Political partisanship, laissez-faire attitudes, and COVID-19 behaviours and viewpoints in Canada and the United States

OBJECTIVE

In the United States, clear partisan differences in responses to COVID-19 have been shown in leadership and elite cueing at the state level as well as in perspectives and behaviours of the citizenry. This study probes differences in political values-particularly the prevalence of laissez-faire attitudes-that might explain the stronger social consensus on pandemic countermeasures seen in Canada.

METHODS

Data were obtained from temporally aligned waves of cross-sectional surveys of Canadian and US adults in the first year of the pandemic. Survey questions were used to construct an index of laissez-faire attitudes (LFA) which, along with demographic variables and measures of partisanship, was incorporated into regression models to predict three outcomes: practice of personal mitigation measures (e.g. mask wearing), level of worry about the pandemic, and likeliness to get a vaccine.

RESULTS

LFA scores had a strong negative relationship to all three outcomes for Canadians and Americans, albeit with larger effects among the Americans on two outcomes. Overall differences in LFA scores between Americans and Canadians were modest (0.04 on a 0-1 scale). However, Republican Party stalwarts had considerably higher LFA scores and were proportionally more numerous than Conservative loyalists in Canada. While there were partisan differences in LFA scores within Canada, the largest gap by far was between Republicans and Democrats in the USA. Respondents from Canada's Prairie provinces had slightly higher average LFA scores but there were no significant residence effects on outcomes.

CONCLUSION

Laissez-faire attitudes that may conflict with public health values and measures are much more prevalent in the USA than in Canada. This difference underpins the limited effects of political partisanship and broad consensus in the Canadian public's responses to the pandemic.

Case Report: What-or who-killed Frank Ramsey? Some reflections on cause of death and the nature of medical reasoning

Philosopher Frank Ramsey died in 1930 aged only 26. There has been much speculation about the nature of his final illness and the sequence of events which led to his death. To prepare this case report, we traced Ramsey's medical records and combined them with an extensive and unique dataset of contemporaneous sources. We use these to evaluate three possible explanations for Ramsey's illness and its unexpectedly fatal trajectory-infectious (Weil's disease), autoimmune (primary sclerosing cholangitis) and obstructive (gallstones). We explore how uncertainty surrounding each of these possibilities might have influenced Ramsey's doctors' thoughts and actions, including their ill-fated decision to perform the emergency operation that appears to have precipitated his final decline. We then reflect on the unfinished opus on which Ramsey was working when he died-on the nature of truth and how humans reason under conditions of uncertainty. We end with some thoughts linking Ramsey's death to his philosophy.

Assessment of activity status and survival according to the Canadian Cardiovascular Society angina classification

BACKGROUND

Despite its widespread use, limited data on the validity of the Canadian Cardiovascular Society angina (CCSA) classification relative to other measures of functional status have been reported.

OBJECTIVE

To assess the validity of the CCSA classification by comparing it with the Duke Activity Status Index (DASI) and evaluate its prognostic significance with respect to long-term mortality.

METHODS

The study population consisted of 1407 patients who underwent cardiac catheterization between 1992 and 1996. The median follow-up period was 9.7 years (interquartile range 6.1 to 11.1 years) and the mortality status as of December 31, 2004 was available for all patients.

RESULTS

The first three CCSA classes were inversely related to the DASI. The mean (+/- SD) scores were as follows: class I, 31.4+/-16.7; class II, 22.5+/-15.4; class III, 14.7+/-14.3; and class IV, 15.5+/-14.9 (P<0.01). Increasing CCSA class was associated with increased long-term mortality, even after adjusting for baseline characteristics. Chest pain course was also an important modulator of mortality among class III and IV patients; one-year mortality rates were 8.1% among unstable patients compared with 4.8% among patients with stable or progressing course.

CONCLUSION

CCSA classes I to III were inversely related to DASI scores and linearly associated with mortality. The similarity in outcomes among class III and IV patients is probably explained by the confounding effect of the stability of the patients' symptoms. The higher mortality risk among class III and IV patients with an unstable course provides impetus for a revised CCSA definition incorporating this information.

Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates

Background— The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level.

Methods and Results— We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, −0.42; P =0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion).

Conclusions— Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.

Impact of Patient and Target-Vessel Characteristics on Arterial and Venous Bypass Graft Patency

Background— The purpose of this investigation was to determine optimal patient and target-vessel characteristics to maximize arterial and venous graft patency on the basis of data from a large clinical trial.

Methods and Results— Angiographic data on 440 radial artery grafts and 440 saphenous vein grafts were analyzed with methodology to account for within-patient clustering. Multivariable models that incorporated patient demographic, operative, anatomic, and postdischarge medical management were constructed to determine predictors of graft occlusion. Radial artery use was strongly protective against graft occlusion at 1 year after adjustment for all covariates, with a larger protective effect seen in women ( P =0.05 for a subgroup-by-treatment interaction). Among all grafts, diabetes and small target-vessel diameter were associated with an increased risk of graft occlusion, and grafting to a target vessel with more severe proximal stenosis was associated with a decreased risk of graft occlusion. With regard to gender, radial artery graft occlusion at 1 year occurred in similar proportions of men (8.6%) and women (5.3%, P =0.6), whereas, for saphenous vein grafts the comparable occlusion rates were 12.0% and 23.3% respectively ( P =0.02). A history of peripheral vascular disease was associated with an elevated risk of radial artery occlusion but was not associated with early vein graft occlusion ( P =0.02 for a subgroup-by-treatment interaction).

Conclusions— Patients benefit from radial artery–coronary artery bypass conduits as opposed to saphenous vein conduits, and this effect is especially strong in women. Small target-vessel size adversely affected graft patency, and grafting to a target vessel with more severe proximal stenosis improved graft patency.

Public versus private institutional performance reporting: what is mandatory for quality improvement?

BACKGROUND

In the past 11 years, Ontario has generated institution-level performance report cards on outcomes of coronary artery bypass graft (CABG) surgery. The objective of this study was to evaluate the differences in patient characteristics and outcomes observed during the transition from no reporting to confidential, and ultimately public performance report cards for CABG surgery in a public health system.

METHODS

We used clinical and administrative data to assess crude, expected, and risk-adjusted 30-day mortality rates after isolated CABG surgery in Ontario for 67693 patients from September 1, 1991, to March 31, 2002. Confidence intervals on relative mortality reductions were determined by bootstrapping. We compared 30-day mortality trends to a control outcome (risk-adjusted 30-day all-cause readmission). We analyzed inhospital mortality trends for Ontario compared with the rest of Canada for the period from 1992 to 1998.

RESULTS

The risk-adjusted 30-day mortality rate decreased 29% (95% CI 21-39) from the era of no reporting (1991-1993) to confidential reporting (1994-1998). There was no further decrease with public reporting (1999-2001). The control outcome of 30-day readmission did not decrease across reporting eras. Inhospital mortality fell significantly faster in Ontario during the period of confidential reporting than in other parts of Canada.

CONCLUSION

Ontario CABG mortality outcomes improved sharply after provider results were confidentially disclosed at an institutional level. No such changes were seen for nondisclosed outcomes or regions outside Ontario. Further public reporting of outcomes had no discernible impact on performance. These results are consistent with the hypothesis that confidential disclosure of outcomes was sufficient to accelerate quality improvement in a public system with little competition for patients between hospitals.

Leadership in academic medicine: reflections from administrative exile

Physicians are drawn into diverse leadership roles in academic medicine, but little in our education and training prepares us for these responsibilities. Fortunately, there is growing convergence in the literature on the attributes of successful leaders for knowledge-based organisations. Top-performing leaders seem to be self-effacing team-builders who eschew rapid-cycle strategic planning and management trends, focusing instead on strategic and incremental changes that will gradually transform their organisations. Academic physicians and search committees often concentrate on personal achievement and intellectual or technical mastery in research and clinical care. In contrast, the literature on leadership suggests other-directed skills matter more, eg mentorship, learning and teaching competencies, and so-called emotional intelligence. As a corollary, teaching hospitals, universities, and professional colleges or societies are long-term organisations with a rich history. Leadership in such a context demands stewardship of tradition along with patient pursuit of changes required to ensure that the organisation evolves successfully.

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

BACKGROUND

Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined.

METHODS

Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated risk-adjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status.

RESULTS

Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P<0.001). The number rather than the type of pre-existing conditions inversely correlated with the use of reperfusion therapy. While the impact of baseline risk and pre-existing conditions was additive, pre-existing conditions exerted a greater impact on the nonuse of reperfusion therapy than did baseline risk.

CONCLUSIONS

A treatment-risk paradox is demonstrable even within a cohort of lower risk patients with ST segment elevation myocardial infarction. These findings are consistent with the view that these clinical decisions are more likely to be attributable to concerns about patient frailty or side effects than to a misunderstanding of treatment benefits.

Interpretation of subgroup results in clinical trial publications: insights from a survey of medical specialists in Ontario, Canada

BACKGROUND

Clinicians routinely apply randomized trial evidence to their patients who meet study selection criteria. However, little is known about how clinicians interpret conflicting subgroup data.

METHODS

We mailed a self-administered survey to all practicing cardiologists (n = 309) and 695 randomly chosen other specialists in Ontario, Canada. The survey presented 6 hypothetical trials where a subgroup result deviated from the overall result. We also elicited responses to some general statements about clinical evidence and subgroups.

RESULTS

Completed surveys were received from 435 physicians (44%). Faced with overall benefit but no apparent treatment effect in a subgroup, almost 44% would exclude subgroup-type patients, notwithstanding the hazard of beta error. Given overall harm but significant benefit for a subgroup, responses were split approximately 60:40 between continuing conventional therapy for all and treating subgroup-type patients with the new drug. For an overall null result with a positive treatment-subgroup interaction term, 25% of respondents would continue conventional therapy, whereas 69% would adopt the new drug for subgroup-type patients. Physicians with an academic appointment, devoting more time to research, or with formal training in research methodology were more likely to ignore subgroups unless a treatment-subgroup interaction term was significant (P values ranging from .018 to <.0001). Asked if in general they paid special attention to individual subgroup results, respondents were again divided with 37.5% agreeing, 39.5% disagreeing, and the rest undecided.

CONCLUSION

Clinicians disagree sharply in interpretation of clinical trials when the overall and subgroup results diverge. Clearer guidelines are needed for undertaking, reporting, and interpreting subgroup analyses.

Socioeconomic status and mortality after acute myocardial infarction

BACKGROUND

Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated.

OBJECTIVE

To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI).

DESIGN

Prospective cohort study.

SETTING

Ontario, Canada.

PATIENTS

3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003.

MEASUREMENTS

The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors.

RESULTS

Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect.

LIMITATIONS

Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals.

CONCLUSIONS

Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the "wealth-health gradient" in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix.

The Impact of Under Coding of Cardiac Severity and Comorbid Diseases on the Accuracy of Hospital Report Cards

CONTEXT

Hospital report cards usually are based on administrative discharge abstracts. However, cardiac severity and comorbidities generally are under-reported in administrative data.

OBJECTIVE

We sought to determine how undercoding of cardiac severity and comorbidities affects the determination that some hospitals are high-mortality outliers.

DESIGN

Simulations using retrospective data on 18,795 patients admitted with an acute myocardial infarction (AMI) to 109 acute care hospitals in Ontario.

MAIN OUTCOME MEASURE

Change in the number of hospitals that remained high-mortality outliers after adjusting for potentially increased prevalence of as many as 9 separate measures of cardiac severity and comorbid conditions, individually or together.

RESULTS

For most measures of cardiac severity and comorbidities, increasing the prevalence of each factor to the highest observed hospital-specific prevalence seldom altered the status of high-mortality outlier hospitals. Increases in the prevalence of cardiogenic shock or acute renal failure to even the median level led to reclassification of up to 4 of the 12 high-mortality outlier hospitals to nonoutlier status. Most high-mortality outlier hospitals were reclassified if the maximum prevalence was imputed for these 2 factors. Simultaneously increasing the prevalence of all comorbidities to the median level typically converted the status of about half the outlier hospitals. Not until the prevalence of all measures of cardiac severity and comorbidities were simultaneously increased to the maximum observed hospital-specific prevalence, did all hospitals initially classified as high-mortality outliers revert to nonoutlier status.

CONCLUSIONS

Undercoding of severity and comorbidities in administrative data in itself is very unlikely to account for the outlier status of most hospitals. However, some potential for misclassification of individual institutions exists if influential factors are variably coded.

A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts

BACKGROUND

In the past decade, the radial artery has frequently been used for coronary bypass surgery despite concern regarding the possibility of graft spasm. Graft patency is a key predictor of long-term survival. We therefore sought to determine the relative patency rate of radial-artery and saphenous-vein grafts in a randomized trial in which we controlled for bias in the selection of patients and vessels.

METHODS

We enrolled 561 patients at 13 centers. The left internal thoracic artery was used to bypass the anterior circulation. The radial-artery graft was randomly assigned to bypass the major vessel in either the inferior (right coronary) territory or the lateral (circumflex) territory, with the saphenous-vein graft used for the opposing territory (control). The primary end point was graft occlusion, determined by angiography 8 to 12 months postoperatively.

RESULTS

Angiography was performed at one year in 440 patients: 8.2 percent of radial-artery grafts and 13.6 percent of saphenous-vein grafts were completely occluded (P=0.009). Diffuse narrowing of the graft (the angiographic "string sign") was present in 7.0 percent of radial-artery grafts and only 0.9 percent of saphenous-vein grafts (P=0.001). The absence of severe native-vessel stenosis was associated with an increased risk of occlusion of the radial-artery graft and diffuse narrowing of the graft. Harvesting of the radial artery was well tolerated.

CONCLUSIONS

Radial-artery grafts are associated with a lower rate of graft occlusion at one year than are saphenous-vein grafts. Because the patency of radial-artery grafts depends on the severity of native-vessel stenosis, such grafts should preferentially be used for target vessels with high-grade lesions.

Influence of education and income on atherogenic risk factor profiles among patients hospitalized with acute myocardial infarction

BACKGROUND

Survival after acute myocardial infarction (AMI) varies with socioeconomic status. It is unknown whether these differences can be attributed, in part, to variations in the prevalence of atherogenic risk factors preceding the index AMI event.

OBJECTIVES

To examine how cardiovascular risk factors varied according to person-level indicators of income and education among a cohort of younger patients (younger than 65 years of age) hospitalized with AMI in Ontario.

METHODS

The Socio-Economic and Acute Myocardial Infarction study (SESAMI) prospectively assembled a cohort of 3335 patients hospitalized with AMI who consented to participate (75% consent rate) from 53 of 57 large-volume institutions (100 AMI cases per year or more) throughout Ontario between December 1, 1999, and June 1, 2002. Given the known challenges inherent in characterizing the socioeconomic status in elderly patients and the ubiquity of atherosclerosis in elderly persons, the study focused on 1635 nonelderly participants. The relationship between income or education and cardiovascular risk factors, after adjustment for age, sex, ethnoracial factors and geography (urban-rural status) was examined.

RESULTS

The prevalence of diabetes, hypertension, smoking and pre-existing heart disease was higher among poorer, less educated patients, as were the total number of cardiovascular risk factors. After adjusting for baseline factors, both income (adjusted OR 0.50, 95% CI 0.31 to 0.82, P=0.006) and education (adjusted OR 0.52, 95% CI 0.31 to 0.87, P=0.01) were independently associated with cardiovascular risk factors or pre-existing heart disease. There were no significant interactions between income, education and baseline cardiovascular risk.

CONCLUSIONS

Outcome differences across socioeconomic strata following AMI may reflect major income- and education-related differences in atherogenic risk profile.

Long-Term Mortality of Patients With Acute Myocardial Infarction in the United States and Canada

BACKGROUND

In a previous substudy of the GUSTO-I trial, we observed better functional and quality-of-life outcomes among patients in the United States (US patients) compared with patients in Canada. Rates of invasive therapy were significantly higher in the United States and were associated with a small mortality benefit (0.4%, adjusted P=0.02). We sought to determine whether Canadian-US differences in practice patterns in GUSTO-I had an impact on 5-year mortality.

METHODS AND RESULTS

Mortality data for 23,105 US and 2898 Canadian patients enrolled in GUSTO-I were obtained from national mortality databases. Median follow-up was 5.46 years in the US and 5.33 years in the Canadian cohort. Five-year mortality rate was 19.6% among US and 21.4% among Canadian patients (P=0.02). After baseline adjustment, enrollment in Canada was associated with a higher hazard of death (1.17; 95% confidence interval, 1.07 to 1.28, P=0.001). Revascularization rates during the index hospitalization in the United States were almost 3 times those in Canada: 30.5% versus 11.4% for angioplasty and 13.1% versus 4.0% for bypass surgery (P<0.01 for both). After accounting for revascularization status as a time-dependent covariate, country was no longer a significant predictor of long-term mortality. These results were confirmed in a propensity-matched analysis.

CONCLUSIONS

Our results suggest, for the first time, that the more conservative pattern of care with regard to early revascularization in Canada for ST-segment elevation acute myocardial infarction may have a detrimental effect on long-term survival. Our results have important policy implications for cardiac care in countries and healthcare systems wherein use of invasive procedures is similarly conservative.

Age, risk-benefit trade-offs, and the projected effects of evidence-based therapies

BACKGROUND

Physicians underutilize evidence-based therapies in the elderly, perhaps because of concerns about the generalizability of clinical trial results in elderly patients given that the relative efficacy of therapies may vary with age. We compared the estimated effects of age and efficacy of treatment on survival among patients with acute coronary syndromes.

METHODS

Baseline risk, defined as mortality in the year after hospitalization for acute coronary syndromes, was determined for different age strata among 81,584 patients who had been discharged between April 1, 1997, and March 31, 2000, in Ontario, Canada. We calculated the relative efficacy (relative risk reduction) needed to achieve a clinically meaningful absolute survival benefit, using a number needed to treat of 50 patients for the different age strata. We also evaluated risk-benefit trade-offs in the elderly versus the young by modeling different levels of the relative efficacy and rates of fatal complication by age.

RESULTS

Baseline risk (1-year all-cause mortality) was 12-fold lower in the youngest patients (age <50 years) than in oldest patients (age > or = 75 years). Given this gradient, a therapy would have to have a relative efficacy of 88% (i.e., a relative risk of 0.12) in the youngest age group, and 7% (a relative risk of 0.93) in the oldest age group, to generate a number needed to treat 50 patients. For a therapy whose relative efficacy was 25%, the fatal complication rate would have to be sevenfold greater in the oldest compared with the youngest age group to outweigh the survival benefits associated with treatment.

CONCLUSION

For acute coronary syndromes, baseline mortality is so much higher for elderly patients that neither sharp reductions in the relative efficacy of therapies nor increases in the rates of serious complications are likely to negate the benefits of therapy. More attention should be paid to overall trial results and less to age-specific subgroup data, unless the latter provide very clear evidence for substantial reductions in absolute efficacy or net harm.

Socioeconomic status, service patterns, and perceptions of care among survivors of acute myocardial infarction in Canada

CONTEXT

Some have argued that Canada's uniquely restrictive approach to private health insurance keeps the socioeconomic elite inside the public system so that their demands and influence elevate the standard of service for all Canadian citizens. The extent to which this theory is a valid representation of Canadian health care is unknown.

OBJECTIVES

To explore how patients with acute myocardial infarction from different socioeconomic backgrounds perceive their care in Canada's universal health care system and to correlate patients' backgrounds and perceptions with actual care received.

DESIGN, SETTING, AND PATIENTS

Prospective observational cohort study with follow-up telephone interviews of 2256 patients 30 days following acute myocardial infarction discharged from 53 hospitals across Ontario, Canada, between December 1999 and June 2002.

MAIN OUTCOME MEASURES

Postdischarge use of cardiac specialty services; satisfaction with care; willingness to pay directly for faster service or more choice; and mortality according to income and education, adjusted for age, sex, ethnicity, clinical factors, onsite angiography capacity at the admitting hospital, and rural-urban residence.

RESULTS

Compared with patients in lower socioeconomic strata, more affluent or better educated patients were more likely to undergo coronary angiography (67.8% vs 52.8%; P<.001), receive cardiac rehabilitation (43.9% vs 25.6%; P<.001), or be followed up by a cardiologist (56.7% vs 47.8%; P<.001). Socioeconomic differences in cardiac care persisted after adjustment for confounders. Despite receiving more specialized services, patients with higher socioeconomic status were more likely to be dissatisfied with their access to specialty care (adjusted RR, 2.02; 95% confidence interval, 1.20-3.32) and to favor out-of-pocket payments for quicker access to a wider selection of treatment options (30% vs 15% for patients with household incomes of Can 60 000 dollars or higher vs less than Can 30 000 dollars, respectively; P<.001). After adjusting for baseline characteristics, socioeconomic status was not significantly associated with mortality at 1 year following hospitalization for myocardial infarction.

CONCLUSIONS

Compared with those with lower incomes or less education, upper middle-class Canadians gain preferential access to services within the publicly funded health care system yet remain more likely to favor supplemental coverage or direct purchase of services.

Better governance in academic health sciences centres: moving beyond the Olivieri/Apotex Affair in Toronto

The Toronto experience suggests that there may be several general lessons for academic health sciences complexes to learn from the Olivieri/Apotex affair (OAA) regarding the ethics, independence, and integrity of clinical research sponsored by for profit enterprises. From a local perspective, the OAA occurred when there already was a focus on the complex and changing relationships among the University of Toronto, its medical school, the fully affiliated teaching hospitals, and off campus faculty because of intertwined interests and responsibilities. The OAA became a catalyst that accelerated various systemic reforms, particularly concerning academic/industry relations. In this article, the evolving governance framework for the Toronto academic health sciences complex is reviewed and these policy and process reforms discussed. These reforms have created collaborative activity among research ethics boards and contract research offices of the partner institutions, and allowed the joint university/hospital ethics centre to play a role in governance and policy, while respecting the missions and mandates of the involved institutions. Although few of the policies are dramatically innovative, what is arguably novel is the elaboration of an overarching governance framework that aims to move ethics to a central focus in the academic complex. Time alone will tell how sustainable and effective these changes are.

Parkinsonism in Ontario: Comorbidity associated with hospitalization in a large cohort

To study comorbidity in patients with Parkinsonism (PKM), relative hospitalization rates from 1994 to 1999 for 15,304 cases were compared with 30,608 controls. After correction for differential survival, the rates were higher for cases compared to controls for aspiration pneumonia (6.34; 95% confidence interval [CI], 5.23, 7.93), affective psychosis (2.71; 95% CI, 2.13, 3.32), hip fractures (2.56; 95% CI, 2.35, 2.76), other urinary tract disorders including infections (2.5; 95% CI, 2.17, 2.86), septicemia (2.39; 95% CI, 2.02, 2.85) and fluid and electrolyte disorders (2.27; 95% CI, 1.93,2.66). The rates for cardiac, cerebrovascular, and peripheral vascular disease were similar. Preventive measures and aggressive management of these conditions as outpatients may reduce the rates of hospitalization and improve the morbidity and mortality of PKM.

Waiting times, revascularization modality, and outcomes after acute myocardial infarction at hospitals with and without on-site revascularization facilities in Canada

OBJECTIVES

This study was designed to determine whether admission to a Canadian hospital with on-site revascularization (invasive hospital) affected revascularization choice, timing, and outcome compared with community (non-invasive) hospitals.

BACKGROUND

Health care systems in Canada are characterized by relative restraint in diffusion of tertiary cardiovascular services, with capacity for revascularization procedures concentrated in large regional referral centers.

METHODS

We used linked administrative data and a clinical registry to follow-up 15,166 Ontario patients who underwent revascularization within the year after their index acute myocardial infarction (MI). Outcomes included recurrent urgent cardiac hospitalization, hospital bed-days, and death within the same year after the index admission. We adjusted for age, gender, socioeconomic status, illness severity, attending physician specialty, and academic hospital affiliation.

RESULTS

After adjusting for baseline factors, patients admitted to invasive hospitals were more likely to receive angioplasty than bypass surgery (adjusted odd ratio: 1.85; 95% confidence interval: 1.68 to 2.04, p < 0.001). The converse pattern was seen for patients admitted to community hospitals. Median revascularization waiting times were significantly shorter at invasive hospitals (12 vs. 48 days, p < 0.001). Patients admitted to invasive hospitals had fewer cardiac re-admissions (41.5 vs. 68.9 events per 100 patients, p < 0.001) before their first revascularization and consumed fewer hospital bed-days (379 vs. 517 per 100 patients, p < 0.001). There were no differences in outcomes beyond revascularization.

CONCLUSIONS

Outcome advantages associated with timely post-MI revascularization highlight the importance of organizing revascularization referral networks and facilitating access to revascularization for patients with acute coronary syndromes admitted to community hospitals in Canada.

Burden of parkinsonism: a population-based study

Parkinson's disease (PD) is associated with a significant burden of illness and cost to society, which has been difficult to quantify. Our objective was to use linked administrative databases from the population of Ontario, Canada, to assess the prevalence of parkinsonism, physician- and drug-related costs, and hospital utilization for parkinsonian patients compared with age/sex matched controls. An inception cohort of parkinsonian cases from 1993/1994 was age and sex matched (1:2) to controls and followed for 6 years. Patients were identified by the diagnostic code for PD, the use of specific PD drugs, or a combination. The parkinsonian case cohort (15,304) was matched to (30,608) controls that did not have parkinsonism. The age-adjusted prevalence rates were 3.63 for men and for 3.24 women per 1,000 (increased by 5.4% for men and 9.8% for women). Physician costs were 1.4 times more, there were 1.44 times more hospital admissions, admissions were on average 1.19 times longer, and drug costs were 3.0 times more for parkinsonian cases. We conclude that the substantially higher physician and drug costs as well as hospitalization rates compared with controls clearly suggest that parkinsonism is associated with large direct costs to society.

Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction

BACKGROUND

Socioeconomic status appears to be an important predictor of coronary angiography use after acute myocardial infarction. One potential explanation for this is that patients with lower socioeconomic status live in neighbourhoods near nonteaching hospitals that have no catheterization capacity, few specialists and lower volumes of patients with acute myocardial infarction. This study was conducted to determine whether the impact of socioeconomic status on angiography use would be lessened by considering variations in the supply of services.

METHODS

We examined payment claims for physician services, hospital discharge abstracts and vital status data for 47 036 patients with acute myocardial infarction admitted to hospitals in Ontario between April 1994 and March 1997. Neighbourhood income of each patient was obtained from Canada's 1996 census. Using multivariate hierarchical logistic regression and adjusting for baseline patient and physician factors, we examined the interaction among hospital and regional characteristics, socioeconomic status and angiography use in the first 90 days after admission to hospital for acute myocardial infarction.

RESULTS

Within each hospital and geographic subgroup, crude rates of angiography rose progressively with increases in neighbourhood income. After adjusting for sociodemographic, clinical and physician characteristics, hospitals with on-site angiography capacity (adjusted odds ratio [OR] 1.88, 95% confidence interval [CI] 1.52-2.33), those with university affiliations (adjusted OR 1.60, 95% CI 1.27-2.01) and those closest to tertiary institutions (adjusted OR 1.57, 95% CI 1.32-1.87) were all associated with higher 90-day angiography use after acute myocardial infarction. However, the relative impact of socioeconomic status on 90-day angiography use was similar whether or not hospitals had on-site procedural capacity (interaction term p = 0.68), had university affiliations (interaction term p = 0.99), were near tertiary facilities (interaction term p = 0.67) or were in rural or urban regions (interaction term p = 0.90).

INTERPRETATION

Socioeconomic status was as important a predictor of angiography use in hospitals with ready access to cardiac catheterization facilities as it was in those without. The socioeconomic gradient in the use of angiography after acute myocardial infarction cannot be explained by the distribution of specialists or tertiary hospitals.

The relevance of subgroup-specific treatment effects: the Studies Of Left Ventricular Dysfunction (SOLVD) revisited

BACKGROUND

The overall effect sizes estimated from randomized clinical trials may not apply similarly to all patients. Univariate subgroup analyses are often used to help determine the generalizability of a trial's results, but may themselves be misleading. We reanalyzed the Studies of Left Ventricular Dysfunction (SOLVD) to determine whether the treatment effect depended on the patients' baseline prognosis, defined on the basis of multiple clinical variables.

METHODS

The SOLVD prevention (4228 patients) and the SOLVD treatment (2569 patients) trials were randomized, double-blind trials that studied the effect of enalapril in patients with reduced left-ventricular function or congestive heart failure. We combined both SOLVD populations and compared the results of a univariate analysis to a multivariate approach in which 3 patient subgroups were defined according to baseline risks for the combined end point of death or hospitalization for heart failure.

RESULTS

Enalapril treatment resulted in 24% fewer events. The strongest predictors of an event were ejection fraction, New York Heart Association classification and age, antiplatelet agents, history of diabetes mellitus, treatment with digoxin or diuretics, and race. Only ejection fraction produced a significant treatment interaction (P =.004). Consistent with the original SOLVD reports, this interaction was also demonstrable when ejection fraction was scaled into tertiles and examined on its own (P =.012). However, there was no interaction present when patients were divided into tertiles of multifactorial baseline risk.

CONCLUSIONS

We confirmed the treatment effect of enalapril, the impact of left-ventricular systolic function, and the negative prognostic importance of diabetes mellitus in this population. Although ejection fraction led to a subgroup-treatment interaction in the main SOLVD publications, a multifactorial approach to prognostic grouping abolished the interaction. These findings highlight the limitations of univariate subgroup analyses and illustrate that multivariate risk group analysis may be a complementary method for assessing the generalizability of the overall treatment effects observed in randomized trials.

Healthy-year equivalents in major joint replacement. Can patients provide meaningful responses?

OBJECTIVES

Healthy-years equivalents (HYEs) have been proposed as an evaluative measure with advantages over quality-adjusted life-years (QALYs). The main purpose was to assess the feasibility of eliciting HYEs from patients who have undergone major joint replacement; a secondary objective was to examine relationships with postsurgical health status.

METHODS

Pre- and postsurgical reports of perceived comorbidity and current arthritic burden were obtained from 194 patients, using a comorbidity checklist, summary scores from the Western Ontario/McMaster Osteoarthritis Questionnaire (WOMAC), summary scores derived from six Likert scales, and holistic utility scores for the same attributes. After surgery, HYEs for the full across-time health profile were also elicited.

RESULTS

All measures of arthritic burden were sensitive to pre/postsurgical changes (p = .0001), and comorbidity scores were stable. Two HYE subgroups emerged. An HYE-invariant subgroup ascribed full HYEs to their profiles, while reporting higher Likert (t = 2.1309; p = .0344) and utility (s = 4.1504; p = .0001) scores for their postsurgical health state. An HYE-variant subgroup reported HYEs that were weakly but significantly (p < .009) correlated with Likert (r = .30), utility (rs = .25), and comorbidity (r = -.26) scores for their postsurgical state.

CONCLUSIONS

Our results indicate that patients can understand the HYE assessment procedures and provide interpretable responses. However, a significant proportion reports invariant HYEs that could inflate estimates of the overall mean HYE. Further exploration of the HYEs reported by different clinical and attitudinal populations is needed before widespread adoption of this measure.

Parkinsonism in Ontario: physician utilization

BACKGROUND

Patients with Parkinsonism have a progressive disorder requiring substantial expertise to manage effectively.

METHODS

Over a six-year period we evaluated physician utilization and related costs for a large, unselected cohort of 15,304 Parkinsonian patients from the general population, comparing them to 30,608 age- and sex-matched controls within a universal health care system in Ontario, Canada.

RESULTS

On average, 45% of Parkinsonian patients saw neurologists annually. The cumulative rate of at least one neurological consultation was only 59.5% over the six years. Patients aged < 65 had a much greater likelihood of consulting a neurologist (73.3%) compared to those > or = 65 (37.2%). Most Parkinsonian patients (97.2%), regardless of age, saw family physicians/general practitioners each year; 50.4% saw internal medicine consultants.

CONCLUSIONS

Parkinsonian patients had increased likelihood of utilizing neurologists, primary care physicians and internists compared to controls; related costs of physicians' services were higher. Further research is necessary to evaluate differences in outcomes and costs between neurologists and other physician service providers.