mortality in the United States are largely due to favorable population-level risk factor trends, specifically with regard to tobacco use, cholesterol, and blood pressure, although improvements in secondary prevention and acute care have also contributed. To realize similar gains in reducing premature death and disability from CVD, India needs to implement population-level policies while strengthening and integrating its local, regional, and national health systems. Achieving universal health coverage that includes financial risk protection should remain a goal to help all Indians realize their right to health.

Regional variation of premature mortality in Ontario, Canada: a spatial analysis

BACKGROUND

Premature mortality is a meaningful indicator of both population health and health system performance, which varies by geography in Ontario. We used the Local Health Integration Network (LHIN) sub-regions to conduct a spatial analysis of premature mortality, adjusting for key population-level demographic and behavioural characteristics.

METHODS

We used linked vital statistics data to identify 163,920 adult premature deaths (deaths between ages 18 and 74) registered in Ontario between 2011 and 2015. We compared premature mortality rates, population demographics, and prevalence of health-relevant behaviours across 76 LHIN sub-regions. We used Bayesian hierarchical spatial models to quantify the contribution of these population characteristics to geographic disparities in premature mortality.

RESULTS

LHIN sub-region premature mortality rates ranged from 1.7 to 6.6 deaths per 1000 per year in males and 1.2 to 4.8 deaths per 1000 per year in females. Regions with higher premature mortality had fewer immigrants and higher prevalence of material deprivation, excess body weight, inadequate fruit and vegetable consumption, sedentary behaviour, and ever-smoked status. Adjusting for all variables eliminated close to 90% of geographic variation in premature mortality, but did not fully explain the spatial pattern of premature mortality in Ontario.

CONCLUSIONS

We conducted the first spatial analysis of mortality in Ontario, revealing large geographic variations. We demonstrate that well-known risk factors explain most of the observed variation in premature mortality. The result emphasizes the importance of population health efforts to reduce the burden of well-known risk factors to reduce variation in premature mortality.

Canadians' views on the use of routinely collected data in health research: a patient-oriented cross-sectional survey

BACKGROUND

Little is known about Canadians' knowledge of and level of support for using administrative and other large, routinely collected data for health research, despite the benefits of this type of research to patients, health care systems and society. We sought to benchmark the views of Canadian adults on this topic.

METHODS

Researchers and patient leaders of 3 joint and skin disease organizations codeveloped a cross-sectional online survey that was conducted between January and August 2017. The patient partners were engaged as full partners. Recruitment was mainly through the organizations' websites, email and social media. The survey captured respondents' initial perceptions, then (after background information on the topic was provided) elicited their views on the benefits of health research using routinely collected data, data access/privacy concerns, ongoing perceptions and educational needs.

RESULTS

Of the 230 people who consented, 183 (79.6%) started the survey, and 151 (65.6%) completed the survey. Of the 151, 117 (77.5%) were women, 84 (55.6%) were British Columbians, 87 (57.6%) were university graduates, and 101 (66.9%) had a chronic disease. At the beginning of the survey, 119 respondents (78.8%) felt positively about the use of routinely collected data for health research. Respondents identified the ability to study long-term treatment effects and rare events (114 [75.5%]) and large numbers of people (110 [72.8%]) as key benefits. Deidentification of personal information was the top privacy measure (135 [89.4%]), and 101 respondents (66.9%) wanted to learn more about data stewards' granting access to data. On survey completion, more respondents (141 [93.4%]) felt positively about the use of routinely collected data, but only 87 (57.6%) were confident about data security and privacy.

INTERPRETATION

Respondents generally supported the use of deidentified routinely collected data for health research. Although further investigation is needed with more representative samples, our findings suggest that additional education, especially about access and privacy controls, may enhance public support for research endeavours using these data.

Making It Happen: Middle Managers' Roles in Innovation Implementation in Health Care

Background

Middle managers are given scant attention in the implementation literature in health care, where the focus is on senior leaders and frontline clinicians.

Aims

To empirically examine the role of middle managers relevant to innovation implementation and how middle managers experience the implementation process.

Methods

A qualitative study was conducted using the methods of grounded theory. Data were collected through semistructured interviews with middle managers (N = 15) in Nova Scotia and New Brunswick, Canada. Participants were purposively sampled, based on their involvement in implementation initiatives and to obtain variation in manager characteristics. Data were collected and analyzed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached.

Results

Middle managers see themselves as being responsible for making implementation happen in their programs and services. As a result, they carry out five roles related to implementation: planner, coordinator, facilitator, motivator, and evaluator. However, the data also revealed two determinants of middle managers' role in implementation, which they must negotiate to fulfill their specific implementation roles and activities: (1) They perform many other roles and responsibilities within their organizations, both clinical and managerial in nature, and (2) they have limited decision‐making power with respect to implementation and must work within the parameters set by upper levels of the organization.

Linking Evidence to Action

Middle managers play an important role in translating adoption decisions into on‐the‐ground implementation. Optimizing their capacity to fulfill this role may be key to improving innovation implementation in healthcare organizations.

Audiometric Testing Guideline Adherence in Children Undergoing Tympanostomy Tubes: A Population-Based Study

Objective

Tympanostomy tube (TT) insertion is the most common ambulatory surgery performed on children. American Academy of Otolaryngology—Head and Neck Surgery Founda-tion (AAO-HNSF) Clinical Practice Guidelines (CPGs) recommend hearing testing for all pediatric TT candidates. The aim of this study was to assess audiometric testing in this population.

Study Design

Retrospective population-based cohort study.

Setting

All hospitals in the Canadian province of Ontario.

Subjects and Methods

All patients 12 years of age and younger who underwent at least 1 TT procedure between January 1993 and June 2016. The primary outcomes were the percentage of patients who underwent a hearing test within 1 year before and/or 1 year after surgery.

Results

A total of 316,599 bilateral TT procedures were performed during the study period (1993 to 2016). Presurgical hearing tests increased from 55.7% to 74.9%, and postsurgical hearing tests increased from 42.2% to 68.9%. Younger surgeons demonstrated a greater adherence to the CPGs (relative risk [RR], 1.22; 95% CI, 1.08-1.38; P = .001). Remarkably, there was not a spike in preoperative hearing tests following the introduction of the CPGs in 2013 (RR, 1.12; 95% CI, 0.85-1.47; P = .432). Presurgical hearing testing ranged from 26.1% to 83.5% across health regions.

Conclusion

In this cohort of children who underwent TT placement, the trends of preoperative and postoperative audiometric testing are increasing but are still lower than recommended by the CPGs, despite a tripling of practicing audiologists. This study describes the current state of testing in Ontario and highlights issues of access to audiology services, possible parent preferences, and the importance of ongoing continuing medical education for all health care practitioners.

The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study

BACKGROUND

High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting.

METHODS

As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system.

RESULTS

A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases.

INTERPRETATION

The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings.