Association Between Immigration Status and Ambulatory Secondary Stroke Preventive Care in Ontario, Canada.

BACKGROUND AND OBJECTIVES: Secondary stroke preventive care includes evaluation and control of vascular risk factors to prevent stroke recurrence. Our objective was to evaluate the quality of ambulatory stroke preventive care and its variation by immigration status in adult stroke survivors in Ontario, Canada. METHODS: We conducted a population-based administrative database-derived retrospective cohort study in Ontario, Canada. Using immigration records, we defined immigrants as those immigrating after 1985 and long-term residents as those arriving before 1985 or those born in Canada. We included community-dwelling stroke survivors 40 years and older with a first-ever stroke between 2011 and 2017. In the year following their stroke, we evaluated the following metrics of stroke prevention: testing for hyperlipidemia and diabetes; among those with the condition, control of diabetes (hemoglobin A1c ≤7%) and hyperlipidemia (low-density lipoprotein <2 mmol/L); medication use to control hypertension, diabetes, and atrial fibrillation; and visit to a family physician and a specialist (neurologist, cardiologist, or geriatrician). We determined age and sex-adjusted absolute prevalence difference (APD) between immigrants and long-term residents for each metric using generalized linear models with binomial distribution and an identity link function. RESULTS: We included 34,947 stroke survivors (median age 70 years, 46.9% women) of whom 12.4% were immigrants. The receipt of each metric ranged from 68% to 90%. Compared with long-term residents, after adjusting for age and sex, immigrants were slightly more likely to receive screening for hyperlipidemia (APD 5.58%; 95% CI 4.18-6.96) and diabetes (5.49%; 3.76-7.23), have visits to family physicians (1.19%; 0.49-1.90), receive a prescription for antihypertensive (3.12%; 1.76-4.49) and antihyperglycemic medications (9.51%; 6.46-12.57), and achieve control of hyperlipidemia (3.82%; 1.01-6.63). By contrast, they were less likely to achieve diabetes control (-4.79%; -7.86 to -1.72) or have visits to a specialist (-1.68%; -3.12 to -0.24). There was minimal variation by region of origin or time since immigration in immigrants. DISCUSSION: Compared with long-term residents, many metrics of secondary stroke preventive care were better in immigrants, albeit with small absolute differences. However, future work is needed to identify and mitigate the factors associated with the suboptimal quality of stroke preventive care for all stroke survivors.

Characterizing medical patients with delirium: A cohort study comparing ICD-10 codes and a validated chart review method.

BACKGROUND: Delirium is a major cause of preventable mortality and morbidity in hospitalized adults, but accurately determining rates of delirium remains a challenge. OBJECTIVE: To characterize and compare medical inpatients identified as having delirium using two common methods, administrative data and retrospective chart review. METHODS: We conducted a retrospective study of 3881 randomly selected internal medicine hospital admissions from six acute care hospitals in Toronto and Mississauga, Ontario, Canada. Delirium status was determined using ICD-10-CA codes from hospital administrative data and through a previously validated chart review method. Baseline sociodemographic and clinical characteristics, processes of care and outcomes were compared across those without delirium in hospital and those with delirium as determined by administrative data and chart review. RESULTS: Delirium was identified in 6.3% of admissions by ICD-10-CA codes compared to 25.7% by chart review. Using chart review as the reference standard, ICD-10-CA codes for delirium had sensitivity 24.1% (95%CI: 21.5-26.8%), specificity 99.8% (95%CI: 99.5-99.9%), positive predictive value 97.6% (95%CI: 94.6-98.9%), and negative predictive value 79.2% (95%CI: 78.6-79.7%). Age over 80, male gender, and Charlson comorbidity index greater than 2 were associated with misclassification of delirium. Inpatient mortality and median costs of care were greater in patients determined to have delirium by ICD-10-CA codes (5.8% greater mortality, 95% CI: 2.0-9.5 and $6824 greater cost, 95%CI: 4713-9264) and by chart review (11.9% greater mortality, 95%CI: 9.5-14.2% and $4967 greater cost, 95%CI: 4415-5701), compared to patients without delirium. CONCLUSIONS: Administrative data are specific but highly insensitive, missing most cases of delirium in hospital. Mortality and costs of care were greater for both the delirium cases that were detected and missed by administrative data. Better methods of routinely measuring delirium in hospital are needed.