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Alter DA, Austin PC, Rosenfeld A. The dynamic nature of the socioeconomic determinants of cardiovascular health: A narrative review. Can J Cardiol 2024:S0828-282X(24)00077-1. [PMID: 38309464 DOI: 10.1016/j.cjca.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/08/2024] [Accepted: 01/14/2024] [Indexed: 02/05/2024] Open
Abstract
Despite decades of social epidemiologic research, health inequities remain pervasive and ubiquitous in Canada and elsewhere. One reason may be our use of socioeconomic measurement, which have often relied on single point-in-time exposures. To explore the extent to which researchers have incorporated dynamic socioeconomic measurement into cardiovascular health outcome evaluations, we performed a narrative review. We estimated the prevalence of socioeconomic longitudinal cardiovascular research studies that identified socioeconomic exposures at two or more points in time between the years of 2019 and 2023. We defined cardiovascular outcome studies as those that examined coronary artery disease, myocardial infarction, acute coronary syndrome, stroke, heart failure, cardiac arrythmias, cardiac death, cardiometabolic factors, transient ischemic attacks, peripheral artery disease, or hypertension. Socioeconomic exposures included individual income, neighborhood income, intergenerational social mobility, education, occupation, insurance status, and economic security. 7% of socioeconomic cardiovascular outcome studies have measured socioeconomic status at two or more points in time throughout the follow-up period. Hypothesized mechanisms by which dynamic socioeconomic measures impacted outcome focused on social mobility, accumulation, and critical period theories. Insights, implications, and future directions are discussed, in which we highlight ways in which postal code data, can be better utilized methodologically as a dynamic socioeconomic measure. Future research must incorporate dynamic socioeconomic measurement to better inform root-causes, interventions, and health system designs if health equity is to be improved.
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Affiliation(s)
- David A Alter
- From the ICES, Sunnybrook Health Sciences, Toronto, Canada; Toronto Rehabilitation Institute-University Health Network, Toronto, Canada; Institute for Health Policy, Management and Evaluation.
| | - Peter C Austin
- From the ICES, Sunnybrook Health Sciences, Toronto, Canada; Institute for Health Policy, Management and Evaluation
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Alter DA, Rosenfeld A, Fang J, Ko DT, Cohen L, Yu B, Austin PC. The Relationship Between Residential Mobility and Mortality Following Acute Myocardial Infarction. Can J Cardiol 2024; 40:18-27. [PMID: 37726076 DOI: 10.1016/j.cjca.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND The extent to which residential mobility is associated with declining health among disease-specific populations, such as survivors of acute myocardial infarction (AMI), remains unknown. METHODS This prospective cohort study consisted of 3377 patients followed from index AMI (December 1, 1999 to March 30, 2003) to death or the last available follow-up date (March 30, 2020) in Ontario, Canada. Each residential postal code move from a patient's sentinel AMI event was tracked. Time-varying Cox proportional hazards examined the associated impact of each residential postal code move on mortality after adjusting for age, sex, baseline socioeconomic, psychosocial factors, changes in neighbourhood income level from each residential move, preexisting cardiovascular and noncardiovascular illnesses, and rural residence. All models evaluated death and long-term care institutionalisation as competing risks to distinguish mortality from other end-of-life destination outcomes among community-dwelling populations. RESULTS The study sample included 3369 patients with 1828 (54.3%) having at least 1 residential move throughout the study; 86.5% of patients either died in the community or moved from a community dwelling into a long-term care facility as an end-of-life destination. When adjusted for baseline factors and changing neighbourhood socioeconomic status over time, each residential move was associated with a 12% higher rate of death (adjusted hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.05-1.19; P < 0.001) and a 26% higher rate of long-term care end-of-life institutionalisation (adjusted HR 1.26, 95% CI 1.14-1.58; P < 0.001). CONCLUSIONS Residential mobility was associated with higher mortality after AMI. Further research is needed to better evaluate intermediary causal pathways that may explain why residential mobility is associated with end-of-life outcomes.
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Affiliation(s)
- David A Alter
- ICES, Toronto, Ontario, Canada; KITE Resarch Institute, Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada.
| | - Aaron Rosenfeld
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | | | - Dennis T Ko
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Schulich Heart Program, Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Lucas Cohen
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Bing Yu
- ICES, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada
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Bobrowski D, Dorovenis A, Abdel-Qadir H, McNaughton CD, Alonzo R, Fang J, Austin PC, Udell JA, Jackevicius CA, Alter DA, Atzema CL, Bhatia RS, Booth GL, Ha ACT, Johnston S, Dhalla I, Kapral MK, Krumholz HM, Roifman I, Wijeysundera HC, Ko DT, Tu K, Ross HJ, Schull MJ, Lee DS. Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study. Eur J Heart Fail 2023; 25:2274-2286. [PMID: 37953731 DOI: 10.1002/ejhf.3090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/10/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
AIM We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. METHODS AND RESULTS In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. CONCLUSION Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.
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Affiliation(s)
- David Bobrowski
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Candace D McNaughton
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rea Alonzo
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Peter C Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jacob A Udell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA, USA
| | - David A Alter
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Clare L Atzema
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Sharon Johnston
- Departments of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institut du Savoir, Hôpital Montfort, Ottawa, ON, Canada
| | - Irfan Dhalla
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Idan Roifman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen Tu
- University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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4
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Akioyamen LE, Abdel-Qadir H, Han L, Sud M, Mistry N, Alter DA, Atzema CL, Austin PC, Bhatia RS, Booth GL, Dhalla I, Ha ACT, Jackevicius CA, Kapral MK, Krumholz HM, Lee DS, McNaughton CD, Roifman I, Schull MJ, Sivaswamy A, Tu K, Udell JA, Wijeysundera HC, Ko DT. Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System. Circ Cardiovasc Qual Outcomes 2023; 16:e010063. [PMID: 38050754 DOI: 10.1161/circoutcomes.123.010063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/06/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.
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Affiliation(s)
- Leo E Akioyamen
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Husam Abdel-Qadir
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Lu Han
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Nikhil Mistry
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - David A Alter
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Clare L Atzema
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Gillian L Booth
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Irfan Dhalla
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Cynthia A Jackevicius
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
| | - Moira K Kapral
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Douglas S Lee
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
| | - Candace D McNaughton
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Idan Roifman
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada (G.L.B., I.R.,)
| | - Michael J Schull
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Atul Sivaswamy
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
| | - Karen Tu
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Department of Family and Community Medicine, (K.T.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- North York General Hospital, Toronto, ON, Canada (K.T.)
| | - Jacob A Udell
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- University Health Network, Toronto, ON, Canada (H.A.-Q., D.A.A., R.S.B., A.C.T.H., M.K.K., D.S.L., J.A.U.)
- Women's College Hospital, Toronto, ON, Canada (H.A.-Q., J.A.U.)
| | - Harindra C Wijeysundera
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
| | - Dennis T Ko
- Department of Medicine (L.E.A., H.A.-Q., D.A.A., C.L.A., R.S.B., I.D., A.C.T.H., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., M.S., D.A.A., C.L.A., P.C.A., G.L.B., I.D., C.A.J., M.K.K., D.S.L., I.R., M.J.S., K.T., J.A.U., H.C.W., D.T.K.), University of Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada (H.A.-Q., L.H., M.S., N.M., D.A.A., C.L.A., P.C.A., G.L.B., C.A.J., M.K.K., D.S.L., C.D.M., I.R., M.J.S., A.S., K.T., J.A.U., H.C.W., D.T.K.)
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada (M.S., C.L.A., C.D.M., I.R., M.J.S., H.C.W., D.T.K.)
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Pupulin A, Ball J, Bajaj R, Alter DA. Evaluating Statin Knowledge-Perceptions and Receptivity Following a Comprehensive Lifestyle Modification Program. Am J Lifestyle Med 2023. [DOI: 10.1177/15598276231163129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background Though clinical guidelines for cholesterol-lowering therapies advocate for both a trial of lifestyle modification and the initiation of statin medication when appropriate, the extent to which lifestyle modification may alter a patient’s knowledge-perceptions and receptivity towards statins remains unclear. Methods Following completion of a 6-month comprehensive lifestyle modification program, perceived changes in knowledge and receptivity towards statins were examined across prespecified subgroups of age, sex, and statin eligibility using a mixed-methods questionnaire. Quantitative and qualitative analyses incorporated binomial tests, McNemar’s test, and thematic analyses. Results Among 192 patients who completed the program and exit questionnaire between December 15, 2020 and July 2, 2021, 88.4% of patients indicated a perceived improvement in cholesterol and/or statin knowledge (P < . 0001). 48.2% of patients acknowledged that their receptivity towards taking statins increased (P = . 61). Changes in receptivity were attributed to several identified program themes including improvements in health knowledge and awareness, motivation and empowerment. Patients who noted improvements in their mental health also reported significantly increased receptivity towards statins (P < . 001). Conclusions Patients’ perceived knowledge and receptivity towards statins may improve following participation in a comprehensive therapeutic lifestyle modification program. Future research must evaluate the impact of these programs on statin uptake, compliance and outcomes.
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Affiliation(s)
- Alaina Pupulin
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (AP); Faculty of Art and Science, University of Toronto, Toronto, ON, Canada (JB); Faculty of Medicine, University of Toronto, Toronto, ON, Canada (RB, DAA); Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada (DAA); Rehabilitation Institute-University Health Network, University of Toronto, Toronto, ON, Canada (DAA); Institute for Clinical Evaluative Sciences, Toronto, ON, Canada (DAA)
| | - Jillian Ball
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (AP); Faculty of Art and Science, University of Toronto, Toronto, ON, Canada (JB); Faculty of Medicine, University of Toronto, Toronto, ON, Canada (RB, DAA); Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada (DAA); Rehabilitation Institute-University Health Network, University of Toronto, Toronto, ON, Canada (DAA); Institute for Clinical Evaluative Sciences, Toronto, ON, Canada (DAA)
| | - Ravi Bajaj
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (AP); Faculty of Art and Science, University of Toronto, Toronto, ON, Canada (JB); Faculty of Medicine, University of Toronto, Toronto, ON, Canada (RB, DAA); Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada (DAA); Rehabilitation Institute-University Health Network, University of Toronto, Toronto, ON, Canada (DAA); Institute for Clinical Evaluative Sciences, Toronto, ON, Canada (DAA)
| | - David A. Alter
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada (AP); Faculty of Art and Science, University of Toronto, Toronto, ON, Canada (JB); Faculty of Medicine, University of Toronto, Toronto, ON, Canada (RB, DAA); Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada (DAA); Rehabilitation Institute-University Health Network, University of Toronto, Toronto, ON, Canada (DAA); Institute for Clinical Evaluative Sciences, Toronto, ON, Canada (DAA)
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6
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Alter DA. Pharmacogenetic screening in a knowledge-based economy: shouldn't more be better? Ann Transl Med 2022; 10:1415. [PMID: 36660638 PMCID: PMC9843425 DOI: 10.21037/atm-2022-60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/19/2022] [Indexed: 11/21/2022]
Affiliation(s)
- David A Alter
- University Health Network-Toronto Rehabilitation Institute, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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7
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Abdel-Qadir H, Akioyamen LE, Fang J, Pang A, Ha AC, Jackevicius CA, Alter DA, Austin PC, Atzema CL, Bhatia RS, Booth GL, Johnston S, Dhalla I, Kapral MK, Krumholz HM, McNaughton CD, Roifman I, Tu K, Udell JA, Wijeysundera HC, Ko DT, Schull MJ, Lee DS. Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study. Circulation 2022; 146:159-171. [PMID: 35678171 PMCID: PMC9287095 DOI: 10.1161/circulationaha.122.058949] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. METHODS This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. RESULTS Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]). CONCLUSIONS Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.
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Affiliation(s)
- Husam Abdel-Qadir
- Women’s College Hospital, Toronto, Canada (H.A.-Q., J.A.U.)
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Leo E. Akioyamen
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
| | - Andrea Pang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
| | - Andrew C.T. Ha
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Cynthia A. Jackevicius
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Western University of Health Sciences, Pomona, CA (C.A.J.)
| | - David A. Alter
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Peter C. Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Clare L. Atzema
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - R. Sacha Bhatia
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Gillian L. Booth
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada (G.L.B., I.D.)
| | - Sharon Johnston
- Departments of Family Medicine, University of Ottawa, Ottawa, Canada (S.J.)
- Institu du Savoir, Hôpital Montfort‚ Ottawa, Canada (S.J.)
| | - Irfan Dhalla
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada (G.L.B., I.D.)
| | - Moira K. Kapral
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT (H.M.K.)
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.)
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.)
| | - Candace D. McNaughton
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Idan Roifman
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Karen Tu
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Family and Community Medicine (K.T.), University of Toronto, Toronto‚ Canada
- North York General Hospital, Toronto, Canada (K.T.)
| | - Jacob A. Udell
- Women’s College Hospital, Toronto, Canada (H.A.-Q., J.A.U.)
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
| | - Harindra C. Wijeysundera
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Dennis T. Ko
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Michael J. Schull
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Sunnybrook Health Sciences Centre, Toronto, Canada (C.L.A., C.D.M., I.R., H.C.W., D.T.K., M.J.S.)
| | - Douglas S. Lee
- University Health Network, Toronto, Canada (H.A.-Q., A.C.T.H., C.A.J., D.A.A., R.S.B., M.K.K., K.T., J.A.U., D.S.L.)
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Canada (H.A.-Q., J.F., A.P., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.)
- Institute of Health Policy, Management, and Evaluation (H.A.-Q., C.A.J., D.A.A., P.C.A., C.L.A., G.L.B., I.D., M.K.K., I.R., K.T., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
- Department of Medicine (H.A.-Q., L.E.A., A.C.T.H., D.A.A., C.L.A., R.S.B., G.L.B., I.D., M.K.K., C.D.M., I.R., J.A.U., H.C.W., D.T.K., M.J.S., D.S.L.), University of Toronto, Toronto‚ Canada
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Karkhanis R, Wijeysundera HC, Tam DY, Oh P, Alter DA, Yu B, Kiss A, Fremes SE. Cardiac Rehabilitation Is Associated With Improved Long-Term Outcomes After Coronary Artery Bypass Grafting. CJC Open 2020; 3:167-175. [PMID: 33644730 PMCID: PMC7893191 DOI: 10.1016/j.cjco.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/03/2020] [Indexed: 12/26/2022] Open
Abstract
Background Although cardiac rehabilitation (CR) has proven to have short- and mid-term benefit in treatment of coronary artery disease, its long-term benefit in patients who have undergone coronary artery bypass grafting (CABG) is less certain. Our objective was to examine the late outcomes of patients who attended CR within the first year after CABG. Methods Adult CABG patients referred to Toronto Rehabilitation Institute (CR group: were referred and attended at least 1 session; No-CR group: were referred but did not attend) between January 1996 and September 2008 were identified through linkages with clinical and provincial administrative databases for comorbidities and outcome ascertainment. The primary outcome was a composite of all-cause mortality, acute myocardial infarction, stroke or repeat revascularization (major adverse cardiac and cerebrovascular events [MACCE]). The secondary outcome was all-cause mortality. Multivariable Cox proportional hazard models were used to assess the CR treatment effect, adjusting for baseline characteristics. Results The study cohort consisted of 5,000 patients-3,685 (73.7%) in the CR group and 1,315 (26.3%) in the No-CR group. Median referral time was 32.5 days, and follow-up was 13.1 years. The CR group patients, compared with the No-CR group, were younger (age 62.6 ± 9.6 vs 64.0 ± 10.5 years), were more likely to be male (85.0% vs 79.5%), and had fewer cardiac comorbidities. In adjusted analyses, the CR group was associated with decreased MACCE (hazard ratio 0.83, 95% confidence interval 0.75-0.91, P < 0.0001) and a higher adjusted survival at 15 years (66.3% vs 60.1%, hazard ratio 0.76, 95% confidence interval 0.68-0.84, P < 0.0001), as compared with the No-CR group. Conclusions There was a reduction in MACCE and late mortality associated with CR attendance, highlighting the importance of patient referral and participation in CR after CABG.
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Affiliation(s)
- Reena Karkhanis
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Harindra C. Wijeysundera
- ICES, Toronto, Ontario, Canada
- Division of Cardiology, Schulich Heart Centre, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y. Tam
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Paul Oh
- Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David A. Alter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bing Yu
- ICES, Toronto, Ontario, Canada
| | - Alex Kiss
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Stephen E. Fremes
- Division of Cardiac Surgery, Schulich Heart Centre, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Stephen E. Fremes, Professor of Surgery, University of Toronto, Schulich Heart Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room H4 05, Toronto, Ontario M4N 3M5, Canada. Tel.: +1-416-480-6073; fax: +1-416-480-4439.
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Yu CW, Alavinia SM, Alter DA. Impact of socioeconomic status on end-of-life costs: a systematic review and meta-analysis. BMC Palliat Care 2020; 19:35. [PMID: 32293403 PMCID: PMC7087362 DOI: 10.1186/s12904-020-0538-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 03/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socioeconomic inequalities in access to, and utilization of medical care have been shown in many jurisdictions. However, the extent to which they exist at end-of-life (EOL) remains unclear. METHODS Studies in MEDLINE, EMBASE, CINAHL, ProQuest, Web of Science, Web of Knowledge, and OpenGrey databases were searched through December 2019 with hand-searching of in-text citations. No publication date or language limitations were set. Studies assessing SES (e.g. income) in adults, correlated to EOL costs in last year(s) or month(s) of life were selected. Two independent reviewers performed data abstraction and quality assessment, with inconsistencies resolved by consensus. RESULTS A total of twenty articles met eligibility criteria. Two meta-analyses were performed on studies that examined total costs in last year of life - the first examined costs without adjustments for confounders (n = 4), the second examined costs that adjusted for confounders, including comorbidities (n = 2). Among studies which did not adjust for comorbidities, SES was positively correlated with EOL costs (standardized mean difference, 0.13 [95% confidence interval, 0.03 to 0.24]). However, among studies adjusting for comorbidities, SES was inversely correlated with EOL expenditures (regression coefficient, -$150.94 [95% confidence interval, -$177.69 to -$124.19], 2015 United States Dollars (USD)). Higher ambulatory care and drug expenditure were consistently found among higher SES patients irrespective of whether or not comorbidity adjustment was employed. CONCLUSION Overall, an inequality leading to higher end-of-life expenditure for higher SES patients existed to varying extents, even within countries providing universal health care, with greatest differences seen for outpatient and prescription drug costs. The magnitude and directionality of the relationship in part depended on whether comorbidity risk-adjustment methodology was employed.
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Affiliation(s)
- Caberry W. Yu
- School of Medicine, Faculty of Health Sciences, Queen’s University, 15 Arch St, Kingston, ON K7L 3N6 Canada
| | - S. Mohammad Alavinia
- Neural Engineering & Therapeutics Team, Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, 27 King’s College Cir, Toronto, Canada
| | - David A. Alter
- Department of Medicine, University Health Network, 27 King’s College Cir, Toronto, ON M5S 1A1 Canada
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6 Canada
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Cir, Toronto, ON M5S 1A8 Canada
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2 Canada
- IC/ES (Institute for Clinical Evaluative Sciences), 2075 Bayview Avenue, G1-06, Toronto, Ontario M4N 3M5 Canada
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Kabboul NN, Tomlinson G, Francis TA, Grace SL, Chaves G, Rac V, Daou-Kabboul T, Bielecki JM, Alter DA, Krahn M. Comparative Effectiveness of the Core Components of Cardiac Rehabilitation on Mortality and Morbidity: A Systematic Review and Network Meta-Analysis. J Clin Med 2018; 7:E514. [PMID: 30518047 PMCID: PMC6306907 DOI: 10.3390/jcm7120514] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 11/26/2018] [Accepted: 11/30/2018] [Indexed: 01/12/2023] Open
Abstract
A systematic review and network meta-analysis (NMA) of randomized controlled trials (RCTs) evaluating the core components of cardiac rehabilitation (CR), nutritional counseling (NC), risk factor modification (RFM), psychosocial management (PM), patient education (PE), and exercise training (ET)) was undertaken. Published RCTs were identified from database inception dates to April 2017, and risk of bias assessed using Cochrane's tool. Endpoints included mortality (all-cause and cardiovascular (CV)) and morbidity (fatal and non-fatal myocardial infarction (MI), coronary artery bypass surgery (CABG), percutaneous coronary intervention (PCI), and hospitalization (all-cause and CV)). Meta-regression models decomposed treatment effects into the main effects of core components, and two-way or all-way interactions between them. Ultimately, 148 RCTs (50,965 participants) were included. Main effects models were best fitting for mortality (e.g., for all-cause, specifically PM (hazard ratio HR = 0.68, 95% credible interval CrI = 0.54⁻0.85) and ET (HR = 0.75, 95% CrI = 0.60⁻0.92) components effective), MI (e.g., for all-cause, specifically PM (hazard ratio HR = 0.76, 95% credible interval CrI = 0.57⁻0.99), ET (HR = 0.75, 95% CrI = 0.56⁻0.99) and PE (HR = 0.68, 95% CrI = 0.47⁻0.99) components effective) and hospitalization (e.g., all-cause, PM (HR = 0.76, 95% CrI = 0.58⁻0.96) effective). For revascularization (including CABG and PCI individually), the full interaction model was best-fitting. Given that each component, individual or in combination, was associated with mortality and/or morbidity, recommendations for comprehensive CR are warranted.
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Affiliation(s)
- Nader N Kabboul
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - George Tomlinson
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
| | - Troy A Francis
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - Sherry L Grace
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2, Canada.
- School of Kinesiology and Health Science, York University, 4700 Keele St, Toronto, ON M3J 1P3, Canada.
| | - Gabriela Chaves
- Department of Physical Therapy, Federal University of Minas Gerais, Av. Pres. Antônio Carlos, 6627-Pampulha, Belo Horizonte, MG 31270-901, Brazil.
| | - Valeria Rac
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - Tamara Daou-Kabboul
- Human Nutrition, Bridgeport University, 126 Park Ave, Bridgeport, CT 06604, USA.
| | - Joanna M Bielecki
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
| | - David A Alter
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
- Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, University of Toronto, 550 University Ave, Toronto, ON M5G 2A2, Canada.
| | - Murray Krahn
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
- Faculty of Pharmacy, University of Toronto, 144 College St, Toronto, ON M5S 3M2, Canada.
- Department of Medicine, University Health Network, 27 King's College Circle, Toronto, ON M5S 1A1, Canada.
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, 4th Floor, 155 College St, Toronto, ON M5T 3M6, Canada.
- Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Cir, Toronto, ON M5S 1A8, Canada.
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Stone JA, Alter DA. The Health Economics of Myocardial Infarction: Black Boxes and Black Holes. Can J Cardiol 2018; 34:1253-1255. [DOI: 10.1016/j.cjca.2018.07.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 10/28/2022] Open
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Biswas A, Oh PI, Faulkner GE, Bonsignore A, Pakosh MT, Alter DA. The energy expenditure benefits of reallocating sedentary time with physical activity: a systematic review and meta-analysis. J Public Health (Oxf) 2018; 40:295-303. [PMID: 28591813 PMCID: PMC6051454 DOI: 10.1093/pubmed/fdx062] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 05/09/2017] [Accepted: 05/18/2017] [Indexed: 01/22/2023] Open
Abstract
Background We compared direct and daily cumulative energy expenditure (EE) differences associated with reallocating sedentary time to physical activity in adults for meaningful EE changes. Methods Peer-reviewed studies in PubMed, Medline, EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were searched from inception to March 2017. Randomized and non-randomized interventions with sedentary time and EE outcomes in adults were included. Study quality was assessed by the National Heart Lung and Blood Institute tool, and summarized using random-effects meta-analysis and meta-regression. Results In total, 26 studies were reviewed, and 24 studies examined by meta-analysis. Reallocating 6-9 h of sedentary time to light-intensity physical activity (LIPA) (standardized mean difference [SMD], 2.501 [CI: 1.204-5.363]) had lower cumulative EE than 6-9 h of combined LIPA and moderate-vigorous intensity physical activity (LIPA and moderate-vigorous physical activity [MVPA]) (SMD, 5.218 [CI: 3.822-6.613]). Reallocating 1 h of MVPA resulted in greater cumulative EE than 3-5 h of LIPA and MVPA, but <6-9 h of LIPA and MVPA. Conclusions Comparable EE can be achieved by different strategies, and promoting MVPA might be effective for those individuals where a combination of MVPA and LIPA is challenging.
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Affiliation(s)
| | - Paul I Oh
- Toronto Rehabilitation Institute—University Health Network, Toronto, Ontario, Canada
| | - Guy E Faulkner
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alis Bonsignore
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, Ontario, Canada
| | - Maureen T Pakosh
- Toronto Rehabilitation Institute—University Health Network, Toronto, Ontario, Canada
| | - David A Alter
- Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute—UHN, Toronto, Canada
- Toronto Rehabilitation Institute—UHN and University of Toronto, Toronto, Canada
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Alter DA, Tu JV, Koh M, Jackevicius CA, Austin PC, Rezai MR, Bhatia RS, Johnston S, Udell JA, Ko DT. Projected Real-World Effectiveness of Using Aggressive Low-Density Lipoprotein Cholesterol Targets Among Elderly Statin Users Following Acute Coronary Syndromes in Canada. J Am Heart Assoc 2018; 7:JAHA.117.007535. [PMID: 29754125 PMCID: PMC6015304 DOI: 10.1161/jaha.117.007535] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The extent to which outcome benefits may be achieved through the implementation of aggressive low-density lipoprotein (LDL) cholesterol targets in real world settings remains unknown, especially among elderly statin users following acute coronary syndromes. METHODS AND RESULTS A population-based cohort study consisting of 19 544 post-acute coronary syndrome statin-users aged ≥66 years between January 1, 2017 and March 31, 2014 was used to project the number of adverse outcome events (acute myocardial infarction or death from any cause) that could be prevented if all post-acute coronary syndrome elderly statin users were treated to 1 of 2 LDL cholesterol target levels (≤50 and ≤70 mg/dL). The number of preventable adverse outcomes was estimated by using model-based expected event probabilities as derived from Cox Proportional hazards models. In total, 61.6% and 25.5% of the elderly patients met LDL cholesterol targets of ≤70 and ≤50 mg/dL, respectively, based on current management. No more than 2.3 adverse events per 1000 elderly statin users (95% confidence interval: -0.7 to 5.4, P=0.62) could be prevented over 8.1 years if all patients were to be treated from current LDL cholesterol levels to either of the 2 LDL cholesterol targets of 70 or 50 mg/dL. CONCLUSIONS The number of acute myocardial infarctions or death that could be prevented through the implementation of LDL cholesterol targets with statins is negligible among an elderly post-acute coronary syndrome population. Such findings may have implications for the applicability of newer agents, such as proprotein convertase subtilisin/kexin type-9- inhibitors.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada .,University of Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Jack V Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada
| | - Maria Koh
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada.,Western University of Health Sciences, Pomona, CA.,VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada
| | - Mohammad R Rezai
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - R Sacha Bhatia
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada.,Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Sharon Johnston
- Department of Family Medicine, University of Ottawa, Toronto, Canada
| | - Jacob A Udell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada.,Women's College Hospital, Toronto, Ontario, Canada
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of Toronto, Ontario, Canada
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14
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Czarnecki A, Qiu F, Koh M, Alter DA, Austin PC, Fremes SE, Tu JV, Wijeysundera HC, Yan AT, Ko DT. Trends in the incidence and outcomes of patients with aortic stenosis hospitalization. Am Heart J 2018; 199:144-149. [PMID: 29754653 DOI: 10.1016/j.ahj.2018.02.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 02/07/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although the burden of aortic stenosis (AS) on our health care system is expected to rise, little is known regarding its epidemiology at the population level. Our primary objective was to evaluate trends in AS hospitalization, treatment and outcomes. METHODS We performed a population-based observational study including 37,970 patients newly hospitalized with AS from 2004 and 2013 in Ontario, Canada. We calculated age- and sex-standardized rate of AS hospitalization through direct standardization. The independent association between year of the hospitalization, and 30-day and 1-year mortality rate was evaluated using logistic regression models to account for temporal changes in patient characteristics. RESULTS The overall age- and sex-standardized AS hospitalization rate increased slightly from 36 per 100,000 in 2004 to 39 per 100,000 in 2013. A substantial increase was seen in patients ≥85years, where hospitalization rates increased 29% from 400 to 516 per 100,000 from 2004 to 2013 (P<.001). In this study period, 36.2% of patients received aortic valve interventions within 30days of hospitalization. Among treated patients, an improving mortality trend was observed in which the adjusted odds ratio (OR) was significantly lower in 2013 as compared to 2004 (OR 0.55 for 30-day mortality, 0.74 for 1-year morality). In contrast, no significant temporal change in mortality was seen among patients without aortic valve intervention. CONCLUSION AS hospitalizations in the elderly increased significantly beyond that was expected from population growth. Many AS patients did not receive aortic valve intervention after hospitalization. Mortality among the treated patients improved significantly over time.
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Affiliation(s)
| | - Peter M Smith
- 1 Institute for Work & Health, Canada.,2 Dalla Lana School of Public Health, University of Toronto, Canada
| | - David A Alter
- 2 Dalla Lana School of Public Health, University of Toronto, Canada.,3 Cardiac Prevention and Rehabilitation Program, University Health Network-Toronto Rehabilitation Institute, Canada, Canada
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16
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Wijeysundera HC, Koh M, Alter DA, Austin PC, Jackevicius CA, Tu JV, Ko DT. Association of high-density lipoprotein cholesterol with non-fatal cardiac and non-cardiac events: a CANHEART substudy. Open Heart 2017; 4:e000731. [PMID: 29344372 PMCID: PMC5761297 DOI: 10.1136/openhrt-2017-000731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/08/2017] [Accepted: 11/14/2017] [Indexed: 11/04/2022] Open
Abstract
Background Emerging evidence has questioned the role of high-density lipoprotein cholesterol (HDL-C) as an independent and modifiable risk factor for cardiovascular disease. We sought to understand the relationship between HDL-C levels and subsequent non-fatal clinical events. Methods Individuals without prior cardiovascular disease or cancer were identified. Outcomes of interest were classified as non-fatal cardiovascular, cancer and infectious. Sex-stratified, multivariable, cause-specific Cox proportional hazards models were created. The reference level HDL-C for both women and men was 51-60 mg/dL. Results Our cohort consisted of 631 762 individuals. For cardiovascular events, there was a consistent inverse relationship, with higher adjusted HRs for the lower HDL-C strata in both men and women. This relationship was also seen in the composite of non-cardiovascular outcomes. In women, the HR in the <30 mg/dL HDL-C category was 2.10 (95% CI 1.66 to 2.57) and 1.86 (95% CI 1.27 to 2.72) for cardiovascular and non-cardiovascular outcomes, respectively; in contrast, in the >90 mg/dL group, it was 0.87 (95% CI 0.74 to 1.02) and 0.81 (95% CI 0.63 to 1.06). For men, HRs were 2.02 (95% CI 1.79 to 2.28) and 1.84 (95% CI 1.47 to 2.31) in the <30 mg/dL HDL-C category for cardiovascular and non-cardiovascular outcomes, respectively, compared with 0.73 (95% CI 0.53 to 1.00) and 1.07 (95% CI 0.67 to 1.70) in the >90 mg/dL group. Conclusions We found an inverse relationship between HDL-C and a wide spectrum of non-fatal outcomes, suggesting that HDL-C is a heavily confounded factor that may be a marker of poor overall health, rather than an independent and modifiable risk factor.
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Affiliation(s)
- Harindra C Wijeysundera
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Maria Koh
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - David A Alter
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Cynthia A Jackevicius
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Jack V Tu
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
| | - Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, Canada
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Alter DA. When Do We Decide That Generic and Brand-Name Drugs Are Clinically Equivalent? Perfecting Decisions With Imperfect Evidence. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.004158. [PMID: 28974513 DOI: 10.1161/circoutcomes.117.004158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David A Alter
- From the University Health Network-Toronto Rehabilitation Institute (UHN-TRI), ON, Canada; and Department of Medicine, Institute for Clinical Evaluative Sciences (ICES), University of Toronto, ON, Canada.
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18
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Alter DA. Tracking Our Physical Inactivity and Progression to Death: Is This Evolutionary Stagnation? Ann Intern Med 2017; 167:513-514. [PMID: 28892823 DOI: 10.7326/m17-2181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- David A Alter
- From University of Toronto, Toronto, Ontario, Canada
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Biswas A, Oh PI, Faulkner GE, Alter DA. A prospective study examining the influence of cardiac rehabilitation on the sedentary time of highly sedentary, physically inactive patients. Ann Phys Rehabil Med 2017; 61:207-214. [PMID: 28923367 DOI: 10.1016/j.rehab.2017.06.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Prolonged sedentary time is recognized as a distinct health risk, and mortality risks are expected to be greatest for individuals with low exercise levels. It is unknown whether participation in exercise-based cardiac rehabilitation (CR) programs influences sedentary behaviour particularly among those patients expected to be at greatest mortality risk. This study examined the influence of CR participation on sedentary behaviour and identified the proportion and characteristics (socio-demographic and clinical) of patients who do not meet exercise recommendations and have prolonged sedentary times. METHODS A prospective study was conducted among patients of an exercise-based CR program and assessments performed at baseline and 3 months. Physical activity and sedentary behaviour information were collected by self-report, and convergent validity was examined on an accelerometer-wearing subsample. RESULTS Of 468 CR patients approached, 130 participants were recruited with an average sedentary time of 8hours/day. Sedentary behaviour remained consistent at follow-up (relative change= -2.4%, P=0.07) notwithstanding a greater proportion meeting exercise recommendations (relative change= 57.4%). 19.2% of participants were classified to have prolonged sedentary time and not meet exercise recommendations at baseline. No significant differences were found between the characteristics of high-risk individuals and lower risk subgroups. Findings were consistent among the accelerometer-derived subgroup and the overall sample despite poor to moderate convergent validity. CONCLUSIONS These results suggest that the exercise-focus of CR may not reduce sedentary behaviours. Future studies are needed to determine whether sedentary behaviour-specific reduction strategies are more effective than traditional exercise-based strategies and lead to meaningful improvements in clinical outcomes.
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Affiliation(s)
- A Biswas
- University Health Network, Toronto rehabilitation institute, Rumsey Centre, 34, Rumsey road, Toronto, ON, Canada
| | - P I Oh
- University Health Network, Toronto rehabilitation institute, Rumsey Centre, 34, Rumsey road, Toronto, ON, Canada
| | - G E Faulkner
- University Health Network, Toronto rehabilitation institute, Rumsey Centre, 34, Rumsey road, Toronto, ON, Canada
| | - D A Alter
- University Health Network, Toronto rehabilitation institute, Rumsey Centre, 34, Rumsey road, Toronto, ON, Canada.
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20
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Affiliation(s)
- David A Alter
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute - University Health Network, Institute for Clinical Evaluative Sciences; Departments of Medicine and Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.
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21
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Biswas A, Faulkner GE, Oh PI, Alter DA. Patient and practitioner perspectives on reducing sedentary behavior at an exercise-based cardiac rehabilitation program. Disabil Rehabil 2017; 40:2267-2274. [PMID: 28583032 DOI: 10.1080/09638288.2017.1334232] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To understand the awareness of sedentary behavior, as well as the perceived facilitators and barriers to reducing sedentary behaviors from the perspectives of patients undertaking an exercise-based cardiac rehabilitation program, and from staff involved in supporting patient self-management. MATERIALS AND METHODS A qualitative study was conducted at a large cardiac rehabilitation program in a metropolitan city in Canada. Guided by an ecological framework, semi-structured interviews were conducted individually with 15 patients, and in two focus groups with six staff. Transcribed interviews were analyzed by thematic analysis. RESULTS Patients placed little importance on reducing sedentary behavior as they were unconvinced of the health benefits, did not perceive themselves to be sedentary, or associated such behaviors with enjoyment and relaxation. While staff were aware of the risks, they saw them as less critical than other health behaviors. Intrapersonal factors (physical and psychosocial health) and environment factors (the information environment, socio-cultural factors) within leisure time, the home, and work, influenced sedentary behavior. CONCLUSIONS While these findings require further testing, future interventions may be effective if aimed at increasing awareness of the health benefits of reducing sedentary behavior, utilizing existing behavior change strategies, and using a participatory approach to tailor strategies to patients. Implications for rehabilitation Cardiac rehabilitation programs effectively use exercise promotion to improve the health of people with established cardiovascular disease. As sedentary lifestyles become more prevalent, recommendations to reduce the health risks of prolonged sedentary behavior that are specific to the characteristics and prognostic profiles of cardiac rehabilitation patients are needed. Cardiac rehabilitation programs must consider extending existing behavior change strategies utilized for exercise promotion towards addressing sedentary behaviors in order to be effective at reducing the sedentary time of patients. A participatory approach involving both patients and health professionals can support patients in reducing their sedentary behavior by providing a supportive environment for behavior change, increasing awareness and understanding of risks, discussing the feasibility of potential strategies, and setting achievable and actionable goals.
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Affiliation(s)
- Aviroop Biswas
- a Institute of Health Policy, Management & Evaluation , University of Toronto , Toronto , Canada
| | - Guy E Faulkner
- b School of Kinesiology , University of British Columbia , Vancouver , Canada
| | - Paul I Oh
- c University Health Network, Toronto Rehabilitation Institute , Toronto , Canada
| | - David A Alter
- c University Health Network, Toronto Rehabilitation Institute , Toronto , Canada
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Jayakar JP, Alter DA. Music for anxiety reduction in patients undergoing cardiac catheterization: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract 2017; 28:122-130. [PMID: 28779919 DOI: 10.1016/j.ctcp.2017.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medical diagnostic procedures, such as cardiac catheterization, can cause significant patient anxiety. Patient anxiety can have negative implications for compliance with healthcare visits, medical tests, and treatments. Music interventions may have a role in reducing anxiety related to cardiac catheterization procedures. OBJECTIVE To perform a comprehensive systematic review and meta-analysis evaluating whether musical interventions reduce anxiety in patients undergoing cardiac catheterization. DATA SOURCES MEDLINE, EMBASE, CENTRAL, AMED, and PsychINFO from inception to May 2015. Reference lists of included articles were further hand searched for additional eligible studies. STUDY SELECTION Randomized controlled trials evaluating the effectiveness of music interventions for anxiety reduction in patients undergoing cardiac catheterization. DATA EXTRACTION AND SYNTHESIS Data on trial design, baseline characteristics and outcomes was extracted using a data extraction table. Study quality and risk of bias were assessed using the JADAD scale. MAIN OUTCOMES AND MEASURES The main outcome was the effectiveness of music interventions in reducing anxiety in this patient population. Meta-analysis was pursued using data from studies that had used the Spielberger state anxiety inventory (STAI-S) to measure anxiety reduction. Other outcomes qualitatively reported include the use of anxiolytic medications and effect on physiological parameters such as blood pressure and heart rate. RESULTS A total of 15 studies were found to be eligible for inclusion (14 published trials and one conference abstract) in this review. Two-thirds of these studies showed statistically significant reduction in measures of patient anxiety or well-being with musical interventions. Meta-analysis included six studies (n = 695) and showed statistically significant reduction in mean STAI-S scores with music (-3.95 points; 95% confidence -5.53 and -2.37; p value less than 0.005). CONCLUSION AND RELEVANCE In conclusion, music is a safe and easily administered intervention that can be used for anxiety reduction among patients undergoing cardiac catheterization. Further research is needed to better evaluate the clinical implications associated with the anxiolytic effects of music interventions during cardiac catheterization.
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Affiliation(s)
- Jai P Jayakar
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David A Alter
- University Health Network - Toronto Rehabilitation Institute, Toronto, Ontario, Canada; The Institute for Clinical Evaluative Sciences of Ontario, Toronto, Ontario, Canada.
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Luca SR, Koh M, Qiu F, Alter DA, Bagai A, Bhatia RS, Czarnecki A, Goodman SG, Lau C, Wijeysundera HC, Ko DT. Stress testing after percutaneous coronary interventions: a population-based study. CMAJ Open 2017; 5:E417-E423. [PMID: 28559388 PMCID: PMC5498181 DOI: 10.9778/cmajo.20160159] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Routine stress testing is commonly used after percutaneous coronary intervention (PCI) to detect in-stent restenosis or suboptimal procedure results; however, recent studies suggest that such testing is rarely indicated. Our main objectives were to assess temporal trends in utilization of stress testing and to determine factors associated with its use. METHODS We conducted an observational study involving all patients who had undergone PCI in Ontario, Canada, from Apr. 1, 2004, to Mar. 31, 2012. The main outcome was stress testing within 2 years after PCI. We constructed multivariable logistic regression models to determine factors associated with the use of stress tests. RESULTS Our cohort consisted of 128 380 patients who underwent PCI procedures. The 2-year rate of stress testing declined significantly, from 68.1% among patients who underwent PCI in 2004 to 60.4% in 2012 (p < 0.001). Similar reductions were observed regardless of patients' risk of restenosis and type of stent received. Patients who were older or had diabetes mellitus, prior myocardial infarction, heart failure or other comorbidities were significantly less likely to undergo stress testing. In contrast, patients with higher income and those whose PCI was performed in a nonteaching hospital were significantly more likely to undergo stress testing. INTERPRETATION We observed a decrease in the use of stress testing after PCI procedures over time. However, stress tests were not performed in accordance with patients' higher baseline risk of adverse outcomes or risk of restenosis. Instead, many nonclinical factors, such as patients' socioeconomic status and hospitals' teaching status, were associated with higher use of stress tests.
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Affiliation(s)
- Simina R Luca
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Maria Koh
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Feng Qiu
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - David A Alter
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Akshay Bagai
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - R Sacha Bhatia
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Andrew Czarnecki
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Shaun G Goodman
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Ching Lau
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Harindra C Wijeysundera
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
| | - Dennis T Ko
- Affiliations: Department of Medicine (Luca), University of Toronto; Institute for Clinical Evaluative Sciences (Koh, Qiu, Alter, Bhatia, Czarnecki, Wijeysundera, Ko); Toronto Rehabilitation Institute (Alter), University Health Network; Terrence Donnelly Heart Centre (Bagai, Goodman), St. Michael's Hospital, University of Toronto; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia); Schulich Heart Centre (Czarnecki, Lau, Wijeysundera, Ko), Sunnybrook Health Sciences Centre, University of Toronto; Canadian Heart Research Centre (Goodman), Toronto, Ont
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Tu JV, Chu A, Maclagan L, Austin PC, Johnston S, Ko DT, Cheung I, Atzema CL, Booth GL, Bhatia RS, Lee DS, Jackevicius CA, Kapral MK, Tu K, Wijeysundera HC, Alter DA, Udell JA, Manuel DG, Mondal P, Hogg W. Regional variations in ambulatory care and incidence of cardiovascular events. CMAJ 2017; 189:E494-E501. [PMID: 28385894 DOI: 10.1503/cmaj.160823] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2016] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates. METHODS We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province's 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates. RESULTS Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone. INTERPRETATION Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes.
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Affiliation(s)
- Jack V Tu
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont.
| | - Anna Chu
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Laura Maclagan
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Sharon Johnston
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Ingrid Cheung
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Clare L Atzema
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Gillian L Booth
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - R Sacha Bhatia
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Cynthia A Jackevicius
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Moira K Kapral
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Karen Tu
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Harindra C Wijeysundera
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - David A Alter
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Jacob A Udell
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Douglas G Manuel
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - Prosanta Mondal
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
| | - William Hogg
- Institute for Clinical Evaluative Sciences (J. Tu, Chu, Maclagan, Austin, Ko, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel, Mondal), Toronto, Ont.; Schulich Heart Centre, Sunnybrook Health Sciences Centre (J. Tu, Ko, Wijeysundera), Toronto, Ont.; University of Toronto (J. Tu, Chu, Austin, Ko, Cheung, Atzema, Booth, Bhatia, Lee, Jackevicius, Kapral, K. Tu, Wijeysundera, Alter, Udell, Manuel), Toronto, Ont.; Bruyère Research Institute (Johnston, Hogg), Ottawa, Ont.; University of Ottawa (Johnston, Hogg), Ottawa, Ont.; Sunnybrook Health Sciences Centre (Atzema), Toronto, Ont.; St. Michael's Hospital (Booth), Toronto, Ont.; Women's College Hospital Institute for Health Systems Solutions and Virtual Care (Bhatia), Toronto, Ont.; University Health Network (Bhatia, Lee, Jackevicius, Kapral, K. Tu, Alter, Udell), Toronto, Ont.; Western University of Health Sciences (Jackevicius), Pomona, Calif.; Women's College Hospital (Udell), Toronto, Ont.; Ottawa Hospital Research Institute (Manuel), Ottawa, Ont
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Alter DA, Yu B, Bajaj RR, Oh PI. Relationship Between Cardiac Rehabilitation Participation and Health Service Expenditures Within a Universal Health Care System. Mayo Clin Proc 2017; 92:S0025-6196(17)30075-7. [PMID: 28365098 DOI: 10.1016/j.mayocp.2016.12.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/06/2016] [Accepted: 12/28/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. PATIENTS AND METHODS A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ≥67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per "eligible day alive" over the 3-year period. RESULTS Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. CONCLUSION Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.
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Affiliation(s)
- David A Alter
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Bing Yu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi R Bajaj
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Alter DA, Yu W. The Burgeoning Roots of Socioeconomic Inequalities in Health: The Legacy Effect. Rev Esp Cardiol (Engl Ed) 2017; 70:138-139. [PMID: 27717778 DOI: 10.1016/j.rec.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/16/2016] [Indexed: 06/06/2023]
Affiliation(s)
- David A Alter
- Cardiac Rehabilitation and Prevention Program, University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Health Policy, Management, and Evaluation, University of Toronto, Ontario, Canada.
| | - WeiYang Yu
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Alabousi M, Abdullah P, Alter DA, Booth GL, Hogg W, Ko DT, Manuel DG, Farkouh ME, Tu JV, Udell JA. Cardiovascular Risk Factor Management Performance in Canada and the United States: A Systematic Review. Can J Cardiol 2017; 33:393-404. [DOI: 10.1016/j.cjca.2016.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 07/03/2016] [Accepted: 07/06/2016] [Indexed: 01/13/2023] Open
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Cheung A, Stukel TA, Alter DA, Glazier RH, Ling V, Wang X, Shah BR. Primary Care Physician Volume and Quality of Diabetes Care: A Population-Based Cohort Study. Ann Intern Med 2017; 166:240-247. [PMID: 27951589 DOI: 10.7326/m16-1056] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND A relationship between higher patient volume and both better quality of care and better outcomes has been shown for many acute care conditions. Whether a volume-quality relationship exists for the outpatient management of chronic diseases is uncertain. OBJECTIVE To explore the association between primary care physician volume and quality of diabetes care. DESIGN Cohort study. SETTING The study was conducted using linked population-based health care administrative data in Ontario, Canada. PATIENTS 1 018 647 adults with diabetes in 2011 who received care from 9014 primary care physicians. Two measures of volume were ascertained for each physician: overall ambulatory volume (representing time available to devote to chronic disease management during patient encounters) and diabetes-specific volume (representing disease-specific expertise). MEASUREMENTS Quality of care was measured over a 2-year period using 6 indicators: disease monitoring (eye examination, hemoglobin A1c testing, and low-density lipoprotein cholesterol testing), prescribing appropriate medications (angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers and statins), and adverse clinical outcomes (emergency department visits for hypoglycemia or hyperglycemia). RESULTS Higher overall ambulatory volume was associated with lower rates of appropriate disease monitoring and medication prescription. In contrast, higher diabetes-specific volume was associated with better quality of care across all 6 indicators. LIMITATION Only a select set of quality indicators and potential confounders could be ascertained from available data. CONCLUSION Primary care physicians with busier ambulatory patient practices delivered lower-quality diabetes care, but those with greater diabetes-specific experience delivered higher-quality care. These findings show that relationships between physician volume and quality can be extended from acute care to outpatient chronic disease care. Health policies or programs to support physicians with a low volume of patients with diabetes may improve care. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research.
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Affiliation(s)
- Andrew Cheung
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Thérèse A Stukel
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David A Alter
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Richard H Glazier
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Vicki Ling
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Xuesong Wang
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Baiju R Shah
- From University of Toronto, Institute for Clinical Evaluative Sciences, Toronto Rehabilitation Institute, St. Michael's Hospital, and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Ko DT, Alter DA, Guo H, Koh M, Lau G, Austin PC, Booth GL, Hogg W, Jackevicius CA, Lee DS, Wijeysundera HC, Wilkins JT, Tu JV. High-Density Lipoprotein Cholesterol and Cause-Specific Mortality in Individuals Without Previous Cardiovascular Conditions. J Am Coll Cardiol 2016; 68:2073-2083. [DOI: 10.1016/j.jacc.2016.08.038] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/09/2016] [Indexed: 01/11/2023]
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Grace SL, Turk-Adawi K, Santiago de Araújo Pio C, Alter DA. Ensuring Cardiac Rehabilitation Access for the Majority of Those in Need: A Call to Action for Canada. Can J Cardiol 2016; 32:S358-S364. [PMID: 27692116 DOI: 10.1016/j.cjca.2016.07.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/04/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022] Open
Abstract
Cardiac rehabilitation (CR) is a proven model of secondary prevention. Indicated cardiac conditions for CR are well established, and participation of these patients results in significantly lower mortality and morbidity when compared with usual care. There are approximately 170 CR programs in Canada, which varies widely by province. There is a grossly insufficient capacity to treat all patients with cardiac indications in Canada and beyond. The density of CR services is about half that in the United States, at 1 program per 208,823 inhabitants or 1 program per 7779 patients with cardiac disease. Despite the Canadian Cardiovascular Society's target of 85% referral for CR for cardiac inpatients with the appropriate indications, significantly fewer patients are referred for CR. Moreover, certain patient groups-such as women, ethnocultural minorities, and those of low socioeconomic status-are less likely to access CR, despite greater need because of poorer outcomes. CR appears to be reaching a healthier population that is perhaps more adherent to secondary prevention recommendations and hence in less need of the limited CR spots available. The reasons for CR underuse are well established and include factors at patient, referring provider, CR program, and health system levels. A Cochrane review has established some effective interventions to increase CR use, and these must be implemented more broadly. We must advocate for CR reimbursement. Finally, we must reallocate our CR resources to patients with the greatest need. This may involve risk stratification, with subsequent allocation of lower-risk patients to a more widely available, lower-cost, and effective alternative model of CR.
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Affiliation(s)
- Sherry L Grace
- York University, Toronto, Ontario, Canada; University Health Network, Toronto, Ontario, Canada.
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Austin PC, Alter DA, Tu JV. The Use of Fixed-and Random-Effects Models for Classifying Hospitals as Mortality Outliers: A Monte Carlo Assessment. Med Decis Making 2016; 23:526-39. [PMID: 14672113 DOI: 10.1177/0272989x03258443] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. There is an increasing movement towards the release of hospital “report-cards.” However, there is a paucity of research into the abilities of the different methods to correctly classify hospitals as performance outliers.Objective.To examine the ability of risk-adjusted mortality rates computed using conventional logistic regression and random-effects logistic regression models to correctly identify hospitals that have higher than acceptable mortality.Research Design.Monte Carlo simulations.Measures.Sensitivity, specificity, and positive predictive value of a classification as a high-outlier for identifying hospitals with higher than acceptable mortality rates.Results.When the distribution of hospital-specific log-odds of death was normal, random-effects models had greater specificity and positive predictive value than fixed-effects models. However, fixed-effects models had greater sensitivity than random-effects models.Conclusions.Researchers and policy makers need to carefully consider the balance between false positives and false negatives when choosing statistical models for determining which hospitals have higher than acceptablemortality in performance profiling.
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Affiliation(s)
- Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Biswas A, Oh PI, E. Faulkner G, A. Alter D. Examining the efficacy of a novel integrative exercise-based intervention in reducing the sedentary time of a clinical population. ACTA ACUST UNITED AC 2016. [DOI: 10.15761/gimci.1000122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Grace SL, Oh PI, Marzolini S, Colella T, Tan Y, Alter DA. Observing temporal trends in cardiac rehabilitation from 1996 to 2010 in Ontario: characteristics of referred patients, programme participation and mortality rates. BMJ Open 2015; 5:e009523. [PMID: 26537501 PMCID: PMC4636616 DOI: 10.1136/bmjopen-2015-009523] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We sought to describe temporal trends in the sociodemographic and clinical characteristics of participants referred to cardiac rehabilitation (CR), and its effect on programme participation and all-cause mortality over 14 years. SETTING A large CR centre in Toronto, Canada. PARTICIPANTS Consecutive patients between 1996 and 2010. PRIMARY AND SECONDARY OUTCOME MEASURES Referrals received were deterministically linked to administrative data, to complement referral form abstraction. Out-of-hospital deaths were identified using vital statistics. Patients were tracked until 2012, and mortality was ascertained. Percentage attendance at prescribed sessions was also assessed. RESULTS There were 29,171 referrals received, of which 28,767 (98.6%) were successfully linked, of whom 22,795 (79.2%) attended an intake assessment. The age of the referred population steadily increased, with more females, less affluent and more single patients referred over time (p<0.001). More patients were referred following percutaneous coronary intervention and less following coronary artery bypass graft surgery (p<0.001). The number of comorbidities decreased (p<0.001). Hypertension increased over time (p<0.001), yet the control of cholesterol steadily improved over time. The proportion of smokers decreased over time (p<0.001). Participation in CR significantly declined, and there were no significant changes in mortality. 3-year mortality rates were less than 5%. CONCLUSIONS Characteristics of referred patients tended to reflect broader trends in risk factors and cardiovascular disease burden. Physicians appear to be referring more sociodemographically diverse patients to CR; however, programmes may need to better adapt to engage these patients to fully participate. More complex patients should be referred, using explicit criteria-based referral processes.
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Affiliation(s)
- Sherry L Grace
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - Paul I Oh
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Marzolini
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - Tracey Colella
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yongyao Tan
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
| | - David A Alter
- Cardiac Rehabilitation and Prevention Program, Toronto Rehabilitation Institution, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Marzolini S, Blanchard C, Alter DA, Grace SL, Oh PI. Delays in Referral and Enrolment Are Associated With Mitigated Benefits of Cardiac Rehabilitation After Coronary Artery Bypass Surgery. Circ Cardiovasc Qual Outcomes 2015; 8:608-20. [DOI: 10.1161/circoutcomes.115.001751] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 09/04/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Susan Marzolini
- From the Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada (S.M., D.L.A., S.L.G., P.I.O.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (C.B.); and Faculty of Health, York University, Toronto, Ontario, Canada (S.G.)
| | - Chris Blanchard
- From the Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada (S.M., D.L.A., S.L.G., P.I.O.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (C.B.); and Faculty of Health, York University, Toronto, Ontario, Canada (S.G.)
| | - David A. Alter
- From the Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada (S.M., D.L.A., S.L.G., P.I.O.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (C.B.); and Faculty of Health, York University, Toronto, Ontario, Canada (S.G.)
| | - Sherry L. Grace
- From the Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada (S.M., D.L.A., S.L.G., P.I.O.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (C.B.); and Faculty of Health, York University, Toronto, Ontario, Canada (S.G.)
| | - Paul I. Oh
- From the Toronto Rehabilitation Institute/University Health Network, Toronto, Ontario, Canada (S.M., D.L.A., S.L.G., P.I.O.); Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada (C.B.); and Faculty of Health, York University, Toronto, Ontario, Canada (S.G.)
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Tu JV, Chu A, Rezai MR, Guo H, Maclagan LC, Austin PC, Booth GL, Manuel DG, Chiu M, Ko DT, Lee DS, Shah BR, Donovan LR, Sohail QZ, Alter DA. The Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada: The CANHEART Immigrant Study. Circulation 2015; 132:1549–1559. [PMID: 26324719 PMCID: PMC4606988 DOI: 10.1161/circulationaha.115.015345] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Immigrants from ethnic minority groups represent an increasing proportion of the population in many high-income countries, but little is known about the causes and amount of variation between various immigrant groups in the incidence of major cardiovascular events.
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Affiliation(s)
- Jack V Tu
- Institute for Clinical Evaluative Sciences; Schulich Heart Centre, Sunnybrook Health Sciences Centre; University of Toronto, Toronto, Ontario, Canada
| | - Anna Chu
- Institute for Clinical Evaluative Sciences & University of Toronto, Toronto, Ontario, Canada
| | - Mohammad R Rezai
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Helen Guo
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Laura C Maclagan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences & University of Toronto, Toronto, Ontario, Canada
| | - Gillian L Booth
- Institute for Clinical Evaluative Sciences; University of Toronto; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Douglas G Manuel
- Institute for Clinical Evaluative Sciences, Toronto; University of Toronto, Toronto; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Maria Chiu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Dennis T Ko
- Institute for Clinical Evaluative Sciences; Schulich Heart Centre, Sunnybrook Health Sciences Centre; University of Toronto, Toronto, Ontario, Canada
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences; University of Toronto; Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Baiju R Shah
- Institute for Clinical Evaluative Sciences; University of Toronto; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Linda R Donovan
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - David A Alter
- Institute for Clinical Evaluative Sciences; University of Toronto; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Affiliation(s)
- Aviroop Biswas
- From Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David A. Alter
- From Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Marzolini S, Swardfager W, Alter DA, Oh PI, Tan Y, Goodman JM. Quality of life and psychosocial measures influenced by exercise modality in patients with coronary artery disease. Eur J Phys Rehabil Med 2015; 51:291-299. [PMID: 24621985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The optimal approach to prescribing resistance training (RT) combined with aerobic training (AT) for psychosocial and health-related quality of life (HRQOL) is unclear. AIM To compare the effects of AT combined with RT (1 versus 3 sets) versus AT alone on HRQOL and psychosocial outcomes. DESIGN Subjects (N.=72) were randomized to AT (5 d∙wk-1) or AT (3 d∙wk-1) with either 1 set (AT/RT1) or 3 sets (AT/RT3) of RT performed 2 d∙wk-1. SETTING Outpatient Cardiac Rehabilitation Program. POPULATION Subjects with coronary artery disease. METHODS HRQOL and psychosocial parameters were assessed before and after 29 weeks of training by questionnaire. RESULTS Fifty-three subjects (mean±SD age 60.6±10.6 years) completed training. There was a group effect for change in self-efficacy of lower body physical activity tasks (P=0.03) with significantly greater improvement for AT/RT3 than AT alone (17.5±16.6% vs. 3.2±12.8% respectively, p=0.04). Lower body self-efficacy improved for AT/RT1 (15.5±13.8%, p<0.001) but not for AT alone (P=0.2). Self-efficacy for upper body tasks improved with AT/RT3 (18.2±19.9%, P=0.003) and AT/RT1 training (12.6±15.8%, P=0.005) but not with AT alone (8.3±16.1%, P=0.1). AT/RT3 and AT/RT1 training yielded improvements in depression score (-4.0±7.7, P=0.04 and -3.0±5.1, P=0.02 respectively) but not with AT alone (-0.5±4.7, P=0.71). The improvement from baseline in physical HRQOL score (MOS, SF-36) averaged 8.2±11.2% for AT (P=0.04), 10.4±11.9% for AT/RT1 (P=0.006) and 12.0±12.9% for AT/RT3 (P=0.004). CONCLUSIONS Both AT+RT groups with either 1 or 3 sets (AT 3 d∙wk-1and RT 2 d∙wk-1) each yield more pronounced psychosocial and HRQOL adaptations than AT alone (5 d∙wk-1). RT prescription beyond 1 set may further augment selected parameters in cardiac patients. CLINICAL REHABILITATION IMPACT These results provide further rationale to develop combined AT+RT regimens for individuals with coronary artery disease.
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Affiliation(s)
- S Marzolini
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada -
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Alter DA, O'Sullivan M, Oh PI, Redelmeier DA, Marzolini S, Liu R, Forhan M, Silver M, Goodman JM, Bartel LR. Synchronized personalized music audio-playlists to improve adherence to physical activity among patients participating in a structured exercise program: a proof-of-principle feasibility study. Sports Med Open 2015; 1:23. [PMID: 26284164 PMCID: PMC5005752 DOI: 10.1186/s40798-015-0017-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 04/09/2015] [Indexed: 11/17/2022]
Abstract
Background Preference-based tempo-pace synchronized music has been shown to reduce perceived physical activity exertion and improve exercise performance. The extent to which such strategies can improve adherence to physical activity remains unknown. The objective of the study is to explore the feasibility and efficacy of tempo-pace synchronized preference-based music audio-playlists on adherence to physical activity among cardiovascular disease patients participating in a cardiac rehabilitation. Methods Thirty-four cardiac rehabilitation patients were randomly allocated to one of two strategies: (1) no music usual-care control and (2) tempo-pace synchronized audio-devices with personalized music playlists + usual-care. All songs uploaded onto audio-playlist devices took into account patient personal music genre and artist preferences. However, actual song selection was restricted to music whose tempos approximated patients’ prescribed exercise walking/running pace (steps per minute) to achieve tempo-pace synchrony. Patients allocated to audio-music playlists underwent further randomization in which half of the patients received songs that were sonically enhanced with rhythmic auditory stimulation (RAS) to accentuate tempo-pace synchrony, whereas the other half did not. RAS was achieved through blinded rhythmic sonic-enhancements undertaken manually to songs within individuals’ music playlists. The primary outcome consisted of the weekly volume of physical activity undertaken over 3 months as determined by tri-axial accelerometers. Statistical methods employed an intention to treat and repeated-measures design. Results Patients randomized to personalized audio-playlists with tempo-pace synchrony achieved higher weekly volumes of physical activity than did their non-music usual-care comparators (475.6 min vs. 370.2 min, P < 0.001). Improvements in weekly physical activity volumes among audio-playlist recipients were driven by those randomized to the RAS group which attained weekly exercise volumes that were nearly twofold greater than either of the two other groups (average weekly minutes of physical activity of 631.3 min vs. 320 min vs. 370.2 min, personalized audio-playlists with RAS vs. personalized audio-playlists without RAS vs. non-music usual-care controls, respectively, P < 0.001). Patients randomized to music with RAS utilized their audio-playlist devices more frequently than did non-RAS music counterparts (P < 0.001). Conclusions The use of tempo-pace synchronized preference-based audio-playlists was feasibly implemented into a structured exercise program and efficacious in improving adherence to physical activity beyond the evidence-based non-music usual standard of care. Larger clinical trials are required to validate these findings. Trial registration ClinicalTrials.gov ID (NCT01752595) Electronic supplementary material The online version of this article (doi:10.1186/s40798-015-0017-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ; University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, Canada ; Department of Health Policy, Management and Evaluation, University of Toronto, 40 St George Street, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Mary O'Sullivan
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Donald A Redelmeier
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, ON M4N 3M5 Canada ; Sunnybrook Health Sciences, 2075 Bayview Avenue, Toronto, Canada ; Department of Medicine, University of Toronto, 27 King's College Circle, Toronto, Canada ; Department of Health Policy, Management and Evaluation, University of Toronto, 40 St George Street, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Susan Marzolini
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Richard Liu
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Mary Forhan
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; Faculty of Rehabilitation Medicine, The University of Alberta, 8205 114 Street, Alberta, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Michael Silver
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Jack M Goodman
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, 550 University Avenue, Toronto, Canada ; Department of Exercise Sciences, Faculty of Physical Education and Health, University of Toronto, 27 King's College Circle, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
| | - Lee R Bartel
- Music and Health Research Collaboratory, Faculty of Music, University of Toronto, 80 Queens Park, Toronto, Canada ; Dean's Office, Faculty of Music, University of Toronto, 80 Queens Park, Toronto, Canada ; The University of Toronto, 27 King's College Circle, Toronto, Canada
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Tu JV, Chu A, Donovan LR, Ko DT, Booth GL, Tu K, Maclagan LC, Guo H, Austin PC, Hogg W, Kapral MK, Wijeysundera HC, Atzema CL, Gershon AS, Alter DA, Lee DS, Jackevicius CA, Bhatia RS, Udell JA, Rezai MR, Stukel TA. The Cardiovascular Health in Ambulatory Care Research Team (CANHEART): using big data to measure and improve cardiovascular health and healthcare services. Circ Cardiovasc Qual Outcomes 2015; 8:204-12. [PMID: 25648464 DOI: 10.1161/circoutcomes.114.001416] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The CArdiovascular HEalth in Ambulatory care Research Team (CANHEART) is conducting a unique, population-based observational research initiative aimed at measuring and improving cardiovascular health and the quality of ambulatory cardiovascular care provided in Ontario, Canada. A particular focus will be on identifying opportunities to improve the primary and secondary prevention of cardiovascular events in Ontario's diverse multiethnic population. METHODS AND RESULTS A population-based cohort comprising 9.8 million Ontario adults ≥20 years in 2008 was assembled by linking multiple electronic survey, health administrative, clinical, laboratory, drug, and electronic medical record databases using encoded personal identifiers. The cohort includes ≈9.4 million primary prevention patients and ≈400,000 secondary prevention patients. Follow-up on clinical events is achieved through record linkage to comprehensive hospitalization, emergency department, and vital statistics administrative databases. Profiles of cardiovascular health and preventive care will be developed at the health region level, and the cohort will be used to study the causes of regional variation in the incidence of major cardiovascular events and other important research questions. CONCLUSIONS Linkage of multiple databases will enable the CANHEART study cohort to serve as a powerful big data resource for scientific research aimed at improving cardiovascular health and health services delivery. Study findings will be shared with clinicians, policy makers, and the public to facilitate population health interventions and quality improvement initiatives.
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Affiliation(s)
- Jack V Tu
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.).
| | - Anna Chu
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Linda R Donovan
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Dennis T Ko
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Gillian L Booth
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Karen Tu
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Laura C Maclagan
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Helen Guo
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Peter C Austin
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - William Hogg
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Moira K Kapral
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Harindra C Wijeysundera
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Clare L Atzema
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Andrea S Gershon
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - David A Alter
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Douglas S Lee
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Cynthia A Jackevicius
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - R Sacha Bhatia
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Jacob A Udell
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Mohammad R Rezai
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
| | - Thérèse A Stukel
- From the Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (J.V.T., A.C., L.R.D., D.T.K., G.L.B., K.T., L.C.M., H.G., P.C.A., W.H., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., M.R.R., T.A.S.); Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (J.V.T., D.T.K., H.C.W.); University of Toronto, Toronto, Ontario, Canada (J.V.T., A.C., D.T.K., G.L.B., K.T., P.C.A., M.K.K., H.C.W., C.L.A., A.S.G., D.A.A., D.S.L., C.A.J., R.S.B., J.A.U., T.A.S.); Division of Endocrinology, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada (G.L.B.); Toronto Western Hospital Family Health Team, University Health Network, Toronto, Ontario, Canada (K.T.); Ottawa Research Group for Primary Health Care, Ottawa, Ontario, Canada (W.H.); Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada (W.H.); Division of General Internal Medicine and Clinical Epidemiology, University Health Network, Toronto, Ontario, Canada (M.K.K.); Division of Emergency Medicine (C.L.A.) and Division of Respirology (A.S.G.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada (D.A.A.); Division of Cardiology, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada (D.S.L.); College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Women's College Hospital Institute for Health Systems Solutions and Virtual Care, Toronto, Ontario, Canada (R.S.B.); Cardiovascular Division, Women's College Hospital, Toronto, Ontario, Canada (R.S.B., J.A.U.); and Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH (T.A.S.)
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Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015; 162:123-32. [PMID: 25599350 DOI: 10.7326/m14-1651] [Citation(s) in RCA: 1613] [Impact Index Per Article: 179.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The magnitude, consistency, and manner of association between sedentary time and outcomes independent of physical activity remain unclear. PURPOSE To quantify the association between sedentary time and hospitalizations, all-cause mortality, cardiovascular disease, diabetes, and cancer in adults independent of physical activity. DATA SOURCES English-language studies in MEDLINE, PubMed, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and Google Scholar databases were searched through August 2014 with hand-searching of in-text citations and no publication date limitations. STUDY SELECTION Studies assessing sedentary behavior in adults, adjusted for physical activity and correlated to at least 1 outcome. DATA EXTRACTION Two independent reviewers performed data abstraction and quality assessment, and a third reviewer resolved inconsistencies. DATA SYNTHESIS Forty-seven articles met our eligibility criteria. Meta-analyses were performed on outcomes for cardiovascular disease and diabetes (14 studies), cancer (14 studies), and all-cause mortality (13 studies). Prospective cohort designs were used in all but 3 studies; sedentary times were quantified using self-report in all but 1 study. Significant hazard ratio (HR) associations were found with all-cause mortality (HR, 1.240 [95% CI, 1.090 to 1.410]), cardiovascular disease mortality (HR, 1.179 [CI, 1.106 to 1.257]), cardiovascular disease incidence (HR, 1.143 [CI, 1.002 to 1.729]), cancer mortality (HR, 1.173 [CI, 1.108 to 1.242]), cancer incidence (HR, 1.130 [CI, 1.053 to 1.213]), and type 2 diabetes incidence (HR, 1.910 [CI, 1.642 to 2.222]). Hazard ratios associated with sedentary time and outcomes were generally more pronounced at lower levels of physical activity than at higher levels. LIMITATION There was marked heterogeneity in research designs and the assessment of sedentary time and physical activity. CONCLUSION Prolonged sedentary time was independently associated with deleterious health outcomes regardless of physical activity. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Aviroop Biswas
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Paul I. Oh
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Guy E. Faulkner
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi R. Bajaj
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Michael A. Silver
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Marc S. Mitchell
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - David A. Alter
- From the Institute of Health Policy, Management and Evaluation, and the Faculty of Kinesiology and Physical Education, University of Toronto; University Health Network–Toronto Rehabilitation Institute, Cardiovascular Prevention and Rehabilitation Program; Sunnybrook Health Sciences Centre; York University; and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Alter DA, Zagorski B, Marzolini S, Forhan M, Oh PI. On-site programmatic attendance to cardiac rehabilitation and the healthy-adherer effect. Eur J Prev Cardiol 2014; 22:1232-46. [DOI: 10.1177/2047487314544084] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/30/2014] [Indexed: 11/17/2022]
Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Department of Medicine, University of Toronto, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Brandon Zagorski
- Department of Health Policy, Management and Evaluation, University of Toronto, Canada
| | - Susan Marzolini
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
| | - Mary Forhan
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Faculty of Rehabilitation Medicine, University of Alberta, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, University of Toronto, Canada
- Department of Medicine, University of Toronto, Canada
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Ko DT, Austin PC, Tu JV, Lee DS, Yun L, Alter DA. Relationship between care gaps and projected life expectancy after acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2014; 7:581-8. [PMID: 24895449 DOI: 10.1161/circoutcomes.113.000795] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Higher-risk patients may not receive evidence-based therapy because of limited life expectancy, which is a composite measure that encompasses many patient factors, including age, frailty, and comorbidities. In this study, we evaluated the extent to which treatment care gaps can be explained by a difference in projected life expectancy. METHODS AND RESULTS An observational cohort study was conducted on acute myocardial infarction patients hospitalized in Ontario, Canada. Projected life expectancy was estimated using actual survival data with extrapolation using proportional hazard models adjusting for important covariates. The relationship between projected life expectancy with statins and reperfusion therapy was examined using generalized linear models. Among the 7001 acute myocardial infarction patients, 84.3% were prescribed statins and 72.9% were treated with reperfusion therapy. When projected life expectancy was <10 years, the likelihood of receiving either treatment declined progressively with reduction in life expectancy (P<0.001). At the 25th percentile of projected life expectancies, the likelihood of receiving a statin decreased by 1.4% (95% confidence interval, 1.0-1.8%), and acute reperfusion therapy decreased by 2.6% (95% confidence interval, 1.8-3.3%) for each year decline in projected life expectancy. CONCLUSIONS Life expectancy of a patient strongly influences evidence-based treatment in acute myocardial infarction. It was seen not only among patients with limited life expectancies but also among those with many years to live. Treatment care gaps may reflect clinicians' synthesis about frailty and life-expectancy gains.
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Affiliation(s)
- Dennis T Ko
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.).
| | - Peter C Austin
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.)
| | - Jack V Tu
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.)
| | - Douglas S Lee
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.)
| | - Lingsong Yun
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.)
| | - David A Alter
- From the Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., L.Y., D.A.A.); Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (D.T.K., J.V.T.); University of Toronto, Toronto, Ontario, Canada (D.T.K., P.C.A., J.V.T., D.S.L., D.A.A.); Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada (D.S.L.); The Cardiac and Secondary Prevention Program, Toronto Rehabilitation Institute, Toronto, Ontario, Canada (D.A.A.); and Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (D.A.A.)
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Mitchell MS, Goodman JM, Alter DA, Oh PI, Faulkner GEJ. 'Will walk for groceries': Acceptability of financial health incentives among Canadian cardiac rehabilitation patients. Psychol Health 2014; 29:1032-43. [PMID: 24731024 DOI: 10.1080/08870446.2014.904863] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Financial health incentives, such as paying people to exercise, remain controversial despite widespread implementation. This focus group study explored the acceptability of incentives among a sample of Canadian cardiac rehabilitation (CR) patients (n = 15). Focus groups were conducted between March and April 2013 until further sampling ceased to produce new analytical concepts. A thematic analysis approach was adopted in analysing the data. Three broad themes emerged from the focus groups. First, ethical concerns were prominent. Half of participants disagreed with the incentive approach believing that it was unfair, unnecessary or a waste of limited resources. Second, ethical concerns were mitigated in considering a range of incentive features including type, size and source. Specifically, privately sponsored (not government funded) health-promoting voucher-based incentives (e.g., grocery or gym vouchers) were perceived to be highly acceptable. Third, if designed like this, then financial incentives were considered potentially effective in motivating behaviour change and in reducing economic barriers to exercise participation. Overall, the majority of participants welcomed incentives if ethical concerns were addressed through thoughtful incentive programme design. The results of this focus group study will inform the design of a financial health incentive feasibility RCT to promote post-CR programme exercise compliance in this population.
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Affiliation(s)
- Marc S Mitchell
- a Faculty of Kinesiology and Physical Education , University of Toronto , Toronto , Ontario , Canada
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Marzolini S, Leung YM, Alter DA, Wu G, Grace SL. Outcomes associated with cardiac rehabilitation participation in patients with musculoskeletal comorbidities. Eur J Phys Rehabil Med 2013; 49:775-783. [PMID: 24309503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Individuals with coronary artery disease (CAD) and musculoskeletal comorbidities (MSKCs) have much to gain from physical activity, yet are less likely to be referred to cardiac rehabilitation (CR) than those without MSKCs. Whether patients with MSKCs achieve demonstrated benefits of CR participation such as improved quantity and quality-of-life remains unknown. AIM To compare all-cause mortality, major acute cardiovascular events (MACEs), quality-of-life and psychosocial well-being in patients with CAD and coexisting MSKCs by CR participation. DESIGN Prospective and observational study in which patients were administered a questionnaire in the hospital and 1 year later. The cohort was linked to provincial databases. SETTING Eleven hospitals in Ontario, Canada. POPULATION CAD patients (N.=1680). METHODS CAD inpatients were administered a questionnaire assessing sociodemographic and clinical characteristics. Clinical data were extracted from charts. CR participation, quality-of-life, depressive symptoms, functional status, and physical activity behavior were measured 1 year later by questionnaire. The cohort was linked to provincial administrative databases to ascertain mortality and MACEs for a median of 2.7 years post-index cardiac hospitalization. Associations of CR participation with outcomes were tested after adjustment for differences in participation propensity. RESULTS Of study participants, 50.7% (851/1680) had MSKCs and of those with MSKCs, 49.8% (424/851) participated in CR. Patients with MSKCs who participated in CR had greater physical quality-of-life (P<0.03) and lower mortality than those with MSKCs who did not attend CR, after adjusting for propensity for CR participation (1.4% vs. 4%; participant vs. non-participants, P=0.03) - non-participants' hazard ratio 3.91 [95%CI,1.23-12.36]). There were no differences for MACEs. CONCLUSION Among those with MSKCs, participation in CR is associated with survival benefit and better physical quality-of-life compared to non-participants. CLINICAL REHABILITATION IMPACT Our findings showing the high prevalence of MSKCs in those with CAD and the benefits of CR, add to the literature that will provide the basis for exploration of initiatives to improve care for those with CAD and MSKC, and to overcome barriers to improved outcomes and reduced death. These results will help to guide focused research to optimize complex outpatient care in this group, including increasing the utilization of CR.
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Affiliation(s)
- S Marzolini
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada -
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Mitchell MS, Goodman JM, Alter DA, John LK, Oh PI, Pakosh MT, Faulkner GE. Financial incentives for exercise adherence in adults: systematic review and meta-analysis. Am J Prev Med 2013; 45:658-67. [PMID: 24139781 DOI: 10.1016/j.amepre.2013.06.017] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/03/2013] [Accepted: 06/25/2013] [Indexed: 01/03/2023]
Abstract
CONTEXT Less than 5% of U.S. adults accumulate the required dose of exercise to maintain health. Behavioral economics has stimulated renewed interest in economic-based, population-level health interventions to address this issue. Despite widespread implementation of financial incentive-based public health and workplace wellness policies, the effects of financial incentives on exercise initiation and maintenance in adults remain unclear. EVIDENCE ACQUISITION A systematic search of 15 electronic databases for RCTs reporting the impact of financial incentives on exercise-related behaviors and outcomes was conducted in June 2012. A meta-analysis of exercise session attendance among included studies was conducted in April 2013. A qualitative analysis was conducted in February 2013 and structured along eight features of financial incentive design. EVIDENCE SYNTHESIS Eleven studies were included (N=1453; ages 18-85 years and 50% female). Pooled results favored the incentive condition (z=3.81, p<0.0001). Incentives also exhibited significant, positive effects on exercise in eight of the 11 included studies. One study determined that incentives can sustain exercise for longer periods (>1 year), and two studies found exercise adherence persisted after the incentive was withdrawn. Promising incentive design feature attributes were noted. Assured, or "sure thing," incentives and objective behavioral assessment in particular appear to moderate incentive effectiveness. Previously sedentary adults responded favorably to incentives 100% of the time (n=4). CONCLUSIONS The effect estimate from the meta-analysis suggests that financial incentives increase exercise session attendance for interventions up to 6 months in duration. Similarly, a simple count of positive (n=8) and null (n=3) effect studies suggests that financial incentives can increase exercise adherence in adults in the short term (<6 months).
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Affiliation(s)
- Marc S Mitchell
- Faculty of Kinesiology and Physical Education, Toronto, Ontario, Canada.
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Wijeysundera HC, Bennell MC, Alter DA. Patients, providers, and systems: the complex and unfinished tale of socioeconomic status and health. Can J Cardiol 2013; 29:1577-8. [PMID: 24041995 DOI: 10.1016/j.cjca.2013.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 08/02/2013] [Accepted: 08/02/2013] [Indexed: 11/29/2022] Open
Affiliation(s)
- Harindra C Wijeysundera
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada.
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Alter DA, Franklin B, Ko DT, Austin PC, Lee DS, Oh PI, Stukel TA, Tu JV. Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One 2013; 8:e65130. [PMID: 23755180 PMCID: PMC3670842 DOI: 10.1371/journal.pone.0065130] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 04/22/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). Background The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. Methods We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. Results As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87–0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70–1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. Conclusions Functional recovery may play an important role in explaining SES-mortality gradients following AMI.
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Affiliation(s)
- David A Alter
- The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Blecker S, Bhatia RS, You JJ, Lee DS, Alter DA, Wang JT, Wong HJ, Tu JV. Temporal trends in the utilization of echocardiography in Ontario, 2001 to 2009. JACC Cardiovasc Imaging 2013; 6:515-22. [PMID: 23579013 PMCID: PMC3915739 DOI: 10.1016/j.jcmg.2012.10.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
The purpose of this study was to examine utilization and growth in echocardiography among the general population of Ontario between 2001 and 2009. The age- and sex-adjusted rates of echocardiography grew from 39.1 per 1,000 persons in 2001 to 59.9 per 1,000 persons in 2009, for an annual rate of increase of 5.5%. Repeat echocardiograms increased at a rate of 10.6% per year and accounted for 25.3% of all procedures in 2009 as compared to 18.5% in 2002. While significant increases in echocardiography utilization were observed, opportunities may exist to improve the clinical utility of the echocardiograms performed in Ontario.
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Affiliation(s)
- Saul Blecker
- Departments of Population Health and Medicine, New York University School of Medicine, New York, New York
| | - R. Sacha Bhatia
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - John J. You
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
- Departments of Medicine and Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Douglas S. Lee
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
- Department of Medicine, University of Toronto, Toronto, Ontario
- Division of Cardiology, University Health Network - Toronto General Hospital, Toronto, Ontario
| | - David A. Alter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
- Department of Medicine, University of Toronto, Toronto, Ontario
- Cardiac rehabilitation and secondary prevention program, Toronto Rehabilitation Institute, Toronto, Ontario
- The Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario
| | - Julie T. Wang
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
| | - Hannah J. Wong
- Institute for Technology Assessment and Department of Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
- Centre for Innovation in Complex Care, University Health Network, Toronto, Ontario
| | - Jack V. Tu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario
- Department of Medicine, University of Toronto, Toronto, Ontario
- Sunnybrook Schulich Heart Centre, Toronto, Ontario
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Alter DA, Ko DT, Tu JV, Stukel TA, Lee DS, Laupacis A, Chong A, Austin PC. The average lifespan of patients discharged from hospital with heart failure. J Gen Intern Med 2012; 27:1171-9. [PMID: 22549300 PMCID: PMC3515002 DOI: 10.1007/s11606-012-2072-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 03/01/2012] [Accepted: 03/22/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk. OBJECTIVE To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden. DESIGN Population-based retrospective cohort study. SETTING Ontario, Canada. PATIENTS 7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000. MEASUREMENTS Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata. RESULTS The average life-span of the cohort was 5.5 years (STD +/- 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year. LIMITATIONS Data regarding changes in patient clinical status over time were unavailable. CONCLUSIONS The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.
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Affiliation(s)
- David A Alter
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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