Cell-based Culture Informs Infectivity and Safe De-Isolation Assessments in Patients with Coronavirus Disease 2019.

BACKGROUND: The detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA by reverse-transcription polymerase chain reaction (PCR) does not necessarily indicate shedding of infective virions. There are limited data on the correlation between the isolation of SARS-CoV-2, which likely indicates infectivity, and PCR. METHODS: A total of 195 patients with Coronavirus disease 2019 were tested (outpatients, n = 178; inpatients, n = 12; and critically unwell patients admitted to the intensive care unit [ICU] patients, n = 5). SARS-CoV-2 PCR-positive samples were cultured in Vero C1008 cells and inspected daily for cytopathic effect (CPE). SARS-CoV-2-induced CPE was confirmed by PCR of culture supernatant. Where no CPE was observed, PCR was performed on day 4 to confirm absence of virus replication. The cycle thresholds (Cts) of the day 4 PCR (Ctculture) and the PCR of the original clinical sample (Ctsample) were compared, and positive cultures were defined where Ctsample - Ctculture was ≥3. RESULTS: Of 234 samples collected, 228 (97%) were from the upper respiratory tract. SARS-CoV-2 was isolated from 56 (24%), including in 28 of 181 (15%), 19 of 42 (45%), and 9 of 11 samples (82%) collected from outpatients, inpatients, and ICU patients, respectively. All 56 samples had Ctsample ≤32; CPE was observed in 46 (20%). The mean duration from symptom onset to culture positivity was 4.5 days (range, 0-18). SARS-CoV-2 was significantly more likely to be isolated from samples collected from inpatients (P < .001) and ICU patients (P < .0001) compared with outpatients, and in samples with lower Ctsample. CONCLUSIONS: SARS-CoV-2 culture may be used as a surrogate marker for infectivity and inform de-isolation protocols.

The Incidence of Major Cardiovascular Events in Immigrants to Ontario, Canada: The CANHEART Immigrant Study.

BACKGROUND: Immigrants from ethnic minority groups represent an increasing proportion of the population in many high-income countries but little is known about the causes and amount of variation between various immigrant groups in the incidence of major cardiovascular events. METHODS AND RESULTS: We conducted the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) Immigrant study, a big data initiative, linking information from Citizenship and Immigration Canada's Permanent Resident database to nine population-based health databases. A cohort of 824 662 first-generation immigrants aged 30 to 74 as of January 2002 from eight major ethnic groups and 201 countries of birth who immigrated to Ontario, Canada between 1985 and 2000 were compared to a reference group of 5.2 million long-term residents. The overall 10-year age-standardized incidence of major cardiovascular events was 30% lower among immigrants compared with long-term residents. East Asian immigrants (predominantly ethnic Chinese) had the lowest incidence overall (2.4 in males, 1.1 in females per 1000 person-years) but this increased with greater duration of stay in Canada. South Asian immigrants, including those born in Guyana had the highest event rates (8.9 in males, 3.6 in females per 1000 person-years), along with immigrants born in Iraq and Afghanistan. Adjustment for traditional risk factors reduced but did not eliminate differences in cardiovascular risk between various ethnic groups and long-term residents. CONCLUSIONS: Striking differences in the incidence of cardiovascular events exist among immigrants to Canada from different ethnic backgrounds. Traditional risk factors explain part but not all of these differences.

Standard admission orders can improve the management of acute myocardial infarction.

OBJECTIVE: To evaluate whether the use of standard admission orders for patients admitted with acute myocardial infarction (AMI) is associated with better hospital quality of care. DESIGN: Secondary analysis of a population-based database derived from a large cluster randomized AMI quality improvement trial. SETTING: Seventy-eight acute care hospital corporations located in Ontario, Canada. PARTICIPANTS: A total of 5338 patients with AMI admitted directly to the coronary care/intensive care units of participating hospitals in 2004/2005. Main outcome measure(s) Hospital performance on seven process-of-care measures and a combined composite process-of-care measure. Secondary outcomes were 30-day and 1-year mortality rates. RESULTS: Most patients (81%) were treated with standard admission orders. These patients were more likely to receive four of seven identified process-of-care measures (P< 0.05), including fibrinolytics ≤ 30 min or primary percutaneous coronary intervention ≤ 90 min of arrival, fibrinolytics administration decided by emergency department physician, aspirin ≤ 6 h of arrival and lipid test ≤ 24 h. After propensity-score matching (for risk adjustment), use of standard admission orders was not associated with significantly lower 30-day or 1-year mortality. However, patients who met the composite process-of-care measure had lower 30-day and 1-year mortality (relative risk= 0.51 (95% confidence interval (CI): 0.40-0.67) and 0.70 (95% CI: 0.58-0.84), respectively). CONCLUSION: In AMI, the use of standard admission orders was associated with improved hospital performance on several but not all acute process-of-care quality indicators. The utilization of standard admission orders should be considered as a strategy for improving hospital care in patients admitted with AMI.

Rescue percutaneous coronary interventions for failed fibrinolytic therapy in ST-segment elevation myocardial infarction: a population-based study.

BACKGROUND: Fibrinolytic therapy remains the reperfusion strategy of choice for many regions treating patients presenting with ST-segment elevation myocardial infarction (STEMI). However, limited data exist regarding the pattern of use of rescue percutaneous coronary intervention (PCI) in patients with STEMI who failed fibrinolysis, factors associated with its use, and its impact on long-term outcomes. METHODS: Observational analysis of a population-based cohort was done, which included 2,953 patients with STEMI hospitalized from 2004 to 2005 in Ontario, Canada. Failed fibrinolysis was defined as <50% ST-segment resolution on follow-up electrocardiogram at 60 to 90 minutes after fibrinolysis. The main outcome of measure was death or repeat hospitalization for acute coronary syndrome at 4 years. RESULTS: Among the 1,517 patients who received fibrinolytic therapy, 611 patients (40.3%) failed fibrinolysis. Of these, rescue PCI was performed in 212 patients (34.7%); conservative management, in 373 patients (61.1%); and repeat fibrinolysis, in 26 patients (4.3%). Initial presentation to a PCI hospital was the strongest predictor of rescue PCI use (odds ratio 3.7, 95% CI 2.2-6.0). At 4-year follow-up, the primary end point occurred in 24.5% of patients who received rescue PCI and 36.5% in patients with no rescue PCI (adjusted hazard ratio 0.69, 95% CI 0.49-0.96). This difference was attributable mainly to a significant reduction in death favoring rescue PCI patients (hazard ratio 0.60, 95% CI 0.38-0.94). CONCLUSIONS: Rescue PCI was associated with significantly lower risk of long-term adverse outcomes for patients with STEMI who failed fibrinolytic therapy. However, rescue PCI is substantially underused in clinical practice.

Identification of 20 common human enterovirus serotypes by use of a reverse transcription-PCR-based reverse line blot hybridization assay.

The more than 100 human enterovirus (HEV) serotypes can also be classified into four species, HEV-A to -D, based on phylogenetic analysis of multiple gene regions. Current molecular typing methods depend largely on reverse transcription-PCR (RT-PCR) amplification and nucleotide sequencing of the entire or 3' half of the VP1 gene. An RT-PCR-based reverse line blot (RLB) hybridization assay was developed as a rapid and efficient approach to characterize common HEVs. Twenty HEV serotypes accounted for 87.1% of all HEVs isolated at an Australian reference virology laboratory from 1979 to 2007. VP1 sequences of all known HEV prototype strains were aligned to design one sense primer and three antisense primers for RT-PCR. After sequencing of the complete VP1 genes of 37 previously serotyped examples of the commonest 20 serotypes and alignment of these VP1 sequences with GenBank sequences, four serotype-specific probes for each serotype were designed for RLB. The RT-PCR-RLB assay was then applied to 132 HEV isolates, made up of the previously sequenced 37 isolates and another 95 serotyped clinical isolates. The RT-PCR-RLB genotypes corresponded with the serotypes for 131/132 isolates; the one exception was confirmed by VP1 sequencing, and the genotype was confirmed by repeat conventional serotyping. Genotyping by RT-PCR-RLB complements traditional serotyping methods and VP1 sequencing and has the advantages of convenience, speed, and accuracy. RT-PCR-RLB allows detection of specific enteroviral serotypes or genotypes associated with HEV outbreaks and significant disease.

Effectiveness of public report cards for improving the quality of cardiac care: the EFFECT study: a randomized trial.

CONTEXT: Publicly released report cards on hospital performance are increasingly common, but whether they are an effective method for improving quality of care remains uncertain. OBJECTIVE: To evaluate whether the public release of data on cardiac quality indicators effectively stimulates hospitals to undertake quality improvement activities that improve health care processes and patient outcomes. DESIGN, SETTING, AND PATIENTS: Population-based cluster randomized trial (Enhanced Feedback for Effective Cardiac Treatment [EFFECT]) of 86 hospital corporations in Ontario, Canada, with patients admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF). INTERVENTION: Participating hospital corporations were randomized to early (January 2004) or delayed (September 2005) feedback of a public report card on their baseline performance (between April 1999 and March 2001) on a set of 12 process-of-care indicators for AMI and 6 for CHF. Follow-up performance data (between April 2004 and March 2005) also were collected. MAIN OUTCOME MEASURES: The coprimary outcomes were composite AMI and CHF indicators based on 12 AMI and 6 CHF process-of-care indicators. Secondary outcomes were the individual process-of-care indicators, a hospital report card impact survey, and all-cause AMI and CHF mortality. RESULTS: The publication of the early feedback hospital report card did not result in a significant systemwide improvement in the early feedback group in either the composite AMI process-of-care indicator (absolute change, 1.5%; 95% confidence interval [CI], -2.2% to 5.1%; P = .43) or the composite CHF process-of-care indicator (absolute change, 0.6%; 95% CI, -4.5% to 5.7%; P = .81). During the follow-up period, the mean 30-day AMI mortality rates were 2.5% lower (95% CI, 0.1% to 4.9%; P = .045) in the early feedback group compared with the delayed feedback group. The hospital mortality rates for CHF were not significantly different. CONCLUSION: Public release of hospital-specific quality indicators did not significantly improve composite process-of-care indicators for AMI or CHF. TRIAL REGISTRATION: http://clinicaltrials.gov Identifier: NCT00187460.

Epidemiology of lymphogranuloma venereum in New South Wales, 2006-2015.

AIM: To describe the epidemiology of lymphogranuloma venereum (LGV) in New South Wales (NSW) from 2006 to 2015. METHODS: LGV notification data between 2006 and 2015 from New South Wales were analysed to describe time trends in counts and rates by gender, age group and area of residence, as well as anatomical sites of infection. A positivity ratio was calculated using the number of LGV notifications per 100 anorectal chlamydia notifications per year. Data linkage was used to ascertain the proportion of LGV cases that were co-infected with HIV. RESULTS: There were 208 notifications of LGV in NSW from 2006 to 2015; all were among men, with a median age of 42 years, and half were residents of inner-city Sydney. Annual notifications peaked at 57 (1.6 per 100,000 males) in 2010, declined to 16 (0.4 per 100,000 males) in 2014, and then increased to 34 (0.9 per 100,000 males) in 2015. Just under half (47.4%) of LGV cases were determined to be co-infected with HIV. CONCLUSION: The number of LGV notifications each year has not returned to the low levels seen prior to the peak in 2010. Continued public health surveillance is important for the management and control of LGV.

Comparing clinical and administrative data for profiling hospitals on postdischarge medication use by patients with acute myocardial infarction.

BACKGROUND: Postdischarge medication use is frequently used as a measure of hospital performance, with many reports produced using clinical data obtained from chart reviews. The introduction of a drug benefit program administered by the Centers for Medicare and Medicaid Services presents an opportunity to use administrative data for routine reporting on hospital performance. We determined the concordance between hospital-specific prescribing rates of evidence-based medical therapies obtained from clinical and administrative data in Ontario, Canada. METHODS: This was a retrospective cohort study using data on patients discharged from 102 hospitals in Ontario, Canada with acute myocardial infarction (AMI) between April 1, 1999, and March 31, 2001. We compared hospital-specific rates of discharge prescribing in AMI patients, determined using clinical data obtained using retrospective chart review with hospital-specific rates of prescriptions filled within 30 days of hospital discharge in elderly patients using administrative data. RESULTS: There was a moderate agreement between hospital-specific rates of discharge prescriptions written for AMI patients in clinical data with hospital-specific rates of prescriptions filled using administrative data. Although differences in rates were, on average, small between the 2 data sources, there was moderate variation in the differences between these 2 rates across hospitals. There was very strong agreement between rates of discharge prescribing in all patients and in ideal patients with no contraindications, both determined using clinical data. CONCLUSIONS: Post-AMI discharge prescribing in all patients determined using clinical data is an excellent proxy for prescribing in ideal patients using clinical data. However, there is weaker agreement between administrative and clinical data.

Indicators of quality of care for patients with acute myocardial infarction.

BACKGROUND: There is a wide practice gap between optimal and actual care for patients with acute myocardial infarction in hospitals around the world. We undertook this initiative to develop an updated set of evidence-based indicators to measure and improve the quality of care for this patient population. METHODS: A 12-member expert panel was convened in 2007 to develop an updated set of quality indicators for acute myocardial infarction. The panel identified a list of potential indicators after reviewing the scientific literature, clinical practice guidelines and other published quality indicators. To develop the new list of indicators, the panel rated each potential indicator on 4 dimensions (reliability, validity, feasibility and usefulness in improving patient outcomes) and discussed the top-ranked quality indicators at a consensus meeting. RESULTS: Consensus was reached on 38 quality indicators: 17 that would be measurable using chart-abstracted data and 21 that would be measurable using administrative data. Of the 17 chart-review indicators, 13 address pharmacologic and nonpharmacologic care delivered to patients in hospital. In-hospital mortality was recommended as a key outcome indicator. Three system indicators were recommended to measure the collaborative responsiveness of the health care system from the call for help to intervention. It was recommended that hospitals strive for a minimum target benchmark of 90% or greater on process-of-care indicators. INTERPRETATION: Implementation of strategies by clinicians and hospitals to meet target benchmarks on these quality indicators could save the lives of many individuals with acute myocardial infarction.

Validation of the Thrombolysis In Myocardial Infarction (TIMI) risk index for predicting early mortality in a population-based cohort of STEMI and non-STEMI patients.

BACKGROUND: The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients. METHODS: The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model's discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status. RESULTS: The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated. CONCLUSIONS: The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.

Appropriateness of spironolactone prescribing in heart failure patients: a population-based study.

BACKGROUND: The Randomized Aldactone Evaluation Study (RALES) established the safety and benefit of spironolactone for heart failure (HF) patients with systolic dysfunction. However, recent data have raised concerns regarding hyperkalemia secondary to spironolactone use and suggest it occurs more commonly in routine practice. METHODS AND RESULTS: We explored factors potentially associated with hyperkalemia from spironolactone therapy in a population-based cohort of 9165 HF patients hospitalized in Ontario, Canada, between 1999 and 2001. Compared with patients enrolled in RALES, community-based patients were older (mean age 75 years versus 65 years, P < .001) and were more likely to be female (50% versus 27%, P < .001). Of the 1502 patients that were prescribed spironolactone at discharge, 18% had elevated serum potassium levels (>5 mmol/L) during hospitalization and 23% were discharged on concurrent potassium supplements. Although only 8% of patients had serum creatinine >2.5 mg/dL, many patients had stage III (53.1%), stage IV (12.8%), or stage V (3.9%) chronic renal insufficiency according to glomerular filtration rate. CONCLUSION: Spironolactone was often prescribed to inappropriate HF candidates because of the presence of relative or absolute contraindications. These findings highlight the need for more careful patient selection when prescribing spironolactone to minimize potential life-threatening hyperkalemia.

Quality of care and outcomes of older patients with heart failure hospitalized in the United States and Canada.

BACKGROUND: Health care expenditure per person is significantly higher in the United States compared with Canada, but whether there are differences in quality of care of many conditions is unknown. We compared the process of care and outcomes of patients with heart failure, the most common cause of hospitalization for individuals 65 years and older in both countries. METHODS: We compared processes of care and 30-day and 1-year risk-standardized mortality rates among 28,521 US Medicare beneficiaries and 8180 similarly aged patients in Ontario, Canada, hospitalized with heart failure from 1998 to 2001. RESULTS: More US patients underwent left ventricular ejection fraction assessment during hospitalization compared with Canadian patients (61.2% vs 41.7%, P<.001). At discharge, patients in the United States were prescribed beta-blockers more frequently (28.7% vs 25.4%, P<.001) but angiotensin-converting enzyme inhibitors less frequently (54.3% vs 63.4%, P<.001). Among ideal candidates, prescription of beta-blockers (32.5% vs 29.7%, P = .08) or angiotensin-converting enzyme inhibitors (78.3% vs 77.6%, P = .68) was not significantly different between the 2 countries. The US patients had lower risk characteristics on admission and lower crude mortality rates at 30 days and 1 year. Thirty-day risk-standardized mortality was significantly lower for the US patients (8.9% vs 10.7%, P<.001), but 1-year risk-standardized mortality was no longer significantly different (32.2% vs 32.3%, P = .98). CONCLUSION: Patients with heart failure who are hospitalized in the United States had lower short-term mortality at 30 days, but 1-year mortality rates were not significantly different between the United States and Canada.

Phylogenetic analysis of human rhinoviruses collected over four successive years in Sydney, Australia.

BACKGROUND: Human rhinoviruses (HRV) cause a wide spectrum of disease, ranging from a mild influenza-like illness (ILI) to severe respiratory infection. Molecular epidemiological data are limited for HRV circulating in the Southern Hemisphere. OBJECTIVES: To identify the species and genotypes of HRV from clinical samples collected in Sydney, Australia, from 2006 to 2009. METHODS: Combined nose and throat swabs or nasopharyngeal aspirates collected from individuals with ILI were tested for HRV using real-time reverse-transcriptase polymerase chain reaction (RT-PCR). Sequencing data of 5'UTR and VP4/VP2 coding regions on RT-PCR-positive specimens were analysed. RESULTS: Human rhinoviruses were detected by real-time PCR in 20.9% (116/555) of samples tested. Phylogenetic analysis of 5'UTR and VP4/VP2 on HRV-positive samples was concordant in the grouping of HRV A and B species but not HRV C species. Eighty per cent (16/20) of sequences that grouped as HRV C in the VP4/VP2 tree clustered as HRV A, alongside some previously described C strains as subspecies C/A. Discordant branching was seen within HRV A group: two sequences clustering as A in the VP4/VP2 tree branched within the C/A subspecies in the 5'UTR tree, and one sequence showed identity to different HRV A strains in the two genes. The prevalence of HRV C and C/A species was greater in paediatric compared to adult patients (47.9% vs 25.5%, P = .032). CONCLUSION: Human rhinoviruses are a common cause of respiratory infections, and HRV C is present in the Southern Hemisphere. Sequencing of multiple HRV regions may be necessary to determine exact phylogenetic relationships.

Can the wrong statistic be bad for health? Improving the reporting of door-to-needle time performance in acute myocardial infarction.

BACKGROUND: Current acute myocardial infarction (AMI) guidelines call for reperfusion to be given to all eligible patients within a set time interval after hospital arrival, yet current hospital performance benchmarks are based on the median door-to-intervention time among treated patients. Our objective is to compare hospital performance rankings when door-to-needle time (DNT) is measured at the current benchmark (median < or = 30 minutes) versus those obtained with more stringent benchmarks common for other AMI treatments. METHODS: A secondary analysis of data from the EFFECT study from 52 small, community and teaching hospitals in Ontario. All Ontario hospital corporations that treated > or = 30 patients with AMI from 1999 to 2001 participated. The charts of approximately 125 patients with AMI per hospital were reviewed; median and 85th percentile DNTs were then calculated for patients with ST-elevation AMI given thrombolysis at each site along with the proportion of patients thrombolysed within the recommended time. Hospitals were then ranked according to each indicator. RESULTS: Data were obtained on 1,578 patients given thrombolytic drugs at 52 hospitals. The median and 85th percentile DNTs were 37 and 82 minutes, respectively; the proportion of patients treated in < or = 30 minutes ranged from 8.5% to 60%. Hospitals that achieved a median DNT of < or = 30 minutes treated 40% to 50% of their patients outside that time frame. The ranks of the top 15 median DNT hospitals changed substantially when re-ranked according to the 85th percentile (average change in rank -16, range +6 to -40). If DNT improved such that a 30-minute median target was achieved, the estimated reduction for the average patient would be 13 minutes versus a 43-minute reduction if the 85th percentile target was achieved. CONCLUSION: Hospitals that achieve a 30-minute median DNT benchmark still treat 40% to 50% of their patients outside the recommended time, which is not consistent with current AMI treatment guidelines. Door-to-needle time for the average patient would be up to 43 minutes faster if the DNT target was achieved at the 85th percentile.

Association between lipid testing and statin therapy in acute myocardial infarction patients.

BACKGROUND: Clinical guidelines recommend lipid testing in all hospitalized acute myocardial infarction (AMI) patients. Inhospital lipid testing has also been proposed as a quality indicator for AMI care, but little is known about its use or importance. We sought to examine rates of inhospital lipid testing and its association with statin therapy at hospital discharge. METHODS: We performed an analysis using medical chart abstraction data that included demographic and comprehensive clinical information for patients hospitalized in Ontario, Canada, with an AMI from 1999 to 2001. RESULTS: Among 11,468 patients, inhospital lipid testing was performed in 6,019 (52.5%) patients and in 4,169 (36.4%) patients within 24 hours of admission. Patients who had lipid testing were significantly more likely to be discharged on statin therapy compared with patients not tested (41.4% vs 23.0%, P < .001). In addition, inhospital lipid testing was strongly associated (odds ratio 3.61, 95% CI 3.15-4.14) with statin therapy prescription at hospital discharge after adjusting for other clinical, physician, and hospital factors. CONCLUSIONS: Despite endorsements from practice guidelines, less than half of all admitted AMI patients received lipid testing within 24 hours of hospital admission. Because inhospital lipid testing was strongly associated with the initiation of statin therapy at discharge, many opportunities to initiate statin therapy were lost. Efforts to increase the use of lipid testing in hospitalized AMI patients may translate into higher rates of lipid-lowering therapy and improved patient outcomes.

Regional variation in self-reported heart disease prevalence in Canada.

BACKGROUND: Cardiovascular disease is the leading cause of death in Canada. OBJECTIVE: To provide an analysis of the self-reported prevalence of heart disease and three specific cardiac conditions--myocardial infarction (MI), angina and congestive heart failure (CHF)--in subgroups of the Canadian population. METHODS: Data from the Public Use Microdata File from Statistics Canada's 2000/2001 Canadian Community Health Survey (CCHS) were used to estimate the crude self-reported prevalence of heart disease, MI, angina and CHF in Canada. The data are reported by age and sex groups, as well as by province or territory and health region. RESULTS: Based on the 2000/2001 CCHS data, it was estimated that among Canadians 12 years of age and older, 5.0% (n=1,286,000) have heart disease, 2.1% (n=537,000) have had a heart attack, 1.9% (n=483,000) have angina and 1.0% (n=264,000) have CHF. Marked variation in the prevalence of heart disease and the other specific cardiac conditions exists across age and sex groups, and across geographical regions. The prevalence of heart disease is low among those younger than 50 years; thereafter, the prevalence of heart disease increases and is more common among men than among women. By 70 years of age, at least one in four men and one in five women report having heart disease. Large differences in the burden of heart disease were observed across provinces, territories and health regions. Comparison of the highest and lowest prevalence rates among provinces and territories revealed a 1.9-fold difference for heart disease, a 2.8-fold difference for MI, a 2.3-fold difference for angina and a 3.3-fold difference for CHF. CONCLUSIONS: Large regional differences in the prevalence of heart disease and other specific cardiac conditions were observed across Canada. These data may assist health system planners to identify those regions and population subgroups most affected by heart disease, and to support the development of heart disease prevention and treatment programs.

Influence of Patient Goals of Care on Performance Measures in Patients Hospitalized for Heart Failure: An Analysis of the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) Registry.

BACKGROUND: Pay for performance programs compare metrics that are risk-adjusted, but goals of care are not considered in current models. We conducted this study to explore the associations between do not resuscitate (DNR) designations, quality of care, and outcomes. METHODS AND RESULTS: Retrospective cohort study with chart review for inpatient quality metrics, 30 day mortality, and readmissions or death within 30 days of discharge in 96 Ontario hospitals participating in the Enhanced Feedback For Effective Cardiac Treatment (EFFECT) study in 2004/05. Of 8339 patients (mean age 77 years) with new heart failure, 1220 (15%) had DNR documented at admission (admission DNR, varying from 0% to 36% between hospitals) and 892 (11%) were switched from full resuscitation to DNR during their index hospitalization (later DNR). Death at 30 days was more common in patients with admission DNR (27%) or later DNR (35%) than full resuscitation (3%)-admission DNR was a stronger predictor (adjusted OR 8.6, 95% confidence interval 6.8-10.7) than any of the variables currently included in heart failure 30 day mortality risk models. Hospital-level rankings differed considerably if DNR patients were excluded: 22 of the 39 EFFECT hospitals in the top and bottom quintiles for 30 day mortality rates (the usual thresholds for rewards/penalties in current performance-based reimbursement schemes) would not have been in those same quintiles if admission DNR patients were excluded. CONCLUSIONS: Alternate goals of care are frequent and important confounders in heart failure comparative studies. Philosophy of care discussions should be considered for inclusion as a potential quality of care indicator.

The Risk of Ischemic Heart Disease and Stroke Among Immigrant Populations: A Systematic Review.

BACKGROUND: The increasing frequency of global migration to Canada and other high-income countries has highlighted the need for information on the risk of ischemic heart disease (IHD) and stroke among migrant populations. METHODS: Using the MEDLINE and EMBASE databases, we conducted an English-language literature review of articles published from 2000 to 2014 to study patterns in the incidence of IHD or stroke in migrant populations to high-income countries. Our search revealed 17 articles of interest. All studies stratified immigrants according to country or region of birth, except 2 from Canada and 1 from Denmark, in which all immigrant groups were analyzed together. RESULTS: The risk of IHD or stroke varied by country of origin, country of destination, and duration of residence. In our review we found that most migrant groups to Western Europe were at a similar or higher risk of IHD and stroke compared with the host population. Those at a higher risk included many Eastern European, Middle-Eastern, and South Asian immigrants. When duration of residence was considered, it appeared that in most migrants the risk of IHD worsened over time. In contrast, immigrants overall were at lower risk of myocardial infarction and stroke in Ontario compared with long-term residents of Canada. CONCLUSIONS: The risks of IHD and stroke vary widely in immigrant populations in Western Europe. Detailed studies of immigrants to Canada according to country of birth and duration of residence should be undertaken to guide future cardiovascular health promotion initiatives.