Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review.

Background: Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females. Methods: Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis. Results: Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke). Conclusions: The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.

Contexte: Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes et leur probabilité augmente après la ménopause. Cependant, on ne sait pas encore si le taux d'estradiol est lié aux MCV. Nous avons tenté d'établir le lien entre le taux d'estradiol sérique et les événements cardiovasculaires (CV) chez les femmes post-ménopausées. Méthodologie: Nous avons consulté systématiquement des bases de données électroniques (MEDLINE, Embase) de leur création jusqu'en octobre 2022. Les études admissibles devaient comprendre les éléments suivants : i) femmes post-ménopausées; ii) examen du lien entre le taux total d'estradiol sérique et les événements CV (décès d'origine CV, MCV, coronaropathie, infarctus du myocarde, accident vasculaire cérébral (AVC), thromboembolie veineuse, insuffisance cardiaque et hospitalisation pour une cause CV); iii) données originales (essai contrôlé randomisé; études quasi expérimentales, de cohorte, cas-témoins ou transversales). Une synthèse narrative a été réalisée parce que les données ne se prêtaient pas à une méta-analyse. Résultats: Parmi les 9 026 citations relevées, 8 articles ont été retenus, représentant un total de 5 635 femmes. Le risque de biais était raisonnable, et une très grande hétérogénéité était présente. Chez les femmes qui ne suivaient pas d'hormonothérapie ménopausique, trois études ont affiché des résultats variables quant au lien entre le taux d'estradiol et le risque de coronaropathie, et une étude a montré que des taux élevés d'estradiol étaient associés à un risque accru d'infarctus du myocarde. Aucun lien notable n'a été observé entre le taux d'estradiol et les autres événements (c.-à-d. décès d'origine CV, insuffisance cardiaque, MCV et AVC). Conclusions: Le lien entre le taux d'estradiol sérique et les événements CV chez les femmes post-ménopausées n'a pas été élucidé. D'autres études sont nécessaires pour évaluer ce lien en raison du risque élevé de MCV au sein de cette population.

Perceived discharge quality and associations with hospital readmissions and emergency department use: a prospective cohort study.

BACKGROUND: At hospital discharge, care is handed over from providers to patients. Discharge encounters must prepare patients to self-manage their health, but have been found to be suboptimal. Our study objectives were to describe and determine the correlates of perceived discharge quality and to explore the association between perceived discharge quality and postdischarge outcomes. METHODS: We conducted a prospective cohort study in medical inpatients admitted to a tertiary care hospital in Calgary, Canada. Perceived discharge quality was measured by the Care Transitions Measure (CTM). Linkage to administrative databases provided data for the composite outcome-90-day hospital readmission or emergency department visit. Logistic regression modelling was used to determine the association between global CTM scores, and the individual CTM components, and the composite outcome. RESULTS: A total of 316 patients were included in the analysis. The median CTM score was 80.0 (IQR 66.6-100.0). The distribution of CTM scores were significantly different based on comorbidity burden, with the median and maximum CTM scores being lower and the IQR being narrower, for those with six or more comorbidities compared with those with fewer comorbidities. CTM scores were not associated with the composite outcome, though a single CTM item-not understanding warning signs and symptoms-was (adjusted OR 3.46 (95% CI 1.02 to 11.73)). CONCLUSION: Perceived quality of discharge varies based on patient burden of comorbidities. While global perceived discharge quality was not associated with postdischarge outcomes, lack of patient understanding of warning symptoms was. Discharging healthcare teams should pay special attention to these priority patient groups and specific discharge process components.

The impacts of partnering with cancer patients in palliative care research: a systematic review and meta-synthesis.

Background: Palliative care (PC) is an added layer of support provided concurrently with cancer care and serves to improve wellbeing and sustain quality of life. Understanding what is meaningful and a priority to patients, their families, and caregivers with lived experience of cancer and PC is critical in supporting their needs and improving their care provision. However, the impacts of engaging cancer patients within the context of PC research remain unknown. Objective: To examine the impacts of engaging individuals with lived experience of cancer and PC as partners in PC research. Methods: An a priori systematic review protocol was registered with PROSPERO (CRD42021286744). Four databases (APA PsycINFO, CINAHL, EMBASE, and MEDLINE) were searched and only published, peer-reviewed primary English studies aligned with the following criteria were included: (1) patients, their families, and/or caregivers with lived experience of cancer and PC; (2) engaged as partners in PC research; and (3) reported the impacts of engaging cancer PC patient partners in PC research. We appraised the quality of eligible studies using the Critical Appraisal Skills Program (CASP) and GRIPP2 reporting checklists. Results: Three studies that included patient partners with lived experience of cancer and PC engaged at all or several of the research stages were identified. Our thematic meta-synthesis revealed impacts (benefits and opportunities) on patient partners (emotional, psychological, cognitive, and social), the research system (practical and ethical) and health care system (service improvements, bureaucratic attitudes, and inaction). Our findings highlight the paucity of evidence investigating the impacts of engaging patients, their families and caregivers with lived experience of cancer and PC, as partners in PC research. Conclusions: The results of this review and meta-synthesis can inform the more effective design of cancer patient partnerships in PC research and the development of feasible and effective strategies given the cancer and PC context patient partners are coming from.

Development and validation of a social vulnerabilities survey for medical inpatients.

OBJECTIVES: Our objective was to validate a Social Vulnerabilities Survey that was developed to identify patient barriers in the following domains: (1) salience or priority of health; (2) social support; (3) transportation; and (4) finances. DESIGN: Cross-sectional psychometric study.Questions for one domain (health salience) were developed de novo while questions for the other domains were derived from national surveys and/or previously validated questionnaires. We tested construct (ie, convergent and discriminative) validity for these new questions through hypothesis testing of correlations between question responses and patient characteristics. Exploratory factor analysis was conducted to determine structural validity of the survey as a whole. SETTING: Patients admitted to the inpatient internal medicine service at a tertiary care hospital in Calgary, Canada. PARTICIPANTS: A total of 406 patients were included in the study. RESULTS: The mean age of respondents was 55.5 (SD 18.6) years, with the majority being men (55.4%). In feasibility testing of the first 107 patients, the Social Vulnerabilities Survey was felt to be acceptable, comprehensive and met face validity. Hypothesis testing of the health salience questions revealed that the majority of observed correlations were exactly as predicted. Exploratory factor analysis of the global survey revealed the presence of five factors (eigenvalue >1): social support, health salience, drug insurance, transportation barriers and drug costs. All but four questions loaded to these five factors. CONCLUSIONS: The Social Vulnerabilities Survey has face, construct and structural validity. It can be used to measure modifiable social vulnerabilities, such that their effects on health outcomes can be explored and understood.

Connect 2 Care, a Novel Community Outreach Program for Vulnerably Housed Patients With High Acute Care Use: A Mixed-Methods Study Protocol.

Introduction: Vulnerably housed individuals, especially those experiencing homelessness, have higher acute care use compared with the general population. Despite available primary care and social services, many face significant challenges accessing needed services. Connect 2 Care (C2C) is a novel transitional case management program that includes registered nurses and health navigators with complementary expertise in chronic disease management, mental health and addictions, social programs, community health, and housing, financial, transportation and legal resources. C2C bridges acute care and community services to improve care coordination. Methods and Analysis: We will perform a mixed-methods evaluation of the C2C program according to the Donabedian framework of structure, process and outcome, to understand how program structure and process, coupled with contextual factors, influence outcomes in a novel intervention. Eligible patients are homeless or unstably housed adults with complex health conditions and high acute care use. Change in emergency department visit rate 12-months after program enrolment is the primary outcome. Secondary outcomes include 12-month post-enrolment hospital admissions, cumulative hospital days, health-related quality of life, housing status, primary care attachment and substance use. Qualitative methods will explore experiences with the C2C program from multiple perspectives and an economic evaluation will assess cost-effectiveness. Discussion: Academic researchers partnered with community service providers to evaluate a novel transitional case management intervention for vulnerably housed patients with high acute-care use. The study uses mixed-methods to evaluate the Connect 2 Care program according to the Donabedian framework of structure, process and outcome, including an assessment of contextual factors that influence program success. Insights gained through this comprehensive evaluation will help refine the C2C program and inform decisions about sustainability and transferability to other settings in Canada.

Patient navigation programs in Alberta, Canada: an environmental scan.

BACKGROUND: Patient navigation is a complex intervention that has garnered substantial interest and investment across Canada. We conducted an environmental scan to understand the landscape of patient navigation programs within the health care system in Alberta, Canada. METHODS: We included patient navigation programs within Alberta Health Services (AHS) and Alberta's Primary Care Networks (PCNs). Key informants were asked in October 2016 to identify existing programs and their corresponding program contacts. These program contacts were invited to complete a telephone-based survey from October 2016 to July 2017, to provide program descriptions and eligibility criteria, and to identify gaps in navigation. Programs were included if they engaged patients on an individual basis, and either facilitated continuity of care or promoted patient and family empowerment. We tabulated results and calculated summary statistics for program characteristics. RESULTS: Ninety-five potentially eligible programs were identified by key informants. The response rate to the study survey was 73% (n = 69). After excluding programs not meeting inclusion criteria, we included a total of 58 programs in the study: 43 AHS programs and 15 PCN programs. Nearly all programs (93%, n = 54) delivered navigation via an individual acting as a navigator. A minority of programs also included nonnavigator components, such as Web-based resources (7%, n = 4) and process or structural changes to facilitate navigation (22%, n = 13). Certain patient subgroups were particularly well-served by patient navigation; these included patients with cancer, substance use disorders or mental health concerns, and pediatric patients. Gaps identified in navigation fell under 4 domains: awareness, resources, geographic distribution and integration. INTERPRETATION: Patient navigation programs are common and have extended beyond cancer care, from which the construct originated; however, gaps include a lack of awareness and inequitable access to the programs. These findings will be of interest to those developing and implementing patient navigation interventions in Alberta and other jurisdictions.

Socioeconomic Status, Mortality, and Access to Cardiac Services After Acute Myocardial Infarction in Canada: A Systematic Review and Meta-analysis.

BACKGROUND: Low socioeconomic status (SES) is an important prognosticator for those with acute myocardial infarction (AMI), having previously been described to be associated with increased short-term mortality. Whether this effect persists over time, and whether access to cardiac interventions is equitable within Canada's universal health care system, remains unknown. METHODS: We conducted a systematic review to determine the associations of SES with mortality and access to a spectrum of interventions including cardiac catheterization, revascularization, and cardiac rehabilitation. Electronic databases (EMBASE and MEDLINE) were searched in March 2019 and December 2019. Original studies from Canada examining associations between SES and any of the above outcomes in AMI patients were included. Meta-analyses were conducted using random effects models. RESULTS: Nineteen studies were included, 11 of which could be meta-analyzed. Low SES was associated with a 48% and 34% increase in short-term and intermediate-term mortality, respectively. There was a trend toward increased long-term mortality more than 1-year post-event (pooled odds ratio [OR] 1.34 [95% confidence interval {CI} 0.95-1.88]). Low SES was also associated with lower rates of cardiac catheterization (pooled OR 0.80 [95% CI 0.65-0.99]) and revascularization (pooled OR 0.76 [95% CI 0.63-0.90]) post-AMI. Studies on cardiac rehabilitation showed reduced access and participation in low-SES groups. CONCLUSIONS: Low SES is associated with not only increased mortality post-AMI, but also reduced access to cardiac interventions that have demonstrated benefits for mortality and morbidity. Interventions that improve access to catheterization, revascularization, and cardiac rehabilitation for low-SES populations are needed if true equitable care in Canada is desired.

CONTEXTE: Le statut socio-économique (SSE) inférieur est un facteur pronostique important chez les personnes ayant subi un infarctus aigu du myocarde (IAM) qui semble être associé à un risque accru de mortalité à court terme. On ignore si cet effet persiste avec le temps et si l'accès aux interventions cardiaques est équitable au sein du système de soins de santé universel canadien. MÉTHODOLOGIE: Nous avons réalisé une revue systématique afin de caractériser les associations entre le SSE et la mortalité et l'accès à une gamme d'interventions, y compris le cathétérisme, la revascularisation et la réadaptation cardiaque. Les recherches ont été effectuées dans les bases de données électroniques EMBASE et MEDLINE en mars 2019 et en décembre 2019. Certaines études originales réalisées au Canada sur les associations entre le SSE et l'un ou l'autre des résultats ci-haut chez des patients ayant subi un IAM ont été incluses. Des méta-analyses à partir de modèles à effets aléatoires ont été réalisées. RÉSULTATS: Dix-neuf études ont été incluses, dont 11 qui ont pu être méta-analysées. Un SSE inférieur était associé à une augmentation de 48 % et de 34 % de la mortalité à court terme et de la mortalité à moyen terme, respectivement. On a observé une tendance à l'augmentation de la mortalité à long terme plus d'un an après l'événement (rapport de cotes [RC] agrégé 1,34 [intervalle de confiance {IC} à 95 % : de 0,95 à 1,88]). Le SSE inférieur était également associé à des taux plus faibles de cathétérisme cardiaque (RC agrégé 0,80 [IC à 95 % : de 0,65 à 0,99]) et de revascularisation (RC agrégé 0,76 [IC à 95 % : de 0,63 à 0,90]) après un IAM. Les études sur la réadaptation cardiaque ont montré une diminution de l'accès et de la participation dans les groupes de SSE inférieur. CONCLUSIONS: Un SSE inférieur est associé, après un IAM, non seulement à une mortalité accrue, mais aussi à un accès réduit aux interventions cardiaques dont les effets positifs sur la mortalité et la morbidité ont été démontrés. Il est nécessaire de mettre en œuvre des interventions qui améliorent l'accès au cathétérisme, à la revascularisation et à la réadaptation cardiaque des populations de SSE inférieur si l'on veut que le système de soins canadien soit réellement équitable.

Risk of Depression in Patients With Psoriatic Disease: A Systematic Review and Meta-Analysis.

BACKGROUND: Previous systematic reviews have assessed the prevalence and odds ratio (OR) of depression for patients with psoriatic disease. Due to probable bidirectional effects, prevalence and prevalence ORs are difficult to interpret. No prior reviews have quantified the relative risk (RR) of depression following a diagnosis of psoriatic disease. OBJECTIVE: To estimate the RR of depression in individuals with psoriasis and in psoriatic arthritis (PsA), clear-to-moderate psoriasis, and moderate-to-severe psoriasis subgroups. METHODS: Observational studies investigating the risk of depression in adults with psoriatic disease were systematically searched for in Medline, EMBASE, PsycINFO, and CINAHL databases; 4989 unique references were screened. Studies that reported measures of incident depression in psoriasis patients were included. Thirty-one studies were included into the systematic review, of which 17 were meta-analyzed. Random effects models were employed to synthesize relevant data. Sources of heterogeneity were explored with subgroup analysis and meta-regression. RESULTS: Seventeen studies were included in meta-analyses. The pooled RR of depression in psoriasis patients compared to nonpsoriasis controls was 1.48 (95% CI: 1.16-1.89). Heterogeneity was high (I2 = 99.8%). Subgroup analysis and meta-regression did not indicate that PsA status or psoriasis severity (clear-to-mild, moderate-to-severe) were sources of heterogeneity. No evidence of publication bias was found. CONCLUSIONS: This review demonstrates that the risk of depression is greater in patients with psoriasis and PsA. Future research should focus on developing strategies to address the mental health needs of this patient population for depression, including primary prevention, earlier detection, and treatment strategies.

Prevalence of antimicrobial resistance genes and its association with restricted antimicrobial use in food-producing animals: a systematic review and meta-analysis.

BACKGROUND: There is ongoing debate regarding potential associations between restrictions of antimicrobial use and prevalence of antimicrobial resistance (AMR) in bacteria. OBJECTIVES: To summarize the effects of interventions reducing antimicrobial use in food-producing animals on the prevalence of AMR genes (ARGs) in bacteria from animals and humans. METHODS: We published a full systematic review of restrictions of antimicrobials in food-producing animals and their associations with AMR in bacteria. Herein, we focus on studies reporting on the association between restricted antimicrobial use and prevalence of ARGs. We used multilevel mixed-effects models and a semi-quantitative approach based on forest plots to summarize findings from studies. RESULTS: A positive effect of intervention [reduction in prevalence or number of ARGs in group(s) with restricted antimicrobial use] was reported from 29 studies for at least one ARG. We detected significant associations between a ban on avoparcin and diminished presence of the vanA gene in samples from animals and humans, whereas for the mecA gene, studies agreed on a positive effect of intervention in samples only from animals. Comparisons involving mcr-1, blaCTX-M, aadA2, vat(E), sul2, dfrA5, dfrA13, tet(E) and tet(P) indicated a reduced prevalence of genes in intervention groups. Conversely, no effects were detected for ß-lactamases other than blaCTX-M and the remaining tet genes. CONCLUSIONS: The available body of scientific evidence supported that restricted use of antimicrobials in food animals was associated with an either lower or equal presence of ARGs in bacteria, with effects dependent on ARG, host species and restricted drug.

Comparison of different approaches to antibiotic restriction in food-producing animals: stratified results from a systematic review and meta-analysis.

BACKGROUND: We have previously reported, in a systematic review of 181 studies, that restriction of antibiotic use in food-producing animals is associated with a reduction in antibiotic-resistant bacterial isolates. While informative, that report did not concretely specify whether different types of restriction are associated with differential effectiveness in reducing resistance. We undertook a sub-analysis of the systematic review to address this question. METHODS: We created a classification scheme of different approaches to antibiotic restriction: (1) complete restriction; (2) single antibiotic-class restriction; (3) single antibiotic restriction; (4) all non-therapeutic use restriction; (5) growth promoter and prophylaxis restriction; (6) growth promoter restriction and (7) other/undetermined. All studies in the original systematic review that were amenable to meta-analysis were included into this substudy and coded by intervention type. Meta-analyses were conducted using random effects models, stratified by intervention type. RESULTS: A total of 127 studies were included. The most frequently studied intervention type was complete restriction (n=51), followed by restriction of non-therapeutic (n=33) and growth promoter (n=19) indications. None examined growth promoter and prophylaxis restrictions together. Three and seven studies examined single antibiotic-class and single antibiotic restrictions, respectively; these two intervention types were not significantly associated with reductions in antibiotic resistance. Though complete restrictions were associated with a 15% reduction in antibiotic resistance, less prohibitive approaches also demonstrated reduction in antibiotic resistance of 9%-30%. CONCLUSION: Broad interventions that restrict global antibiotic use appear to be more effective in reducing antibiotic resistance compared with restrictions that narrowly target one specific antibiotic or antibiotic class. Importantly, interventions that allow for therapeutic antibiotic use appear similarly effective compared with those that restrict all uses of antibiotics, suggesting that complete bans are not necessary. These findings directly inform the creation of specific policies to restrict antibiotic use in food-producing animals.

Examination of unintended consequences of antibiotic use restrictions in food-producing animals: Sub-analysis of a systematic review.

Antimicrobial resistance is considered one of the greatest threats to global and public health today. The World Health Organization, the Food and Agriculture Organization, and the World Organisation for Animal Health, known as the Tripartite Collaboration, have called for urgent action. We have previously published a systematic review of 181 studies, demonstrating that interventions that restrict antibiotic use in food-producing animals are associated with a reduction in antibiotic resistant bacterial isolates in both animals and humans. What remains unknown, however, are whether (and what) unintended consequences may arise from such interventions. We therefore undertook a sub-analysis of the original review to address this research question. A total of 47 studies described potential consequences of antibiotic restrictions. There were no consistent trends to suggest clear harm. There may be increased bacterial contamination of food products, the clinical significance of which remains unclear. There is a need for rigorous evaluation of the unintended consequences of antibiotic restrictions in human health, food availability, and economics, given their possible widespread implications.

The Effect of Cardiac Rehabilitation Attendance on Sexual Activity Outcomes in Cardiovascular Disease Patients: A Systematic Review.

BACKGROUND: Decreased sexual activity (SA) is a common problem in patients with cardiovascular disease (CVD). Although there is evidence that cardiac rehabilitation (CR) is effective in improving physical outcomes and overall quality of life, its effects on SA remain unclear. In this systematic review we assessed the association between CR attendance and SA outcomes in adults with CVD. METHODS: Electronic databases (MEDLINE, PsycINFO, EMBASE, CINAHL) were systematically searched in January 2018. Original studies that compared attendance to CR vs no attendance to CR in adults 18 years and older with diagnosed CVD that also reported on SA outcomes were included. A narrative synthesis was conducted because the data did not permit meta-analysis. RESULTS: Fourteen studies were identified: 6 randomized controlled trials, 5 nonrandomized controlled trials, and 3 prospective cohort studies. All CR programs included an exercise-based component and 4 included an SA-specific component. Seven studies reported a significant benefit in SA outcomes in the CR group, 1 study reported significant harm, and 11 studies reported a nonsignificant difference. CONCLUSIONS: The effect of CR on SA outcomes was generally reported to be equivocal or positive. CR showed some promise in improving sexual functioning and frequency, with mixed results with regard to sexual resumption and satisfaction. In conclusion, it remains uncertain if CR consistently improves sexual outcomes in adults with CVD but these data suggest that further exploration might be justified.

Long-term risk of cardiovascular mortality in lymphoma survivors: A systematic review and meta-analysis.

Cardiovascular disease has been identified as one of the late complications of cancer therapy. The purpose of this study was to quantify the long-term risk of cardiovascular mortality among lymphoma survivors relative to that of the general population. A systematic review and meta-analysis were conducted. Articles were identified in November 2016 by searching EMBASE, MEDLINE, and CINAHL databases. Observational studies were included if they assessed cardiovascular mortality in patients with lymphoma who survived for at least 5 years from time of diagnosis or if they had a median follow-up of 10 years. A pooled standardized mortality ratio (SMR) was estimated using a DerSimonian and Laird random-effects model. The Q and I2 statistics were used to assess heterogeneity. Funnel plots and Begg's and Egger's tests were used to evaluate publication bias. Of the 7450 articles screened, 27 studies were included in the systematic review representing 46 829 Hodgkin and 14 764 non-Hodgkin lymphoma survivors. The pooled number of deaths attributable to cardiovascular disease among Hodgkin and non-Hodgkin disease was estimated to be 7.31 (95% CI: 5.29-10.10; I2  = 95.4%) and 5.35 (95% CI: 2.55-11.24; I2  = 94.0%) times that of the general population, respectively. This association was greater among Hodgkin lymphoma survivors treated before the age of 21 (pooled SMR = 13.43; 95% CI: 9.22-19.57; I2  = 78.9%). There was a high degree of heterogeneity and a high risk of bias due to confounding in this body of literature. Lymphoma survivors have an increased risk of fatal cardiovascular events compared to the general population and should be targeted for cardiovascular screening and prevention campaigns.

An Exploration of the Content and Usability of Web-Based Resources Used by Individuals to Find and Access Family Physicians.

Background: The most commonly recommended strategy in Canada for patients wishing to find a regular family physician (FP) is through the use of websites with FP listings. We aimed to explore the content and usability of these websites. Methods: We identified publicly available websites with FP listings in Western Canada, analyzing them thematically through open coding for website content and conducting framework analysis for website usability. Results: Twelve unique websites were identified and grouped into three categories: (1) Physician regulatory authorities ("Colleges"); (2) Governmental; and (3) Miscellaneous. College websites provided the greatest detail about the FPs and enabled searching, though had low readability. Governmental websites listed basic contact information and were credible but contained less detail than College websites. Miscellaneous websites were narrower in focus and therefore easier to navigate but lacked updated and accurate information. Conclusions: Many websites help patients find FPs. Their content and usability are variable, suggesting a need for guidance in the development of these resources.

An exploration of the subjective social status construct in patients with acute coronary syndrome.

BACKGROUND: Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association. METHODS: We conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS. RESULTS: One thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings. CONCLUSION: Low societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies.

Weekend Surgical Care and Postoperative Mortality: A Systematic Review and Meta-Analysis of Cohort Studies.

BACKGROUND: An association between weekend health care delivery and poor outcomes has become known as the "weekend effect." Evidence for such an association among surgery patients has not previously been synthesized. OBJECTIVE: To systematically review associations between weekend surgical care and postoperative mortality. METHODS: We searched PubMed, EMBASE, and references of relevant articles for studies that compared postoperative mortality either; (1) according to the day of the week of surgery for elective operations, or (2) according to weekend versus weekday admission for urgent/emergent operations. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) for postoperative mortality (≤90 d or inpatient mortality) were pooled using random-effects models. RESULTS: Among 4027 citations identified, 10 elective surgery studies and 19 urgent/emergent surgery studies with a total of >6,685,970 and >1,424,316 patients, respectively, met the inclusion criteria. Pooled odds of mortality following elective surgery rose in a graded manner as the day of the week of surgery approached the weekend [Monday OR=1 (reference); Tuesday OR=1.04 (95% CI=0.97-1.11); Wednesday OR=1.08 (95% CI=0.98-1.19); Thursday OR=1.12 (95% CI=1.03-1.22); Friday OR=1.24 (95% CI=1.10-1.38)]. Mortality was also higher among patients who underwent urgent/emergent surgery after admission on the weekend relative to admission on weekdays (OR=1.27; 95% CI=1.08-1.49). CONCLUSIONS: Postoperative mortality rises as the day of the week of elective surgery approaches the weekend, and is higher after admission for urgent/emergent surgery on the weekend compared with weekdays. Future research should focus on clarifying underlying causes of this association and potentially mitigating its impact.

Blood pressure at age 60-65 versus age 70-75 and vascular dementia: a population based observational study.

BACKGROUND: Vascular dementia (VaD) is the second most common form of dementia. However, there were mixed evidences about the association between blood pressure (BP) and risk of VaD in midlife and late life and limited evidence on the association between pulse pressure and VaD. METHODS: This is a population-based observational study. 265,897 individuals with at least one BP measurement between the ages of 60 to 65 years and 211,116 individuals with at least one BP measurement between the ages of 70 to 75 years were extracted from The Health Improvement Network in United Kingdom. Blood pressures were categorized into four groups: normal, prehypertension, stage 1 hypertension, and stage 2 hypertension. Cases of VaD were identified from the recorded clinical diagnoses. Multivariable survival analysis was used to adjust other confounders and competing risk of death. All the analysis were stratified based on antihypertensive drug use status. Multiple imputation was used to fill in missing values. RESULTS: After accounting for the competing risk of death and adjustment for potential confounders, there was an association between higher BP levels in the age 60-65 cohort with the risk of developing VaD (hazard ratio [HR] 1.53 (95% confidence interval: 1.04, 2.25) for prehypertension, 1.90 (1.30, 2.78) for stage 1 hypertension, and 2.19 (1.48, 3.26) for stage 2 hypertension) in the untreated group. There was no statistically significant association between BP levels and VaD in the treated group in the age 60-65 cohort and age 70-75 cohort. Analysis on Pulse Pressure (PP) stratified by blood pressure level showed that PP was not independently associated with VaD. CONCLUSION: High BP between the ages of 60 to 65 years is a significant risk for VaD in late midlife. Greater efforts should be placed on early diagnosis of hypertension and tight control of BP for hypertensive patients for the prevention of VaD.

Coder perspectives on physician-related barriers to producing high-quality administrative data: a qualitative study.

BACKGROUND: Professional coding specialists ("coders") are experts at translating patient chart information into alphanumerical codes, which are then widely used in research and health policy decision-making. Coders rely solely on documentation by health care providers to complete this task. We aimed to explore physician-related barriers to coding that results in high-quality administrative data. METHODS: In a qualitative study conducted from December 2015 to March 2016, we recruited 28 coders who worked in health care facilities in Alberta using purposive and snowball sampling. Semistructured interviews were conducted, audio-recorded and transcribed. The interviews delved into coder training, work environment, documentation and coding standards. Thematic content analysis of transcripts was performed by 2 study investigators through line-by-line coding and constant comparison, after which the codes were collated into themes. RESULTS: Five themes emerged regarding physician-related barriers in coding of high-quality administrative data: 1) coders are limited in their ability to add to, modify or interpret physician documentation, which supersedes all other chart documentation, 2) physician documentation is incomplete and nonspecific, 3) chart information tends to be replete with errors and discrepancies, 4) physicians and coders use different terminology to describe clinical diagnoses and 5) there is a communication divide between coders and physicians, such that questions and issues regarding physician documentation cannot be reconciled. INTERPRETATION: Physicians play a major role in influencing the quality of administrative data. There is a need for physicians to advocate for culture change in physicians' attitudes toward coders and chart documentation, in recognition of the importance of accurate chart information.

Efficacy of Calcium Channel Blockers on Major Cardiovascular Outcomes for the Treatment of Hypertension in Asian Populations: A Meta-analysis.

BACKGROUND: Whether calcium channel blockers exert a greater effect on cardiovascular risk reduction in Asian populations than other antihypertensive agents is unclear. We conducted a meta-analysis of hypertension trials of dihydropyridine calcium channel blockers in Asian populations to clarify this association. METHODS: EMBASE, MEDLINE, and Cochrane databases were searched (from inception to August 2016) for randomized controlled trials on cardiovascular death, major adverse cardiovascular events, stroke, congestive heart failure, and coronary revascularization in Asian persons with hypertension. We identified 9 trials that reported data specific to Asian populations (N = 29,643). These trials included 1 placebo-controlled trial and 8 active comparator trials; of these, 5 had angiotensin receptor blockers as the active comparator. RESULTS: One placebo-controlled trial (n = 9711) showed significantly reduced cardiovascular mortality, major adverse cardiovascular events, and stroke with calcium channel blockers. Among 8 active comparator trials (n = 19,932), there were no significant differences in mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.72-1.67; I2 = 0.0%), major adverse cardiovascular events (RR, 1.02; 95% CI, 0.90-1.15; I2 = 0.0%), stroke (RR, 0.97; 95% CI, 0.80-1.17; I2 = 0.0%), congestive heart failure (RR, 1.01; 95% CI, 0.51-2.00; I2 = 53.7), or coronary revascularization rates (RR, 0.98; 95% CI, 0.76-1.25; I2 = 0.0%) in the calcium channel blocker group compared with other antihypertensive agents. When restricting the meta-analysis to angiotensin receptor blocker comparators (n = 10,384), there were no significant differences in cardiovascular outcomes. CONCLUSIONS: There is no evidence that dihydropyridine calcium channel blockers are superior to other antihypertensive agents in Asian populations for the treatment of hypertension.