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Muharram FR, Multazam CECZ, Harmadha WS, Andrianto A, Salsabilla SA, Dakota I, Andriantoro H, Firman D, Montain MM, Prakoso R, Anggraeni D. Distribution of catheterisation laboratories in Indonesia 2017-2022: a nationwide survey. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 26:100418. [PMID: 38764713 PMCID: PMC11101891 DOI: 10.1016/j.lansea.2024.100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/06/2024] [Accepted: 04/24/2024] [Indexed: 05/21/2024]
Abstract
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.
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Affiliation(s)
- Farizal Rizky Muharram
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | - Andrianto Andrianto
- Faculty of Medicine, Airlangga University, Soetomo General Hospital, Surabaya, Indonesia
| | | | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Hananto Andriantoro
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Doni Firman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Maya Marinda Montain
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Radityo Prakoso
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
| | - Dilla Anggraeni
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, University of Indonesia, National Cardiovascular Centre Harapan Kita, West Jakarta, Indonesia
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Kaur G, Masket D, Reddy T, Revankar S, Satish P, Paquin A, Mulvagh S, O'Donoghue ML, Zieroth S, Farkouh M, Gulati M. Socioeconomic Disparities in Women's Cardiovascular Health in the United States and Canada. Can J Cardiol 2024; 40:1056-1068. [PMID: 38593915 DOI: 10.1016/j.cjca.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/12/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
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.
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Affiliation(s)
- Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Diane Masket
- Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Tina Reddy
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Shruti Revankar
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Priyanka Satish
- Ascension Texas Cardiovascular, University of Texas at Austin Dell School of Medicine, Austin, Texas, USA
| | - Amelie Paquin
- Barbra Streisand Women's Heart Center, Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Sharon Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shelley Zieroth
- Division of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael Farkouh
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA.
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Wardle G, Sanfilippo AJ, Narula A, Kolos A, Chan K, Leong-Poi H, Sasson Z, Woodward G. Variations and inequities in access to cardiac diagnostic services in Ontario Canada. Health Policy 2024; 143:105033. [PMID: 38564973 DOI: 10.1016/j.healthpol.2024.105033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Gavin Wardle
- Preyra Solutions Group, 172 Palmerston Ave. Toronto ON M6J 2J4 Canada.
| | | | - Ashrut Narula
- Preyra Solutions Group, 172 Palmerston Ave. Toronto ON M6J 2J4 Canada
| | | | - Kwan Chan
- Ottawa Heart Institute, 40 Ruskin Street K1Y 4W7 Ottawa, Ontario Canada
| | - Howard Leong-Poi
- University of Toronto, Temerty Faculty of Medicine, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Zion Sasson
- University of Toronto, Temerty Faculty of Medicine, 1 King's College Circle, Medical Sciences Building, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Graham Woodward
- Ontario Health, 500 - 525 University Ave, Toronto, ON M5G 2L3, Canada
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4
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Bade V, Schmitz H, Tawiah BB. Regional variations in vaccination against COVID-19 in Germany. PLoS One 2024; 19:e0296976. [PMID: 38635523 PMCID: PMC11025766 DOI: 10.1371/journal.pone.0296976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 12/25/2023] [Indexed: 04/20/2024] Open
Abstract
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.
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Affiliation(s)
| | - Hendrik Schmitz
- Paderborn University, Paderborn, Germany
- RWI – Leibniz Institute for Economic Research, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
| | - Beatrice Baaba Tawiah
- Munich Research Institute for the Economics of Aging ans SHARE Analyses, Munich, Germany
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5
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Farivar D, Peterman NJ, Narendran N, Illingworth KD, Nuckols TK, Bonda D, Skaggs DL. Geographic access to pediatric neurosurgeons in the USA: an analysis of sociodemographic factors. Childs Nerv Syst 2024; 40:905-912. [PMID: 37794171 PMCID: PMC10891277 DOI: 10.1007/s00381-023-06172-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
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.
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Affiliation(s)
- Daniel Farivar
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicholas J Peterman
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nakul Narendran
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Kenneth D Illingworth
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Teryl K Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - David Bonda
- Department of Neurological Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - David L Skaggs
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Dreyfus J, Munnangi S, Bengtsson C, Correia B, Figueiredo R, Stark JH, Zawora M, Riddle MS, Maguire JD, Jiang Q, Ianos C, Naredo Turrado J, Svanström H, Bailey S, DeKoven M. Background incidence rates of health outcomes in populations at risk for Lyme disease using US administrative claims data. Vaccine 2024; 42:1094-1107. [PMID: 38262807 DOI: 10.1016/j.vaccine.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/09/2024] [Accepted: 01/12/2024] [Indexed: 01/25/2024]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - James H Stark
- Vaccines, Antivirals, and Evidence Generation, Medical Affairs, Pfizer Biopharma Group, Cambridge, MA, USA
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7
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Norris CM, Mullen KA, Foulds HJ, Jaffer S, Nerenberg K, Gulati M, Parast N, Tegg N, Gonsalves CA, Grewal J, Hart D, Levinsson AL, Mulvagh SL. 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. CJC Open 2024; 6:205-219. [PMID: 38487069 PMCID: PMC10935698 DOI: 10.1016/j.cjco.2023.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 07/31/2023] [Indexed: 03/17/2024] Open
Abstract
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.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kerri-Anne Mullen
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Heather J.A. Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kara Nerenberg
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Martha Gulati
- Barbra Streisand Women’s Heart Centre, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nazli Parast
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nicole Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Jasmine Grewal
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donna Hart
- Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | | | - Sharon L. Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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8
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McGinley MP, Harvey T, Lopez R, Ontaneda D, Buchalter RB. Geographic Disparities in Access to Neurologists and Multiple Sclerosis Care in the United States. Neurology 2024; 102:e207916. [PMID: 38165332 DOI: 10.1212/wnl.0000000000207916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/20/2023] [Indexed: 01/03/2024] Open
Abstract
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.
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Affiliation(s)
- Marisa P McGinley
- From the Mellen Center (M.P.M., D.O.), Cleveland; Center for Populations Health Research (R.B.B.), Department of Quantitative Health Sciences (T.H.), Cleveland Clinic, OH; and Department of Surgery (R.L.), University of Colorado Anschutz Medical Center, Aurora
| | - Tucker Harvey
- From the Mellen Center (M.P.M., D.O.), Cleveland; Center for Populations Health Research (R.B.B.), Department of Quantitative Health Sciences (T.H.), Cleveland Clinic, OH; and Department of Surgery (R.L.), University of Colorado Anschutz Medical Center, Aurora
| | - Rocio Lopez
- From the Mellen Center (M.P.M., D.O.), Cleveland; Center for Populations Health Research (R.B.B.), Department of Quantitative Health Sciences (T.H.), Cleveland Clinic, OH; and Department of Surgery (R.L.), University of Colorado Anschutz Medical Center, Aurora
| | - Daniel Ontaneda
- From the Mellen Center (M.P.M., D.O.), Cleveland; Center for Populations Health Research (R.B.B.), Department of Quantitative Health Sciences (T.H.), Cleveland Clinic, OH; and Department of Surgery (R.L.), University of Colorado Anschutz Medical Center, Aurora
| | - R Blake Buchalter
- From the Mellen Center (M.P.M., D.O.), Cleveland; Center for Populations Health Research (R.B.B.), Department of Quantitative Health Sciences (T.H.), Cleveland Clinic, OH; and Department of Surgery (R.L.), University of Colorado Anschutz Medical Center, Aurora
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Maclagan LC, Croxford R, Chu A, Sin DD, Udell JA, Lee DS, Austin PC, Gershon AS. Quantifying COPD as a risk factor for cardiac disease in a primary prevention cohort. Eur Respir J 2023; 62:2202364. [PMID: 37385658 DOI: 10.1183/13993003.02364-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/15/2023] [Indexed: 07/01/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Don D Sin
- Centre for Heart Lung Innovation, St Paul's Hospital and Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Jacob A Udell
- ICES, Toronto, ON, Canada
- Cardiovascular Division, Department of Medicine, Women's College Hospital and Women's College Research Institute, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Douglas S Lee
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andrea S Gershon
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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10
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Udell JA, Brickman AR, Chu A, Ferreira-Legere LE, Sheth MS, Ko DT, Austin PC, Abdel-Qadir H, Ivers NM, Bhatia RS, Farkouh ME, Stukel TA, Tu JV. Primary Care Clinical Volumes, Cholesterol Testing, and Cardiovascular Outcomes. Can J Cardiol 2023; 39:340-349. [PMID: 36574928 DOI: 10.1016/j.cjca.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/07/2022] [Accepted: 12/20/2022] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Jacob A Udell
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Arielle R Brickman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | | | | | - Maya S Sheth
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Noah M Ivers
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Family Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Thérèse A Stukel
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jack V Tu
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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11
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Vilela de Sousa T, Cavalcante AMRZ, Lima NX, Souza JS, Sousa ALL, Brasil VV, Vieira FVM, Guimarães JV, de Matos MA, Silveira EA, Pagotto V. Cardiovascular risk factors in the elderly: a 10-year follow-up survival analysis. Eur J Cardiovasc Nurs 2023; 22:43-52. [PMID: 35574942 DOI: 10.1093/eurjcn/zvac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Thaís Vilela de Sousa
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Agueda Maria Ruiz Zimmer Cavalcante
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Nathália Xavier Lima
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Jennifer Siqueira Souza
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Ana Luiza Lima Sousa
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Virginia Visconde Brasil
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Flaviana Vely Mendonça Vieira
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Janaína Valadares Guimarães
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Marcos André de Matos
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Erika Aparecida Silveira
- 2 College of Medicine, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
| | - Valéria Pagotto
- 1 College of Nursing, Universidade Federal de Goias, 227 Street, Viela Q. 68, S/N - Sector Leste Universitario, Goiania, GO 74605-080, Brazil
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12
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Yadav RS, Chaudhary D, Avula V, Shahjouei S, Azarpazhooh MR, Abedi V, Li J, Zand R. Social Determinants of Stroke Hospitalization and Mortality in United States' Counties. J Clin Med 2022; 11:jcm11144101. [PMID: 35887865 PMCID: PMC9320068 DOI: 10.3390/jcm11144101] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/29/2022] [Accepted: 06/28/2022] [Indexed: 12/10/2022] Open
Abstract
(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.
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Affiliation(s)
- Randhir Sagar Yadav
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Pediatrics, University of Florida College of Medicine, Jacksonville, FL 32207, USA
| | - Durgesh Chaudhary
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Venkatesh Avula
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA 17822, USA; (V.A.); (J.L.)
| | - Shima Shahjouei
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
| | - Mahmoud Reza Azarpazhooh
- Departments of Clinical Neurological Sciences and Epidemiology, University of Western Ontario, London, ON N6A 3K7, Canada;
| | - Vida Abedi
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA 17033, USA;
| | - Jiang Li
- Department of Molecular and Functional Genomics, Weis Center for Research, Geisinger Health System, Danville, PA 17822, USA; (V.A.); (J.L.)
| | - Ramin Zand
- Geisinger Neuroscience Institute, Geisinger Health System, Danville, PA 17822, USA; (R.S.Y.); (D.C.); (S.S.)
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA 17033, USA
- Neuroscience Institute, The Pennsylvania State University, Hershey, PA 17033, USA
- Correspondence:
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13
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Chu A, Hennessy DA, Johnston S, Udell JA, Lee DS, Jia J, Tu JV, Ko DT. Using big data for cardiovascular health surveillance: Insights from 10.3 million individuals in the CANHEART cohort. Can J Cardiol 2022; 38:1558-1566. [DOI: 10.1016/j.cjca.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 05/23/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022] Open
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14
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Yi SE, Harish V, Gutierrez J, Ravaut M, Kornas K, Watson T, Poutanen T, Ghassemi M, Volkovs M, Rosella LC. Predicting hospitalisations related to ambulatory care sensitive conditions with machine learning for population health planning: derivation and validation cohort study. BMJ Open 2022; 12:e051403. [PMID: 35365510 PMCID: PMC8977821 DOI: 10.1136/bmjopen-2021-051403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 02/28/2022] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Seung Eun Yi
- Layer6 AI, Toronto, Ontario, Canada
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Vinyas Harish
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
| | | | - Mathieu Ravaut
- School of Computer Science and Engineering, Nanyang Technological University, Singapore
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tristan Watson
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Marzyeh Ghassemi
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
| | | | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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15
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Roifman I, Han L, Fang J, Chu A, Austin P, Ko DT, Douglas P, Wijeysundera H. Patient, physician and geographic predictors of cardiac stress testing strategy in Ontario, Canada: a population-based study. BMJ Open 2022; 12:e059199. [PMID: 35273065 PMCID: PMC8915339 DOI: 10.1136/bmjopen-2021-059199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Idan Roifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | | | - Peter Austin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Pamela Douglas
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Harindra Wijeysundera
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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16
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Randell EW, Thakur V. Leading POCT Networks: Operating POCT Programs Across Multiple Sites Involving Vast Geographical Areas and Rural Communities. EJIFCC 2021; 32:179-189. [PMID: 34421486 PMCID: PMC8343053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
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.
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Affiliation(s)
- Edward W. Randell
- Laboratory Medicine, Eastern Health Authority, St. John’s, Newfoundland and Labrador, Canada, Faculty of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada,Corresponding author: Prof. Edward W. Randell Lab. Medicine, Eastern Health Authority & Faculty of Medicine, Memorial University Rm 1J442 Laboratory Medicine Eastern Health St. John’s, NL Canada Phone: 709-777-6375 Fax: 709-777-2442 E-mail:
| | - Vinita Thakur
- Laboratory Medicine, Eastern Health Authority, St. John’s, Newfoundland and Labrador, Canada, Faculty of Medicine, Memorial University, St. John’s, Newfoundland and Labrador, Canada
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17
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Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
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18
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Jaffer S, Foulds HJA, Parry M, Gonsalves CA, Pacheco C, Clavel MA, Mullen KA, Yip CYY, Mulvagh SL, Norris CM. 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. CJC Open 2021; 3:1-11. [PMID: 33458627 PMCID: PMC7801195 DOI: 10.1016/j.cjco.2020.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/12/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Shahin Jaffer
- Department of Medicine/Community Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Heather J A Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Christine Pacheco
- Pierre-Boucher Hospital, Centre Hospitalier de l'Université de Montréal (CHUM), University of Montreal, Montreal, Quebec, Canada
| | - Marie-Annick Clavel
- Laval University, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Ville de Québec, Québec, Canada
| | - Kerri A Mullen
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Cindy Y Y Yip
- HeartLife Foundation of Canada, Toronto, Ontario, Canada
| | - Sharon L Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.,Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services, Alberta, Canada
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19
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Campbell DJT, Lee-Krueger RCW, McBrien K, Anderson T, Quan H, Leung AA, Chen G, Lu M, Naugler C, Butalia S. 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. BMJ Open 2020; 10:e038469. [PMID: 33234627 PMCID: PMC7689086 DOI: 10.1136/bmjopen-2020-038469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 10/17/2020] [Accepted: 10/28/2020] [Indexed: 12/24/2022] Open
Abstract
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.
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Affiliation(s)
- David J T Campbell
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Kerry McBrien
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Todd Anderson
- Department of Cardiac Sciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Guanmin Chen
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mingshan Lu
- Department of Economics, University of Calgary, Calgary, Alberta, Canada
| | - Christopher Naugler
- Department of Pathology & Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sonia Butalia
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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20
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Roifman I, Han L, Koh M, Wijeysundera HC, Austin PC, Douglas PS, Ko DT. Use of Cardiac Noninvasive Testing After Emergency Department Discharge: Association of Hospital Network Testing Intensity and Outcomes in Ontario, Canada. J Am Heart Assoc 2020; 9:e017330. [PMID: 33086926 PMCID: PMC7763399 DOI: 10.1161/jaha.120.017330] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Idan Roifman
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | | | | | - Harindra C Wijeysundera
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | | | - Dennis T Ko
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
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Lee TMH, Tobe SW, Butt DA, Ivers NM, Gershon AS, Barnsley J, Liu PP, Jaakkimainen L, Walker KM, Tu K. Patient- and Physician-Level Factors Associated With Adherence to C-CHANGE Recommendations in Primary Care Settings in Ontario. CJC Open 2020; 2:563-576. [PMID: 33305217 PMCID: PMC7711016 DOI: 10.1016/j.cjco.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/11/2020] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Theresa Min-Hyung Lee
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Sheldon W. Tobe
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Canadian Cardiovascular Harmonization of National Guidelines Endeavour, Ottawa, Ontario, Canada
| | - Debra A. Butt
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Scarborough Health Network, Toronto, Ontario, Canada
| | - Noah M. Ivers
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital, Toronto, Ontario, Canada
| | - Andrea S. Gershon
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Peter P. Liu
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Canadian Cardiovascular Harmonization of National Guidelines Endeavour, Ottawa, Ontario, Canada
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Liisa Jaakkimainen
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Kimberly M. Walker
- Canadian Cardiovascular Harmonization of National Guidelines Endeavour, Ottawa, Ontario, Canada
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Karen Tu
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto, Ontario, Canada
- Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada
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22
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de Mestral C, Hussain MA, Austin PC, Forbes TL, Sivaswamy A, Kayssi A, Salata K, Wijeysundera HC, Verma S, Al-Omran M. Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study. CMAJ Open 2020; 8:E659-E666. [PMID: 33109531 PMCID: PMC7595755 DOI: 10.9778/cmajo.20200048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Charles de Mestral
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.
| | - Mohamad A Hussain
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Peter C Austin
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Thomas L Forbes
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Atul Sivaswamy
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Ahmed Kayssi
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Konrad Salata
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Harindra C Wijeysundera
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Subodh Verma
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont
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23
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Roifman I, Sivaswamy A, Chu A, Austin PC, Ko DT, Douglas PS, Wijeysundera HC. Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Outpatients Evaluated for Stable Coronary Artery Disease. J Am Heart Assoc 2020; 9:e015724. [PMID: 32605412 PMCID: PMC7670545 DOI: 10.1161/jaha.119.015724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Idan Roifman
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | | | | | - Peter C. Austin
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | - Dennis T. Ko
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
| | | | - Harindra C. Wijeysundera
- Schulich Heart ProgramSunnybrook Health Sciences CentreUniversity of TorontoCanada
- Institute of Health Policy Management, and EvaluationUniversity of TorontoCanada
- ICESTorontoCanada
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Wijeysundera HC, Henning KA, Qiu F, Adams C, Al Qoofi F, Asgar A, Austin P, Bainey KR, Cohen EA, Daneault B, Fremes S, Kass M, Ko DT, Lambert L, Lauck SB, MacFarlane K, Nadeem SN, Oakes G, Paddock V, Pelletier M, Peterson M, Piazza N, Potter BJ, Radhakrishnan S, Rodes-Cabau J, Toleva O, Webb JG, Welsh R, Wood D, Woodward G, Zimmermann R. Inequity in Access to Transcatheter Aortic Valve Replacement: A Pan-Canadian Evaluation of Wait-Times. Can J Cardiol 2020; 36:844-851. [DOI: 10.1016/j.cjca.2019.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 01/03/2023] Open
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Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease. Coron Artery Dis 2020; 31:733-738. [PMID: 32404592 DOI: 10.1097/mca.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Tsui J, Hirsch JA, Bayer FJ, Quinn JW, Cahill J, Siscovick D, Lovasi GS. 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. JAMA Netw Open 2020; 3:e205105. [PMID: 32412637 PMCID: PMC7229525 DOI: 10.1001/jamanetworkopen.2020.5105] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, Rutgers, The State University of New Jersey, New Brunswick
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Rutgers, The State University of New Jersey, New Brunswick
- Rutgers Center for State Health Policy, Rutgers, The State University of New Jersey, New Brunswick
| | - Jana A. Hirsch
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Felicia J. Bayer
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - James W. Quinn
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Jesse Cahill
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - David Siscovick
- Research, Evaluation & Policy, New York Academy of Medicine, New York, New York
| | - Gina S. Lovasi
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
- Urban Health Collaborative, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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Houben E, Mendel A, Carette S, Voskuyl AE, Penne EL, Pagnoux C. Predictors of fatal and non-fatal cardiovascular events in ANCA-associated vasculitis: Data from the Toronto CanVasc cohort. Joint Bone Spine 2020; 87:221-224. [DOI: 10.1016/j.jbspin.2019.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/17/2019] [Indexed: 01/26/2023]
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Norris CM, Yip CYY, Nerenberg KA, Clavel M, Pacheco C, Foulds HJA, Hardy M, Gonsalves CA, Jaffer S, Parry M, Colella TJF, Dhukai A, Grewal J, Price JAD, Levinsson ALE, Hart D, Harvey PJ, Van Spall HGC, Sarfi H, Sedlak TL, Ahmed SB, Baer C, Coutinho T, Edwards JD, Green CR, Kirkham AA, Srivaratharajah K, Dumanski S, Keeping‐Burke L, Lappa N, Reid RD, Robert H, Smith G, Martin‐Rhee M, Mulvagh SL. State of the Science in Women's Cardiovascular Disease: A Canadian Perspective on the Influence of Sex and Gender. J Am Heart Assoc 2020; 9:e015634. [PMID: 32063119 PMCID: PMC7070224 DOI: 10.1161/jaha.119.015634] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Kara A. Nerenberg
- Department of Medicine/Division of General Internal MedicineUniversity of CalgaryAlbertaCanada
| | | | | | | | - Marsha Hardy
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | | | - Shahin Jaffer
- Department of Medicine/Community Internal MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Tracey J. F. Colella
- University Health Network/Toronto Rehab Cardiovascular Prevention and Rehabilitation ProgramTorontoOntarioCanada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
| | - Jasmine Grewal
- Division of CardiologyUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Jennifer A. D. Price
- Lawrence S. Bloomberg Faculty of NursingUniversity of TorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
| | - Anna L. E. Levinsson
- Montreal Heart InstituteMontrealQuebecCanada
- Beaulieu‐Saucier Université de Montréal Pharmacogenomics CentreMontrealQuebecCanada
- Faculty of MedicineUniversité de MontréalMontrealQuebecCanada
| | - Donna Hart
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Paula J. Harvey
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
- Women's College Research Institute and Division of CardiologyDepartment of Medicine Women's College HospitalUniversity of TorontoOntarioCanada
| | | | - Hope Sarfi
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Tara L. Sedlak
- Leslie Diamond Women's Heart CentreVancouver General HospitalUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Sofia B. Ahmed
- Department of Medicine and Libin Cardiovascular InstituteUniversity of CalgaryAlbertaCanada
| | - Carolyn Baer
- Division of General Internal MedicineDepartment of MedicineMoncton HospitalDalhousie UniversityHalifaxNova ScotiaCanada
| | - Thais Coutinho
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Jodi D. Edwards
- School of Epidemiology and Public HealthUniversity of Ottawa and University of Ottawa Heart InstituteOttawaOntarioCanada
| | - Courtney R. Green
- Society of Obstetricians and Gynaecologists of CanadaOttawaOntarioCanada
| | - Amy A. Kirkham
- Department of Biomedical EngineeringUniversity of AlbertaEdmontonAlbertaCanada
| | - Kajenny Srivaratharajah
- Division of General Internal MedicineDepartment of MedicineMcMaster UniversityHamiltonOntarioCanada
| | | | | | - Nadia Lappa
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Robert D. Reid
- Division of Cardiac Prevention and RehabilitationDivision of Cardiology and Canadian Women's Heart Health CentreUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Helen Robert
- Canadian Women's Heart Health AllianceOttawaOntarioCanada
| | - Graeme Smith
- Department of Obstetrics and GynecologyKingston Health Sciences CentreQueen's UniversityKingstonOntarioCanada
| | | | - Sharon L. Mulvagh
- Division of CardiologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
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Roifman I, Han L, Koh M, Wijeysundera HC, Austin PC, Douglas PS, Ko DT. Clinical Effectiveness of Cardiac Noninvasive Diagnostic Testing in Patients Discharged From the Emergency Department for Chest Pain. J Am Heart Assoc 2019; 8:e013824. [PMID: 31684795 PMCID: PMC6898808 DOI: 10.1161/jaha.119.013824] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Idan Roifman
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | | | | | - Harindra C Wijeysundera
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
| | | | - Dennis T Ko
- Schulich Heart Program Sunnybrook Health Sciences Centre University of Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,ICES Toronto Canada
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30
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Prabhakaran D, Singh K, Roth GA, Banerjee A, Pagidipati NJ, Huffman MD. Cardiovascular Diseases in India Compared With the United States. J Am Coll Cardiol 2019; 72:79-95. [PMID: 29957235 DOI: 10.1016/j.jacc.2018.04.042] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/11/2018] [Accepted: 04/25/2018] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Dorairaj Prabhakaran
- Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, India; London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Kavita Singh
- Public Health Foundation of India and Centre for Chronic Disease Control, Gurgaon, India
| | - Gregory A Roth
- Institute for Health Metrics and Evaluation and the Division of Cardiology at the University of Washington School of Medicine, Seattle, Washington
| | - Amitava Banerjee
- Farr Institute of Health Informatics, University College London, London, United Kingdom
| | - Neha J Pagidipati
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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31
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Buajitti E, Watson T, Norwood T, Kornas K, Bornbaum C, Henry D, Rosella LC. Regional variation of premature mortality in Ontario, Canada: a spatial analysis. Popul Health Metr 2019; 17:9. [PMID: 31366354 PMCID: PMC6670187 DOI: 10.1186/s12963-019-0193-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 07/24/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Emmalin Buajitti
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada
- Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Avenue, Toronto, Ontario, M4N 3 M5, Canada
| | - Tristan Watson
- Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Avenue, Toronto, Ontario, M4N 3 M5, Canada
| | - Todd Norwood
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada
| | - Catherine Bornbaum
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada
| | - David Henry
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada
- Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Avenue, Toronto, Ontario, M4N 3 M5, Canada
| | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, M5T 3 M7, Canada.
- Institute for Clinical Evaluative Sciences, Room G-106, 2075 Bayview Avenue, Toronto, Ontario, M4N 3 M5, Canada.
- Public Health Ontario, 480 University Ave, Toronto, Ontario, M5G 1 V2, Canada.
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32
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Udell JA. Socioeconomics and Atherosclerosis: Where There's Smoke, There's Fire. J Am Coll Cardiol 2019; 74:536-537. [PMID: 31345428 DOI: 10.1016/j.jacc.2019.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jacob A Udell
- Cardiovascular Division, Department of Medicine, Peter Munk Cardiac Centre, Toronto General Hospital and Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.
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33
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McCormick N, Hamilton CB, Koehn CL, English K, Stordy A, Li LC. Canadians' views on the use of routinely collected data in health research: a patient-oriented cross-sectional survey. CMAJ Open 2019; 7:E203-E209. [PMID: 30948649 PMCID: PMC6450795 DOI: 10.9778/cmajo.20180105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
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.
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Affiliation(s)
- Natalie McCormick
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Clayon B Hamilton
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Cheryl L Koehn
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Kelly English
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Allan Stordy
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Linda C Li
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta.
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Hussain MA, Al-Omran M, Salata K, Sivaswamy A, Verma S, Forbes TL, Kayssi A, de Mestral C. A call for integrated foot care and amputation prevention pathways for patients with diabetes and peripheral arterial disease across Canada. Canadian Journal of Public Health 2019; 110:253-255. [PMID: 30617989 DOI: 10.17269/s41997-018-0166-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 12/07/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Mohamad A Hussain
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Mohammed Al-Omran
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia.,Diabetes Action Canada Working Group on Foot Care and Amputation Prevention, Toronto, Canada
| | - Konrad Salata
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.,ICES, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Subodh Verma
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Diabetes Action Canada Working Group on Foot Care and Amputation Prevention, Toronto, Canada
| | - Thomas L Forbes
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada.,Department of Surgery, University of Toronto, Toronto, Canada.,Diabetes Action Canada Working Group on Foot Care and Amputation Prevention, Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Ahmed Kayssi
- Department of Surgery, University of Toronto, Toronto, Canada.,Diabetes Action Canada Working Group on Foot Care and Amputation Prevention, Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.,Sunnybrook Research Institute of Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Charles de Mestral
- Li Ka Shing Knowledge Institute of St. Michaels Hospital, 30 Bond Street, 7-080 Bond Wing, Toronto, Ontario, M5B 1W8, Canada. .,ICES, Toronto, Ontario, Canada. .,Department of Surgery, University of Toronto, Toronto, Canada. .,Diabetes Action Canada Working Group on Foot Care and Amputation Prevention, Toronto, Canada.
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35
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Tobe SW, Stone JA, Anderson T, Bacon S, Cheng AYY, Daskalopoulou SS, Ezekowitz JA, Gregoire JC, Gubitz G, Jain R, Keshavjee K, Lindsay P, L'Abbe M, Lau DCW, Leiter LA, O'Meara E, Pearson GJ, Rabi DM, Sherifali D, Selby P, Tu JV, Wharton S, Walker KM, Hua-Stewart D, Liu PP. Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2018 update. CMAJ 2018; 190:E1192-E1206. [PMID: 30301743 PMCID: PMC6175624 DOI: 10.1503/cmaj.180194] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Sheldon W Tobe
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont.
| | - James A Stone
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Todd Anderson
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Simon Bacon
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Alice Y Y Cheng
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Stella S Daskalopoulou
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Justin A Ezekowitz
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Jean C Gregoire
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Gord Gubitz
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Rahul Jain
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Karim Keshavjee
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Patty Lindsay
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Mary L'Abbe
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - David C W Lau
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Lawrence A Leiter
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Eileen O'Meara
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Glen J Pearson
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Doreen M Rabi
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Diana Sherifali
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Peter Selby
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Jack V Tu
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Sean Wharton
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Kimberly M Walker
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Diane Hua-Stewart
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
| | - Peter P Liu
- Libin Cardiovascular Institute, Cumming School of Medicine (Anderson), University of Calgary, Calgary, Alta.; Department of Health, Kinesiology, and Applied Physiology (Bacon), Concordia University, Montreal, Que. & Montreal Behavioural Medicine Centre, CIUSSS-NIM, Montreal, Que.; St. Michael's Hospital (Cheng), University of Toronto, Toronto, Ont.; McGill University (Daskalopoulou), Montreal, Que.; Department of Medicine (Ezekowitz), University of Alberta, Edmonton, Alta.; Institut de cardiologie de Montreal (Gregoire), Montreal, Que.; Universite de Montreal (Gubitz), Montreal, Que.; Sunnybrook Research Institute (Hua-Stewart), Toronto, Ont.; Department of Family and Community Medicine (Jain), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Keshavjee), University of Toronto, Toronto, Ont.; Department of Nutritional Sciences (L'Abbe), University of Toronto, Toronto, Ont.; Department of Medicine and Libin Cardiovascular Institute (Lau), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Li Ka Shing Knowledge Institute (Leiter), St. Michael's Hospital, University of Toronto, Toronto, Ont.; Heart and Stroke Foundation (Lindsay), Ottawa, Ont.; Ottawa Heart Institute (Liu), University of Ottawa, Ottawa, Ont.; Insitut de Cardiologie de Montreal (O'Meara), Universite de Montreal, Montreal, Que.; Division of Cardiology, Mazankowski Alberta Heart Institute; University of Alberta, Faculty of Medicine and Dentistry (Pearson), Edmonton, Alta.; Departments of Medicine, Community Health and Cardiac Sciences (Rabi), University of Calgary, Calgary, Alta.; Centre for Addiction and Mental Health, Departments of Family and Community Medicine, Psychiatry and Public Health Sciences (Selby), University of Toronto, Toronto, Ont.; School of Nursing and Health Research Methods, Evidence and Impact, Faculty of Health Sciences (Sherifali), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Stone), University of Calgary, Calgary, Alta.; Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; ICES, Sunnybrook Research Institute (Tu), University of Toronto, Toronto, Ont.; St. Joseph's Health Care Centre (Walker), Toronto, Ont.; McMaster University (Wharton), Hamilton Ont.; York University (Wharton), Toronto, Ont
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Urquhart R, Kendell C, Folkes A, Reiman T, Grunfeld E, Porter GA. Making It Happen: Middle Managers' Roles in Innovation Implementation in Health Care. Worldviews Evid Based Nurs 2018; 15:414-423. [PMID: 30291739 PMCID: PMC6518932 DOI: 10.1111/wvn.12324] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2018] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Robin Urquhart
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Cynthia Kendell
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amy Folkes
- Central Health Regional Health Authority, Grand Falls-Windsor, Newfoundland and Labrador, Canada
| | - Tony Reiman
- Department of Medicine, Dalhousie University, Saint John, New Brunswick, Canada
| | - Eva Grunfeld
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Geoffery A Porter
- Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Beyea JA, Rosen E, Stephens T, Nguyen P, Hall SF. Audiometric Testing Guideline Adherence in Children Undergoing Tympanostomy Tubes: A Population-Based Study. Otolaryngol Head Neck Surg 2018; 158:1127-1133. [DOI: 10.1177/0194599818760562] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Jason A. Beyea
- Department of Otolaryngology, Hotel Dieu Hospital, Kingston Health Sciences Centre, Queen’s University School of Medicine, Kingston, ON, Canada
| | - Emily Rosen
- Department of Speech Pathology and Audiology, Hotel Dieu Hospital, Kingston, ON, Canada
| | - Trina Stephens
- Department of Otolaryngology, Hotel Dieu Hospital, Kingston Health Sciences Centre, Queen’s University School of Medicine, Kingston, ON, Canada
| | - Paul Nguyen
- Institute for Clinical Evaluative Sciences (ICES), Queen’s University, Kingston, ON, Canada
| | - Stephen F. Hall
- Department of Otolaryngology, Hotel Dieu Hospital, Kingston Health Sciences Centre, Queen’s University School of Medicine, Kingston, ON, Canada
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Gabb G, Arnolda L. Geographic location as a modifiable cardiac risk factor. CMAJ 2017; 189:E482-E483. [PMID: 28385892 DOI: 10.1503/cmaj.170116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Genevieve Gabb
- Royal Adelaide Hospital (Gabb), University of Adelaide, Adelaide, Australia; Illawarra Health and Medical Research Institute (Arnolda), University of Wollongong, New South Wales, Australia
| | - Leonard Arnolda
- Royal Adelaide Hospital (Gabb), University of Adelaide, Adelaide, Australia; Illawarra Health and Medical Research Institute (Arnolda), University of Wollongong, New South Wales, Australia
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Tu JV. Response to: "A comprehensive approach needed to address regional variation". CMAJ 2017. [PMID: 28630364 DOI: 10.1503/cmaj.733086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jack V Tu
- Senior Core Scientist Cardivascular Program Lead, Institute for Clinical Evaluative Sciences; Staff Cardiologist, Schulich Heart Centre, Sunnybrook Hospital; Principal Investigator, CArdiovascular HEalth in Ambulatory Care Research Team (CANHEART), Toronto, Ont
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40
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Gardner C, Simon L, Sutcliffe P, Loh LC, Noseworthy L, Salvaterra RP, Young-Hoon K. A comprehensive approach needed to address regional variation. CMAJ 2017. [PMID: 28630363 DOI: 10.1503/cmaj.733075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Charles Gardner
- Medical Officer of Health, Simcoe Muskoka District Health Unit, Barrie, Ont
| | - Lisa Simon
- Associate Medical Officer of Health, Simcoe Muskoka District Health Unit, Barrie, Ont
| | - Penny Sutcliffe
- Medical Officer of Health, Sudbury & District Health Unit, Sudbury, Ont
| | - Lawrence C Loh
- Acting Medical Officer of Health, Peel Public Health, Mississauga, Ont
| | - Lynn Noseworthy
- Medical Officer of Health, Haliburton, Kawartha, Pine Ridge District Health Unit, Port Hope, Ont
| | | | - Kit Young-Hoon
- Medical Officer of Health, Northwestern Health Unit, Kenora, Ont
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Tu JV, Maclagan LC, Ko DT, Atzema CL, Booth GL, Johnston S, Tu K, Lee DS, Bierman A, Hall R, Bhatia RS, Gershon AS, Tobe SW, Sanmartin C, Liu P, Chu A. The Cardiovascular Health in Ambulatory Care Research Team performance indicators for the primary prevention of cardiovascular disease: a modified Delphi panel study. CMAJ Open 2017; 5:E315-E321. [PMID: 28446446 PMCID: PMC5498313 DOI: 10.9778/cmajo.20160139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jack V Tu
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Laura C Maclagan
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Dennis T Ko
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Clare L Atzema
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Gillian L Booth
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Sharon Johnston
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Karen Tu
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Douglas S Lee
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Arlene Bierman
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Ruth Hall
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - R Sacha Bhatia
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Andrea S Gershon
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Sheldon W Tobe
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Claudia Sanmartin
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Peter Liu
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
| | - Anna Chu
- Affiliations: Institute for Clinical Evaluative Sciences (J. Tu, Maclagan, Ko, Atzema, Booth, K. Tu, Lee, Hall, Bhatia, Gershon, Chu); Schulich Heart Centre (J. Tu, Ko), Division of Emergency Medicine (Atzema), and Division of Nephrology (Tobe), Sunnybrook Health Sciences Centre; University of Toronto (J. Tu, Ko, Atzema, Booth, K. Tu, Lee, Bierman, Hall, Bhatia, Gershon, Tobe, Liu, Chu); St. Michael's Hospital (Booth), Toronto, Ont.; Bruyère Research Institute (Johnston); University of Ottawa (Johnston), Ottawa, Ont.; University Health Network (K. Tu, Lee, Bhatia), Toronto, Ont.; Center for Evidence and Practice Improvement (Bierman), Agency for Healthcare Research and Quality, Rockville, MD; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; Northern Ontario School of Medicine (Tobe), Sudbury, Ont.; University of Ottawa Heart Institute (Liu); Statistics Canada (Sanmartin), Ottawa, Ont
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