Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes.

OBJECTIVE: To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery. BACKGROUND: Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care. METHODS: This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. RESULTS: Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes. CONCLUSIONS: Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

BACKGROUND: Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions. METHODS: We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs. RESULTS: Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%). INTERPRETATION: Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.

Prevalence of Cardiovascular Disease in a Population-Based Cohort of High-Cost Healthcare Services Users.

BACKGROUND: Data are limited data on the prevalence of cardiovascular disease (CVD) and multimorbidity in contemporary cohorts of high-cost users (HCUs) in Canada.We examined the following: (i) the prevalence of CVD, with a comparison of total healthcare costs among HCUs with vs without CVD; (ii) the contribution of other comorbidities to costs among HCUs with CVD; and (iii) the trajectory of healthcare costs in the years before and after becoming an HCU. METHODS: The study included adult Alberta patients in the Canadian Institutes of Health Research/Canadian Institute for Health Information Dynamic Cohort of Complex, High System Users from 2011-2012 through 2014-2015. We examined total healthcare costs, including hospital, ambulatory care, physician services, and drugs. RESULTS: Among 88,536 HCUs, 23.4% had no CVD, 28.9% were hospitalized with a primary diagnosis of CVD, and 47.7% were hospitalized with a secondary diagnosis of CVD. Total healthcare costs were $2.0 billion (20.4% non-hospital costs), $2.8 billion (24.1% non-hospital costs), and $4.9 billion (19.8% non-hospital costs), respectively, in the 3 groups. Many HCUs with CVD were frail (74.2%) and many had diabetes (33.8%) or chronic obstructive pulmonary disease (27.9%), which contributed to higher costs and mortality. Healthcare expenditures in HCUs with CVD were several times higher than per capita health expenditures in the years prior to, and following, their inclusion in the dynamic HCU cohort. CONCLUSIONS: CVD is very common in HCUs of healthcare. HCUs with CVD have high rates of frailty and multimorbidity. Further research is needed to identify and intervene earlier, in order to flatten the cost curve in these complex patients.

INTRODUCTION: Les données sur la prévalence des maladies cardiovasculaires (MCV) et de la multimorbidité au sein des cohortes contemporaines de grands utilisateurs (GU) du Canada sont limitées. Nous avons examiné ce qui suit : (i) la prévalence des MCV en comparant les coûts totaux des soins de santé entre les GU atteints de MCV et les GU non atteints de MCV; (ii) la contribution des autres comorbidités aux coûts liés aux GU atteints de MCV; (iii) la trajectoire des coûts des soins de santé dans les années avant et après avoir été considérés comme un GU. MÉTHODES: L'étude portait sur des patients adultes de l'Alberta de la Cohorte dynamique de grands utilisateurs du système de santé aux besoins complexes de 2011-2012 à 2014-2015 des Instituts de recherche en santé du Canada et de l'Institut canadien d'information sur la santé. Nous avons examiné les coûts totaux des soins de santé, notamment les coûts hospitaliers, les coûts des soins ambulatoires, des services médicaux et des médicaments. RÉSULTATS: Parmi les 88 536 GU, 23,4 % n'avaient pas de MCV, 28,9 % étaient hospitalisés et avaient un diagnostic principal de MCV, et 47,7 % étaient hospitalisés et avaient un diagnostic secondaire de MCV. Les coûts totaux des soins de santé des 3 groupes étaient respectivement de 2,0 G$ (20,4 % de coûts non hospitaliers), 2,8 G$ (24,1 % de coûts non hospitaliers) et 4,9 G$ (19,8 % de coûts non hospitaliers). Plusieurs GU atteints de MCV étaient fragiles (74,2 %) et beaucoup avaient le diabète (33,8 %) ou une maladie pulmonaire obstructive chronique (27,9 %), qui contribuaient à des coûts et à une mortalité plus élevés. Les dépenses de santé par personne liées aux GU atteints de MCV étaient beaucoup plus élevées que les dépenses de santé par personne dans les années qui précédaient ou suivaient leur inclusion dans la cohorte dynamique de GU atteints de MCV. CONCLUSIONS: Les GU de soins de santé sont très fréquemment atteints de MCV. Les GU atteints de MCV présentent des taux de fragilité et de multimorbidité élevés. D'autres recherches sont nécessaires pour cerner et intervenir plus tôt afin d'aplatir la courbe des coûts chez ces patients aux besoins complexes.

Implications of the COVID-19 Pandemic for Cardiovascular Disease and Risk-Factor Management.

COVID-19 and our public health responses to the pandemic may have far-reaching implications for cardiovascular (CV) risk, affecting the general population and not only survivors of COVID-19. In this narrative review, we discuss how the pandemic may affect general CV risk for years to come and explore the mitigating potential of telehealth interventions. From a health care perspective, the shift away from in-person office visits may have led many to defer routine risk- factor management and may have had unforeseen effects on continuity of care and adherence. Fear of COVID-19 has led some patients to forego care for acute CV events. Curtailment of routine outpatient laboratory testing has likely delayed intensification of risk-factor-modifying medical therapy, and drug shortages and misinformation may have negative impacts on adherence to antihypertensive, glucose-lowering, and lipid-lowering agents. From a societal perspective, the unprecedented curtailment of social and economic activities has led to loss of income, unemployment, social isolation, decreased physical activity, and increased frequency of depression and anxiety, all of which are known to be associated with worse CV risk-factor control and outcomes. We must embrace and evaluate measures to mitigate these potential harms to avoid an epidemic of CV morbidity and mortality in the coming years that could dwarf the initial health effects of COVID-19.

The ecology of medical care for adults in Alberta, 2002/03 to 2016/17: a retrospective cohort study.

BACKGROUND: If we are to improve the patient experience, knowing where and with whom people receive professional health advice and treatment (the ecology of medical care) is the first step. We designed this study to define the ecology of medical care in Alberta and to examine whether province-wide implementation of 5 policy changes between 2003 and 2012 changed patterns of care among adults in the province. METHODS: This was a retrospective cohort study of adults (age ≥ 18 yr) in Alberta using routinely collected data from 6 linked administrative health databases, the 2016 Canadian Community Health Survey and the Alberta Health Link teletriage system. We collected data on all encounters with pharmacists, primary care physicians, specialists, emergency departments and hospitals in 2002/03, 2009/10 and 2016/17. RESULTS: Between 2002/03 and 2016/17, the community-dwelling adult population of Alberta increased from 2.66 million to 3.84 million; the median age increased from 41 to 43 years, and the proportion with at least 1 ambulatory-care-sensitive condition increased from 20.6% to 27.8%. The proportion who saw a primary care physician decreased significantly (from 70.8% to 68.2%, p < 0.001), as did the proportion who visited an emergency department (from 20.6% to 19.2%, p < 0.001); the declines were seen in all subgroups examined. The proportion who saw a specialist as an outpatient increased from 31.9% to 33.2% (p < 0.001), and the proportion who received at least 1 medication dispensation increased from 54.9% to 60.2% (p < 0.001). The proportion admitted to an acute care hospital (5.6%-6.5%) or academic hospital (1.2%) was relatively stable over time. INTERPRETATION: Despite implementation of 5 system-wide changes designed to affect the delivery of primary and specialty medical care as well as the use of pharmacist and nursing services in Alberta, patterns of health care delivery changed little between 2002/03 and 2016/17. Rather than searching for a policy "magic bullet," health care planners may be better served by focusing on upscaling and implementing interventions proven to be efficacious.

Empirical Insights When Defining the Population Burden of Atrial Fibrillation and Oral Anticoagulation Utilization Using Administrative Data.

Health administrative data are routinely used to assess disease burden, quality of care, and outcomes for atrial fibrillation (AF). Governments, administrators, and researchers define cohorts differently, based on 3 key factors: the case definition algorithm to identify AF, inclusion/exclusion of transient AF, and the lookback period to identify cases. We assessed the impact of varying these key factors on estimates of the use of guideline-indicated oral anticoagulation (OAC). Hospitalization, ED, and outpatient claim databases were linked in British Columbia. AF was defined by ICD-9 or 10 codes 427.3x or I48.x. We examined a specific (1 hospital or 1 ED or 2 outpatient) vs a sensitive (1 hospital or ED or outpatient) algorithm; inclusion/exclusion of AF associated with open-heart surgery; and lookback periods of 1 to 10 years. We found the more specific AF definition increased OAC utilization by 5% (58.7% vs 53.4%); excluding AF associated with open-heart surgery increased OAC utilization by 0.7% to 2.3%; and each additional lookback year identified more prevalent cases but reduced OAC utilization by approximately 1%. In 40 scenarios, generated by varying all 3 key factors, OAC utilization ranged from 52% to 72%. Assuming a ceiling of 90%, the estimated "treatment gap" therefore varied from 18% to 38%. The 2-fold variation in the OAC treatment gap was based entirely on cohort definition. This has significant implications for health policy and quality indicators.

Incremental costs of high intensive care utilisation in patients hospitalised with heart failure.

AIMS: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. METHODS: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. RESULTS: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. CONCLUSIONS: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.

Cost-Effectiveness of Osteoporosis Interventions to Improve Quality of Care After Upper Extremity Fracture: Results From a Randomized Trial (C-STOP Trial).

We assessed the cost-effectiveness of two models of osteoporosis care after upper extremity fragility fracture using a high-intensity Fracture Liaison Service (FLS) Case-Manager intervention versus a low-intensity FLS (ie, Active Control), and both relative to usual care. This analysis used data from a pragmatic patient-level parallel-arm comparative effectiveness trial of 361 community-dwelling participants 50 years or older with upper extremity fractures undertaken at a Canadian academic hospital. We used a decision-analytic Markov model to evaluate the cost-effectiveness of the three treatment alternatives. The perspective was health service payer; the analytical horizon was lifetime; costs and health outcomes were discounted by 3%. Costs were expressed in 2016 Canadian dollars (CAD) and the health effect was measured by quality adjusted life years (QALYs). The average age of enrolled patients was 63 years and 89% were female. Per patient cost of the Case Manager and Active Control interventions were $66CAD and $18CAD, respectively. Compared to the Active Control, the Case Manager saved $333,000, gained seven QALYs, and averted nine additional fractures per 1000 patients. Compared to usual care, the Case Manager saved $564,000, gained 14 QALYs, and incurred 18 fewer fractures per 1000 patients, whereas the Active Control saved $231,000, gained seven QALYs, and incurred nine fewer fractures per 1000 patients. Although both interventions dominated usual care, the Case Manager intervention also dominated the Active Control. In 5000 probabilistic simulations, the probability that the Case Manager intervention was cost-effective was greater than 75% whereas the Active Control intervention was cost-effective in less than 20% of simulations. In summary, although the adoption of either of these approaches into clinical settings should lead to cost savings, reduced fractures, and increased quality-adjusted life for older adults following upper extremity fracture, the Case Manager intervention would be the most likely to be cost-effective. © 2019 American Society for Bone and Mineral Research.

Cost-effectiveness of home blood pressure telemonitoring and case management in the secondary prevention of cerebrovascular disease in Canada.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost-effectiveness assessments are mixed. We examined the incremental cost-effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost-utility analysis examining community-residing, high-risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality-adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3 months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention-associated BP lowering, resource use, and costs were obtained from Canadian published literature. Reduction in systolic BP of 9.7 mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per-patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost-effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2-3 times base case cost, incremental cost-effectiveness was $1200-$4700 per quality-adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

Total and Cause-Specific Mortality After Percutaneous Coronary Intervention: Observations From the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease Registry.

BACKGROUND: Patients undergoing percutaneous coronary intervention (PCI) are increasingly older and have a higher comorbidity burden. This study evaluated trends in 30-day, 1-year, and 2-year total and cause-specific mortality using a large, contemporary cohort of patients who underwent PCI in Alberta, Canada. METHODS: We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry to identify patients aged ≥ 20 years who underwent PCI between 2005 and 2013. All patients were followed until death or being censored by August 2016. Cause of death was from the Vital Statistics database and classified as cardiac or noncardiac. Multivariable logistic regression was used to calculate predicted mortality at 30 days, 1 year, and 2 years post-PCI. RESULTS: Of the 35,602 patients who underwent PCI, 5284 (14.8%) had died. Mean (standard deviation) follow-up was 74.9 (35.1) months. Over the study period, patients were older and more likely to undergo PCI for an acute coronary syndrome indication. Thirty-day (2005: 1.3%; 2013: 3.2%; P < 0.001), 1-year (2005: 2.7%; 2013: 5.7%; P < 0.001), and 2-year (2005: 4.5%; 2013: 7.5%; P < 0.001) predicted mortality after PCI increased over the study period. Cardiac cause of death dominated in the short-term, but the proportion of noncardiac deaths increased as time from PCI to death increased (30 days = 11.5%, 1 year = 31.5%, 2 years = 39.6%; P < 0.001). CONCLUSIONS: In this population-based study, we found all-cause mortality at 30 days, 1 year, and 2 years after PCI increased over time. Cardiac causes of death dominate in the short-term after PCI; however, noncardiac cause becomes a major driver of mortality in the long-term.

CONTEXTE: Les patients devant subir une intervention coronarienne percutanée (ICP) sont de plus en plus âgés et subissent un fardeau accru de comorbidités. La présente étude a évalué les tendances de la mortalité totale et due à une cause particulière à 30 jours, 1 an et 2 ans, au sein d'une vaste cohorte contemporaine de patients ayant subi une ICP en Alberta, au Canada. MÉTHODOLOGIE: Nous avons utilisé le registre APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease) pour recenser les patients âgés de 20 ans ou plus qui avaient subi une ICP entre 2005 et 2013. Tous les patients ont fait l'objet d'un suivi jusqu'au décès ou à la censure des données en août 2016. La cause du décès était issue de la Base de données sur l'état civil et classée comme étant d'origine cardiaque ou non cardiaque. On a eu recours à un modèle de régression logistique multivarié pour calculer la mortalité prédite 30 jours, 1 an et 2 ans après l'ICP. RÉSULTATS: Sur les 35 602 patients ayant subi une ICP, 5 284 (14,8 %) étaient décédés. La durée moyenne de suivi (écart type) était de 74,9 (35,1) mois. Au cours de la période de l'étude, les patients étaient plus âgés et plus susceptibles de subir une ICP pour une indication de syndrome coronarien aigu. On observe une augmentation de la mortalité prédite après l'ICP au cours de la période de l'étude selon les taux suivants : à trente jours (2005 : 1,3 %; 2013 : 3,2 %; p < 0,001), à 1 an (2005 : 2,7 %; 2013 : 5,7 %; p < 0,001) et à 2 ans (2005 : 4,5 %; 2013 : 7,5 %; p < 0,001). Les causes cardiaques de décès dominaient à court terme, mais la proportion de décès d'origine non cardiaque augmentait avec le temps au fur et à mesure de l'allongement de l'intervalle entre la date de l'ICP et le décès (30 jours = 11,5 %, 1 an = 31,5 %, 2 ans = 39,6 %; p < 0,001). CONCLUSIONS: Dans cette étude de population, nous avons trouvé que la mortalité toutes causes confondues à 30 jours, 1 an et 2 ans après une ICP augmente au fil du temps. Les causes cardiaques de décès dominent peu de temps après l'ICP, tandis que les causes non cardiaques jouent un rôle déterminant dans la mortalité à long terme.

Acute Coronary Syndromes and Heart Failure Critical Care Units Utilization and Outcomes in Teaching and Community Hospitals: A National Population-Based Analysis.

Acute coronary syndromes (ACS) and heart failure (HF) are the leading diagnoses in patients admitted to critical care units (CCUs). Little is known about the differences between CCU resource use and outcomes across hospital types. The Canadian Institute for Health Information was used to identify patients hospitalized with primary diagnoses of ACS or HF. CCUs were categorized as teaching, large community, medium community, and small community hospitals. Outcomes included CCU rates of admission, use of critical care therapy/procedures, and in-hospital mortality. Among 204,900 patients hospitalized with ACS or HF, 73,338 (35.8%, hospital range 0% to 81.4%) were admitted to CCUs, and it varied across hospital types: 41.0% in teaching, 30.0% in large, 45.4% in medium, and 30.9% in small community hospitals (P < 0.001). The percentage of patients admitted to CCUs who received critical care therapies in teaching, large, medium, and small hospitals were as follows: 73.6%, 50.9%, 24.6%, and 8.8% (P < 0.0001). Compared with the in-hospital mortality rate for patients admitted to CCUs in teaching hospitals (8.2%), outcomes were worse for CCU patients in large (11.0%, adjusted odds ratio [aOR] 1.50; 95% CI, 1.19-1.90), medium (10.5%, aOR 1.56; 95% CI, 1.27-1.92), and small community hospitals (9.2%, aOR 1.59; 95% CI, 1.20-2.10). Patients admitted with ACS or HF to teaching hospital CCUs had a higher observed use of critical care therapies and lower mortality compared with community hospitals. These differences highlight the need to examine differences in CCU admission thresholds, resource utilization, and outcomes across hospitals types.

The high cost of critical care unit over-utilization for patients with NSTE ACS.

BACKGROUND: There is substantial variability among hospitals in critical care unit (CCU) utilization for patients admitted with non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS). We estimated the potential cost saving if all hospitals adopted low CCU utilization practices for patients with NSTE ACS. METHODS: National hospital claims data were used to identify all patients with a primary diagnosis of NSTE ACS initially admitted to an acute care hospital between 2007 and 2013. Hospital CCU utilization was classified as low (<30%), medium (30-70%), or high (>70%). RESULTS: Among the 270,564 NSTE ACS hospitalizations (71.6% non-ST-segment elevation myocardial infarction; 28.4% unstable angina) admitted to 261 hospitals, 41.9% (inter-hospital range 0.3%-95.1%) were admitted to a CCU. The proportion of patients admitted to a CCU in low, medium and high utilization hospitals was 16.3%, 49.5%, and high 81.1%, respectively. No differences in adjusted inpatient mortality were observed by hospital CCU utilization. The overall inpatient costs of caring for NSTE ACS were $1.1 billion. CCU care accounted for 45.2% of all hospitalization costs including 22.6%, 49.9%, and 69.0% (P < .001) of costs in low, medium and high utilization centers. The national potential direct cost savings of medium and high CCU utilization centers adopting low NSTE ACS CCU utilization practices was $113.4 million over the study period. CONCLUSIONS: In a population-based contemporary cohort, CCU utilization for patients with NSTE ACS varied widely and in-hospital mortality was similar between low, medium and high utilization centers. CCU care accounted for 45% of hospitalization costs; thus, implementing policies and admission practices to align hospital resources with patient care needs have the potential to reduce overall health care costs.

Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states.

BACKGROUND: To examine the intensity of glycemic and blood pressure control in British adults with diabetes mellitus and whether control levels or treatment deintensification rates differ across health states. METHODS: Retrospective cohort study using primary care electronic medical records (the United Kingdom Health Improvement Network Database) for adults with diabetes diagnosed at least 6 months before the index HbA1C and systolic blood pressure (SBP) measurements (to give their primary care physicians time to achieve treatment goals). We used prescribing records for 6 months pre/post the index measurements to determine who had therapy subsequently deintensified (based on "glycemic therapy score" and "antihypertensive therapy score" derived from number and dosage of medications). RESULTS: Of 292,170 individuals with diabetes, HbA1C < 6% or SBP < 120 mmHg after at least 6 months of management was less common in otherwise fit patients (15.0 and 12.7%) than in those who were mildly frail (16.6 and 13.2%) or moderately-severely frail (20.2 and 17.0%, both p < 0.0001). In the next 6 months, only 44.7% of those with HbA1C < 6% had glycemic therapy reduced (44.4% of fit, 47.1% of mildly frail, and 41.5% of moderate-severely frail patients) and 39.8% of those with SBP < 120 had their antihypertensives decreased (39.3% of fit, 43.0% of mildly frail, and 46.7% of moderate-severely frail patients). On the other hand, more individuals exhibited higher than recommended levels for HbA1C or SBP after the first 6 months of therapy (37.3, 33.4, and 31.3% of fit, mildly frail, and moderately-severely frail patients had HbA1C > 7.5% and 46.6, 51.4, and 48.5% had SBP > 140 mmHg). The proportions of patients with HbA1C or SBP out of recommended treatment ranges changed little 6 months later despite frequent (median 14 per year) primary care visits. CONCLUSIONS: Glycemic and hypertensive control exhibited statistically significant but small magnitude differences across frailty states. Medication deintensification was uncommon, even in frail patients below SBP and HbA1C targets. SBP levels were more likely to be outside recommended treatment ranges than glycemic levels. Trial registration As this study is a retrospective secondary analysis of electronic medical record data and not a health care intervention trial it was not registered.

Frequency of low-value care in Alberta, Canada: a retrospective cohort study.

OBJECTIVE: To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision. METHODS: This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided. RESULTS: Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient's region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery. CONCLUSIONS: Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

The current and future financial burden of hospital admissions for heart failure in Canada: a cost analysis.

BACKGROUND: Heart failure is a costly health condition and a major public health concern. We sought to examine the costs of hospital admissions for heart failure between fiscal years 2004 and 2013 in Canada and to model the future costs to 2030. METHODS: Canadian Institutes for Health Information Discharge Abstract Database was used to identify admissions to hospital with heart failure as the primary diagnosis between fiscal years 2004 and 2013. Multiple linear regression models were used to calculate the trend in prevalence and extrapolate these to 2030. Canadian Institutes for Health Information patient cost estimates were used to identify costs of hospital admissions for heart failure. Generalized linear models were used to estimate average annual costs per heart failure patient. We conducted a sensitivity analysis including all admissions for heart failure in any diagnostic field. RESULTS: In 2013, 45 600 (95% confidence interval [CI]: 43 800-47 200) patients were admitted with heart failure as the primary diagnosis, accounting for $482 (95% CI $464-$500) million. By 2030, we estimate 54 000 (95% CI 49 000-60 000) patients and costs of $722 (95% CI $650-$801) million, with older adults (age ≥ 80 yr) accounting for 52% of costs. Including admissions for which heart failure was a secondary diagnosis increases the total cost to $2.8 (95% CI $2.6-$3.0) billion in 2030. INTERPRETATION: As in other developed countries, hospital costs related to heart failure in Canada are on the rise. Older adults are the main consumers of such hospital services. Strategies to improve outpatient care to reduce rates of admission for heart failure are needed.

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

BACKGROUND: Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described. METHODS: We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728). RESULTS: Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina. CONCLUSIONS: There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.

The Interplay Between Continuity of Care, Multimorbidity, and Adverse Events in Patients With Diabetes.

OBJECTIVES: To evaluate the impact of continuity of care and multimorbidity on health outcomes in patients with diabetes. RESEARCH DESIGN: Using a US claims database of insured patients, we identified those with incident diabetes between 2004 and 2008 and followed them until death, disenrollment, or December 31, 2010. Continuity of care was defined using Breslau's Usual Provider of Continuity (UPC; proportion of visits to the usual or predominant provider within 2 y of diabetes diagnosis). Multivariable logistic regression was used to determine the association between UPC in the first 2 years after diabetes diagnosis and subsequent 1-year composite primary outcome of all-cause hospitalization or death in year 3 in patients with/without multimorbidity. RESULTS: Of the 285,231 patients with incident diabetes, 74% had multimorbidity; their average age was 53 years (SD=10.5) and 49% were female. A total of 77,270 (27%) individuals had a mean UPC≥75% in the first 2 years. During year 3 of follow-up, 33,632 (12%) patients died or were hospitalized for any cause. Greater continuity of care (UPC≥75%) was associated with reduced risk of subsequent death or hospitalization [7.2% vs. 13.5%; adjusted odds ratio (aOR)=0.72; 95% CI, 0.70-0.75]. Although multimorbidity was independently associated with an increased risk of our primary composite endpoint (13.4% vs. 7.2%; aOR=1.26; 95% CI, 1.21-1.30), the association between greater continuity and better outcomes was similar in those with multimorbidity (aOR=0.71; 95% CI, 0.69-0.71) as in those without (aOR=0.75; 95% CI, 0.71-0.80). CONCLUSIONS: In patients with incident diabetes, greater continuity of care is associated with improved outcomes, irrespective of whether or not they have multimorbidity.

Epidemiology of Hypertension in Canada: An Update.

BACKGROUND: High blood pressure (BP) is the leading cause of death and disability in the world. The objective of this analysis was to perform a detailed update of the epidemiology of hypertension in Canada. METHODS: Five population-based data sources were analyzed. We used the Canadian Health Measures Survey to determine the latest directly measured prevalence, awareness, and control estimates (2012-2013); the National Population Health Survey, and Canadian Community Health Survey to assess crude and age-standardized self-reported prevalence (1994-2013); the Canadian Chronic Disease Surveillance System to assess administrative data-ascertained prevalence and mortality trends (1998-2010); and Intercontinental Medical Statistics Health data to examine antihypertensive drug-prescribing trends and costs (2007-2014). RESULTS: In 2012-2013, the prevalence of hypertension (defined as drug treatment for high BP or BP ≥ 140/90 mm Hg) in Canadian adults was 22.6%, and the proportion of disease controlled was 68.1%. In Canadians with diabetes, the prevalence (defined as drug treatment or BP ≥ 130/80 mm Hg) was 67.1%, and 60.1% of cases were controlled. Self-reported hypertension prevalence has increased by approximately 2-fold over nearly 2 decades. Age-standardized mortality rates are falling in hypertensive Canadians (from 9.4 to 7.9 deaths per 1000 individuals), but to a lesser extent than in nonhypertensive individuals. Total antihypertensive drug prescription volume has increased steadily since 2007 amid falling drug costs. CONCLUSIONS: Hypertension prevalence in Canada continues to rise. Increased use of antihypertensive drugs and improvements in control are apparent. Coordinated efforts to further improve the treatment and control of hypertension in Canada are needed.