Associations between environmental noise and myocardial infarction and stroke: Investigating the potential mediating effects of hypertension.

BACKGROUND: We investigated whether hypertension may be a mediator in the pathway linking environmental noise exposure to incident MI and stroke. METHODS: Separately for MI and stroke, we built two population-based cohorts from linked health administrative data. Participants were residents of Montreal (Canada) between 2000 and 2014, aged 45 years and older who were free of hypertension and MI or stroke at time of entry. MI, stroke and hypertension were ascertained from validated case definitions. Residential long-term environmental noise exposure, expressed as the annual mean level acoustic equivalent 24 h (LAeq24h), was estimated from a land use regression model. We performed mediation analysis based on the potential outcomes framework. We used a Cox proportional hazards model for the exposure-outcome model and a logistic regression for the exposure-mediator model. In sensitivity analysis we applied a marginal structural approach to estimate the natural direct and indirect effects. RESULTS: Each cohort included approximately 900 000 individuals, with 26 647 incident cases of MI and 16 656 incident cases of stroke. 36% of incident MI and 40% of incident stokes had previously developed hypertension. The estimated total effect per interquartile range increase (from 55.0 to 60.5 dB A) in the annual mean LAeq24h was 1.073 (95% confidence interval (CI): 1.070-1.077) for both MI for stroke. We found no evidence of exposure-mediator interaction for both outcomes. The relationships between environmental noise and MI and stroke was not mediated by hypertension. CONCLUSIONS: This population-based cohort study suggests that the main route by which environmental noise exposure may cause MI or stroke is not through hypertension.

Exposure to guideline-recommended drugs after a first acute myocardial infarction in older adults: does deprivation matter?

BACKGROUND: Inequities between guideline-recommended drugs (GRD) exposure and socioeconomic status might exist. The objective was to assess the association between a material and a social deprivation index and GRD exposure following a first acute myocardial infarction (AMI) in older adults in the province of Quebec. METHODS: We conducted a retrospective cohort study using the Quebec Integrated Chronic Disease Surveillance System. Elderly ≥66 years, hospitalized for a first AMI between January 1, 2006, and December 31, 2011 and covered by the public drug plan were identified. Exposure to GRD (i.e. simultaneous use of 1) antiplatelet, 2) beta-blocker, 3) lipid-lowering and 4) angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker drugs) was assessed 30 and 365 days following hospital discharge. Associations between deprivation index and GRD exposure were estimated with log-binomial regressions adjusting for potential confounders. RESULTS: Exposure to GRD was 52.2% and 48.0%, 30 and 365 days after hospital discharge, respectively. No statistically significant association was observed in multivariate analysis for both time points. Thirty days post hospital discharge, adjusted prevalence ratio of non-exposure to GRD was 0.98 (95% confidence interval [CI]: 0.95-1.02) for most materially deprived vs. least deprived and 1.04 (95% CI: 0.99-1.08) for most socially deprived vs. least deprived. Similar results were observed for 365 days. CONCLUSION: Exposure to GRD after a first urgent AMI among older adults insured by the public drug plan in the province of Quebec is relatively low. Reasons and risk groups for this low exposure should be studied to improve secondary prevention. However, results suggest equitable access to GRD, regardless of deprivation.

A new metric for centralization of ruptured abdominal aortic aneurysm repair in large territories.

OBJECTIVE: This study proposes the DEDE (Door-from-Emergency to Door-to-EVAR [endovascular aneurysm repair]) time as a new metric for ruptured abdominal aortic aneurysm (RAAA) delay time to surgery, permitting coherent centralization in large territories. It demonstrates how the DEDE time can be applied, using data from the province of Quebec, and looks at its potential effect on 30-day mortality. METHODS: We used the Quebec Integrated Chronic Disease Surveillance System (QICDSS), the linkage of five health administrative databases, to build a retrospective cohort of RAAA patients repaired operatively between April 1, 2006, and March 31, 2013. A validated algorithm was used to identify open surgical repair (OSR) and EVAR patients. Hospitals performing these operations were further characterized according to their location, volume of RAAA, types of surgeries (OSR vs EVAR), and surgeon's volume. Logistic and log-binomial regression analyses identified the risk of 30-day mortality with age, sex, hospital volume, and surgical groups as variables. Using the DEDE 90 metric and the attributable fraction, we projected how centralization and increasing the number of EVAR would affect the 30-day mortality. RESULTS: Among patients aged ≥65 years, 895 RAAAs were identified. OSR was performed in 839 patients (93.7%) and EVAR in 56 (6.3%). The overall 30-day mortality was 34.4%, and more specifically, was 35.5% for OSR compared with 17.9% for EVAR (P = .0046). RAAAs were treated in 39 hospitals, including 16 centers averaging less than one RAAA repair per year. Low-volume (39.4%) vs high-volume centers (32.5%) had similar 30-day mortality (P = .2198). In the multivariate analysis, the relative risk for OSR was 1.95 (P = .0211) and was not significant for hospital volume. Applying the DEDE 90 metric and increasing access to EVAR to 50% of patients, the overall 30-day mortality would be 26.8%. CONCLUSIONS: DEDE 90 is a new metric for a coherent centralization model, particularly in large territories, where transport time is crucial. Increasing access to EVAR performed in high-volume centers, with consideration to transport time, could improve the 30-day mortality after a RAAA repair.

Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation.

OBJECTIVES: Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year. STUDY DESIGN AND SETTING: We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting. RESULTS: A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously. CONCLUSION: We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.

Iron and cardiac ischemia: a natural, quasi-random experiment comparing eligible with disqualified blood donors.

BACKGROUND: The theory that elevated iron stores can induce vascular injury and ischemia remains controversial. We conducted a cohort study of the effect of blood donation on the risk of coronary heart disease (CHD) by taking advantage of the quasi-random exclusion of donors who obtained a falsely reactive test for a transmissible disease (TD) marker. STUDY DESIGN AND METHODS: Whole blood donors who were permanently disqualified because of a false-reactive test between 1990 and 2007 in the province of Quebec were compared to donors who remained eligible, matched for baseline characteristics. The incidence of CHD after entry into the study was determined through hospitalization and death records. We compared eligible and disqualified donors using an "intention-to-treat" framework. RESULTS: Overall, 12,357 donors who were permanently disqualified were followed for 124,123 person-years of observation, plus 50,889 donors who remained eligible (516,823 person-years). On average, donors who remained eligible made 0.36 donation/year during follow-up and had an incidence of hospitalizations or deaths attributable to CHD of 3.60/1000 person-years, compared to 3.52 among permanently disqualified donors (rate ratio, 1.02; 95% confidence interval, 0.92-1.13). CONCLUSION: Donors who remained eligible did not have a lower risk of CHD, compared to donors who were permanently disqualified due to a false-reactive TD marker. Because of the quasi-random nature of false-reactive screening tests, this natural experiment has a level of validity approaching that of a randomized trial evaluating the effect of regular blood donation on CHD risk. These results do not support the iron hypothesis.

Surveillance of ischemic heart disease should include physician billing claims: population-based evidence from administrative health data across seven Canadian provinces.

BACKGROUND: Canadian provinces and territories routinely collect health information for administrative purposes. This study used Canadian medical and hospital administrative data for population-based surveillance of diagnosed ischemic heart disease (IHD). METHODS: Hospital discharge abstracts and physician billing claims data from seven provinces were analyzed to estimate prevalence and incidence of IHD using three validated algorithms: a) one hospital discharge abstract with an IHD diagnosis or procedure code (1H); b) 1H or at least three physician claims within a one-year period (1H3P) and c) 1H or at least two physician claims within a one-year period (1H2P). Crude and age-standardized prevalence and incidence rates were calculated for Canadian adults aged 20 +. RESULTS: IHD prevalence and incidence varied by province, were consistently higher among males than females, and increased with age. Prevalence and incidence were lower using the 1H method compared to using the 1H2P or 1H3P methods in all provinces studied for all age groups. For instance, in 2006/07, crude prevalence by province ranged from 3.4%-5.5% (1H), from 4.9%-7.7% (1H3P) and from 6.0%-9.2% (1H2P). Similarly, crude incidence by province ranged from 3.7-5.9 per 1,000 (1H), from 5.0-6.9 per 1,000 (1H3P) and from 6.1-7.9 per 1,000 (1H2P). CONCLUSIONS: Study findings show that incidence and prevalence of diagnosed IHD will be underestimated by as much as 50% using inpatient data alone. The addition of physician claims data are needed to better assess the burden of IHD in Canada.

Sex-specific medication trajectories in older adults newly diagnosed with diabetes.

Background: People with diabetes tend to use many medications to treat diabetes and comorbidities. Nevertheless, the evolution of polypharmacy in newly diagnosed males and females has been little studied. Objective: The objective of this paper was to identify and describe medication trajectories in incident diabetes cases according to sex. Methods: Data were obtained from the Quebec Integrated Chronic Disease Surveillance System. We built a population-based cohort of community-dwelling individuals aged >65 years diagnosed with diabetes in 2014 who were alive and covered with the public drug plan until March 31, 2019. Latent class models were used to identify medication trajectory groups in males and females separately. Results: Of the 10,363 included individuals, 51.4% were males. Females were older and more likely to have more medication claims than males. Four trajectory groups were identified for males and five for females. Most trajectories showed sustained and stable number of medications over time. For each sex, only one of the trajectory groups included a mean annual number of medications lesser than five. Slight increasing trends of medication use were detected in the trajectories composed of very high users, which included older, more comorbid individuals frequently exposed to potentially inappropriate medications. Conclusions: Most males and females with incident diabetes had a high burden of medication following the year of diagnosis and were classified in a group of sustained medication use over time. The largest increase in medication was among those who had higher level of polypharmacy of questionable quality at baseline, raising concerns about the innocuity of such medication trajectories.

Evolution in Trends of Primary Lower-Extremity Amputations Associated With Diabetes or Peripheral Artery Disease From 2006 to 2019.

BACKGROUND: Given the importance in prevention of lower extremity amputations (LEAs) associated with diabetes or peripheral artery disease (PAD), we sought to document the trends of primary LEA in Québec, Canada, from years 2006 to 2019. METHODS: Using the Québec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of primary LEA associated with diabetes and PAD among adults ≥ 40 years (99% confidence intervals [CI]), and all-cause 1-year mortality proportion trends following a primary LEA (95% CI), stratified by minor or major as the highest level of LEA during the same hospital stay and age groups. Trends were assessed using multivariate regression models. RESULTS: In 2019, the crude rate of primary LEA was 116.0 per 100,000 (n = 825) with 93.7 and 21.9 per 100,000 of minor (n = 665) and major (n = 160) LEA, respectively. A tendency of decrease by 8% (-15.0 to 0.4%) of age-standardized incidence of primary LEA was observed between 2006 and 2019, while the absolute number of primary LEA increased from 610 to 825 cases. Minor LEA increased by 14.2% (3.7 to 25.9%) and major LEA decreased by 49.5% (-57.1 to -40.5%). Incidence trends remained stable among the 40 to 64 years, and declined by 14.6% and 20.1% for the 65 to 79 and ≥ 80 years of age groups, respectively. Major LEA decreased in all age groups, whereas minor LEA increased by 26.2% among the patients 40 to 64 years of age only. Age-standardized 1-year mortality decreased by 35.1% (95% CI, -43.4 to -25.7%) between 2006 and 2019, with a crude 1-year mortality of 11.3% in 2019. CONCLUSIONS: The reduction of major LEA and 1-year mortality are encouraging, although increased minor LEA, especially in younger age groups, emphasizes the importance to improve preventive care further.

Marginal structural models with latent class growth analysis of treatment trajectories: Statins for primary prevention among older adults.

Latent class growth analysis is increasingly proposed as a solution to summarize the observed longitudinal treatment into a few distinct groups. When latent class growth analysis is combined with standard approaches like Cox proportional hazards models, confounding bias is not properly addressed because of time-varying covariates that have a double role of confounders and mediators. We propose to use latent class growth analysis to classify individuals into a few latent classes based on their medication adherence pattern, then choose a working marginal structural model that relates the outcome to these groups. The parameter of interest is defined as a projection of the true marginal structural model onto the chosen working model. Simulation studies are used to illustrate our approach and compare it with unadjusted, baseline covariates adjusted, time-varying covariates adjusted, and inverse probability of trajectory groups weighted adjusted models. Our proposed approach yielded estimators with little or no bias and appropriate coverage of confidence intervals in these simulations. We applied our latent class growth analysis and marginal structural model approach to a database comprising information on 52,790 individuals from the province of Quebec, Canada, aged more than 65 and who were statin initiators to estimate the effect of statin-usage trajectories on a first cardiovascular event.

Diagnosed hypertension in Canada: incidence, prevalence and associated mortality.

BACKGROUND: Hypertension is a leading risk factor for cardiovascular diseases. Our objectives were to examine the prevalence and incidence of diagnosed hypertension in Canada and compare mortality among people with and without diagnosed hypertension. METHODS: We obtained data from linked health administrative databases from each province and territory for adults aged 20 years and older. We used a validated case definition to identify people with hypertension diagnosed between 1998/99 and 2007/08. We excluded pregnant women from the analysis. RESULTS: This retrospective population-based study included more than 26 million people. In 2007/08, about 6 million adults (23.0%) were living with diagnosed hypertension and about 418,000 had a new diagnosis. The age-standardized prevalence increased significantly from 12.5% in 1998/99 to 19.6% in 2007/08, and the incidence decreased from 2.7 to 2.4 per 100. Among people aged 60 years and older, the prevalence was higher among women than among men, as was the incidence among people aged 75 years and older. The prevalence and incidence were highest in the Atlantic region. For all age groups, all-cause mortality was higher among adults with diagnosed hypertension than among those without diagnosed hypertension. INTERPRETATION: The overall prevalence of diagnosed hypertension in Canada from 1998 to 2008 was high and increasing, whereas the incidence declined during the same period. These findings highlight the need to continue monitoring the effectiveness of efforts for managing hypertension and to enhance public health programs aimed at preventing hypertension.

Polypharmacy among older individuals with heart failure: trends between 2000 and 2017 in the province of Quebec, Canada.

OBJECTIVE: Pharmacological management of heart failure and comorbidities may result in polypharmacy, but there are few population-based studies that portray the use of medications over time. We aimed to describe the trends in polypharmacy and medication use in older adults with heart failure. METHODS: We performed a study including all adults >65 years with heart failure between 2000 and 2017 using health administrative databases in Quebec, Canada. Medication use was ascertained by the presence of at least one claim in each year. We defined three levels of polypharmacy: ⩾10, ⩾15 and ⩾20 different medications/year, and evaluated the use of guideline-recommended and potentially inappropriate medications. We calculated age- and sex-standardized proportions of users each year. RESULTS: The use of ⩾10, ⩾15 and ⩾20 medications increased from 62.2%, 30.6% and 12.2% in 2000 to 71.9%, 43.9% and 22.7%, respectively, in 2017. The combination of ß-blocker and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) was used by 30.4% of individuals in 2000 and 45.5% in 2017. ACEI/ARB users decreased from 65.8% in 2000 to 62.1% in 2017. Potentially inappropriate medication use decreased over time. CONCLUSION: Polypharmacy is significant among older adults with heart failure. Implications of such medication burden should be investigated.

Temporal trends of aortic stenosis and comorbid chronic kidney disease in the province of Quebec, Canada.

OBJECTIVE: To investigate temporal trends of chronic kidney disease (CKD) among patients with incident aortic stenosis (AS) and to compare these trends with that of a matched control population. METHODS: Using the Quebec Integrated Chronic Disease Surveillance System, we performed a population-based nested case-control study including 108 780 patients newly hospitalised with AS and 543 900 age-matched, sex-matched and fiscal year-matched patients without AS from 2000 to 2016 in Quebec (Canada). Three subgroups were considered. Dialysis subgroup had at least two outpatient billing codes of dialysis. The predialysis subgroup had at least one hospital or two billing diagnostic codes of CKD. The remaining individuals were included in the non-CKD subgroup. We estimated overall and sex-specific standardised annual proportions of CKD subgroups through direct standardisation using the 2016-2017 age structure of the incident AS cohort. The trends overtime were estimated through fitting robust Poisson regression models. Age-specific distribution of AS and control population were assessed for each subgroup. RESULTS: From 2000 to 2016, age-standardised proportions of patients with AS with dialysis and predialysis increased by 41% (99% CI 12.0% to 78.1%) and by 45% (99% CI 39.1% to 51.6%), respectively. Inversely, age-standardised proportions of dialysis and pre-dialysis among non-AS patients decreased by 63% (99% CI 55.8% to 68.7%) and by 32% (99% CI 29.9% to 34.6%), respectively, during the same study period. In patients with and without AS, age-standardised annual proportions of males in predialysis were significantly higher than females in most of the study period. Patients with AS on dialysis and predialysis were younger than their respective controls (dialysis: 29.6% vs 45.1% had ≥80 years, predialysis: 60.8% vs 72.7% had ≥80 years). CONCLUSIONS: Over time, the proportion of patients with CKD increased significantly and remained consistently higher in incident AS individuals compared with controls. Our results highlight the need to investigate whether interventions targeting CKD risk factors may influence AS incidence in the future.

Evolution of the burden of aortic stenosis by sex in the province of Quebec between 2006 and 2018.

OBJECTIVES: To evaluate the evolution of the burden of aortic stenosis (AS) by sex in the province of Quebec from 2006-2007 to 2018-2019 and compare the percentage of mortality between people who underwent aortic valve intervention and those who did not. METHODS: Persons aged ≥20 years were identified from the Quebec Integrated Chronic Disease Surveillance System using International Classification of Diseases and intervention codes in the hospital files. RESULTS: In 2018, the crude prevalence and incidence of AS were 0.89% (99% CI 0.89 to 0.90) (n=59 025) and 1.39 per 1000 (1.35 to 1.43) (n=9105), respectively. Age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018 from 0.67% (0.66 to 0.68) to 0.75% (0.74 to 0.76) and from 0.91 per 1000 (0.88 to 0.95) to 1.20 per 1000 (1.17 to 1.23), respectively. Among incident AS, the age-standardised percentage of valve interventions increased from 11.7% (10.9 to 12.6) to 14.5% (13.9 to 15.3). This increase was only observed in men. The 30-day mortality was stable among patients with incident AS treated conservatively, from 6.9% (6.5 to 7.4) to 7.3% (6.9 to 7.6), and decreased from 7.6% (6.1 to 9.3) to 3.8% (3.1 to 4.7) among operated patients with incident AS. This decrease was only observed in women. However, from 2010, the age-adjusted mortality among prevalent AS tended to be higher in women. CONCLUSIONS: In the province of Quebec, age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018. Among incident AS, there was an increase in valve intervention in men and a decrease in 30-day mortality in women who underwent valve intervention. Overall and age-standardised mortality remained higher in women.

Great diversity in the utilization and reporting of latent growth modeling approaches in type 2 diabetes: A literature review.

Introduction: The progression of complications of type 2 diabetes (T2D) is unique to each patient and can be depicted through individual temporal trajectories. Latent growth modeling approaches (latent growth mixture models [LGMM] or latent class growth analysis [LCGA]) can be used to classify similar individual trajectories in a priori non-observed groups (latent groups), sharing common characteristics. Although increasingly used in the field of T2D, many questions remain regarding the utilization of these methods. Objective: To review the literature of longitudinal studies using latent growth modeling approaches to study T2D. Methods: MEDLINE (Ovid), EMBASE, CINAHL and Wb of Science were searched through August 25th, 2021. Data was collected on the type of latent growth modeling approaches (LGMM or LCGA), characteristics of studies and quality of reporting using the GRoLTS-Checklist and presented as frequencies. Results: From the 4,694 citations screened, a total of 38 studies were included. The studies were published beetween 2011 and 2021 and the length of follow-up ranged from 8 weeks to 14 years. Six studies used LGMM, while 32 studies used LCGA. The fields of research varied from clinical research, psychological science, healthcare utilization research and drug usage/pharmaco-epidemiology. Data sources included primary data (clinical trials, prospective/retrospective cohorts, surveys), or secondary data (health records/registries, medico-administrative). Fifty percent of studies evaluated trajectory groups as exposures for a subsequent clinical outcome, while 24% used predictive models of group membership and 5% used both. Regarding the quality of reporting, trajectory groups were adequately presented, however many studies failed to report important decisions made for the trajectory group identification. Conclusion: Although LCGA were preferred, the contexts of utilization were diverse and unrelated to the type of methods. We recommend future authors to clearly report the decisions made regarding trajectory groups identification.

Comparison of Socioeconomic Disparities in Pump Uptake Among Children With Type 1 Diabetes in 2 Canadian Provinces With Different Payment Models.

Importance: Insulin pumps improve glycemic control and quality of life in children with type 1 diabetes (T1D). Canada's provinces have implemented universal pediatric programs to improve access. However, these programs provide differing financial coverage, allowing for unique cross-jurisdictional comparisons. Objective: To evaluate possible socioeconomic status (SES) disparities in pump uptake in Québec, where pumps are fully funded, with those in Manitoba, where pumps are partially funded. Design, Setting, and Participants: Using health administrative databases and a clinical registry, parallel, population-based cohort studies of children with diabetes were conducted from April 1, 2011, in Québec, and April 1, 2012, in Manitoba, until March 31, 2017. In analysis conducted from July 1, 2019, to November 30, 2021, multivariable Cox proportional hazards regression models were applied to study the association between pump uptake and SES, defined using validated area-based material and social deprivation indices. Children aged 1 to 17 years with T1D were identified using a validated definition in administrative data (Québec) and a clinical registry (Manitoba). Those using pumps before the initiation of provincial programs were excluded. Exposures: Socioeconomic status. Main Outcomes and Measures: Insulin pump uptake. Results: A total of 2919 children with T1D were identified in Québec: 1550 male (53.1%), mean (SD) age at diagnosis, 8.3 (4.4) years, and 1067 (36.6%) were using a pump. In Manitoba, 636 children were identified: 364 male (57.2%), mean (SD) age at diagnosis, 8.8 (4.4) years, and 106 (16.7%) were using a pump. In Québec, the mean age at diagnosis of T1D was lower in children using the pump compared with those not using a pump (7.6 [4.1] vs 8.7 [4.5] years); sex distribution was similar (562 [52.7%] vs 988 [53.3%] male). No differences in mean (SD) age at diagnosis (8.8 [4.4] vs 8.8 [4.3] years) or sex (57 [53.8%] vs 307 [57.9%] male) were noted in both groups in Manitoba. Increasing material deprivation was associated with decreased pump uptake in both Québec (adjusted hazard ratio [aHR] 0.89; 95% CI, 0.85-0.93) and Manitoba (aHR, 0.70; 95% CI, 0.60-0.82). Inclusion of ethnic concentration did not change this association. Socioeconomic disparities in pump uptake were greater in Manitoba than Québec (P = .006 by t test; Cochran Q, 8.15; P = .004; I2 = 87.7%; 95% CI, 52.5%-96.8%). Conclusions and Relevance: The results of this study suggest that the program of full coverage for pumps available in Québec partially mitigates observed SES disparities in uptake and may be a model to improve access for all children with T1D.

Relationships between long-term residential exposure to total environmental noise and stroke incidence.

Background: Noise has been related to several cardiovascular diseases (CVDs) such as coronary heart disease and to their risk factors such as hypertension, but associations with stroke remain under-researched, even if CVD likely share similar pathophysiologic mechanisms. Aim: The objective of the study was to examine the association between long-term residential exposure to total environmental noise and stroke incidence in Montreal, Canada. Materials and Methods: We created an open cohort of adults aged ≥45years, free of stroke before entering the cohort for the years 2000 to 2014 with health administrative data. Residential total environmental noise levels were estimated with land use regression (LUR) models. Incident stroke was based on hospital admissions. Cox hazard models with age as the time axis and time-varying exposures were used to estimate associations, which were adjusted for material deprivation, year, nitrogen dioxide, stratified for sex, and indirectly adjusted for smoking. Results: There were 9,072,492 person-years of follow-up with 47% men; 26,741 developed stroke (21,402 ischemic; 4947 hemorrhagic; 392 had both). LUR total noise level acoustic equivalent for 24 hours (LAeq24h) ranged 44 to 79 dBA. The adjusted hazard ratio (HR) for stroke (all types), for a 10-dBA increase in LAeq24h, was 1.06 [95% confidence interval (CI): 1.03-1.09]. The LAeq24h was associated with ischemic (HR per 10 dBA: 1.08; 95% CI: 1.04-1.12) but not hemorrhagic stroke (HR per 10 dBA: 0.97; 95% CI: 0.90-1.04). Conclusion: The results suggest that total environmental noise is associated with incident stroke, which is consistent with studies on transportation noise and other CVD.

The State of Heart Failure Care in Canada: Minimal Improvement in Readmissions Over Time Despite an Increased Number of Evidence-Based Therapies.

Background: An unanswered question is whether the combination of advances in medical and device therapy over the past decade has translated into improved outcomes for patients with heart failure (HF) in Canada. Methods: The Canadian Institute for Health Information (CIHI) Hospital Morbidity Database was used to identify hospitalizations for HF among patients aged 18 years and older in Canadian hospitals during fiscal years 2009/2010 and 2018/2019. We assessed interprovincial differences in age, sex, length of stay (LOS), discharge disposition, type of admitting hospital, and most responsible service, for all HF admissions. National and provincial rates of HF admissions and all-cause 30-day readmissions were calculated. Results: After adjusting for age, the rate of HF admissions in Canada was 216 per 100,000 population in 2009/2010 and 2018/2019. The majority of patients with HF were admitted to general internal medicine and community hospitals in both 2009/2010 and 2018/2019. The national, crude, all-cause 30-day readmission rate stayed constant at 20.6%, and the majority of patients were readmitted with the diagnosis of HF in both 2009/2010 (62.5%) and 2018/2019 (59.0%). Median and interquartile range of HF LOS also remained unchanged at 7 days (3-14). Conclusions: The national rate of HF admissions, 30-day readmissions, and HF LOS have remained unchanged from 2009/2010 to 2018/2019, despite advances in medical and device therapy during this timeframe.

Introduction: La question demeure de savoir si, au cours de la dernière décennie au Canada, la combinaison des avancées dans les traitements médicaux et à l'aide d'un dispositif s'est traduite par de meilleurs résultats cliniques chez les patients atteints d'insuffisance cardiaque (IC). Méthodes: Nous avons utilisé la base de données sur la morbidité hospitalière de l'Institut canadien d'information sur la santé (ICIS) pour recenser les hospitalisations de patients atteints d'IC âgés de 18 ans et plus dans les hôpitaux du Canada au cours des années financières 2009/2010 et 2018/2019. Nous avons évalué les différences interprovinciales selon l'âge, le sexe, la durée du séjour (DDS), l'état à la sortie, le type d'hôpital à l'admission et le service le plus tenu à la prise en charge du patient, de toutes les admissions liées à l'IC. Nous avons calculé les taux provinciaux et national des admissions liées à l'IC et les réadmissions toutes causes confondues dans les 30 jours. Résultats: Après ajustement en fonction de l'âge, le taux d'admissions liées à l'IC au Canada était de 216 pour 100 000 habitants en 2009/2010 et en 2018/2019. La majorité des patients atteints d'IC avaient été admis en médecine interne générale et dans les hôpitaux communautaires en 2009/2010 et en 2018/2019. Le taux national, brut, toutes causes confondues de réadmissions dans les 30 jours était resté constant à 20,6 %, et la majorité des patients avaient eu des réadmissions liées au diagnostic d'IC en 2009/2010 (62,5 %) et en 2018/2019 (59,0 %). L'écart interquartile et la médiane de la DDS liée à l'IC étaient aussi demeurés inchangés après 7 jours (3-14). Conclusions: Le taux national des admissions liées à l'IC, les réadmissions dans les 30 jours et la DDS liée à l'IC étaient demeurés inchangés de 2009/2010 à 2018/2019, malgré les avancées des traitements médicaux et à l'aide d'un dispositif durant cette période de temps.

Manuscript title: Long─term residential exposure to environmental/transportation noise and the incidence of myocardial infarction.

BACKGROUND: Cardiovascular effects of environmental noise are a growing concern. However, the evidence remains largely limited to the association between road traffic noise and hypertension and coronary heart diseases. OBJECTIVES: To investigate the association between long-term residential exposure to environmental/transportation noise and the incidence of myocardial infarction (MI) in the adult population living in Montreal. METHODS: An open cohort of adults aged 45 years old and over, living on the island of Montreal and free of MI before entering the cohort was created for the years 2000-2014 with the Quebec Integrated Chronic Disease Surveillance System; a systematic surveillance system from the Canadian province of Quebec starting in 1996. Residential noise exposure was calculated in three ways: 1) total ambient noise levels estimated by Land use regression (LUR) models; 2) road traffic noise estimated by a noise propagation model CadnaA and 3) distances to transportation sources (roads, airport, railways). Incident MI was based on diagnostic codes in hospital admission records. Cox models with time-varying exposures (age as the time axis) were used to estimate the associations with various adjustments (material deprivation indicator, calendar year, nitrogen dioxide, stratification for sex). Indirect adjustment based on ancillary data for smoking was performed. RESULTS: 1,065,414 individuals were followed (total of 9,000,443 person-years) and 40,718 (3.8%) developed MI. We found positive associations between total environmental noise, estimated by LUR models and the incidence of MI. Total noise LUR levels ranged from ~44 to ~79 dBA and varied slightly with the metric used. The adjusted hazard ratios (HRs) (also adjusted for smoking) were 1.12 (95% Confidence Intervals [CI]: 1.08-1.15), 1.11 (95%CI: 1.07-1.14) and 1.10 (95%CI: 1.06-1.14) per 10 dBA noise levels increase respectively in Level Accoustic equivalent 24 h (LAeq24 h), Level day-evening-night (Lden) and night level (Lnight). We found a borderline negative association between road noise levels estimated with CadnaA and MI (HR: 0.99 per 10 dBA; 95%CI: 0.98-1.00). Distances to major roads and highways were not associated with MI while the proximity to railways was positively associated with MI (HR for ≤100 vs > 1000 m: 1.07; 95%CI: 1.01-1.14). A negative association was found with the proximity to the airport noise exposure forecast (NEF25); HR (<1 vs >1000 m) = 0.88 (95%CI: 0.81-0.96). CONCLUSIONS: These associations suggest that exposure to total environmental noise at current urban levels may be related to the incidence of MI. Additional studies with more accurate road noise estimates are needed to explain the counterintuitive associations with road noise and specific transportation sources.