Stroke risk in women with atrial fibrillation.

BACKGROUND AND AIMS: Female sex is associated with higher rates of stroke in atrial fibrillation (AF) after adjustment for other CHA2DS2-VASc factors. This study aimed to describe sex differences in age and cardiovascular care to examine their relationship with stroke hazard in AF. METHODS: Population-based cohort study using administrative datasets of people aged ≥66 years diagnosed with AF in Ontario between 2007 and 2019. Cause-specific hazard regression was used to estimate the adjusted hazard ratio (HR) for stroke associated with female sex over a 2-year follow-up. Model 1 included CHA2DS2-VASc factors, with age modelled as 66-74 vs. ≥ 75 years. Model 2 treated age as a continuous variable and included an age-sex interaction term. Model 3 further accounted for multimorbidity and markers of cardiovascular care. RESULTS: The cohort consisted of 354 254 individuals with AF (median age 78 years, 49.2% female). Females were more likely to be diagnosed in emergency departments and less likely to receive cardiologist assessments, statins, or LDL-C testing, with higher LDL-C levels among females than males. In Model 1, the adjusted HR for stroke associated with female sex was 1.27 (95% confidence interval 1.21-1.32). Model 2 revealed a significant age-sex interaction, such that female sex was only associated with increased stroke hazard at age >70 years. Adjusting for markers of cardiovascular care and multimorbidity further decreased the HR, so that female sex was not associated with increased stroke hazard at age ≤80 years. CONCLUSION: Older age and inequities in cardiovascular care may partly explain higher stroke rates in females with AF.

Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System.

BACKGROUND: Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. METHODS: Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. RESULTS: Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. CONCLUSIONS: In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study.

AIM: We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. METHODS AND RESULTS: In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. CONCLUSION: Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Hospital admission from the emergency department for selected emergent diagnoses during the first year of the COVID-19 pandemic in Ontario: a retrospective population-based study.

BACKGROUND: Avoidance of care during the pandemic may have contributed to delays in care, and as a result, worse patient outcomes. We evaluated markers of illness acuity on presentation to the emergency department among patients with non-COVID-19-related emergent diagnoses and associated outcomes. METHODS: We conducted a retrospective study using linked administrative data from Ontario. We selected 4 emergent diagnoses, namely appendicitis, ectopic pregnancy, renal failure and diabetic ketoacidosis. We used the nonemergent diagnosis of cellulitis as a control. Our primary outcome of interest was hospital admission. Secondary outcomes were ambulance arrival, surgical intervention, subsequent hospital admission within 30 days of discharge from the emergency department or hospital and 30-day mortality. We compared outcomes during the first year of the COVID-19 pandemic (Mar. 15-Dec. 31, 2020) with a control period (Mar. 15-Dec. 31, 2018, and Mar. 15-Dec. 31, 2019). RESULTS: Emergency department visits for all conditions initially decreased during the pandemic. During this period, patients across all study diagnoses were more likely to arrive to the emergency department via ambulance. Patients with an ectopic pregnancy had higher odds of surgery in the pandemic period (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.04-1.55) but this was not observed among patients with appendicitis. Patients with renal failure had increased odds of hospital admission (OR 1.14, 95% CI 1.04-1.24) and 30-day mortality (OR 1.17, 95% CI 1.04-1.31) during the pandemic period. INTERPRETATION: The pandemic period was associated with increased arrival to the emergency department via ambulance across all study diagnoses. Although patients with renal failure had increased hospital admission and death, and patients with ectopic pregnancy had an increased risk of surgery, there were no differences in outcomes for other populations, suggesting the health care system was able to care for these patients effectively.

Comparing methods to classify admitted patients with SARS-CoV-2 as admitted for COVID-19 versus with incidental SARS-CoV-2: A cohort study.

INTRODUCTION: Not all patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection develop symptomatic coronavirus disease 2019 (COVID-19), making it challenging to assess the burden of COVID-19-related hospitalizations and mortality. We aimed to determine the proportion, resource utilization, and outcomes of SARS-CoV-2 positive patients admitted for COVID-19, and assess the impact of using the Center for Disease Control's (CDC) discharge diagnosis-based algorithm and the Massachusetts state department's drug administration-based classification system on identifying admissions for COVID-19. METHODS: In this retrospective cohort study, we enrolled consecutive SARS-CoV-2 positive patients admitted to one of five hospitals in British Columbia between December 19, 2021 and May 31,2022. We completed medical record reviews, and classified hospitalizations as being primarily for COVID-19 or with incidental SARS-CoV-2 infection. We applied the CDC algorithm and the Massachusetts classification to estimate the difference in hospital days, intensive care unit (ICU) days and in-hospital mortality and calculated sensitivity and specificity. RESULTS: Of 42,505 Emergency Department patients, 1,651 were admitted and tested positive for SARS-CoV-2, with 858 (52.0%, 95% CI 49.6-54.4) admitted for COVID-19. Patients hospitalized for COVID-19 required ICU admission (14.0% versus 8.2%, p<0.001) and died (12.6% versus 6.4%, p<0.001) more frequently compared with patients with incidental SARS-CoV-2. Compared to case classification by clinicians, the CDC algorithm had a sensitivity of 82.9% (711/858, 95% CI 80.3%, 85.4%) and specificity of 98.1% (778/793, 95% CI 97.2%, 99.1%) for COVID-19-related admissions and underestimated COVID-19 attributable hospital days. The Massachusetts classification had a sensitivity of 60.5% (519/858, 95% CI 57.2%, 63.8%) and specificity of 78.6% (623/793, 95% CI 75.7%, 81.4%) for COVID-19-related admissions, underestimating total number of hospital and ICU bed days while overestimating COVID-19-related intubations, ICU admissions, and deaths. CONCLUSION: Half of SARS-CoV-2 hospitalizations were for COVID-19 during the Omicron wave. The CDC algorithm was more specific and sensitive than the Massachusetts classification, but underestimated the burden of COVID-19 admissions. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04702945.

Prediction models in prehospital and emergency medicine research: How to derive and internally validate a clinical prediction model.

Clinical prediction models are created to help clinicians with medical decision making, aid in risk stratification, and improve diagnosis and/or prognosis. With growing availability of both prehospital and in-hospital observational registries and electronic health records, there is an opportunity to develop, validate, and incorporate prediction models into clinical practice. However, many prediction models have high risk of bias due to poor methodology. Given that there are no methodological standards aimed at developing prediction models specifically in the prehospital setting, the objective of this paper is to describe the appropriate methodology for the derivation and validation of clinical prediction models in this setting. What follows can also be applied to the emergency medicine (EM) setting. There are eight steps that should be followed when developing and internally validating a prediction model: (1) problem definition, (2) coding of predictors, (3) addressing missing data, (4) ensuring adequate sample size, (5) variable selection, (6) evaluating model performance, (7) internal validation, and (8) model presentation. Subsequent steps include external validation, assessment of impact, and cost-effectiveness. By following these steps, researchers can develop a prediction model with the methodological rigor and quality required for prehospital and EM research.

Prescribing patterns and factors associated with sodium-glucose cotransporter-2 inhibitor prescribing in patients with diabetes mellitus and atherosclerotic cardiovascular disease.

BACKGROUND: Sodium-glucose cotransporter-2 (SGLT2) inhibitors are cardioprotective agents in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). Since little is known about their uptake in atherosclerotic CVD, we examined SGLT2 inhibitor prescribing trends and identified potential disparities in prescribing patterns. METHODS: We conducted an observational study using linked population-based health data in Ontario, Canada, from April 2016 to March 2020 of patients aged 65 years or older with concomitant type 2 diabetes and atherosclerotic CVD. To examine prevalent prescribing of SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin), we constructed 4 cross-sectional yearly cohorts from Apr. 1 to Mar. 31 (2016/17, 2017/18, 2018/19 and 2019/20). We estimated prevalent SGLT2 inhibitor prescribing by year and by subgroups, and identified factors associated with SGTL2 inhibitor prescribing using multivariable logistic regression. RESULTS: There were 208 303 patients in our overall cohort (median age 74.0 yr [interquartile range 68.0-80.0 yr], 132 196 [63.5%] male). Although SGLT2 inhibitor prescribing increased over time, from 7.0% to 20.1%, statin prescribing was initially 10-fold higher and later threefold higher than SGLT2 inhibitor prescribing. In 2019/20, SGLT2 inhibitor prescribing was roughly 50% lower among those aged 75 years or older than among those younger than 75 years (12.9% v. 28.3%, p < 0.001) and in women than in men (15.3% v. 22.9%, p < 0.001). Age 75 years or older, female sex, history of heart failure and kidney disease, and low income were independent factors of lower SGLT2 inhibitor prescribing. Among physician specialists, visits to endocrinologists and family physicians were stronger factors of SGLT2 inhibitor prescribing than cardiologist visits. INTERPRETATION: We found that 1 in 5 patients with diabetes and atherosclerotic CVD were prescribed SGLT2 inhibitors in 2019/20, whereas statins were prescribed for 4 of every 5 patients. Although SGLT2 inhibitor prescribing increased over the study period, disparities in adoption by age, sex, socioeconomic status, comorbidities and physician specialty remained.

Sex-Based Differences in Severe Outcomes, Including Cardiovascular Hospitalization, in Adults With COVID-19 in Ontario, Canada.

Background: While men have experienced higher risks of SARS-CoV-2 infection compared to women, an analysis of sex differences by age in severe outcomes during the acute phase of infection is lacking. Objectives: The purpose of this study was to assess heterogeneity in severe outcome risks by age and sex by conducting a retrospective cohort study of community-dwelling adults in Ontario who tested positive for SARS-CoV-2 infection during the first 3 waves. Methods: Adjusted odds ratios were estimated using multilevel multivariable logistic regression models including an interaction term for age and sex. The primary outcome was a composite of severe outcomes (hospitalization for a cardiovascular (CV) event, intensive care unit admission, mechanical ventilation, or death) within 30 days. Results: Among 30,736, 199,132, and 186,131 adults who tested positive during the first 3 waves, 1,908 (6.2%), 5,437 (2.7%), and 5,653 (3.0%) experienced a severe outcome within 30 days. For all outcomes, the sex-specific risk depended on age (all P for interaction <0.05). Men with SARS-CoV-2 infection experienced a higher risk of outcomes than infected women of the same age, except for the risk of all-cause hospitalization being higher for young women than men (ages 18-45 years) during waves 2 and 3. The sex disparity in CV hospitalization across all ages either persisted or increased with each subsequent wave. Conclusions: To mitigate risks in subsequent waves, it is helpful to further understand the factors that contribute to the generally higher risks faced by men across all ages, and the persistent or increasing sex disparity in the risk of CV hospitalization.

Limited evidence that emergency department care is more costly than other outpatient settings for low-acuity conditions: a systematic review.

PURPOSE: Caring for patients with low-acuity conditions in Emergency Departments (ED) is often thought to cost more than treating those patients in other ambulatory settings. Understanding the relative cost of care between settings has critical implications for healthcare policy and system design. METHODS: We conducted a systematic review of papers comparing the cost of care for low-acuity and ambulatory care sensitive conditions in ED and other outpatient settings. We searched PubMed, EMBASE, CINAHL, and Web of Science for peer reviewed papers, plus Google for grey literature. We conducted duplicate screening and data extraction, and quality assessment of included studies using an adapted SIGN checklist for economic studies. We calculated an unweighted mean charge ratio across studies and summarized our findings in narrative and tabular format. RESULTS: We identified one study comparing costs. 18 studies assessed physician or facility charges, conducted in the United States, United Kingdom, and Canada, including cohort analyses (5), charge analyses (5), survey (1), and database searches (5) assessing populations ranging from 370 participants to 60 million. Charge ratios ranged from 0.60 to 13.45 with an unweighted mean of 4.20. Most (12) studies were of acceptable quality. CONCLUSION: No studies since 2001 assess the comparative costs of ED versus non-ED care for low-acuity ambulatory conditions. Physician and facility charges for ED care are higher than in other ambulatory settings for low-acuity conditions. Empirical evidence is lacking to support that ED care is more costly than similar care in other ambulatory settings.

RéSUMé: OBJECTIFS: La prise en charge des patients souffrant d'affections de faible gravité dans les services d'urgence est souvent considérée comme plus coûteuse que la prise en charge de ces mêmes patients dans d'autres structures ambulatoires. Comprendre le coût relatif des soins entre les différents environnements a des implications cruciales pour la politique des soins de santé et la conception des systèmes. MéTHODES: Nous avons procédé à un examen systématique des documents comparant le coût des soins pour les affections à faible gravité et les affections sensibles aux soins ambulatoires dans les services d'urgence et dans d'autres établissements de soins ambulatoires. Nous avons effectué des recherches dans PubMed, EMBASE, CINAHL et Web of Science pour les articles évalués par des pairs, ainsi que dans Google pour la littérature grise. Nous avons procédé à une double sélection et à une extraction des données, ainsi qu'à une évaluation de la qualité des études incluses à l'aide d'une liste de contrôle SIGN adaptée aux études économiques. Nous avons calculé un ratio moyen non pondéré pour l'ensemble des études et avons résumé nos conclusions sous forme de texte et de tableau. RéSULTATS: Nous avons identifié une étude comparant les coûts. 18 études ont évalué les frais des médecins ou des établissements, menées aux États-Unis, au Royaume-Uni et au Canada, y compris des analyses de cohortes (5), des analyses de frais (5), des enquêtes (1) et des recherches dans des bases de données (5) évaluant des populations allant de 370 participants à 60 millions de personnes. Les taux d'imputation allaient de 0,60 à 13,45, avec une moyenne non pondérée de 4,20. La plupart des études (12) étaient de qualité acceptable. CONCLUSION: Depuis 2001, aucune étude n'a évalué les coûts comparatifs des soins aux urgences par rapport aux soins hors urgences pour les affections ambulatoires de faible gravité. Les honoraires des médecins et des établissements pour les soins aux urgences sont plus élevés que dans d'autres structures ambulatoires pour les affections de faible gravité. Il n'existe pas de données empiriques permettant d'affirmer que les soins aux urgences sont plus coûteux que des soins similaires dispensés dans d'autres structures ambulatoires.

Validating emergency department cardioversion procedures in provincial administrative data in Ontario, Canada.

BACKGROUND: Cardioversion of acute-onset atrial fibrillation (AF) via electrical or pharmacological means is a common procedure performed in many emergency departments. While these procedures appear to be very safe, the rarity of subsequent adverse outcomes such as stroke would require huge sample sizes to confirm that conclusion. Big data can supply such sample sizes. OBJECTIVE: We aimed to validate several potential codes for successful emergency department cardioversion of AF patients. METHODS: This study combined 3 observational datasets of emergency department AF visits seen at one of 26 hospitals in Ontario, Canada, between 2008 and 2012. We linked patients who were eligible for emergency department cardioversion to several province-wide health administrative datasets to search for the associated cardioversion billing and procedural codes. Using the observational data as the gold standard for successful cardioversion, we calculated the test characteristics of a billing code (Z437) and of procedural codes 1.HZ.09JAFS and 1.HZ.09JAJS. Both include pharmacological and electrical cardioversions, as well as unsuccessful attempts; the latter is <10% using electricity (in Canada, standard practice is to proceed to electrical cardioversion if pharmacological cardioversion is unsuccessful). RESULTS: Of 4557 unique patients in the three datasets, 2055 (45.1%) were eligible for cardioversion. Nine hundred thirty-three (45.4%) of these were successfully cardioverted to normal sinus rhythm. The billing code had slightly better test characteristics overall than the procedural codes. Positive predictive value (PPV) of a billing was 89.8% (95% CI, 87.0-92.2), negative predictive value (NPV) 70.5% (95% CI, 68.1-72.8), sensitivity 52.1% (95% CI, 48.8-55.3), and specificity 95.1% (95% CI, 93.7-96.3). CONCLUSIONS: AF patients who have been successfully cardioverted in an emergency department can be identified with high PPV and specificity using a billing code. Studies that require high sensitivity for cardioversion should consider other methods to identify cardioverted patients.

Post-acute health care burden after SARS-CoV-2 infection: a retrospective cohort study.

BACKGROUND: The post-acute burden of health care use after SARS-CoV-2 infection is unknown. We sought to quantify the post-acute burden of health care use after SARS-CoV-2 infection among community-dwelling adults in Ontario by comparing those with positive and negative polymerase chain reaction (PCR) test results for SARS-CoV-2 infection. METHODS: We conducted a retrospective cohort study involving community-dwelling adults in Ontario who had a PCR test between Jan. 1, 2020, and Mar. 31, 2021. Follow-up began 56 days after PCR testing. We matched people 1:1 on a comprehensive propensity score. We compared per-person-year rates for health care encounters at the mean and 99th percentiles, and compared counts using negative binomial models, stratified by sex. RESULTS: Among 531 702 matched people, mean age was 44 (standard deviation [SD] 17) years and 51% were female. Females who tested positive for SARS-CoV-2 had a mean of 1.98 (95% CI 1.63 to 2.29) more health care encounters overall per-person-year than those who had a negative test result, with 0.31 (95% CI 0.05 to 0.56) more home care encounters to 0.81 (95% CI 0.69 to 0.93) more long-term care days. At the 99th percentile per-person-year, females who tested positive had 6.48 more days of hospital admission and 28.37 more home care encounters. Males who tested positive for SARS-CoV-2 had 0.66 (95% CI 0.34 to 0.99) more overall health care encounters per-person-year than those who tested negative, with 0.14 (95% CI 0.06 to 0.21) more outpatient encounters and 0.48 (95% CI 0.36 to 0.60) long-term care days, and 0.43 (95% CI -0.67 to -0.21) fewer home care encounters. At the 99th percentile, they had 8.69 more days in hospital per-person-year, with fewer home care (-27.31) and outpatient (-0.87) encounters. INTERPRETATION: We found significantly higher rates of health care use after a positive SARS-CoV-2 PCR test in an analysis that matched test-positive with test-negative people. Stakeholders can use these findings to prepare for health care demand associated with post-COVID-19 condition (long COVID).

Delayed intracranial hemorrhage after head injury among elderly patients on anticoagulation seen in the emergency department.

INTRODUCTION: Elderly patients on oral anticoagulation are commonly seen in emergency departments (EDs). Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. Data on delayed bleeds in anticoagulated patients are limited. The objective of this study was to examine risk of delayed intracranial hemorrhage in patients presenting to the ED with a head injury anticoagulated with warfarin or a direct oral anticoagulant, compared to patients not anticoagulated. METHODS: Cohort study using administrative data from Ontario of patients ≥ 65 years presenting to the ED with a complaint of head injury between 2016 and 2018. The primary outcome was delayed intracranial hemorrhage, defined as a new ICD-10 code for intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed. The main exposure variable was oral anticoagulation use, which was a three-level variable (warfarin, direct oral anticoagulants, or no oral anticoagulation). We used multivariable logistic regression to determine the odds of delayed intracranial hemorrhage based on anticoagulation status. RESULTS: 69,321 patients were included: 58,233 (84.0%) had not been prescribed oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant prescription. Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients not anticoagulated, 586 (1.0%) had a delayed intracranial hemorrhage, 54 (1.8%) patients on warfarin, and 78 (1.0%) patients on a direct oral anticoagulant had a delayed intracranial hemorrhage. There was an increased odds of delayed intracranial hemorrhage with warfarin use compared with no anticoagulation (OR 1.5, 95% CI 1.1-2.1). There was no association between delayed intracranial hemorrhage and direct oral anticoagulant use compared to no anticoagulation (OR 0.9, 95% CI 0.6-1.1). CONCLUSIONS: There was an increased odds of delayed intracranial hemorrhage within 90 days in older ED head injured patients prescribed warfarin compared to patients not on anticoagulation. direct oral anticoagulant use was not associated with increased risk of delayed intracranial hemorrhage.

RéSUMé: INTRODUCTION: Les patients âgés sous anticoagulation orale sont fréquemment accueillis dans les services d'urgence. L'anticoagulation orale, en particulier la warfarine, est associée à un risque accru d'hémorragie intracrânienne après un traumatisme crânien. Les données sur les saignements retardés chez les patients anticoagulés sont limitées. L'objectif de cette étude était d'examiner le risque d'hémorragie intracrânienne tardive chez les patients se présentant aux urgences avec un traumatisme crânien et anticoagulés avec de la warfarine ou un anticoagulant oral direct, par rapport aux patients non anticoagulés. MéTHODES: Étude de cohorte utilisant les données administratives de l'Ontario des patients ≥ 65 ans se présentant aux urgences avec une plainte de traumatisme crânien entre 2016 et 2018. L'issue primaire était l'hémorragie intracrânienne tardive, définie comme un nouveau code CIM-10 pour une hémorragie intracrânienne dans les 90 jours suivant la visite initiale aux urgences où aucune hémorragie intracrânienne n'a été diagnostiquée. La principale variable d'exposition était le recours à l'anticoagulation orale, qui était une variable à trois niveaux (warfarine, anticoagulants oraux directs ou pas d'anticoagulation orale). Nous avons utilisé une régression logistique multivariable pour déterminer les chances d'hémorragie intracrânienne tardive en fonction du statut d'anticoagulation. RéSULTATS: 69 321 patients ont été inclus : 58 233 (84,0 %) n'avaient pas reçu de prescription d'anticoagulant oral, 3 081 (4,4 %) avaient une prescription de warfarine et 8 007 (11,6 %) avaient une prescription directe d'anticoagulant oral. Dans l'ensemble, 718 (1,0 %) patients ont présenté une hémorragie intracrânienne tardive dans les 90 jours suivant leur visite aux urgences pour un traumatisme crânien. Parmi les patients non anticoagulés, 586 (1,0 %) ont eu une hémorragie intracrânienne retardée, 54 (1,8 %) patients sous warfarine et 78 (1,0 %) patients sous anticoagulant oral direct ont eu une hémorragie intracrânienne retardée. Le risque d'hémorragie intracrânienne tardive était plus élevé avec l'utilisation de la warfarine qu'en l'absence d'anticoagulation (OR : 1,5, IC 95 % : 1,1-2,1). Il n'y avait pas d'association entre l'hémorragie intracrânienne tardive et l'utilisation d'anticoagulants oraux directs par rapport à l'absence d'anticoagulation (OR : 0,9, IC 95 % : 0,6-1,1). CONCLUSIONS: Il y avait une probabilité accrue d'hémorragie intracrânienne retardée dans les 90 jours chez les patients plus âgés victimes d'un traumatisme crânien aux urgences à qui l'on avait prescrit de la warfarine que chez les patients qui n'étaient pas sous anticoagulation. L'utilisation d'anticoagulants oraux directs n'était pas associée à un risque accru d'hémorragie intracrânienne tardive.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study.

BACKGROUND: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. METHODS: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. RESULTS: Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]). CONCLUSIONS: Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Which Recommendations Are You Using? A Survey of Emergency Physician Management of Paroxysmal Atrial Fibrillation.

Background: Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown. Methods: We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces. Results: Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA2DS2-VASc score as their stroke-risk assessment tool. Conclusions: Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation.

Introduction: La Société canadienne de cardiologie (SCC) et l'Association canadienne des médecins d'urgence (ACMU) ont publié des documents pour orienter la prise en charge de la fibrillation auriculaire (FA). En 2021, l'ACMU a actualisé sa liste de vérification sur la FA. Avant cette actualisation, les recommandations des deux organismes différaient sur plusieurs points importants, notamment le laps de temps suggéré avant la cardioversion, les facteurs qui déterminent l'admissibilité à la cardioversion, et l'amorce du traitement anticoagulant après la cardioversion. On ignore si les médecins d'urgence (MU) connaissent ou adhère à un, à deux ou à aucun de ces documents. Méthodes: Nous avons évalué la connaissance qu'ont les MU de ces documents, leur adhésion et leur pratique grâce à un questionnaire pilote soumis aux MU de cinq services des urgences de trois provinces. Résultats: Parmi les 166 participants à l'enquête, 123 (74,1 %) y ont répondu. La majorité (64,7 %) travaillait dans un établissement universitaire, 38,8 % étaient des femmes, et le nombre médian d'années de pratique était de 10,0. La plupart (93,1 %) connaissaient au moins un des documents; 45,7 % connaissaient les deux. La connaissance rapportée était plus élevée pour les lignes directrices de la SCC (77,6 %) que pour les lignes directrices de l'ACMU (61,2 %). L'adhésion des répondants variait, mais 40,5 % utilisaient des parties des deux documents. La variabilité considérable de la pratique était observée lorsque les recommandations étaient contradictoires. Bien que son utilisation ne soit pas recommandée par l'un ou l'autre de ces organismes, la moitié des répondants (50,0 %) signalaient utiliser le score CHA2DS2-VASc comme outil d'évaluation du risque d'accident vasculaire cérébral. Conclusions: Bien que la plupart des MU interrogés connaissaient au moins un document sur la FA des organismes, plusieurs signalaient utiliser des parties des deux documents. Lorsque les recommandations étaient contradictoires, les MU étaient divisés sur la prise de décision. Ces résultats confirment la nécessité d'améliorer le consensus entre les organismes et d'améliorer davantage l'application des connaissances.

Risk of intracranial hemorrhage between different direct oral anticoagulants in older patients seen in the emergency department with a head injury: A population-based cohort study.

INTRODUCTION: Patients taking direct oral anticoagulants (DOACs) are increasingly managed in emergency departments (ED). It is unknown whether the risk of traumatic intracranial hemorrhage (ICH) after a head injury differs between DOACs. The objective of this study was to compare risk of ICH at the index ED visit among older adults presenting to the ED with a head injury prescribed different DOACs. METHODS: Retrospective cohort study using population-based administrative databases from Ontario, Canada between 2016 and 2018 of patients age 65 years and older prescribed DOACs who were seen in the ED with a head injury. Patients were matched on the propensity score to create three pairwise-matched cohorts based on the DOAC prescribed (dabigatran vs rivaroxaban; dabigatran vs apixaban; rivaroxaban vs apixaban). For each cohort, relative risk (RR) and 95% confidence intervals (CI) of ICH diagnosed at the index ED visit were calculated. RESULTS: We identified 9230 older adults presenting with a head injury prescribed a DOAC. There were 1274 (13.8%) patients with a prescription for dabigatran, 3136 (34.0%) patients with a prescription for rivaroxaban, and 4820 (52.2%) patients with a prescription for apixaban. Overall, 5.9% of patients had an ICH at the index ED visit. After matching, there were no significant differences in the risk of ICH between any matched DOAC cohorts. CONCLUSION: In patients aged 65 years and older with a prescription for a DOAC seen in the ED for a head injury, there were no differences in the risk of ICH between DOACs.

The association between anticoagulation and adverse outcomes after a positive SARS-CoV-2 test among older outpatients: A population-based cohort study.

INTRODUCTION: Anticoagulation may improve outcomes in patients with COVID-19 when started early in the course of illness. MATERIALS AND METHODS: This was a population-based cohort study using linked administrative datasets of outpatients aged ≥65 years old testing positive for SARS-CoV-2 between January 1 and December 31, 2020 in Ontario, Canada. The key exposure was anticoagulation with warfarin or direct oral anticoagulants before COVID-19 diagnosis. We calculated propensity scores and used matching weights (MWs) to reduce baseline differences between anticoagulated and non-anticoagulated patients. The primary outcome was a composite of death or hospitalization within 60 days of a positive SARS-CoV-2 test. We used the Kaplan-Meier method and cumulative incidence functions to estimate risk of the primary and component outcomes at 60 days. RESULTS: We studied 23,159 outpatients (mean age 78.5 years; 13,474 [58.2%] female), among whom 3200 (13.8%) deaths and 3183 (13.7%) hospitalizations occurred within 60 days of the SARS-CoV-2 test. After application of MWs, the 60-day risk of death or hospitalization was 29.2% (95% CI 27.4%-31.2%) for anticoagulated individuals and 32.1% (95% CI 30.7%-33.5%) without anticoagulation (absolute risk difference [ARD], -2.9%; p = 0.005). Anticoagulation was also associated with a lower risk of death: 18.6% (95% CI 17.0%-20.2%) with anticoagulation and 20.9% (95% CI 19.7%-22.2%) in non-anticoagulated patients (ARD -2.3%; p = 0.005). CONCLUSIONS: Among outpatients aged ≥65 years, oral anticoagulation at the time of a positive SARS-CoV-2 test was associated with a lower risk of a composite of death or hospitalization within 60 days.

Using Case Costing to Evaluate the Potential Impact of a Reintegration Unit on an Acute-Care Hospital's Capacity and Resources.

The Ontario Ministry of Health funded a reintegration unit to transition hospitalized patients who no longer required acute care to alternate level of care (ALC), such as long-term care. In its first year, 102 (3.5%) patients of the hospital's waiting-for-ALC population were transferred, with 37.3% transferred on the day of ALC readiness. The reintegration unit reduced direct hospital costs by $861,000. Using case costing, we modelled optimized scenarios including all transfers on the day of ALC readiness and increased transfers to the reintegration unit; this helped reduce avoided direct costs by $2.3-$5.4 million. Acute-care bed capacity could have increased by 11%. We outline strategies to optimize future performance of the reintegration unit.