Validated administrative data based ICD-10 algorithms for chronic conditions: A systematic review.

OBJECTIVE: This systematic review aimed to identify ICD-10 based validated algorithms for chronic conditions using health administrative data. METHODS: A comprehensive systematic literature search using Ovid MEDLINE, Embase, PsycINFO, Web of Science and CINAHL was performed to identify studies, published between 1983 and May 2023, on validated algorithms for chronic conditions using administrative health data. Two reviewers independently screened titles and abstracts and reviewed full text of selected studies to complete data extraction. A third reviewer resolved conflicts arising at the screening or study selection stages. The primary outcome was validated studies of ICD-10 based algorithms with both sensitivity and PPV of ≥70 %. Studies with either sensitivity or PPV <70 % were included as secondary outcomes. RESULTS: Overall, the search identified 1686 studies of which 54 met the inclusion criteria. Combining a previously published literature search, a total of 61 studies were included for data extraction. The study identified 40 chronic conditions with high validity and 22 conditions with moderate validity. The validated algorithms were based on administrative data from different countries including Canada, USA, Australia, Japan, France, South Korea, and Taiwan. The algorithms identified included several types of cancers, cardiovascular conditions, kidney diseases, gastrointestinal disorders, and peripheral vascular diseases, amongst others. CONCLUSION: With ICD-10 prominently used across the world, this up-to-date systematic review can prove to be a helpful resource for research and surveillance initiatives using administrative health data for identifying chronic conditions.

Performance of machine learning algorithms for surgical site infection case detection and prediction: A systematic review and meta-analysis.

Background: Medical researchers and clinicians have shown much interest in developing machine learning (ML) algorithms to detect/predict surgical site infections (SSIs). However, little is known about the overall performance of ML algorithms in predicting SSIs and how to improve the algorithm's robustness. We conducted a systematic review and meta-analysis to summarize the performance of ML algorithms in SSIs case detection and prediction and to describe the impact of using unstructured and textual data in the development of ML algorithms. Methods: MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science were searched from inception to March 25, 2021. Study characteristics and algorithm development information were extracted. Performance statistics (e.g., sensitivity, area under the receiver operating characteristic curve [AUC]) were pooled using a random effect model. Stratified analysis was applied to different study characteristic levels. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Diagnostic Test Accuracy Studies (PRISMA-DTA) was followed. Results: Of 945 articles identified, 108 algorithms from 32 articles were included in this review. The overall pooled estimate of the SSI incidence rate was 3.67%, 95% CI: 3.58-3.76. Mixed-use of structured and textual data-based algorithms (pooled estimates of sensitivity 0.83, 95% CI: 0.78-0.87, specificity 0.92, 95% CI: 0.86-0.95, AUC 0.92, 95% CI: 0.89-0.94) outperformed algorithms solely based on structured data (sensitivity 0.56, 95% CI:0.43-0.69, specificity 0.95, 95% CI:0.91-0.97, AUC = 0.90, 95% CI: 0.87-0.92). Conclusions: ML algorithms developed with structured and textual data provided optimal performance. External validation of ML algorithms is needed to translate current knowledge into clinical practice.

The impact of optimal medical therapy on patients with recurrent acute myocardial infarction: Subanalysis from the BleeMACS study.

BACKGROUND: Acute myocardial infarction (AMI) recurrence is still high despite great progress in secondary prevention. Patients with recurrent AMI suffer worse prognosis compared to those with first AMI. The objective was to evaluate the effect of optimal medical therapy (OMT) on these patients with recurrent AMI. METHODS AND RESULTS: Sub-analysis was performed including 13,343 patients with AMI from the international multicenter Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) registry. OMT was defined as the combination of aspirin, any P2Y12 inhibitor, statin, angiotensin converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. Among 1285 patients with prior AMI, 56.8% received OMT prescription. Patients receiving OMT suffered from less congestive heart failure, peripheral artery disease, malignancy, and bleeding history. Kaplan-Meier survival estimates revealed that OMT was strongly related to decreased in all-cause death (4.2% vs. 10.1%, p < .001) and the composite endpoint of death/re-AMI (11.1% vs. 16.9%, p = .005) at 1-year follow-up. OMT was the independent protect factor of primary endpoint even after adjusting for multiple possible confounders (HR, 0.46; 95% CI, 0.27-0.78; p = .004). However, no significant difference was observed regarding re-AMI between OMT and non-OMT groups. OMT also reduced all-cause death in patients with recurrent AMI after propensity score matching. CONCLUSIONS: The prescription of OMT was seriously insufficient in patients with recurrent AMI, especially high-risk patients, even though OMT was associated with improved prognosis. Further improvements in pharmacological therapy are needed to reduce subsequent recurrent events.

Automated Referral to Cardiac Rehabilitation After Coronary Artery Bypass Grafting Is Associated With Modest Improvement in Program Completion.

BACKGROUND: Cardiac rehabilitation (CR) is a guideline-indicated modality for reducing residual cardiovascular risk among patients undergoing coronary artery bypass grafting (CABG) surgery. However, many referred patients do not initiate or complete a CR program; even more patients are never even referred. METHODS: All post-CABG patients in Calgary, Alberta, Canada, from January 1, 1996, to March 31, 2016, were included. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation databases. Automated referral to CR at discharge after CABG was instituted on July 1, 2007. We used interrupted time series analysis to evaluate the impact of automated referral on CR referral and completion rates and studied the association of these CR process markers with mortality. RESULTS: A total of 8,118 patients underwent CABG surgery during the study period: 5,103 before automation and 3,015 after automation. Automation increased referral rates from 39.5% to 75.0% (P < 0.001). Automated referral was associated with a 7.2% increase in CR completion in the overall population (33.3% vs 26.1%; P < 0.001). In adjusted models, CR referral alone was not associated with reduced mortality (hazard ratio [HR] 0.84, 95% CI 0.64-1.11), but CR completion was (HR 0.43, 95% CI 0.31-0.61). CONCLUSION: Automated referral in post-CABG patients resulted in modest improvement in CR program completion. Therefore, even when CR referral is automated to include all eligible patients, additional strategies to support CR program enrollment and completion remain necessary to achieve the desired health benefits.

Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score.

PURPOSE: The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated. MATERIAL AND METHODS: In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI). RESULTS: A total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749). CONCLUSIONS: In a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.

Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study.

OBJECTIVES: Successful treatment of acute coronary syndrome (ACS) relies on its rapid recognition. It is unclear whether the accepted presentation of chest pain applies to different ethnic groups. We thus examined potential ethnic variations in ACS symptoms and clinical care outcomes in white, South Asian and Chinese patients. DESIGN: Cross-sectional survey. SETTING: Participants were hospitalised at 1 of 12 Canadian centres across four provinces. PARTICIPANTS: 1334 patients with ACS (630 white; 488 South Asian; 216 Chinese). MAIN OUTCOME MEASURES: ACS presentation symptoms (classic/typical midsternal pain/discomfort with or without radiation to the left neck, shoulder or arm) were assessed by self-report. Clinical care outcomes (time to emergency room [ER] presentation, cardiac catheterisation; receipt of cardiac catheterisation, percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) were obtained by health record audit. RESULTS: The mean age of the sample was 62 years and 30% had ST-elevation myocardial infarction (STEMI). The most common presenting symptom was midsternal pain/discomfort of any intensity regardless of ethnic status. Yet, a substantial proportion of patients reported atypical symptoms (33% white, 19% South Asian, 20% Chinese; p<0.006). After adjustment for age, sex, education, current smoking, extent of coronary artery disease, presence of diabetes or chronic kidney disease and STEMI vs non-STEMI/unstable angina, South Asians were more likely to present with at least moderate intensity midsternal pain/discomfort (adjusted OR [AOR] 1.44; 95% CI 1.05 to 1.98), whereas Chinese were less likely to present with radiating symptoms (AOR 0.53; 95% CI 0.38 to 0.74) compared with whites. South Asians with atypical pain (relative to those with midsternal pain/discomfort) took significantly longer to present to the ER (p=0.037), and were less likely to receive PCI (p=0.008) or CABG (p=0.041). CONCLUSIONS: Atypical presentations were associated with greater delays in arrival to the emergency department and reduced invasive cardiovascular care in South Asians.

The Association between Chronic Obstructive Pulmonary Disease and Coronary Artery Disease in Patients Undergoing Coronary Angiography.

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of morbidity and mortality. There are conflicting results regarding the association between COPD and CAD. We sought to measure the association between COPD and angiographically diagnosed CAD in a population-based cohort. We performed a retrospective analysis using data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a prospectively collected registry capturing all patients undergoing coronary angiography in Alberta, Canada, since 1995. We included adult patients who had undergone coronary angiogram between April 1, 2007 and March 31, 2014. CAD was present if at least one coronary artery had a significant stenosis ≥50%. COPD was present if the patient had a documented COPD history and was prescribed bronchodilators or inhaled steroids. We evaluated the association between COPD and CAD using univariable and multivariable logistic regression. There were 26,137 patients included with a mean age of 63.3 ± 12.2 years, and 19,542 (74.8%) were male. The crude odds ratio (OR) of having CAD was 0.83 (95% CI 0.74-0.92) for patients with COPD compared to those without COPD. The adjusted OR was 0.75 (95% CI 0.67-0.84) after controlling for age, sex, smoking history, body mass index, hypertension, diabetes, hyperlipidemia, peripheral artery disease and cardiac family history. In patients undergoing coronary angiography, COPD was negatively associated with CAD with and without the adjustment for classic risk factors. COPD patients should be properly examined for heart disease to reduce premature mortality.

Evaluation of an electronic health record structured discharge summary to provide real time adverse event reporting in thoracic surgery.

BACKGROUND: The reporting of adverse events (AE) remains an important part of quality improvement in thoracic surgery. The best methodology for AE reporting in surgery is unclear. An AE reporting system using an electronic discharge summary with embedded data collection fields, specifying surgical procedure and complications, was developed. The data are automatically transferred daily to a web-based reporting system. METHODS: We determined the accuracy and sustainability of this electronic real time data collection system (ERD) by comparing the completeness of record capture on procedures and complications with coded discharge data (administrative data), and with the standard of chart audit at two intervals. All surgical procedures performed for 2 consecutive months at initiation (Ti) and 1 year later (T1yr) were audited by an objective trained abstractor. A second abstractor audited 10% of the charts. RESULTS: The ERD captured 71/72 (99%) of charts at Ti and 56/65 (86%) at T1yr. Comparing the presence/absence of complications between ERD and chart audit demonstrated at Ti a high sensitivity and specificity, positive predictive value (PPV) of 95.5%, negative predictive value (NPV) of 93.9% with a kappa of 0.872 (95% CI 0.750 to 0.994), and at T1yr a sensitivity, specificity, PPV and NPV of 100% with a kappa of 1.0 (95% CI 1.0). Comparing the presence/absence of complications between administrative data and chart audit at Ti demonstrated a low sensitivity, high specificity and a kappa of 0.471 (95% CI 0.256 to 0.686), and at T1yr a low sensitivity, high specificity of 85% and a kappa of 0.479 (95% CI 0.245 to 0.714). CONCLUSIONS: We found that the ERD can provide accurate real time AE reporting in thoracic surgery, has advantages over previous reporting methodologies and is an alternative system for surgical clinical teams developing AE reporting systems.

Trajectories of perceived social support in acute coronary syndrome.

PURPOSE: Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS. METHODS: Data are from 3013 patients from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry who had their first cardiac catheterization between 2004 and 2011. Perceived social support was assessed using the 19-item Medical Outcomes Study Social Support Survey (MOS) 2 weeks, 1 year, and 3 years post catheterization. Group-based trajectory analysis based on longitudinal multiple imputation model was used to identify distinct subgroups of trajectories of perceived social support over a 3-year follow-up period. RESULTS: Three distinct social support trajectory subgroups were identified, namely: "High" social support group (60%), "Intermediate" social support group (30%), and "Low" social support subgroup (10%). Being female (OR = 1.67; 95% CI = [1.18-2.36]), depression (OR = 8.10; 95% CI = [4.27-15.36]) and smoking (OR = 1.70; 95% CI = [1.23-2.35]) were predictors of the differences among these trajectory subgroups. CONCLUSION: Although the majority of ACS patients showed increased or fairly stable trajectories of social support, about 10% of the cohort reported declining social support. These findings can inform targeted psycho-social interventions to improve their perceived social support and health outcomes.

Trajectories of Health-Related Quality of Life in Coronary Artery Disease.

BACKGROUND: Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD. METHODS AND RESULTS: Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups. CONCLUSIONS: This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.

Development and external validation of a post-discharge bleeding risk score in patients with acute coronary syndrome: The BleeMACS score.

BACKGROUND: Accurate 1-year bleeding risk estimation after hospital discharge for acute coronary syndrome (ACS) may help clinicians guide the type and duration of antithrombotic therapy. Currently there are no predictive models for this purpose. The aim of this study was to derive and validate a simple clinical tool for bedside risk estimation of 1-year post-discharge serious bleeding in ACS patients. METHODS: The risk score was derived and internally validated in the BleeMACS (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome) registry, an observational international registry involving 15,401 patients surviving admission for ACS and undergoing percutaneous coronary intervention (PCI) from 2003 to 2014, engaging 15 hospitals from 10 countries located in America, Europe and Asia. External validation was conducted in the SWEDEHEART population, with 96,239 ACS patients underwent PCI and 93,150 without PCI. RESULTS: Seven independent predictors of bleeding were identified and included in the BleeMACS score: age, hypertension, vascular disease, history of bleeding, malignancy, creatinine and hemoglobin. The BleeMACS risk score exhibited a C-statistic value of 0.71 (95% CI 0.68-0.74) in the derivation cohort and 0.72 (95% CI 0.67-0.76) in the internal validation sample. In the SWEDEHEART external validation cohort, the C-statistic was 0.65 (95% CI 0.64-0.66) for PCI patients and 0.63 (95% CI 0.62-0.64) for non-PCI patients. The calibration was excellent in the derivation and validation cohorts. CONCLUSIONS: The BleeMACS bleeding risk score is a simple tool useful for identifying those ACS patients at higher risk of serious 1-year post-discharge bleeding. ClinicalTrials.govIdentifier: NCT02466854.

Kidney function modifies the selection of treatment strategies and long-term survival in stable ischaemic heart disease: insights from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry.

Aims: Patients with chronic kidney disease (CKD) have been under-represented in stable ischaemic heart disease (SIHD) trials despite their heightened risk of cardiovascular mortality. We examine associations between kidney disease, treatment selection, and long-term survival in patients with SIHD. Methods and results: SIHD patients with angiographically significant stenosis (≥70%) were categorized by renal function [dialysis-dependent, severe CKD [estimated glomerular filtration rate (eGFR) < 30], mild-moderate CKD (eGFR 30-59), and no CKD (eGFR ≥ 60)] and by treatment groups [revascularization ≤3 months of angiogram (percutaneous coronary intervention or coronary artery bypass surgery) vs. medical therapy]. The association between renal function category and treatment on long-term survival was examined and adjusted for differences in age, sex, co-morbidities, and coronary anatomy. Of the 17 910 SIHD patients, 0.7% (n = 118) were dialysis-dependent, 1.2% (n = 215) severe CKD, 12.0% (n = 2157) mild-moderate CKD, and 86.1% (n = 15420) no CKD. The presence of CKD was associated with significantly lower adjusted odds of receiving revascularization [reference no CKD: dialysis-dependent: odds ratio (OR) 0.52 (0.35, 0.79), severe (non-dialysis) CKD: OR 0.54 (0.40, 0.73), and mild-moderate CKD: OR 0.80 (0.71, 0.89)]. Over a median follow-up of 8.0 (interquartile range 3.2) years, patients with progressive CKD had higher long-term mortality (dialysis-dependent, 53.4%; severe CKD, 30.2%; mild-moderate CKD, 22.2%; no CKD, 11.9%, Ptrend < 0.0001). Revascularization was associated with improved long-term survival [adjusted hazard ratio (HR): dialysis-dependent: HR 0.29 (0.15, 0.55), severe CKD: HR 0.63 (0.36, 1.08), mild-moderate CKD: HR 0.49 (0.40, 0.60), and no CKD: HR 0.47 (0.42, 0.52)] (Pinteraction < 0.001). Conclusion: In SIHD, the presence of CKD was accompanied by lower revascularization rates and a higher risk of mortality. However, revascularization in CKD was associated with improved long-term survival.

Prevalence and outcome of patients with cancer and acute coronary syndrome undergoing percutaneous coronary intervention: a BleeMACS substudy.

BACKGROUND: The prevalence and outcome of patients with cancer that experience acute coronary syndrome (ACS) have to be determined. METHODS AND RESULTS: The BleeMACS project is a multicentre observational registry enrolling patients with acute coronary syndrome undergoing percutaneous coronary intervention worldwide in 15 hospitals. The primary endpoint was a composite event of death and re-infarction after one year of follow-up. Bleedings were the secondary endpoint. 15,401 patients were enrolled, 926 (6.4%) in the cancer group and 14,475 (93.6%) in the group of patients without cancer. Patients with cancer were older (70.8±10.3 vs. 62.8±12.1 years, P<0.001) with more severe comorbidities and presented more frequently with non-ST-segment elevation myocardial infarction compared with patients without cancer. After one year, patients with cancer more often experienced the composite endpoint (15.2% vs. 5.3%, P<0.001) and bleedings (6.5% vs. 3%, P<0.001). At multiple regression analysis the presence of cancer was the strongest independent predictor for the primary endpoint (hazard ratio (HR) 2.1, 1.8-2.5, P<0.001) and bleedings (HR 1.5, 1.1-2.1, P=0.015). Despite patients with cancer generally being undertreated, beta-blockers (relative risk (RR) 0.6, 0.4-0.9, P=0.05), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 0.5, 0.3-0.8, P=0.02), statins (RR 0.3, 0.2-0.5, P<0.001) and dual antiplatelet therapy (RR 0.5, 0.3-0.9, P=0.05) were shown to be protective factors, while proton pump inhibitors (RR 1, 0.6-1.5, P=0.9) were neutral. CONCLUSION: Cancer has a non-negligible prevalence in patients with acute coronary syndrome undergoing percutaneous coronary intervention, with a major risk of cardiovascular events and bleedings. Moreover, these patients are often undertreated from clinical despite medical therapy seems to be protective. Registration:The BleeMACS project (NCT02466854).

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

OBJECTIVE: To assess the utility of the proposed World Health Organization (WHO)'s International Classification of Disease (ICD) framework for classifying patient safety events. SETTING: Independent classification of 45 clinical vignettes using a web-based platform. STUDY PARTICIPANTS: The WHO's multi-disciplinary Quality and Safety Topic Advisory Group. MAIN OUTCOME MEASURE(S): The framework consists of three concepts: harm, cause and mode. We defined a concept as 'classifiable' if more than half of the raters could assign an ICD-11 code for the case. We evaluated reasons why cases were nonclassifiable using a qualitative approach. RESULTS: Harm was classifiable in 31 of 45 cases (69%). Of these, only 20 could be classified according to cause and mode. Classifiable cases were those in which a clear cause and effect relationship existed (e.g. medication administration error). Nonclassifiable cases were those without clear causal attribution (e.g. pressure ulcer). Of the 14 cases in which harm was not evident (31%), only 5 could be classified according to cause and mode and represented potential adverse events. Overall, nine cases (20%) were nonclassifiable using the three-part patient safety framework and contained significant ambiguity in the relationship between healthcare outcome and putative cause. CONCLUSIONS: The proposed framework enabled classification of the majority of patient safety events. Cases in which potentially harmful events did not cause harm were not classifiable; additional code categories within the ICD-11 are one proposal to address this concern. Cases with ambiguity in cause and effect relationship between healthcare processes and outcomes remain difficult to classify.

Incidence and Prognostic Implications of Late Bleeding After Myocardial Infarction or Unstable Angina According to Treatment Strategy.

BACKGROUND: Bleeding complications accompanying coronary revascularization are associated with increased mortality; however, few data are available on subsequent bleeding risk. We used administrative data to assess the incidence of late bleeding events in patients with acute coronary syndrome (ACS) according to treatment allocation. METHODS: The cohort and bleeding events were identified through the Canadian Institute for Health Information discharge abstract database. Crude and adjusted odds ratios (ORs) were calculated for index and postindex admission bleeding up to 1 year after discharge. RESULTS: Of 31,941 patients hospitalized with ACS, 7681 (32.4%) patients were treated with medication alone, 3728 (15.2%) underwent angiography without intervention, and 13,075 (53.4%) underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The overall incidence of readmission with bleeding based on administrative codes was low (3.8% for medically treated patients, 2.8% for patients who underwent angiography alone, 2.6% for patients who underwent CABG, and 1.8% for patients who underwent PCI; P < 0.0001). Bleeding codes were mainly gastrointestinal bleeding (52%), but 7.8% were intracranial episodes of bleeding. Patients who received PCI had significantly lower odds of late bleeding compared with medically treated patients (OR, 0.76; 95% CI, 0.62-0.94). Late bleeding during the first year after ACS was associated with mortality (OR, 4.96; 95% CI, 2.47-9.93). CONCLUSIONS: Patients who underwent revascularization procedures had a relatively low risk for late bleeding events after a hospitalization for ACS. Late bleeding events were associated with an increased risk of death.

Optimal Medical Therapy in Patients with Malignancy Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome: a BleeMACS Sub-Study.

OBJECTIVE: Our objective was to define the most appropriate treatment for acute coronary syndrome (ACS) in patients with malignancy. METHODS AND RESULTS: The BleeMACS project is a worldwide multicenter observational prospective registry in 16 hospitals enrolling patients with ACS undergoing percutaneous coronary intervention. Primary endpoints were death, re-infarction, and major adverse cardiac events (MACE; composite of death and re-infarction) after 1 year of follow-up. The secondary endpoint was bleeding events during follow-up. We performed sub-study analyses according to whether ß-blockers (BBs), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), statins, or proton pump inhibitors (PPIs) were prescribed at discharge. We also calculated the propensity score for optimal medical therapy (OMT; combination of BB, ACEI/ARB, and statins). The study included 926 patients. According to the multivariate analysis, ACEIs/ARBs (hazard ratio [HR] 0.58, 95 % confidence interval [CI] 0.36-1.94; p = 0.03) and statins (HR 0.37, 95 % CI 0.23-0.61; p < 0.01) reduced the risk of MACE, while the effects of BBs (HR 0.85, 95 % CI 0.55-1.32; p = 0.48) and PPIs (HR 1.33, 95 % CI 0.83-2.12; p = 0.23) were not significant. OMT was prescribed at discharge in 300 (32.4 %) patients; after propensity score analysis, OMT showed a significant reduction in death (3 % vs. 12.5 %, HR 0.21, 95 % CI 0.1-0.4; log-rank p < 0.001) and MACE (6.7 vs. 15.2 %, log-rank p = 0.01). CONCLUSION: In patients with ACS and malignancy, OMT reduces the risk of adverse events at 1 year; in particular, ACEIs/ARBs and statins were the most protective drugs. (Clinical trials identifier: NCT02466854).

Charts versus Discharge ICD-10 Coding for Sternal Wound Infection Following Coronary Artery Bypass Grafting.

BACKGROUND: Sternal wound infection (SWI) in patients undergoing coronary artery bypass grafting (CABG) can carry a significant risk of morbidity and mortality. The objective of this work is to describe the methods used to identify cases of SWI in an administrative database and to demonstrate the effectiveness of using an International Classification of Diseases, Tenth Revision (ICD-10) coding algorithm for this purpose. METHODS: ICD-10 codes were used to identify cases of SWI within one year of CABG between April 2002 and November 2009. We randomly chose 200 charts for detailed chart review (100 from each of the groups coded as having SWI and not having SWI) to determine the utility of the ICD-10 coding algorithm. RESULTS: There were 2,820 patients undergoing CABG. Of these, 264 (9.4 percent) were coded as having SWI. Thirty-eight cases of SWI were identified by chart review. The ICD-10 coding algorithm of T81.3 or T81.4 was able to identify incident SWI with a positive predictive value of 35 percent and a negative predictive value of 97 percent. The agreement between the ICD-10 coding algorithm and presence of SWI remained fair, with an overall kappa coefficient of 0.32 (95 percent confidence interval, 0.22-0.43). The effectiveness of identifying deep SWI cases is also presented. CONCLUSIONS: This article describes an effective algorithm for identifying a cohort of patients with SWI following open sternotomy in large databases using ICD-10 coding. In addition, alternative search strategies are presented to suit researchers' needs.

Trends in postcoronary artery bypass graft sternal wound dehiscence in a provincial population.

BACKGROUND: It appears that the medical profile of patients undergoing coronary artery bypass graft (CABG) surgery has changed. The impact of this demographic shift on CABG outcomes, such as sternal wound dehiscence, is unclear. OBJECTIVES: To quantify the incidence and trends of sternal wound dehiscence, quantify the demographic shift of those undergoing CABG and identify patient factors predictive of disease. METHODS: A prospective analysis was performed on a historical cohort of consecutive patients who underwent CABG (without valve replacement) in Alberta between April 1, 2002 and November 30, 2009. The incidence and trends of sternal wound dehiscence were determined. In addition, the trend of the mean Charlson index score and European System for Cardiac Operative Risk Evaluation (EuroSCORE) (capturing patient comorbidities) was analyzed. Univariable analysis and multivariable models were performed to determine factors predictive of wound dehiscence. RESULTS: A total of 5815 patients underwent CABG during the study period. The incidence proportion of sternal wound dehiscence in Alberta was 1.86% and the incidence rate was 1.98 cases per 100 person-years. Although both the EuroSCORE and Charlson scores significantly increased over the study period, the incidence of sternal wound dehiscence did not change significantly. Factors predictive of sternal wound dehiscence were diabetes (OR 2.97 [95% CI 1.73 to 5.10]), obesity (OR 1.55 [95% CI 1.05 to 2.27]) and female sex (OR 1.90 [95% CI 1.26 to 2.87]). CONCLUSIONS: The incidence proportion of sternal wound dehiscence in Alberta was comparable with the incidence previously published in the literature. While patients undergoing CABG had worsening medical profiles, the incidence of sternal wound dehiscence did not appear to be increasing significantly.

HISTORIQUE: Il semble que le profil médical des patients qui subisent un pontage aortocoronarien (PAC) a changé. On ne connaît pas les effets de ce changement démographique sur les résultats des PAC, tels que la déhiscence sternale. OBJECTIF: Quantifier l'incidence et les tendances de déhiscence sternale, quantifier le changement démographique des personnes qui subissent un PAC et cerner les facteurs liés aux patients qui sont prédictifs de maladie. MÉTHODOLOGIE: Les chercheurs ont effectué une analyse prospective auprès d'une cohorte historique de patients consécutifs qui avaient subi un PAC (sans remplacement valvulaire) en Alberta entre le 1er avril 2002 et le 30 novembre 2009. Ils ont déterminé l'incidence et les tendances des déhiscences sternales. Ils ont analysé la tendance de l'indice moyen de Charlson et de l'EuroSCORE (European System for Cardiac Operative Risk Evaluation) (qui saisit les comorbidités des patients). Ils ont utilisé des analyses univariables et des modèles multivariables pour déterminer les facteurs prédictifs d'une déhiscence de la plaie. RÉSULTATS: Au total, 5 815 patients ont subi un PAC pendant la période de l'étude. La proportion de déhiscence sternale en Alberta était de 1,86 % et le taux d'incidence, de 1,98 cas sur 100 personnes-année. Même si l'EuroSCORE et l'indice de Charlson ont augmenté considérablement pendant la période de l'étude, l'incidence de déhiscence sternale n'a pas changé de manière significative. Le diabète (RC 2,97 [95 % IC 1,73 à 5,10]), l'obésité (RC 1,55 [95 % IC 1,05 à 2,27]) et le sexe féminin (RC 1,90 [95 % IC 1,26 à 2,87]) étaient les facteurs prédictifs de déhiscence sternale. CONCLUSIONS: La proportion de déhiscence sternale en Alberta était comparable à celle publiée par le passé. Le profil médical des patients qui subissent un PAC s'aggravait, mais l'incidence de déhiscence sternale ne semblait pas augmenter de manière significative.

Coronary revascularization for patients with severe left ventricular dysfunction.

BACKGROUND: The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction <35%) were underrepresented in these trials, and management of these complex patients remains unclear. The purpose of this study was to compare the outcomes of patients with coronary artery disease and left ventricular dysfunction undergoing CABG versus PCI. METHODS: The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection and outcome monitoring initiative for the province of Alberta, Canada, was used to identify 2925 patients with coronary artery disease and left ventricular dysfunction undergoing CABG (n = 1,326) or PCI (n = 1,599) between 1995 and 2008. Patients were propensity matched to obtain comparable subgroups among left ventricular dysfunction patients. RESULTS: Cox proportional hazard analysis of the propensity-matched subgroups identified that CABG was significantly associated with lower rates of repeat revascularization and better survival compared with PCI at 1, 5, 10, and 15 years. Other significant independent predictors of poor long-term survival included age, renal failure, heart failure, diabetes mellitus, peripheral vascular disease, prior myocardial infarction, left main coronary artery disease, and prior CABG. CONCLUSIONS: For patients with coronary artery disease and left ventricular dysfunction, CABG was associated with lower rates of repeat revascularization and improved survival over PCI, after adjustment for baseline risk profile differences. Further research exploring the factors leading to use of a particular revascularization modality in this patient population is required.