Descriptive analysis and evaluation of Health Link referrals to the emergency department before and during the COVID-19 pandemic.

BACKGROUND: In Alberta, Health Link (HL) provides a 24-h, nurse-staffed, phone resource to the public for health-care advice. HL directs callers to either seek care in the emergency department (ED), with a primary care provider or provide self-care at home. This work aims to describe HL ED referrals prior to and during the COVID-19 pandemic. METHODS: Data from January 1, 2018-December 31, 2019, and July 1, 2020-June 30, 2022, were selected. HL calls were categorized as likely appropriate if the patient was referred and presented to the ED within 24 h and had a Canadian Triage and Acuity Scale (CTAS) of 1-3; or a CTAS of 4-5 and the patient was admitted, specialist consulted, or diagnostic imaging or laboratory tests were completed. The primary outcome was the percentage of likely appropriate referrals among all HL ED referrals. RESULTS: In the 2018-2019 and 2020-2022 samples, respectively, there were 845,372 and 832,730 calls. Of the 211,723 and 213,486 ED referrals, only 140,614 (66.4%) and 143,322 (67.1%) presented to an ED. Of these, 84.3 and 86.7 per 100 patient visits were categorized as likely appropriate referrals. Health Link referrals account for 3.2% and 3.8% of all ED visits. IMPACT: HL referrals to the ED represent only a small percentage of all ED visits. Based on our definition, most referrals by HL are likely appropriate. The COVID-19 pandemic does not appear to have altered the rates of calls to HL, the number of HL calls referred to the ED, nor the likely appropriateness of those referrals.

Perinatal and early life factors and asthma control among preschoolers: a population-based retrospective cohort study.

BACKGROUND: Preventing poor childhood asthma control is crucial for short-term and long-term respiratory health. This study evaluated associations between perinatal and early-life factors and early childhood asthma control. METHODS: This retrospective study used administrative health data from mothers and children born 2010-2012 with a diagnosis of asthma before age 5 years, in Alberta, Canada. The outcome was asthma control within 2 years after diagnosis. Associations between perinatal and early-life factors and risk of partly and uncontrolled asthma were evaluated by multinomial logistic regression. RESULTS: Of 7206 preschoolers with asthma, 52% had controlled, 37% partly controlled and 12% uncontrolled asthma 2 years after diagnosis. Compared with controlled asthma, prenatal antibiotics (adjusted risk ratio (aRR): 1.19; 95% CI 1.06 to 1.33) and smoking (aRR: 1.18; 95% CI 1.02 to 1.37), C-section delivery (aRR: 1.11; 95% CI 1.00 to 1.25), summer birth (aRR: 1.16; 95% CI 1.00 to 1.34) and early-life hospitalisation for respiratory illness (aRR: 2.24; 95% CI 1.81 to 2.76) increased the risk of partly controlled asthma. Gestational diabetes (aRR: 1.41; 95% CI 1.06 to 1.87), C-section delivery (aRR: 1.18; 95% CI 1.00 to 1.39), antibiotics (aRR: 1.32; 95% CI 1.08 to 1.61) and hospitalisation for early-life respiratory illness (aRR: 1.65; 95% CI 1.19 to 2.27) were associated with uncontrolled asthma. CONCLUSION: Maternal perinatal and early-life factors including antibiotics in pregnancy and childhood, gestational diabetes, prenatal smoking, C-section and summertime birth, and hospitalisations for respiratory illness are associated with partly or uncontrolled childhood asthma. These results underline the significance of perinatal health and the lasting effects of early-life experiences on lung development and disease programming.

Days Alive and Out of Hospital: Exploring a Patient-Centered, Pragmatic Outcome in a Clinical Trial of Patients With Acute Coronary Syndromes.

Background Cardiovascular clinical trials have traditionally incorporated separate time-to-first-event analyses for their primary efficacy and safety comparisons, but this framework has a number of limitations, including limited patient-centeredness and a traditional requirement for central adjudication. Days alive and out of the hospital (DAOH) has the potential to provide additional insight. Methods and Results TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a randomized, multinational clinical trial that compared the effect of prasugrel versus clopidogrel in patients stabilized after non-ST segment elevation acute coronary syndrome treated without revascularization; the trial had a neutral result. DAOH was calculated for each patient using site-submitted adverse event reporting data. We described patterns of DAOH overall, and among younger adults (<75 years old), older adults (≥75 years old), and frail/prefrail patients over 12 months follow-up and used Poisson regression to compare DAOH for patients randomized to prasugrel versus clopidogrel. Of 9249 patients in the overall trial population, 500 (5.4%) died, and 2504 (27.1%) were hospitalized 4150 times over 12 months' follow-up; the mean±SD DAOH was 317±86. The distribution of DAOH over 12 months was left-skewed, with median DAOH 363 days. Among younger adults, older adults, and frail/prefrail patients, mean DAOH were 323, 293, and 304 days, respectively. There were no differences in DAOH by treatment arm in the overall population (rate ratio, 1.00; 95% CI, 0.99-1.01) or any subgroup. Conclusions These results support the feasibility of determining DAOH, a patient-centered outcome that can potentially overcome many of the disadvantages of the traditional time-to-composite-event framework in the clinical trial setting. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT00699998.

Challenges Associated with Cross-Jurisdictional Analyses using Administrative Health Data and Primary Care Electronic Medical Records in Canada.

Over the last 30 years, public investments in Canada and many other countries have created clinical and administrative health data repositories to support research on health and social services, population health and health policy. However, there is limited capacity to share and use data across jurisdictional boundaries, in part because of inefficient and cumbersome procedures to access these data and gain approval for their use in research. A lack of harmonization among variables and indicators makes it difficult to compare research among jurisdictions. These challenges affect the quality, scope, and impact of work that could be done. The purpose of this paper is to compare and contrast the data access procedures in three Canadian jurisdictions (Manitoba, Alberta and British Columbia), and to describe how we addressed the challenges presented by differences in data governance and architecture in a Canadian cross-jurisdictional research study. We characterize common stages in gaining access to administrative data among jurisdictions, including obtaining ethics approval, applying for data access from data custodians, and ensuring the extracted data is released to accredited individuals in secure data environments. We identify advantages of Manitoba's flexible 'stewardship' model over the more restrictive 'custodianship' model in British Columbia, and highlight the importance of communication between analysts in each jurisdiction to compensate for differences in coding variables and poor quality data. Researchers and system planners must have access to and be able to make effective use of administrative health data to ensure that Canadians continue to have access to high-quality health care and benefit from effective health policies. The considerable benefits of collaborative population-based research that spans jurisdictional borders have been recognized by the Canadian Institutes for Health Research in their recent call for the creation of a National Data Platform to resolve many of the issues in harmonization and validation of administrative data elements.

The association between meteorological events and acute heart failure: new insights from ASCEND-HF.

INTRODUCTION: Given the rising prevalence of heart failure (HF), our objective is to explore the relationships between meteorological events and acute HF (AHF) globally. METHODS: We used data from 30 countries participating in the ASCEND-HF trial. Parameters including temperature were normalized by location for the 37 days prior to the HF event. Meteorological events were classified as a change that occurred <10% compared to baseline. The 7 days prior to the HF event was subdivided: T1: the day of and -1 day; T2: 2 and 3 days; T3: 4 and 5 days; and T4: 6 and 7 days. Results are reported as ratios of observed to expected weather events at the time of AHF presentation. RESULTS: From 7141 patients, median age was 67 (IQR 56-76) with 66% male patients and 60% of patients with ischemic cardiomyopathy. In T1, temperatures were warmer than expected with 10% fewer decreases in average [OR 0.91 95% CI (0.83-0.98)] and minimum [OR 0.90 95% CI (0.82-0.97)] temperature. In T2, temperatures were again warmer than expected with an excess number of increases in maximum [OR 1.18 95% CI (1.06-1.30)] and average [OR 1.21 95% CI (1.10-1.32)] temperature. In T4 temperatures were cooler than baseline with fewer increases [OR 0.84 95% CI (0.74-0.95)] in average temperature. CONCLUSIONS: Meteorological fluctuations appear most relevant in the 3 days (T1 and T2) prior to the HF hospitalization with temperature demonstrating a bidirectional relationship with AHF. Continued validation of biometeorological trends in HF will contribute to healthcare system planning globally.

Declining in-hospital mortality and increasing heart failure incidence in elderly patients with first myocardial infarction.

OBJECTIVES: The purpose of this study was to examine the long-term incidence of heart failure (HF) in elderly patients with myocardial infarction (MI). BACKGROUND: In-hospital HF is common after MI and is associated with poor short-term prognosis. Limited data exist concerning the long-term incidence or prognosis of HF after MI, particularly in the era of coronary revascularization. METHODS: A population-based cohort of 7,733 patients > or = 65 years of age hospitalized for a first MI (International Classification of Diseases-9th Revision-Clinical Modification code 410.x) and without a prior history of HF was established between 1994 and 2000 in Alberta, Canada, and followed up for 5 years. RESULTS: During the index MI hospitalization, 2,831 (37%) MI patients were diagnosed with new HF and 1,024 (13%) died. Among hospital survivors who did not have HF during their index hospitalization (n = 4,291), an additional 3,040 patients (71%) developed HF by 5 years, 64% of which occurred in the first year. In total, 5,871 (76%) elderly patients who survived their first MI developed HF over 5 years. Among those who survived the index hospitalization, the 5-year mortality rate was 39.1% for those with HF during the index MI hospitalization compared with 26.7% among those without HF (p < 0.0001) during the index MI hospitalization. Over the study period, the 5-year mortality rate after MI decreased by 28%, whereas the 5-year rate of HF increased by 25%. CONCLUSIONS: In this large cohort of elderly patients without a history of HF, HF developed in three-quarters in the 5 years after their first MI; this proportion increased over time as peri-MI mortality rates declined. New-onset HF significantly increases the mortality risk among these patients.

Acute heart failure in the emergency department: short and long-term outcomes of elderly patients with heart failure.

AIMS: Previous epidemiologic studies of acute heart failure (AHF) have involved patients admitted to hospital and fail to account for that unknown proportion discharged directly from the emergency department (ED). We examined discharge rates, and whether outcomes, including mortality, differed based on admission status in AHF. METHODS AND RESULTS: This population-based cohort included all patients > or =65 years presenting to an Alberta ED with HF (ICD9-CM 428.x; 1998 to 2001). Patients were either not admitted (Not-ADM) or directly admitted to hospital (ADM) and followed for one-year. Of 10,415 AHF patients evaluated in the ED, 35% were Not-ADM whereas 65% were ADM. Thirty days after ED presentation the rates of death, re-ED or initial/re-hospitalisation were 3.3%, 44% and 19% for Not-ADM, and 10.9%, 33% and 21% for the ADM patients, respectively (all p<0.0001). At one-year, the rates of death, re-ED or initial/re-hospitalisation were 20%, 82% and 58% for Not-ADM, and 34%, 72% and 60% for ADM, respectively (all p<0.0001). CONCLUSIONS: One third of AHF patients were not immediately admitted after an ED visit but most present again to the ED, two-thirds were hospitalised and 20% died within the first year. Our findings provide new impetus to undertake risk assessment and treatment strategies in the ED for AHF.