Association between temperature exposure and cognition: a cross-sectional analysis of 20,687 aging adults in the United States.

BACKGROUND: Older adults are particularly vulnerable to the adverse health effects of extreme temperature-related events. A growing body of literature highlights the importance of the natural environment, including air pollution and sunlight, on cognitive health. However, the relationship between exposure to outdoor temperatures and cognitive functioning, and whether there exists any differences across climate region, remains largely unexplored. We address this gap by examining the temperature-cognition association, and whether there exists any variation across climate regions in a national cohort of aging adults. METHODS: In this cross-sectional study, we obtained data on temperature exposure based on geocoded residential location of participants in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. For each participant, this information was linked to their cognitive scores from Word List Learning and Recall tests to assess cognitive functioning. We used distributed lag non-linear models (dlnm) to model temperature effects over 2 days. Multivariable linear regression was used to compute temperature-cognitive functioning associations, adjusted for important covariates. Region-specific ("Dry", "Mediterranean/oceanic", "Tropical" and "Continental") associations were examined by including an interaction term between climate region and temperature. RESULTS: Amongst 20,687 individuals (mean age = 67.8; standard deviation = 9.2), exposure to region-specific extreme cold temperatures in the "dry" region (e.g., Arizona) over 2 days was associated with lower cognitive scores (Mean Difference [MD]: -0.76, 95% Confidence Interval [CI]: - 1.45, - 0.07). Associations remained significant for cumulative effects of temperature over 2 days. Extremely cold exposure in the "Mediterranean/oceanic" region (e.g., California) over 2 days was also associated with significantly lower cognitive performance (MD: -0.25, 95% CI: - 0.47, - 0.04). No significant associations were observed for exposure to hot temperatures. Cognitive performance was slightly higher in late summer and fall compared to early summer. CONCLUSION: We noted adverse cognitive associations with cold temperatures in traditionally warmer regions of the country and improved cognition in summer and early fall seasons. While we did not observe very large significant associations, this study deepens understanding of the impact of climate change on the cognitive health of aging adults and can inform clinical care and public health preparedness plans.

Factors associated with door-in to door-out delays among ST-segment elevation myocardial infarction (STEMI) patients transferred for primary percutaneous coronary intervention: a population-based cohort study in Ontario, Canada.

BACKGROUND: Compared to ST-segment elevation myocardial infarction (STEMI) patients who present at centres with catheterization facilities, those transferred for primary percutaneous coronary intervention (PCI) have substantially longer door-in to door-out (DIDO) times, where DIDO is defined as the time interval from arrival at a non-PCI hospital, to transfer to a PCI hospital. We aimed to identify potentially modifiable factors to improve DIDO times in Ontario, Canada and to assess the impact of DIDO times on 30-day mortality. METHODS: A population-based, retrospective cohort study of 966 STEMI patients transferred for primary PCI in Ontario in 2012 was conducted. Baseline factors were examined across timely DIDO status. Multivariate logistic regression was used to examine independent predictors of timely DIDO as well as the association between DIDO times and 30-day mortality. RESULTS: The median DIDO time was 55 min, with 20.1% of patients achieving the recommended DIDO benchmark of ≤30 min. Age (OR> 75 vs 18-55 0.30, 95% CI: 0.16-0.56), symptom-to-first medical contact (FMC) time (OR61-120mins vs < 60mins 0.60, 95% CI: 0.39-0.90; OR>120mins vs < 60mins 0.53, 95% CI:0.35-0.81) and emergency medical services transport with a pre-hospital electrocardiogram (ECG) (OREMS transport + ECG vs self-transport 2.63, 95% CI:1.59-4.35) were the strongest predictors of timely DIDO. Patients with timely ECG were more likely to have recommended DIDO times (33.0% vs 12.3%; P < 0.001). A significantly higher proportion of those who met the DIDO benchmark had timely FMC-to-balloon times (78.7% vs 27.4%; P < 0.001). Compared to patients with DIDO time ≤ 30 min, those with DIDO times > 90 min had significantly higher adjusted 30-day mortality rates (OR 2.82, 95% CI:1.10-7.19). CONCLUSIONS: While benchmark DIDO times were still rarely achieved in the province, we identified several potentially modifiable factors in the STEMI system that might be targeted to improve DIDO times. Our findings that patients who received a pre-hospital ECG were still being transferred to non-PCI capable centres suggest strategies addressing this gap may improve patient outcomes.

Location Matters: The Role of the Neighborhood Environment for Incident Cardiometabolic Disease in Adults Aging With Physical Disability.

PURPOSE: People aging with disability may be limited in their ability to engage in healthy behaviors to maintain cardiometabolic health. We investigated the role of health promoting features in the neighborhood environment for incident cardiometabolic disease in adults aging with physical disability in the United States. DESIGN: Retrospective cohort study. SETTING: Optum's Clinformatics® Data Mart Database (2007-2018) of administrative health claims. SUBJECTS: ICD-9-CM codes were used to identify 15 467 individuals with a diagnosis of Cerebral Palsy, Spina Bifida, Multiple Sclerosis, or Spinal Cord Injury. MEASURES: Cardiometabolic disease was identified using ICD-9-CM/ICD-10-CM codes over 3 years of follow-up. Measures of the neighborhood environment came from the National Neighborhood Data Archive and linked to individual residential ZIP codes over time. Covariates included age, sex, and comorbid health conditions. ANALYSIS: Cox regression models estimated hazard ratios (HR) for incident cardiometabolic disease. Using a 1-year lookback period, individuals with pre-existing cardiometabolic disease were excluded from the analysis. RESULTS: Net of individual risk factors, residing in neighborhoods with a greater density of broadband Internet connections (HR = .88, 95% CI: .81, .97), public transit stops (HR = .89, 95% CI: .83, .95), recreational establishments (HR = .89, 95% CI: .83, .96), and parks (HR = .88, 95% CI: .82, .94), was associated with reduced risk of 3-year incident cardiometabolic disease. CONCLUSION: Findings identify health-promoting resources that may mitigate health disparities in adults aging with disability.

Ciliary body lymphangiogenesis in uveal melanoma with and without extraocular extension.

PURPOSE: To determine whether peritumoral ciliary body lymphatics are found in uveal melanoma in the absence of extraocular extension. DESIGN: Consecutive case series from 1999 to 2005. PARTICIPANTS: Thirty-two uveal melanoma cases involving the ciliary body from the Ophthalmic Pathology Laboratory, University of Toronto, of which 23 showed no extraocular extension. METHODS: All immunofluorescence studies and quantitative analyses were performed in a masked fashion. Sections were immunostained for the presence of lymphatic endothelium using podoplanin (D2-40 antibody) and blood vessel endothelium using CD34. MAIN OUTCOME MEASURES: Identification and quantification of D2-40-positive lymphatic vessels in the ciliary body. RESULTS: In every case (n = 32), D2-40-positive lymphatics were detected in the peritumoral ciliary body. Lymphatic signal was significantly increased in the peritumoral ciliary body compared with the nonperitumoral ciliary body (P < 0.0001). There was no difference in lymphatic signal between cases with and without extraocular extension (P > 0.05). Lymphatics were not detected within the tumors. CONCLUSIONS: Peritumoral lymphangiogenesis was present in the ciliary body in uveal melanomas with and without extraocular extension, and as such, the presence of peritumoral lymphatics is not recommended as a prognostic marker in uveal melanoma.

Continuity of Care in Adults Aging with Cerebral Palsy and Spina Bifida: The Importance of Community Healthcare and Socioeconomic Context.

Continuity of care is considered a key metric of quality healthcare. Yet, continuity of care in adults aging with congenital disability and the factors that contribute to care continuity are largely unknown. Using data from a national private administrative health claims database in the United States (2007-2018). we examined continuity of care in 8596 adults (mean age 48.6 years) with cerebral palsy or spina bifida. Logistic regression models analyzed how proximity to health care facilities, availability of care providers, and community socioeconomic context were associated with more continuous care. We found that adults aging with cerebral palsy or spina bifida saw a variety of different physician specialty types and generally had discontinuous care. Individuals who lived in areas with more hospitals and residential care facilities received more continuous care than those with limited access to these resources. Residence in more affluent areas was associated with receiving more fragmented care. Findings suggest that over and above individual factors, community healthcare resources and socioeconomic context serve as important factors to consider in understanding continuity of care patterns in adults aging with cerebral palsy or spina bifida.

Risk of type 2 diabetes mellitus among adults aging with vision impairment: The role of the neighborhood environment.

BACKGROUND: Vision impairment (VI) affects approximately 1 in 28 Americans over the age of 40 and the prevalence increases sharply with age. However, experiencing vision loss with aging can be very different from aging with VI acquired earlier in life. People aging with VI may be at increased risk for diabetes due to environmental barriers in accessing health care, healthy food, and recreational resources that can facilitate positive health behaviors. OBJECTIVE: This study examined the relationship between neighborhood characteristics and incident type 2 diabetes mellitus (T2DM) among a cohort of 22,719 adults aging with VI. METHODS: Data are from Optum® Clinformatics® DataMart, a private administrative claims database (2008-2017). Individuals 18 years of age and older at the time of their initial VI diagnosis were eligible for analysis. VI was determined using vision impairment, low vision, and blindness codes (ICD-9-CM, ICD-10-CM). Covariates included age, sex, and comorbidities. Cox models estimated adjusted hazard ratios (HRs) for incident T2DM. Stratified models examined differences in those aging with (age 18-64) and aging into (age 65+) vision impairment. RESULTS: Residence in neighborhoods with greater intersection density (HR = 1.26) and high-speed roads (HR = 1.22) were associated with increased risk of T2DM among older adults with VI. Living in neighborhoods with broadband internet access (HR = 0.67), optical stores (HR = 0.62), supermarkets (HR = 0.78), and gyms/fitness centers (HR = 0.63) was associated with reduced risk of T2DM for both younger and older adults with VI. CONCLUSIONS: Findings emphasize the importance of neighborhood context for mitigating the adverse consequences of vision loss for health.

The spatial variability of NDVI within a wheat field: Information content and implications for yield and grain protein monitoring.

Wheat is a staple crop that is critical for feeding a hungry and growing planet, but its nutritive value has declined as global temperatures have warmed. The price offered to producers depends not only on yield but also grain protein content (GPC), which are often negatively related at the field scale but can positively covary depending in part on management strategies, emphasizing the need to understand their variability within individual fields. We measured yield and GPC in a winter wheat field in Sun River, Montana, USA, and tested the ability of normalized difference vegetation index (NDVI) measurements from an unoccupied aerial vehicle (UAV) on spatial scales of ~10 cm and from Landsat on spatial scales of 30 m to predict them. Landsat observations were poorly related to yield and GPC measurements. A multiple linear model using information from four (three) UAV flyovers was selected as the most parsimonious and predicted 26% (40%) of the variability in wheat yield (GPC). We sought to understand the optimal spatial scale for interpreting UAV observations given that the ~ 10 cm pixels yielded more than 12 million measurements at far finer resolution than the 12 m scale of the harvester. The variance in NDVI observations was "averaged out" at larger pixel sizes but only ~ 20% of the total variance was averaged out at the spatial scale of the harvester on some measurement dates. Spatial averaging to the scale of the harvester also made little difference in the total information content of NDVI fit using Beta distributions as quantified using the Kullback-Leibler divergence. Radially-averaged power spectra of UAV-measured NDVI revealed relatively steep power-law relationships with exponentially less variance at finer spatial scales. Results suggest that larger pixels can reasonably capture the information content of within-field NDVI, but the 30 m Landsat scale is too coarse to describe some of the key features of the field, which are consistent with topography, historic management practices, and edaphic variability. Future research should seek to determine an 'optimum' spatial scale for NDVI observations that minimizes effort (and therefore cost) while maintaining the ability of producers to make management decisions that positively impact wheat yield and GPC.

Can Neighborhood Social Infrastructure Modify Cognitive Function? A Mixed-Methods Study of Urban-Dwelling Aging Americans.

Objectives: Socialization predicts cognitive aging outcomes. Neighborhoods may facilitate socially engaged aging and thus shape cognition. We investigated places where older adults socialized and whether availability of these sites was associated with cognitive outcomes. Methods: Qualitative analysis of interviews and ethnography with 125 older adults (mean age 71 years) in Minneapolis identified where participants socialized outside of home. This informed quantitative analysis of a national sample of 21,151 older Americans (mean age at baseline 67 years) from the Reasons for Geographic and Racial Differences in Stroke study. Multilevel generalized additive models described associations between access to key social places and cognitive function and decline. Results: Qualitative analysis identified eateries, senior centers, and civic groups as key places to socialize. We identified significant positive associations between kernel density of senior centers, civic/social organizations, and cognitive function. Discussion: Specific neighborhood social infrastructures may support cognitive health among older adults aging in place.

Visual impairment and the Ontario Disability Support Program.

OBJECTIVES: To report on the 2003-2013 trends in sociodemographics, financial support, and use of vision care benefits by visually impaired (VI) individuals in the Ontario Disability Support Program (ODSP). DESIGN: Retrospective analysis. PARTICIPANTS: ODSP recipients with a VI diagnosis from 2003 to 2013. METHODS: ODSP administrative data were analyzed. VI diagnoses were identified using International Classification of Diseases, 9th Revision codes. Diabetes was excluded and then included as part of the VI definition. RESULTS: Per 100 000 population, the age-standardized number of VI recipients increased from 35 in 2003 to 39 (p < 0.05) in 2013 when diabetes was excluded from the analyses. The mean age of VI recipients increased from 43 to 46 years. Females and married/common-law status consistently represented 42% and 23% of VI individuals, respectively. The financial value of in-kind benefits (e.g., providing shelter cost) and "cash" assistance grew in parallel over the 11 years. The total financial support in 2013 Canadian dollars increased from 81 million dollars in 2003 to 102 million dollars in 2013. Use of ODSP-provided vision care benefits ranged from 0.6% to 1.9% for eye examinations and eyeglasses, from 0.3% to 0.8% for optical visual aids, and from 3.4% to 4.2% for guide dogs. Results were strongly similar when diabetes was included in the analyses. CONCLUSIONS: The ODSP-supported VI recipients and related financial support increased significantly from 2003 to 2013. The ODSP-provided vision care benefits were seldom used. Studies are needed to understand reasons for the reported increased number of VI recipients and the low use of vision care benefits.

The Canadian Alliance for Healthy Hearts and Minds: How Well Does It Reflect the Canadian Population?

BACKGROUND: The intent of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to understand the early determinants of subclinical cardiac and vascular disease and progression in adults selected from existing cohorts-the Canadian Partnership for Tomorrow's Health, the Prospective Urban and Rural Evaluation (PURE) cohort, and the Montreal Heart Institute Biobank. We evaluated how well the CAHHM-Health Services Research (CAHHM-HSR) subcohort reflects the Canadian population. METHODS: A cross-sectional design was used among a prospective cohort of community-dwelling adults aged 35-69 years who met the CAHHM inclusion criteria, and a cohort of adults aged 35-69 years who responded to the 2015 Canadian Community Health Survey-Rapid Response module. The INTERHEART risk score was calculated at the individual level with means and proportions reported at the overall and provincial level. RESULTS: There are modest differences between CAHHM-HSR study participants and the 2015 Canadian Community Health Survey-Rapid Response respondents in age (56.3 vs 51.7 mean years), proportion of men (44.9% vs 49.3%), and mean INTERHEART risk score (9.7 vs 10.1). Larger differences were observed in postsecondary education (86.8% vs 70.2%), Chinese ethnicity (11.0% vs 3.3%), obesity (23.2% vs 29.3%), current smoker status (6.1% vs 18.4%), and having no cardiac testing (30.4% vs 55.9%). CONCLUSIONS: CAHHM-HSR participants are older, of higher socioeconomic status, and have a similar mean INTERHEART risk score, compared with participants in the Canadian Community Health Survey. Differing sampling strategies and missing data may explain some differences between the CAHHM-HSR cohort and Canadian community-dwelling adults and should be considered when using the CAHHM-HSR for scientific research.

CONTEXTE: L'étude Alliance canadienne cœurs et cerveaux sains (CAHHM) vise à mieux comprendre les facteurs déterminants précoces et la progression de l'atteinte cardiovasculaire subclinique chez des adultes sélectionnés au sein de cohortes existantes ­ soit celles de l'étude menée par le Partenariat canadien pour la santé de demain, de l'étude PURE (Prospective Urban and Rural Evaluation) et de la biobanque de l'Institut de cardiologie de Montréal. Nous avons évalué la mesure dans laquelle la sous-cohorte du volet de recherche sur l'utilisation des services de santé de la CAHHM (CAHHM-HSR) représente la population canadienne. MÉTHODOLOGIE: Nous avons adopté une approche transversale pour étudier une cohorte prospective d'adultes vivant dans la communauté âgés de 35 à 69 ans et répondant aux critères d'inclusion de l'étude CAHHM, ainsi qu'une cohorte d'adultes âgés de 35 à 69 ans ayant participé au volet de réponse rapide de l'Enquête sur la santé dans les collectivités canadiennes (ESCC) de 2015. Le score de risque INTERHEART individuel des participants a été calculé à partir des moyennes et des proportions rapportées à l'échelle globale et à l'échelle provinciale. RÉSULTATS: Les différences entre les participants du volet CAHHM-HSR et ceux du volet de réponse rapide de l'ESCC de 2015 étaient minimes quant à l'âge (56,3 ans vs 51,7 ans en moyenne), à la proportion d'hommes (44,9 % vs 49,3 %) et au score de risque INTERHEART moyen (9,7 vs 10,1). On a toutefois noté des différences plus importantes en ce qui concerne les caractéristiques suivantes : éducation postsecondaire (86,8 % vs 70,2 %), origine ethnique chinoise (11,0 % vs 3,3 %), obésité (23,2 % vs 29,3 %), tabagisme actuel (6,1 % vs 18,4 %) et absence d'antécédents d'examen cardiaque (30,4 % vs 55,9 %). CONCLUSIONS: Les participants du volet CAHHM-HSR sont plus âgés et ont un statut socioéconomique plus élevé que ceux du volet de réponse rapide de l'ESCC, mais ont un score de risque INTERHEART moyen comparable. Les différences quant aux stratégies d'échantillonnage et des données manquantes pourraient expliquer certains des écarts observés entre la cohorte CAHHM-HSR et celle des adultes canadiens vivant dans la communauté; il conviendrait d'en tenir compte lorsqu'on utilise les données du volet CAHHM-HSR à des fins de recherche scientifique.

Rural-Urban Differences in Stroke Risk Factors, Incidence, and Mortality in People With and Without Prior Stroke.

Background Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Canada, and divided into primary (N=6 207 032) and secondary (N=75 823) prevention cohorts based on the absence or presence of prior stroke. We defined rural communities as those with a population size of ≤10 000 and within each of the primary and secondary prevention cohorts, compared cardiovascular risk factors and care between rural and urban areas. We then calculated sex-/age-standardized rates of stroke incidence and mortality per 1000 person-years between January 1, 2008 and December 31, 2012 and used cause-specific hazard models to compare outcomes in rural versus urban areas adjusting for age, sex, income, ethnicity, smoking, physical activity and comorbid conditions, and accounting for the competing risk of death in the model for the occurrence of stroke incidence. In the primary prevention cohort, rural residents were less likely than urban ones to be screened for diabetes mellitus (70.9% versus 81.3%) and hyperlipidemia (66.2% versus 78.4%) and less likely to achieve diabetes mellitus control (hemoglobin A1c ≤7% in 51.3% versus 54.3%; P<0.001 for all comparisons). In the secondary prevention cohort, the prevalence and treatment of risk factors were similar in rural and urban residents. After adjustment for sociodemographic and comorbid conditions, rural residence was associated with higher rates of stroke and all-cause mortality in both the primary prevention (adjusted hazard ratio [aHR] for stroke, 1.06; 95% CI, 1.04-1.09; aHR for mortality, 1.09; 95% CI, 1.08-1.10) and the secondary prevention cohort (aHR for stroke, 1.11; 95% CI, 1.02-1.19; aHR for mortality, 1.07; 95% CI, 1.03-1.11). Conclusions In this population-based study of over 6 million people with universal access to physician and hospital services, risk factors were more prevalent but less likely to be controlled in rural than in urban residents without prior stroke, whereas in those with prior stroke, risk factor prevalence and treatment were similar. Rural residence was associated with the rate of stroke and death even after adjustment for risk factors. Future efforts should focus not only on control of known vascular risk factors but also on addressing other determinants of health in rural communities.

Effectiveness of Interventions Aimed at Increasing Statin-Prescribing Rates in Primary Cardiovascular Disease Prevention: A Systematic Review of Randomized Clinical Trials.

Importance: Statins are a cornerstone medication in cardiovascular disease prevention, but their use in clinical practice remains suboptimal, with less than half of people who are indicated for statins actually taking the medication. Objective: To perform a systematic review and synthesis of the literature on patient-oriented and physician-oriented interventions aimed at increasing statin-prescribing rates in adults without a history of cardiovascular disease. Evidence Review: PubMed, Embase, and the Cochrane Library were searched for randomized clinical trials published between January 2000 and May 2019. Data abstraction was performed using the Cochrane Public Health Review Group's data collection template, and a narrative synthesis of study results was conducted. The risk of bias in each study was qualitatively assessed, and a funnel plot was created to further evaluate the risk of publication bias. Findings: Among 7948 citations and 128 full-text articles reviewed, 20 studies (of 109 807 patients) were included in the review. Eight trials reported a statistically significant increases in statin-prescribing rates. Among the effective trials, absolute effect sizes ranged from 4.2% (95% CI, 2.2%-6.4%) to 23% (95% CI, 7.3%-38.9%) and odds ratios from 1.29 (95% CI, 1.01-1.66) to 11.8 (95% CI, 8.8-15.9). Patient-education initiatives were the most commonly effective intervention, with 4 of 7 trials indicating increases in statin-prescribing rates. Two trials combined electronic decision-support tools with audit-and-feedback systems, both of which were effective overall. Physician-education programs without dynamic input regarding patient risk or updated treatment recommendations were generally found to be less effective. Conclusions and Relevance: While heterogeneous in their interventions and outcomes, a number of interventions have demonstrated increases in statin-prescribing rates, with patient-education initiatives demonstrating more promising results than those focused on physician education alone. As opposed to more education about generic recommendations, tailored patient-focused and physician-focused interventions were more effective when they provided personalized cardiovascular risk information, dynamic decision-support tools, or audit-and-feedback reports in a multicomponent program. There are a number of modestly successful approaches to implement increases in rates of statin prescribing, a proven yet underused cardiovascular disease prevention class of therapy.

Eligibility, Clinical Outcomes, and Budget Impact of PCSK9 Inhibitor Adoption: The CANHEART PCSK9 Study.

Background The FOURIER (Further Cardiovascular Outcomes Research With PCSK9i [Proprotein Convertase Subtilisin-Kexin Type 9 Inhibitors] in Subjects With Elevated Risk) trial found a reduction in cardiovascular events in patients with atherosclerotic cardiovascular disease ( ASCVD ). Our objective was to estimate the eligibility, clinical outcomes, and budget impact of adopting PCSK 9i in a large healthcare system. Methods and Results Ontario, Canada, residents alive in 2011, aged 40 to 85 years, were eligible for inclusion. PCSK 9i eligibility was determined on the basis of FOURIER trial definition. Hazard ratios observed in the FOURIER trial were applied to assess the number of events that could be avoided. Budget impact was calculated as the difference between projected costs of treatment adoption and events avoided if PCSK 9i were used. Of the 2.4 million included individuals, 5.3% had a history of ASCVD . We estimated that 2.7% of the general population and 51.9% of the patients with ASCVD would be eligible for PCSK 9i. Adoption of PCSK 9i in all eligible patients with ASCVD was projected to reduce primary events rates by 1.8% after 3 years. Despite cost reduction of $44 million in events, PCSK 9i adoption would have a net budget impact of $1.5 billion over 3 years. Potential benefits of PCSK 9i varied widely across subgroups, with the largest absolute risk reduction estimated to be 4.3% at 3 years in peripheral artery disease. In this subgroup of 5601 patients, the budget impact of treatment adoption was $116 million. Conclusions We estimated that ≈1 in 2 patients with ASCVD would be eligible for PCSK 9i. The budget impact of adopting PCSK 9i for all patients with ASCVD is substantial. Selective adoption to high-risk patients will lessen the overall budgetary impact of PCSK 9i treatment.

Recent Temporal Changes in Atherosclerotic Cardiovascular Diseases in Ontario: Clinical and Health Systems Impact.

BACKGROUND: It is unknown how the contemporary burden of atherosclerotic cardiovascular disease (ASCVD) compares with historical trends. METHODS: As part of the Cardiovascular Health in Ambulatory Care Research Team "big data" initiative, we used information from multiple population-based databases to study 20-year temporal trends in hospitalizations and deaths from ASCVD. We calculated hospitalization rates for 6 ASCVD events (acute myocardial infarction, unstable angina, stroke, transient ischemic attack, peripheral arterial disease, and congestive heart failure) and death rates resulting from ischemic heart disease, cerebrovascular disease and circulatory and noncirculatory causes in adults aged 20-105 years in Ontario, Canada from 1994-2014 (to 2012 for deaths). RESULTS: The overall age-standardized composite rate of hospitalization for the 6 conditions or circulatory deaths declined 49.2% in men (from 1533.4 per 100,000 in 1994 to 778.3 per 100,000 in 2012) and 49.9% in women (from 1191.2 per 100,000 in 1994 to 596.2 per 100,000 in 2012). The annual rates of decline were least evident among those aged 20-49 years for both sexes. The overall self-reported prevalence of Ontarians living with heart disease or stroke, or both, declined nonsignificantly (P for trend = 0.19), from 7.7% to 7.1% for men, and significantly (P for trend = 0.01), from 7.3% to 5.8% for women, from 2001-2012. CONCLUSIONS: Striking declines in hospitalizations and deaths from ASCVD were observed in Ontario from 1994-2014. However, the limited progress observed in younger Canadians highlights the need for ongoing efforts aimed at preventing and treating ASCVDs and their associated risk factors.

Socioeconomic gradients in all-cause, premature and avoidable mortality among immigrants and long-term residents using linked death records in Ontario, Canada.

BACKGROUND: Immigrants have been shown to possess a health advantage, yet are also more likely to reside in arduous economic conditions. Little is known about if and how the socioeconomic gradient for all-cause, premature and avoidable mortality differs according to immigration status. METHODS: Using several linked population-based vital and demographic databases from Ontario, we examined a cohort of all deaths in the province between 2002 and 2012. We constructed count models, adjusted for relevant covariates, to attain age-adjusted mortality rates and rate ratios for all-cause, premature and avoidable mortality across income quintile in immigrants and long-term residents, stratified by sex. RESULTS: A downward gradient in age-adjusted all-cause mortality was observed with increasing income quintile, in immigrants (males: Q5: 13.32, Q1: 20.18; females: Q5: 9.88, Q1: 12.51) and long-term residents (males: Q5: 33.25, Q1: 57.67; females: Q5: 22.31, Q1: 36.76). Comparing the lowest and highest income quintiles, male and female immigrants had a 56% and 28% lower all-cause mortality rate, respectively. Similar trends were observed for premature and avoidable mortality. Although immigrants had consistently lower mortality rates compared with long-term residents, trends only differed statistically across immigration status for females (p<0.05). CONCLUSIONS: This study illustrated the presence of income disparities as it pertains to all-cause, premature, and avoidable mortality, irrespective of immigration status. Additionally, the immigrant health advantage was observed and income disparities were less pronounced in immigrants compared with long-term residents. These findings support the need to examine the factors that drive inequalities in mortality within and across immigration status.