The associations between direct and delayed critical care unit admission with mortality and readmissions among patients with heart failure.

BACKGROUND: Although greater than 20% of patients hospitalized with heart failure (HF) are admitted to a critical care unit, associated outcomes, and costs have not been delineated. We determined 30-day mortality, 30-day readmissions, and hospital costs associated with direct or delayed critical care unit admission. METHODS: In a population-based analysis, we compared HF patients who were admitted to critical care directly from the emergency department (direct), after initial ward admission (delayed), or never admitted to critical care during their hospital stay (ward-only). RESULTS: Among 178,997 HF patients (median age 80 [IQR 71-86] years, 49.6% men) 36,175 (20.2%) were admitted to critical care during their hospitalization (April 2003 to March 2018). Critical care patients were admitted directly from the emergency department (direct, 81.9%) or after initial ward admission (delayed, 18.1%). Multivariable-adjusted hazard ratios (HR) for all-cause 30-day mortality were: 1.69 for direct (95% confidence interval [CI]; 1.55, 1.84) and 4.92 for delayed (95% CI; 4.26, 5.68) critical care-admitted compared to ward-only patients. Multivariable-adjusted repeated events analysis demonstrated increased risk for all-cause 30-day readmission with both direct (HR 1.04, 95% CI; 1.01, 1.08, P = .013) and delayed critical care unit admissions (HR 1.20, 95% CI; 1.13, 1.28, P < .001). Median 30-day costs were $12,163 for direct admissions, $20,173 for delayed admissions, and $9,575 for ward-only patients (P < .001). CONCLUSIONS: While critical care unit admission indicates increased risk of mortality and readmission at 30 days, those who experienced delayed critical care unit admission exhibited the highest risk of death and highest costs of care.

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

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

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

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

Emergency Department Volume and Outcomes for Patients After Chest Pain Assessment.

BACKGROUND: Chest pain is one of the most common reasons for emergency department (ED) visits in developed countries. Whether higher volume EDs have better outcomes, specifically for patients with chest pain, is unknown and pertinent. METHODS AND RESULTS: We conducted a study using population-based data on 498 291 patients ≥40 years old, presenting to ED in Ontario, Canada from 2008 to 2014, with chest pain and were discharged after assessment. We evaluated processes of care after discharge from ED. The primary outcome was a composite of all-cause death or hospitalization for acute coronary syndrome. Hierarchical logistic regression models adjusting for potential confounding variables were used to evaluate the association of annual ED chest pain volume and outcome. We also determined if there was a volume threshold above which an increased ED volume was not associated with a lower adverse outcome. The mean age of our patients was 59 years, 46.7% were men, and 20% had diabetes mellitus. Patients discharged from higher volume EDs had higher rates of cardiologist consultations, cardiac medication use, and cardiac testing within 30 days of ED assessment. Higher ED volume was associated with significantly lower adjusted odds ratio for mortality or acute coronary syndrome (odds ratio, 0.87; 95% CI, 0.82-0.92 per each unit increase in the log of volume) at 30 days and at 1 year (odds ratio, 0.92; 95% CI, 0.88-0.92). Once the annual ED chest pain volume reached 1400 cases (95% CI, 910-1900), an increase of annual chest pain volume of 100 was associated with relative decrease in the odds of the composite outcome at 30 days of <1%. CONCLUSIONS: Evaluations of chest pain in EDs with higher chest pain volume had lower rates of death or hospitalizations for acute coronary syndrome. There was a volume threshold above which an increase in volume was no longer associated with reduced outcomes.

Canadian Alliance for Healthy Hearts and Minds: First Nations Cohort Study Rationale and Design.

BACKGROUND: This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. OBJECTIVES: The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. METHODS: CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). RESULTS: Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. CONCLUSIONS: Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Clinical Outcomes of Plavix and Generic Clopidogrel for Patients Hospitalized With an Acute Coronary Syndrome.

BACKGROUND: Clopidogrel is one of the most commonly prescribed medications because of its ability to improve clinical outcomes for a broad range of cardiovascular conditions. After patent protection expired for Plavix in 2012, many healthcare systems adopted generic clopidogrel as a strategy to reduce healthcare costs. METHODS AND RESULTS: We conducted a population-based observational study to determine whether generic clopidogrel was noninferior to Plavix. Patients who were hospitalized with an acute coronary syndrome (ACS) from 2009 to 2014 in Ontario, Canada, >65 years, survived ≥7 days after discharge, were eligible for inclusion. The primary outcome was a composite of death and recurrent ACS at 1 year. The noninferiority margin was prespecified at a relative hazard difference of 10%. Inverse propensity of treatment weighting of the propensity score was used to account for differences in baseline characteristics between the treatment groups. The effect of clopidogrel on the hazard of clinical outcomes was estimated using a Cox proportional hazards model within the propensity-weighted cohort using Plavix as a reference. Our study included 24 530 patients with ACS, 12 643 were prescribed Plavix and 11 887 were prescribed generic clopidogrel at hospital discharge. The mean age was 77 years, 57% were men, and 21% had an ST-segment-elevation myocardial infarction. At 1 year, 17.6% of patients prescribed Plavix and 17.9% of patients prescribed clopidogrel experienced the primary outcome (hazard ratio, 1.02; 95% confidence interval, 0.96-1.08; P=0.005 for noninferiority). No significant differences between rates of death, all-cause readmission, ACS, stroke or transient ischemic attack, or bleeding were observed. CONCLUSIONS: Generic clopidogrel was noninferior to Plavix with respect to the composite end point of death and recurrent hospitalization for ACS at 1 year among adults >65 years after an ACS hospitalization. Our findings support generic clopidogrel in ACS, which could lead to substantial healthcare cost savings.

Effect of Electrophysiology Assessment on Mortality and Hospitalizations in Patients With New-Onset Atrial Fibrillation.

Few patients with atrial fibrillation (AF) receive care by cardiac electrophysiologists. Although previous work has highlighted differential care for patients with AF treated by electrophysiologists, it is unclear whether this is associated with improved clinical outcomes. This retrospective population-level propensity score-matched cohort study included patients aged 20 to 80 years with new-onset AF presenting to an emergency department (ED) in Ontario, Canada, between 2010 and 2012. Patients were followed until March 31, 2015. Patients who saw an electrophysiologist within 1 year of the index ED visit were matched to patients who did not see an electrophysiologist. Linked administrative databases were used for cohort construction and allow 1-year follow-up to assess for the clinical end points of all-cause mortality and hospitalization for AF, heart failure, bleeding, and stroke. A total of 5,221 unique pairs of patients were matched. One hundred seventeen patients (2.2%) in the electrophysiologist cohort underwent an AF ablation procedure during the 1-year follow-up period. All-cause mortality (hazard ratio [HR] = 1.1, p = 0.17) and stroke (HR = 1.4, p = 0.09) were not significantly different between the 2 groups. Hospitalization for AF (HR = 1.4, p <0.001), bleeding (HR = 1.5, p = 0.0001), and congestive heart failure (HR = 1.5, p <0.0001) was increased in the group that saw an electrophysiologist. In conclusion, electrophysiologist care was not associated with improved clinical outcomes in patients with new-onset AF.

Interventions Supporting Long-term Adherence aNd Decreasing cardiovascular events (ISLAND): Pragmatic randomized trial protocol.

BACKGROUND: Guidelines recommend cardiac rehabilitation and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary prevention treatments is suboptimal. METHODS: This is a multicenter, pragmatic, 3-arm randomized trial. Eligible patients (n = 2,742) with obstructive coronary artery disease are randomized post-MI to usual care or 1 of 2 intervention arms. Patients in the first intervention arm receive mail-outs sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system telephone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the interactive voice response system identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of cardiac rehabilitation. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned. CONCLUSIONS: We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions.

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

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

Association of a Blood Glucose Test Strip Quantity-Limit Policy With Patient Outcomes: A Population-Based Study.

Importance: Given their high costs, payers have considered implementing quantity limits for reimbursement of blood glucose test strips. The effect of these limits on patient outcomes is unknown. Objective: To determine whether the introduction of quantity limits for blood glucose test strips in August 2013 was associated with changes in clinical outcomes. Design, Setting, and Participants: Cross-sectional time series analysis from April 2008 to March 2015 of residents of Ontario, Canada, aged 19 years and older with diabetes who were eligible for public drug coverage. In a sensitivity analysis, we studied high-volume users of test strips, who were most likely to be affected by the quantity limits. Exposures: Eligible patients were stratified into 4 mutually exclusive groups based on diabetes therapy: insulin, hypoglycemia-inducing oral diabetes agents, nonhypoglycemia-inducing oral diabetes agents, and no drug therapy. Main Outcomes and Measures: The primary outcome was emergency department visits for hypoglycemia or hyperglycemia, and the secondary outcome was mean hemoglobin A1c (HbA1c) levels. Outcomes were measured for all patients in each quarter, stratified by age group (<65 vs ≥65 years) and diabetes therapy. Results: By the end of the study period, 834 309 people met inclusion criteria. Among those younger than 65 years, the rate of hypoglycemia and hyperglycemia declined over the study period (from 4.9 to 3.0 visits per 1000 Ontario drug benefit [ODB]-eligible patients and from 4.2 to 3.6 visits per 1000 ODB-eligible patients, respectively) and was not significantly associated with the introduction of quantity limits (P = .67 and P = .37, respectively). Similarly, among those aged 65 years and older, rates of hypoglycemia and hyperglycemia declined over the study period (from 2.9 to 1.3 visits per 1000 eligible patients and from 0.8 to 0.5 visits per 1000 eligible patients, respectively) and was not significantly associated with the introduction of quantity limits (P = .12 and P = .24, respectively). Results were consistent for the secondary outcome of mean HbA1c levels and in the sensitivity analysis of high-volume test strip users. Conclusions and Relevance: The imposition of quantity limits for blood glucose test strips was not associated with worsening short-term outcomes, suggesting that these policies can reduce costs associated with test strips without causing patient harm.

A Population-Based Study of Cardiovascular Mortality Following Early-Stage Breast Cancer.

Importance: There is increasing interest in the effect of cardiovascular disease on cancer survivors. However, there are limited contemporary population-based data on the risk of cardiovascular death after early-stage breast cancer. Objective: To describe the incidence of cardiovascular death in a contemporary population of women with early-stage breast cancer while accounting for competing risks. Design, Setting, and Participants: A population-based cohort study was conducted among 98 999 women diagnosed with early-stage breast cancer between April 1, 1998, and March 31, 2012. Patients were followed up until death or were censored on December 31, 2013. Baseline characteristics were determined from administrative databases and the Ontario Cancer registry. Vital statistics data were used to determine the cause of death. Cumulative incidence functions were used to estimate the incidence of cause-specific mortality. We studied the association between baseline characteristics and rates of cardiovascular death using cause-specific hazard functions. The analyses accounted for competing risks of noncardiovascular death. Statistical analysis was performed from July 16, 2015, to August 4, 2016. Exposures: Early-stage breast cancer, age, cardiovascular disease, hypertension, and diabetes. Main Outcomes and Measures: Cause of death, which was classified as breast cancer, cardiovascular disease, other cancers, or other noncancer causes. Results: Of the 98 999 women (median age, 60 years [interquartile range, 50-71 years]) in the study, 21 123 (21.3%) died during follow-up. The median time to death was 4.2 years (IQR, 2.2-7.1 years). Breast cancer was the most common cause of death (10 550 deaths [49.9%]); 3444 deaths [16.3%] were from cardiovascular causes. Cardiovascular death was infrequent in women younger than 66 years without prior cardiovascular disease, diabetes, or hypertension. Among women 66 years or older, the risks of breast cancer death and cardiovascular death at 10 years were 11.9% (95% CI, 11.6%-12.3%) and 7.6% (95% CI, 7.3%-7.9%), respectively. Among patients with prior cardiovascular disease, the risk of death from breast cancer and cardiovascular disease were equivalent for the first 5 years, after which death from cardiovascular causes was more frequent (10-year cumulative incidence, 14.6% [95% CI, 13.7%-15.4%] for breast cancer vs 16.9% [95% CI, 16.0%-17.8%] for cardiovascular disease). For women 66 years or older who survived 5 years or more after diagnosis of breast cancer, cardiovascular disease exceeded breast cancer as the leading cause of death at 10 years after diagnosis, when the cumulative incidence of each was 5%. Conclusions and Relevance: Cardiovascular death is an important competing risk for older women with early-stage breast cancer. This finding mandates adequate attention to cardiovascular preventive therapy after diagnosis of breast cancer.

Factors Associated With Cardiac Electrophysiologist Assessment and Catheter Ablation Procedures in Patients With Atrial Fibrillation.

OBJECTIVES: This study sought to determine factors associated with cardiac electrophysiologist assessment and atrial fibrillation (AF) ablation in patients with new-onset AF. BACKGROUND: Factors driving variation in the use of AF ablation have not been well described. METHODS: All individuals with new-onset AF in Ontario, Canada, between January 1, 2010, and December 31, 2012, were identified. Survival analysis accounting for the competing risk of death was used to evaluate the association between clinical and nonclinical factors and receipt of an electrophysiologist assessment. Factors associated with AF ablation were then determined in the subgroup of patients who received an electrophysiologist assessment. RESULTS: A total of 22,032 patients with new-onset AF were identified, 8,161 (37%) of whom received an electrophysiology assessment. Prior cardiologist care was associated with electrophysiologist assessment (hazard ratio [HR]: 1.57; p < 0.0001). Rural residence was associated with a decreased incidence of electrophysiology assessment (HR: 0.80; p < 0.0001). A total of 424 (5.2%) patients receiving an electrophysiologist assessment had an AF ablation. Recurrent AF emergency department (ED) visits between the index ED visit and the initial electrophysiologist assessment (HR for ≥2 ED visits: 4.22; p < 0.0001) and rural residence (HR: 1.50; p = 0.002) were both associated with AF ablation. Cardiovascular comorbidities were associated with a decreased incidence of AF ablation. CONCLUSIONS: Rural patients with AF have a lower incidence of electrophysiologist assessment but paradoxically a higher incidence of AF ablation compared with their urban counterparts. Clinical factors such as recurrent ED visits for AF and cardiovascular comorbidities are the most important factors associated with of AF ablation.

Utilization of cardiac computed tomography angiography and outpatient invasive coronary angiography in Ontario, Canada.

BACKGROUND: Cardiac computed tomography angiography (coronary CTA) has emerged as a non-invasive method of diagnosing coronary artery disease. The extent of utilization and uptake of this technology since initiation of its funding by the government of Ontario is unknown. OBJECTIVES: The aim of our study was to examine coronary CTA utilization and the rates of elective invasive coronary angiography and revascularization before and after funding initiation. METHODS: We studied all coronary CTAs performed on adults in Ontario after initiation of funding. We also used an interrupted time series analysis to compare the average monthly rates of invasive angiography and revascularization before and after initiation of funding. RESULTS: There was an initial steep increase in age-and sex-standardized rates of coronary CTA from 5.0 to 11.4/100,000 over the first two quarters after funding initiation. Afterwards, there was a gradual increase in utilization from 11.4 to 17.1/100,000 over two subsequent calendar years. There was a significant reduction in both the mean monthly outpatient invasive coronary angiography (from 20.7 to 19.9 per 100,000 (p = 0.0004)) and revascularization (from 4.9 to 4.4 per 100,000 (p < 0.0001)) rates in the three years following introduction of the coronary CTA billing code as compared to the three prior to its introduction. CONCLUSIONS: Since the introduction of coronary CTA funding in Ontario, there has been a steady and controlled increase in its utilization. The increasing use of coronary CTA was associated with a reduction in both the rates of invasive angiography and revascularization.

The role of primary care physician and cardiologist follow-up for low-risk patients with chest pain after emergency department assessment.

BACKGROUND: Chest pain is one of the most common reasons for presentation to the emergency department (ED); however, there is a paucity of data evaluating the impact of physician follow-up and subsequent management. To evaluate the impact of physician follow-up for low-risk chest pain patients after ED assessment. METHODS: We performed a retrospective observational study of low-risk chest pain patients who were assessed and discharged home from an Ontario ED. Low risk was defined as ≥50 years of age and no diabetes or preexisting cardiovascular disease. Follow-up within 30 days was stratified as (a) no physician, (b) primary care physician (PCP) alone, (c) PCP with cardiologist, and (d) cardiologist alone. The primary outcome was death or myocardial infarction (MI) at 1 year. RESULTS: Among 216,527 patients, 29% had no-physician, 60% had PCP-alone, 8% had PCP with cardiologist, and 4% had cardiologist-alone follow-up after ED discharge. The mean age of the study cohort was 64.2 years, and 42% of the patients were male. After adjusting for important differences in baseline characteristics between physician follow-up groups, the adjusted hazard ratios for death or MI were 1.07 (95% CI 1.00-1.14) for the PCP group, 0.81 (95% CI 0.72-0.91) for the PCP with cardiologist group, and 0.87 (95% CI 0.74-1.02) for the cardiologist alone group, as compared with patients who had no follow-up. CONCLUSION: In this cohort of low-risk patients who presented to an ED with chest pain, follow-up with a PCP and cardiologist was associated with significantly reduced risk of death or MI at 1 year.

Impact of drug policy on regional trends in ezetimibe use.

BACKGROUND: Ezetimibe use has steadily increased in Canada during the past decade even in the absence of evidence demonstrating a beneficial effect on clinical outcomes. Among the 4 most populated provinces in Canada, there is a gradient in the restrictiveness of ezetimibe in public-funded formularies (most to least strict: British Columbia, Alberta, Quebec, and Ontario). The effect of formulary policy on the use of ezetimibe over time is unknown. METHODS AND RESULTS: We conducted a population-level cohort study using Intercontinental Marketing Services Health Canada's data from June 2003 to December 2012 to examine ezetimibe use in these 4 provinces to better understand the association between use and formulary restrictiveness. We found regional variations in the patterns of ezetimibe use. From June 2003 to December 2012, British Columbia (most restrictive) had the lowest monthly increasing rate from $261 to $21 926 ($190/100 000 population/mo), whereas Ontario (least restrictive) had the most rapid monthly increase from $223 to $74 030 ($ 647/100 000 population/mo), and Quebec from $130 to $59 690 ($522/100 000 population/mo) and Alberta from $356 to $ 37 604 ($327/100 000 population/mo) were intermediate (P<0.001). CONCLUSIONS: Ezetimibe use remains common, increasing during the past decade. Use steadily increased in provinces with the most lenient formularies. In contrast, use was lower, plateauing since 2008 in British Columbia and Alberta, which have more restrictive formularies. The gradient in ezetimibe use was related to variability in restrictiveness of the provincial formularies, illustrating the potential of a policy response gradient that may be used to more effectively manage medication use.

Impact of the ENHANCE trial on the use of ezetimibe in the United States and Canada.

BACKGROUND: We previously found that the use of ezetimibe increased rapidly with different patterns between the United States (US) and Canada prior to the landmark Ezetimibe and Simvastatin in Hypercholesterolemia Enhance Atherosclerosis Regression (ENHANCE) trial, which was reported in January 2008, and failed to show that the drug slowed the progression of atherosclerosis. What is not known is how practice in the 2 countries changed after the ENHANCE trial. We examined ezetimibe use trends in the US and Canada before and after the reporting of the ENHANCE trial. METHODS: We conducted a population-based, retrospective, time-series analysis using the data collected by IMS Health in the US and CompuScript in Canada from January 1, 2002, to December 31, 2009. The main outcome measure was monthly number of prescriptions for ezetimibe-containing products. RESULTS: The monthly number of ezetimibe prescriptions/100,000 population rose from 6 to 1,082 in the US from November 2002 to January 2008, then significantly declined to 572/100,000 population by December 2009 after the release of the ENHANCE trial, a decrease of 47.1% (P < .001). In contrast, in Canada, use continuously rose from 2 to 495/100,000 population from June 2003 to December 2009 (P = .2). United States expenditures totaled $2.24 billion in 2009. CONCLUSIONS: Ezetimibe remains commonly used in both the US and Canada. Ezetimibe use has decreased in the US post-ENHANCE, whereas use has gradually but steadily increased in Canada. The diverging patterns of ezetimibe use in the US and Canada require further investigation, as they reveal that a common evidence base is eliciting very different utilization patterns in neighboring countries.

The effect of multidisciplinary heart failure clinic characteristics on 1-year postdischarge health care costs: a population-based study.

BACKGROUND: Although multidisciplinary heart failure (HF) clinics are efficacious, it is not known how patient factors or HF clinic structural indicators and process measures have an impact on the cumulative health care costs. RESEARCH DESIGN: In this retrospective cohort study using administrative databases in Ontario, Canada, we identified 1216 HF patients discharged alive after an acute care hospitalization in 2006 and treated at a HF clinic. The primary outcome was the cumulative 1-year health care costs. A hierarchical generalized linear model with a logarithmic link and gamma distribution was developed to determine patient-level and clinic-level predictors of cost. RESULTS: The mean 1-year cost was $27,809 (range, $69 to $343,743). There was a 7-fold variation in the mean costs by clinic, from $14,670 to $96,524. Delays in being seen at a HF clinic were a significant patient-level predictor of costs (rate ratio 1.0015 per day; P<0.001). Being treated at a clinic with >3 physicians was associated with lower costs (rate ratio 0.78; P=0.035). Unmeasured patient-level differences accounted for 97.4% of the between-patient variations in cost. The between-clinic variation in costs decreased by 16.3% when patient-level factors were accounted for; it decreased by a further 49.8% when clinic-level factors were added. CONCLUSIONS: From a policy perspective, the wide spectrum of HF clinic structure translates to inefficient care. Greater guidance as to the type of patient seen at a HF clinic, the timeliness of the initial visit, and the most appropriate structure of the HF clinics may potentially result in more cost-effective care.

The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population.

BACKGROUND: To comprehensively examine the cardiovascular health of Canadians, we developed the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index. We analyzed trends in health behaviours and factors to monitor the cardiovascular health of the Canadian population. METHODS: We used data from the Canadian Community Health Survey (2003-2011 [excluding 2005]; response rates 70%-81%) to examine trends in the prevalence of 6 cardiovascular health factors and behaviours (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension) among Canadian adults aged 20 or older. We defined ideal criteria for each of the 6 health metrics. The number of ideal metrics was summed to create the CANHEART health index; values range from 0 (worst) to 6 (best or ideal). A separate CANHEART index was developed for youth age 12-19 years; this index included 4 health factors and behaviours (smoking, physical activity, fruit and vegetable consumption and overweight/obesity). We determined the prevalence of ideal cardiovascular health and the mean CANHEART health index score, stratified by age, sex and province. RESULTS: During the study period, physical activity and fruit and vegetable consumption increased and smoking decreased among Canadian adults. The prevalence of overweight/obesity, hypertension and diabetes increased. In 2009-2010, 9.4% of Canadian adults were in ideal cardiovascular health, 53.3% were in intermediate health (4-5 healthy factors or behaviours), and 37.3% were in poor cardiovascular health (0-3 healthy factors or behaviours). Twice as many women as men were in ideal cardiovascular health (12.8% vs. 6.1%). Among youth, the prevalence of smoking decreased and the prevalence of overweight/obesity increased. In 2009-2010, 16.6% of Canadian youth were in ideal cardiovascular health, 33.7% were in intermediate health (3 healthy factors or behaviours), and 49.7% were in poor cardiovascular health (0-2 healthy factors or behaviours). INTERPRETATION: Fewer than 1 in 10 Canadian adults and 1 in 5 Canadian youth were in ideal cardiovascular health from 2003 to 2011. Intensive health promotion activities are needed to meet the Heart and Stroke Foundation of Canada's goal of improving the cardiovascular health of Canadians by 10% by 2020 as measured by the CANHEART health index.

Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction.

OBJECTIVES: To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI). BACKGROUND: The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear. METHODS: We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity. RESULTS: As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87-0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70-1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation. CONCLUSIONS: Functional recovery may play an important role in explaining SES-mortality gradients following AMI.

Prevalence and extent of obstructive coronary artery disease among patients undergoing elective coronary catheterization in New York State and Ontario.

IMPORTANCE: Prior studies have shown that physicians in New York State (New York) perform twice as many cardiac catheterizations per capita as those in Ontario for stable patients. However, the role of patient selection in these findings and their implications for detection of obstructive coronary artery disease (CAD) are largely unknown. OBJECTIVE: To evaluate the extent of obstructive CAD and to compare the probability of detecting obstructive CAD for patients undergoing cardiac catheterization. DESIGN, SETTING, AND PATIENTS: An observational study was conducted involving patients without a history of cardiac disease who underwent elective cardiac catheterization between October 1, 2008, and September 30, 2011. Obstructive CAD was defined as diameter stenosis of 50% or more in the left main coronary artery or stenosis of 70% or more in a major epicardial vessel. MAIN OUTCOMES AND MEASURES: Observed rates and predicted probabilities of obstructive CAD. Predicted probabilities were estimated using logistic regression models. RESULTS: A total of 18,114 patients from New York and 54,933 from Ontario were included. The observed rate of obstructive CAD was significantly lower in New York at 30.4% (95% CI, 29.7%-31.0%) than in Ontario at 44.8% (95% CI, 44.4%-45.3%; P < .001). The percentage of patients with left main or 3-vessel CAD was also significantly lower in New York than in Ontario (7.0% [95% CI, 6.6%-7.3%] vs 13.0% [95% CI, 12.8%-13.3%]; P < .001). In New York, a substantially higher percentage of patients with low predicted probability of obstructive CAD underwent cardiac catheterization; for example, only 19.3% (95% CI, 18.7%-19.9%) of patients undergoing cardiac catheterization in New York had a greater than 50% predicted probability of having obstructive CAD than those in Ontario at 41% (95% CI, 40.6%-41.4%; P < .001). At 30 days, crude mortality for patients undergoing cardiac catheterization was slightly higher in New York at 0.65% (90 of 13,824; 95% CI, 0.51%-0.78%) than in Ontario at 0.38% (153 of 40,794; 95% CI, 0.32%-0.43%; P < .001). CONCLUSIONS AND RELEVANCE: In Ontario compared with New York State, patients undergoing elective cardiac catheterization were significantly more likely to have obstructive CAD. This appears to be related to a higher percentage of patients in New York with low predicted probability of CAD undergoing cardiac catheterization.