Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation.

Background: Healthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs. Methods: All patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$). Results: Among 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001). Conclusions: Despite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients.

Contexte: L'utilisation des ressources en santé est élevée pour la fibrillation auriculaire (FA), mais elle n'est pas forcément équivalente pour tous les patients. Nous avons examiné s'il existait des différences entre les sexes pour ce qui est des cas très coûteux de FA, qui représentent les 10 % supérieurs des coûts totaux de soins de courte durée. Méthodologie: Tous les patients âgés de 20 ans et plus qui se sont présentés au service des urgences ou qui ont été hospitalisés pour une FA ont été répertoriés en Alberta, au Canada, entre 2011 et 2015. La cohorte a été divisée par sexe en fonction des utilisateurs très coûteux et des autres utilisateurs. L'utilisation des soins de santé était définie comme des consultations aux urgences, à l'hôpital ou chez le médecin, et les coûts comprenaient les hospitalisations, les soins ambulatoires, les honoraires des médecins et les médicaments. Tous les coûts ont été convertis en dollars canadiens ($ CA) de 2022. Résultats: Parmi les 48 030 patients atteints de FA, 45,1 % étaient des femmes et 31,8 % étaient des utilisateurs très coûteux, en proportions égales entre les femmes et les hommes (31,9 % vs 31,7 %). Parmi les utilisateurs très coûteux, les femmes étaient plus âgées, plus susceptibles de présenter de l'hypertension et une insuffisance cardiaque, et leur risque d'AVC était plus élevé comparativement aux hommes. L'utilisation moyenne des soins de santé n'affichait pas de différences chez les utilisateurs très coûteux selon le sexe, à l'exception des consultations aux urgences, qui étaient plus fréquentes chez les hommes (12,7 % vs 9,2 %, p < 0,0001). Dans l'ensemble, les utilisateurs très coûteux représentaient 65,8 % des coûts totaux, qui étaient de 3,4 milliards de dollars canadiens. Les femmes représentaient par ailleurs près de la moitié du total des utilisations très coûteuses (966,1 millions de dollars canadiens). Des différences significatives ont été observées quant à la répartition des coûts liés aux utilisateurs très coûteux (hommes : hospitalisations [74,6 %], soins ambulatoires [9,5 %], honoraires des médecins [12,4 %], médicaments [3,5 %]; femmes : hospitalisations [77,7 %], soins ambulatoires [7,4 %], honoraires des médecins [11,5 %], médicaments [3,5 %], p < 0,0001). Conclusions: Bien que la FA soit moins fréquente chez les femmes que chez les hommes, celles-ci représentent une proportion tout aussi importante des utilisations très coûteuses et comptent pour presque la moitié des coûts totaux attribuables aux utilisateurs très coûteux. Des interventions visant à réduire les utilisations très coûteuses pour la FA sont donc nécessaires, particulièrement chez les femmes.

Arrhythmias in Female Patients: Incidence, Presentation and Management.

There is a growing appreciation for differences in epidemiology, treatment, and outcomes of cardiovascular conditions by sex. Historically, cardiovascular clinical trials have under-represented females, but findings have nonetheless been applied to clinical care in a sex-agnostic manner. Thus, much of the collective knowledge about sex-specific cardiovascular outcomes result from post hoc and secondary analyses. In some cases, these investigations have revealed important sex-based differences with implications for optimizing care for female patients with arrhythmias. This review explores the available evidence related to cardiac arrhythmia care among females, with emphasis on areas in which important sex differences are known or suggested. Considerations related to improving female enrollment in clinical trials as a way to establish more robust clinical evidence for the treatment of females are discussed. Areas of remaining evidence gaps are provided, and recommendations for areas of future research and specific action items are suggested. The overarching goal is to improve appreciation for sex-based differences in cardiac arrhythmia care as 1 component of a comprehensive plan to optimize arrhythmia care for all patients.

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.

Cost-Utility of Catheter Ablation for Atrial Fibrillation in Patients with Heart Failure: An Economic Evaluation.

Background Recent trials comparing catheter ablation to medical therapy in patients with heart failure (HF) with symptomatic atrial fibrillation despite first-line management have demonstrated a reduction in adverse outcomes. We performed an economic evaluation to estimate the cost-utility of catheter ablation as second line therapy in patients with HF with reduced ejection fraction. Methods and Results A Markov model with health states of alive, dead, and alive with amiodarone toxicity was constructed, using the perspective of the Canadian healthcare payer. Patients in the alive states were at risk of HF and non-HF hospitalizations. Parameters were obtained from randomized trials and Alberta health system data for costs and outcomes. A lifetime time horizon was adopted, with discounting at 3.0% annually. Probabilistic and 1-way sensitivity analyses were performed. Costs are reported in 2018 Canadian dollars. A patient treated with catheter ablation experienced lifetime costs of $64 960 and 5.63 quality-adjusted life-years (QALY), compared with $49 865 and 5.18 QALYs for medical treatment. The incremental cost-effectiveness ratio was $35 360/QALY (95% CI, $21 518-77 419), with a 90% chance of being cost-effective at a willingness-to-pay threshold of $50 000/QALY. A minimum mortality reduction of 28%, or a minimum duration of benefit of >1 to 2 years was required for catheter ablation to be attractive at this threshold. Conclusions Catheter ablation is likely to be cost-effective as a second line intervention for patients with HF with symptomatic atrial fibrillation, with incremental cost-effectiveness ratio $35 360/QALY, as long as over half of the relative mortality benefit observed in extant trials is borne out in future studies.

Is Screening for Atrial Fibrillation and Its Risk Factors Useful and Cost-Effective?

Atrial fibrillation (AF) is a major, preventable cause of stroke, whose prevalence is increasing with the aging of the population. There are safe and effective anticoagulation therapies to prevent stroke and new technologies that can identify AF in asymptomatic individuals. Ongoing research will determine if AF screening is cost-effective and will define the best screening strategies. The effectiveness of AF screening can be enhanced by simultaneously screening for the cardiovascular conditions that predispose to the development and progression of AF and its complications. Future studies evaluating an integrated screening program on outcomes, health care utilization, and cost are needed.

Ambulance Use, Health Outcomes, and Costs for Emergency Department Visits for Primary Diagnosis of Syncope in Canada.

BACKGROUND: Syncope is a common presentation to the emergency department (ED), yet little is known regarding patient mode of arrival. METHODS: We identified patients ≥20 years old who presented to the ED with a primary diagnosis of syncope in Alberta and Ontario, Canada, between 2010 and 2016. Outcomes included 30-day in-hospital mortality, ED revisits, and rehospitalizations according to mode of arrival and discharge status. The estimated cost for ambulance use was calculated based on the provincial rates (Alberta CAD$385 and Ontario $240). RESULTS: A total of 271,601 syncope presentations to the ED were identified and 60.7% arrived by ambulance. A total of 76.3% (n = 125,793) of ambulance users and 87.0% of self-presenters (n = 92,845) were discharged from the ED. Regardless of mode of arrival, discharged patients were younger with fewer comorbidities. Compared with ambulance users admitted, those discharged had lower in-hospital mortality (0.2% vs 3.5%, P < 0.001), ED revisits (4.4% vs 10.4%, P < 0.001), and rehospitalizations (3.6% vs 10.7%, P < 0.001). Discharged self-presenters also had significantly lower outcomes (P < 0.001, for each outcome) compared with admitted self-presenters. The estimated cost for ambulance use among patients discharged from the ED was $33,137,735. CONCLUSION: A majority of syncope patients arrived to the ED by ambulance, and over 3 quarters were directly discharged home. Although discharged patients had a favourable short-term prognosis, they incurred high transportation costs. Strategies aimed at preventing unnecessary ambulance use are needed.

CONTEXTE: La syncope est une manifestation courante chez les patients qui se présentent au service des urgences; pourtant, on en sait peu sur la façon dont ces patients arrivent à l'hôpital. MÉTHODOLOGIE: Nous avons examiné les dossiers de patients âgés de 20 ans ou plus qui se sont présentés au service des urgences d'hôpitaux de l'Alberta et de l'Ontario, au Canada, et qui ont reçu un diagnostic de syncope entre 2010 et 2016. Les issues évaluées comprenaient la mortalité hospitalière à 30 jours, les nouvelles visites au service des urgences et les réadmissions à l'hôpital en fonction du mode d'arrivée et du statut au moment de la sortie de l'hôpital. Le coût estimatif des services d'ambulance a été calculé à partir des tarifs provinciaux (385 $ en Alberta et 240 $ en Ontario). RÉSULTATS: En tout, 271 601 cas de syncope ont été recensés dans les services des urgences; dans 60,7 % des cas, le patient est arrivé en ambulance. Au total, 76,3 % (n = 125 793) des patients arrivés en ambulance et 87,0 % des patients qui se sont présentés d'eux-mêmes (n = 92 845) ont reçu leur congé du service des urgences. Quel que soit leur mode d'arrivée, les patients qui ont reçu leur congé étaient plus jeunes et présentaient moins d'affections concomitantes. Chez les patients arrivés en ambulance, ceux qui ont reçu leur congé ont affiché des résultats inférieurs à ceux qui ont été admis à l'hôpital quant à la mortalité hospitalière (0,2 % vs 3,5 %, p < 0,001), aux nouvelles visites au service des urgences (4,4 % vs 10,4 %, p < 0,001) et aux réadmissions à l'hôpital (3,6 % vs 10,7 %, p < 0,001). Dans le cas des patients qui se sont présentés d'eux-mêmes, l'incidence des issues évaluées était aussi plus faible chez ceux qui ont reçu leur congé (p < 0,001 pour chaque issue) que chez ceux qui ont été admis à l'hôpital. Le coût estimatif du recours aux services d'ambulance par les patients qui ont reçu leur congé du service des urgences se chiffrait à 33 137 735 $. CONCLUSION: La majorité des patients subissant une syncope sont arrivés au service des urgences en ambulance, et plus des trois quarts ont reçu directement leur congé à la maison. Bien que le pronostic à court terme des patients ayant reçu leur congé du service des urgences ait été favorable, ces patients ont dû payer des frais de transport élevés. Des stratégies visant à prévenir le recours inutile aux services d'ambulance s'imposent.

Canadian Cardiovascular Society Clinical Practice Update on the Assessment and Management of Syncope.

Syncope is a symptom that occurs in multiple settings and has a variety of underlying causes, ranging from benign to life threatening. Determining the underlying diagnosis and prognosis can be challenging and often results in an unstructured approach to evaluation, which is ineffective and costly. In this first ever document, the Canadian Cardiovascular Society (CCS) provides a clinical practice update on the assessment and management of syncope. It highlights similarities and differences between the 2017 American College of Cardiology/American Heart Association/Heart Rhythm Society and the 2018 European Society of Cardiology guidelines, draws on new data following a thorough review of medical literature, and takes the best available evidence and clinical experience to provide clinical practice tips. Where appropriate, a focus on a Canadian perspective is emphasized in order to illuminate larger international issues. This document represents the consensus of a Canadian panel comprised of multidisciplinary experts on this topic with a mandate to formulate disease-specific advice. The primary writing panel wrote the document, followed by peer review from the secondary writing panel. The CCS Guidelines Committee reviewed and approved the statement. The practice tips represent the consensus opinion of the primary writing panel authors, endorsed by the CCS. The CCS clinical practice update on the assessment and management of syncope focuses on epidemiology, the initial evaluation including risk stratification and disposition from the emergency department, initial diagnostic work-up, management of vasovagal syncope and orthostatic hypotension, and syncope and driving.

The Current and Future Hospitalization Cost Burden of Syncope in Canada.

BACKGROUND: Single-center studies have shown the high costs associated with the hospital evaluation of syncope. National cost estimates for syncope-related hospitalizations are sparse, and none exist in Canada. METHODS: The Canadian Institute for Health Information Discharge Abstract Database was used to identify acute care hospitalizations with a primary diagnosis of syncope between fiscal years (FY) 2004 and 2015 in all provinces and territories (except Quebec). We used multiple linear regression to calculate the trends in prevalence of hospital admissions and generalized linear regression to estimate the costs of a hospitalization. The syncope hospitalization rate and the cost per hospitalization in Quebec were assumed to be the average of the rest of the country. The future hospitalization cost burden of syncope was projected to 2030. RESULTS: There were 128,263 hospitalizations for a primary diagnosis of syncope over the 10-year study period, resulting in a total cost of $619.9 million (Canadian). An estimate of 41,044 syncope hospitalizations occurred in Quebec, costing $198.7 million. The total hospitalization cost of syncope in Canada was estimated at $818.5 million. The annual costs of syncope hospitalizations increased from $66.6 to $68.5 million between FY2004 and FY2015, respectively, and are projected to increase to $87.1 million in 2030. CONCLUSION: Hospitalization costs for syncope in Canada are high and rising. Research is needed to identify opportunities to deliver more efficient and cost-effective care.

CONTEXTE: Des études monocentriques ont mis en lumière les coûts élevés associés à l'évaluation hospitalière d'une syncope. Les estimations nationales du coût des hospitalisations liées aux syncopes sont rares, et il n'en existe aucune au Canada. MÉTHODOLOGIE: La base de données sur les congés des patients de l'Institut canadien d'information sur la santé a été utilisée pour recenser les hospitalisations de courte durée liées à un diagnostic primaire de syncope entre les années financières (AF) 2004 et 2015 dans toutes les provinces et territoires (sauf le Québec). Nous avons eu recours, d'une part, à la régression linéaire multiple pour calculer les tendances de la prévalence d'admissions à l'hôpital et, d'autre part, à la régression linéaire généralisée pour estimer les coûts d'une hospitalisation. Le taux d'hospitalisations liées à une syncope et le coût par hospitalisation au Québec ont été établis hypothétiquement à la moyenne du reste du pays. Le futur fardeau du coût des hospitalisations liées à une syncope a été projeté jusqu'en 2030. RÉSULTATS: Nous avons recensé 128 263 hospitalisations liées à un diagnostic primaire de syncope au cours de la période de 10 ans à l'étude, ce qui se traduit par un coût total de 619,9 M$ (canadiens). Selon une estimation, 41 044 hospitalisations liées à une syncope seraient survenues au Québec, au coût de 198,7 M$. Le coût total des hospitalisations liées à une syncope au Canada a été estimé à 818,5 M$. Les coûts annuels des hospitalisations liées à une syncope ont augmenté, passant de 66,6 à 68,5 M$ entre les AF 2004 et 2015, respectivement, et ils devraient encore augmenter pour atteindre 87,1 M$ en 2030. CONCLUSION: Les coûts des hospitalisations liées à une syncope au Canada sont élevés et en hausse. D'autres travaux de recherche devront être effectués pour cerner les possibilités de prestations de soins plus efficaces et rentables.

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.

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.

An Update on the Development and Feasibility Assessment of Canadian Quality Indicators for Atrial Fibrillation and Atrial Flutter.

BACKGROUND: In 2010, the Canadian Cardiovascular Society Atrial Fibrillation/Atrial Flutter (AF/AFL) quality indicator (QI) working group was established to develop QIs and assess feasibility of measurement. After extensive review, 3 priority QIs were selected. However, none were measurable at a national level. METHODS: The working group reconvened in 2017 to review the relevance of previously proposed QIs, identify opportunities to develop new QIs, and propose an initial strategy for measuring and reporting. RESULTS: Two additional priority QIs were added to the previous 3: proportion of patients with nonvalvular (NV) AF/AFL sorted by stroke risk stratum and annual rate of hospitalization for a new heart failure diagnosis. An environmental scan was undertaken to determine the potential of existing databases to provide national and provincial estimates. On the basis of validated administrative codes, the Canadian Institute for Health Information discharge abstract database can be used for inpatients. In collaboration with the Canadian Primary Care Sentinel Surveillance Network, 2 of the 5 QIs can be assessed in outpatients (patients with NVAF/AFL sorted by stroke risk stratum and high risk for stroke NVAF/AFL receiving oral anticoagulation). Stroke prevention therapy can be further measured in selected provinces with linked databases including prescriptions. CONCLUSIONS: This first step could provide a better initial understanding of the quality of AF/AFL care in Canada, but important gaps in the meaningful measurement of QIs remain. The AF/AFL QI working group has limited capacity to make progress without national level leadership and the resources to support data aggregation, data analysis, and pan-Canadian reporting.

CONTEXTE: En 2010, le groupe de travail des indicateurs de qualité (IQ) de la Société canadienne de cardiologie sur la fibrillation auriculaire (FA) et le flutter auriculaire (FLA) a été mis sur pied pour élaborer des IQ et évaluer la faisabilité d'utiliser ces IQ comme outils de mesure. Après un examen approfondi, trois IQ prioritaires ont été sélectionnés, mais aucun n'a pu être mesuré à l'échelle nationale. MÉTHODOLOGIE: Le groupe de travail s'est réuni à nouveau en 2017 afin d'examiner la pertinence des IQ proposés au départ, de recenser des occasions d'élaborer de nouveau IQ et de proposer une stratégie initiale de mesure et de production de rapports à cet égard. RÉSULTATS: Deux IQ prioritaires supplémentaires ont été ajoutés aux trois premiers : la proportion de patients atteints de FA non valvulaire (FANV) ou de FLA ayant fait l'objet d'un tri selon la strate de risque d'AVC et le taux annuel d'hospitalisations attribuables à un nouveau diagnostic d'insuffisance cardiaque. Une analyse de l'environnement a été réalisée afin de déterminer si les bases de données existantes pouvaient fournir des estimations nationales et provinciales. Dans le cas de patients hospitalisés, on peut utiliser la Base de données sur les congés des patients de l'Institut canadien d'information sur la santé en se servant de codes administratifs validés. Dans le cas de patients non hospitalisés (patients atteints de FANV/FLA, triés par strate de risque, exposés à un risque élevé d'AVC en raison d'une FANV ou d'un FLA et recevant une anticoagulation orale), on peut mesurer deux des cinq IQ, en collaboration avec le Réseau canadien de surveillance sentinelle en soins primaires. Le traitement préventif de l'AVC peut continuer à faire l'objet de mesures dans certaines provinces grâce aux bases de données interreliées, comme les bases de données sur les ordonnances. CONCLUSIONS: Cette première étape a permis d'obtenir une meilleure compréhension initiale de la qualité de la prise en charge de la FA et du FLA au Canada, mais d'importantes lacunes restent à combler pour rendre pertinente la mesure des IQ. Le groupe de travail des IQ sur de la FA et le FLA n'a pas toutes les capacités requises pour réaliser des progrès en l'absence de leadership national et de ressources permettant de soutenir le regroupement et l'analyse des données, ainsi que la production de rapports à l'échelle pancanadienne.

Is Screening for Atrial Fibrillation in Canadian Family Practices Cost-Effective in Patients 65 Years and Older?

We present an economic evaluation of a recently completed cohort study in which 2054 seniors were screened for atrial fibrillation (AF) in 22 Canadian family practices. Using a Markov model, trial and literature data were used to project long-term outcomes and costs associated with 4 AF screening strategies for individuals aged 65 years or older: no screening, screen with 30-second radial manual pulse check (pulse check), screen with a blood pressure machine with AF detection (BP-AF), and screen with a single-lead electrocardiogram (SL-ECG). Costs and outcomes were discounted at 1.5% and the model used a lifetime horizon from a public payer perspective. Compared with no screening, screening for AF in Canadian family practice offices using pulse check or screen with a blood pressure machine with AF detection is the dominant strategy whereas screening with SL-ECG is a highly cost-effective strategy with an incremental cost per quality-adjusted life-year (QALY) gained of CAD$4788. When different screening strategies were compared, screening with pulse check had the lowest expected costs ($202) and screening with SL-ECG had the highest expected costs ($222). The no-screening arm resulted in the lowest number of QALYs (8.74195) whereas pulse check and SL-ECG resulted in the highest expected QALYs (8.74362). Probabilistic analysis confirmed that pulse check had the highest probability of being cost-effective (63%) assuming a willingness to pay of $50,000 per QALY gained. Screening for AF in seniors during routine appointments with Canadian family physicians is a cost-effective strategy compared with no screening. Screening with a pulse check is likely to be the most cost-effective strategy.

Geographical Differences in Comorbidity Burden and Outcomes in Adults With Syncope Hospitalizations in Canada.

A recent study found that rates of hospitalization for syncope vary across provinces; however, it is unknown whether differences in comorbidity burden and outcomes also exist. The Canadian Institute for Health Information Discharge Abstract Database was used to identify primary syncope hospitalizations (ICD-10 code R55) from 2004 to 2013 for all provinces (except Quebec). Charlson comorbidity score was calculated from comorbidities at the time of hospitalization. Outcomes were defined as in-hospital mortality, 30-day readmission for any cause, and syncope. Logistic regression models were constructed for odds ratios (ORs) and 95% confidence intervals (CIs) to estimate interprovincial differences in outcomes. The interprovincial range (IPR) for mean age was 61.1 ± 17.5 to 73.7 ± 16.3 years, and at least half were male patients. There were significant differences in comorbidity burden across provinces (P < 0.01); however, the majority of patients had a Charlson comorbidity score = 0 (IPR, 53.9%- 71.9%). In multivariable analysis, compared with Ontario, in-hospital mortality was higher for British Columbia (OR, 1.59; 95% CI, 1.22-2.06), Nova Scotia (OR, 1.67; 95% CI, 1.05-2.65), and Newfoundland (OR, 2.27; 95% CI, 1.29-4.00); 30-day readmission for any cause was higher for British Columbia (OR, 1.15; 95% CI, 1.06-1.26), Alberta (OR, 1.19; 95% CI, 1.07-1.31), Manitoba (OR, 1.36; 95% CI, 1.18-1.56), and Prince Edward Island (OR, 1.38; 95% CI, 1.0-1.89), and all outcomes were higher in Saskatchewan. There is significant interprovincial heterogeneity in comorbidity burden and outcomes for hospitalizations for syncope. Future research evaluating whether standardized practices for management of syncope reduce variability and improve healthcare utilization and costs is needed.

A Population-Based Cohort Study Evaluating Outcomes and Costs for Syncope Presentations to the Emergency Department.

OBJECTIVES: This study sought to examine outcomes and costs of patients with syncope admitted and discharged from the emergency department (ED). BACKGROUND: ED visits for syncope are common, yet the impact on health care utilization is relatively unknown. METHODS: A total of 51,831 consecutive patients presented to the ED with a primary diagnosis of syncope (International Classification of Diseases-9 code 780.2 and International Classification of Diseases-10 code R55) in Alberta, Canada from 2006 to 2014. Outcomes included 30-day syncope ED and hospital readmissions; 30-day and 1-year mortality; and annual inpatient, outpatient, physician, and drug costs, cumulative. RESULTS: Of adults presenting to the ED, 6.6% were hospitalized and discharged with a primary diagnosis of syncope (Cohort 1), 8.7% were hospitalized and discharged with a primary diagnosis other than syncope (Cohort 2), and 84.7% were discharged home with a syncope diagnosis (Cohort 3). The 30-day ED revisits for syncope varied from 1.2% (Cohort 2) to 2.4% (Cohort 1) (p < 0.001), and readmission rates were <1% among cohorts. Short- and long-term mortality rates were highest for Cohort 2 and lowest for Cohort 3 (30-day mortality: Cohort 1 of 1.2%, Cohort 2 of 5.2%, Cohort 3 of 0.4%; p < 0.001) (1-year mortality: Cohort 1 of 9.2%, Cohort 2 of 17.7%, Cohort 3 of 3.0%; p < 0.001). Total cost of syncope presentations was $530.6 million (Cohort 1: $75.3 million; $29,519/patient, Cohort 2: $138.1 million; $42,042/patient, Cohort 3: $317.3 million; $9,963/patient; p<0.001). CONCLUSIONS: Most patients with syncope presenting to the ED were discharged and had a favorable prognosis but overall costs were high compared with patients hospitalized. Further research is needed for cost-saving strategies across all cohorts.

Screening for atrial fibrillation in Canadian pharmacies: an economic evaluation.

BACKGROUND: Screening for undiagnosed atrial fibrillation may lead to treatment with oral anticoagulation therapy, which can decrease the risk of ischemic stroke. The objective of this study was to conduct an economic evaluation of the Program for the Identification of 'Actionable' Atrial Fibrillation in the Pharmacy Setting (PIAAF-Pharmacy), which screened 1145 participants aged 65 years or more at 30 community pharmacies in Ontario and Alberta between October 2014 and April 2015. METHODS: We used a 2-part decision model to evaluate the short- and long-term costs and quality-adjusted life-years (QALYs) of a pharmacy screening program for atrial fibrillation compared to no screening. Data from the PIAAF-Pharmacy study were used for the short-term model, and the relevant literature was used to extrapolate the benefits of the PIAAF-Pharmacy study in the long-term model. Costs and QALYs were calculated from a payer perspective over a lifetime horizon and were discounted at 1.5%/year. RESULTS: Screening for atrial fibrillation in pharmacies was associated with higher costs ($26) and more QALYs (0.0035) compared to no screening, yielding an incremental cost per QALY gained of $7480. Univariate and probabilistic sensitivity analyses confirmed that screening for atrial fibrillation in a pharmacy setting was a cost-effective strategy. INTERPRETATION: Our results support screening for atrial fibrillation in Canadian pharmacies. Given this finding, efforts should be made by provincial governments and pharmacies to implement such programs in Canada. The addition of atrial fibrillation screening alongside screening and management of other cardiovascular conditions may help to reduce the burden of stroke.

Dietary fat quality and risk of sudden cardiac death in women.

BACKGROUND: Dietary n-3 PUFAs are inversely associated with risk of sudden cardiac death (SCD); however, little is known about other fats and SCD. Furthermore, concerns have been raised that high n-6 PUFA intake may attenuate the benefits of n-3 PUFAs. OBJECTIVE: We examined associations and selected interactions between dietary fatty acids, expressed as a proportion of total fat and SCD. DESIGN: We conducted a prospective cohort study among 91,981 women aged 34-59 y from the Nurses' Health Study in 1980. Over 30 y, we documented 385 SCDs. RESULTS: In multivariable models, women in the highest compared with the lowest quintile of SFA intake had an RR of SCD of 1.44 (95% CI: 1.04, 1.98). Conversely, women in the highest compared with the lowest quintile of PUFA intake had an RR of SCD of 0.57 (95% CI: 0.41, 0.78). Intakes of n-6 and n-3 PUFAs were both significantly associated with a lower risk of SCD, and n-6 PUFAs did not modify the association between n-3 PUFAs and SCD. MUFAs and trans fats were not associated with SCD risk. After further adjustment for coronary heart disease (CHD) and CHD risk factors potentially in the causal pathway, the association between PUFAs and SCD remained significant, whereas the association for SFAs was no longer significant. CONCLUSIONS: Intake of PUFAs as a proportion of fat was inversely associated with SCD risk, independent of traditional CHD risk factors. These results support dietary guidelines to improve dietary fat quality by replacing intake of SFAs with n-6 and n-3 PUFAs.