Canadian Cardiovascular Harmonized National Guidelines Endeavour (C-CHANGE) guideline for the prevention and management of cardiovascular disease in primary care: 2018 update

This guideline is directed to primary health care providers caring for Canadian adults who have or are at risk of developing chronic cardiovascular diseases, including hypertension, diabetes, dyslipidemia, heart failure and stroke, and the risk factors for these conditions, including smoking, obesity and physical inactivity. The purpose of the C-CHANGE guideline is to bring together a comprehensive set of recommendations drawn from the nine participating guideline groups applicable to the care of people with multiple comorbidities. The aim is also to do this with sufficient rigour that health care practitioners and patients have confidence in the C-CHANGE process, as well as in the guidelines from the nine participating groups.

Urgency of carotid endarterectomy for secondary stroke prevention: results from the Registry of the Canadian Stroke Network.

BACKGROUND AND PURPOSE: The benefit of carotid endarterectomy for preventing recurrent stroke is maximal when surgery is performed within 2 weeks after ischemic stroke or transient ischemic attack; the benefit is reduced when surgery is delayed >2 weeks and essentially lost if delayed >3 months. Guidelines recommend endarterectomy within 2 weeks poststroke/transient ischemic attack for patients with symptomatic carotid stenosis. This study examined time to endarterectomy at designated stroke centers as a measure of evidence-based best practices for stroke prevention. METHODS: From the Registry of the Canadian Stroke Network, we identified all consecutive patients presenting with acute ischemic stroke or transient ischemic attack at 12 provincial stroke centers (Ontario, Canada, 2003 to 2006) and selected those with unilateral symptomatic carotid stenosis of moderate (50% to 69%) or severe (70% to 99%) degree. Using linkages to administrative databases, we identified patients who underwent carotid endarterectomy within 6 months after the symptomatic event and calculated the time intervals between the index event and surgery. We compared the timing of surgery according to age, sex, degree of stenosis, index event, geographic region, and year. Logistic regression assessed variables associated with early surgery. RESULTS: One hundred five patients underwent endarterectomy for unilateral symptomatic carotid stenosis (50% to 99%) within 6 months of the index event. The median time from index event to surgery was 30 days (interquartile range, 10 to 81). Only one third (38 of 105) received endarterectomy within the recommended 2-week target timeframe, and in one fourth (26 of 105), surgery was delayed >3 months. Surgery within 2 weeks was more likely if the index event was a transient ischemic attack rather than a stroke. Access to early endarterectomy varied markedly between hospitals across the province and improved over time from 2003 to 2006. CONCLUSIONS: In this hospital-based cohort, the majority of patients undergoing carotid endarterectomy after a transient ischemic attack or stroke had surgery delayed well beyond the period of maximum effectiveness. To enhance secondary stroke prevention, greater efforts are needed to minimize delays to diagnosis and surgical treatment for patients with symptomatic carotid stenosis.

Development of measures of the quality of emergency department care for children using a structured panel process.

BACKGROUND: Performance measures are essential components of public reporting and quality improvement. To date, few such measures exist to provide a comprehensive assessment of the quality of emergency department services for children. OBJECTIVES: Our goal was to use a systematic process to develop measures of emergency department care for children (0-19 years) that are (1) based on research evidence and expert opinion, (2) representative of a range of conditions treated in most emergency departments, (3) related to links between processes and outcomes, and (4) feasible to measure. METHODS: We presented a panel of providers and managers data from emergency department use to identify common conditions across levels of patient acuity, which could be targets for quality improvement. We used a structured panel process informed by a literature review to (1) identify condition-specific links between processes of care and defined outcomes and (2) select indicators to assess these process-outcome links. We determined the feasibility of calculating these indicators using an administrative data set of emergency department visits for Ontario, Canada. RESULTS: The panel identified 18 clinical conditions for indicator development and 61 condition-specific links between processes of care and outcomes. After 2 rounds of ratings, the panel defined 68 specific clinical indicators for the following conditions: adolescent mental health problems, ankle injury, asthma, bronchiolitis, croup, diabetes, fever, gastroenteritis, minor head injury, neonatal jaundice, seizures, and urinary tract infections. Visits for these conditions account for 23% of all pediatric emergency department use. Using an administrative data set, we were able to calculate 19 indicators, covering 9 conditions, representing 20% of all emergency department visits by children. CONCLUSIONS: Using a structured panel process, data on emergency department use, and literature review, it was possible to define indicators of emergency department care for children. The feasibility of these indicators will depend on the availability of high-quality data.