A formalized shared decision-making process with individualized decision aids for older patients referred for cardiac surgery.

BACKGROUND: Comprehension of risks, benefits and alternative treatment options is poor among patients referred for cardiac surgery interventions. We sought to explore the impact of a formalized shared decision-making (SDM) process on patient comprehension and decisional quality among older patients referred for cardiac surgery. METHODS: We developed and evaluated a paper-based decision aid for cardiac surgery within the context of a prospective SDM design. Surgeons were trained in SDM through a Web-based program. We acted as decisional coaches, going through the decision aids with the patients and their families, and remaining available for consultation. Patients (aged ≥ 65 yr) undergoing isolated valve, coronary artery bypass graft (CABG) or CABG and valve surgery were eligible. Participants in the non-SDM phase followed standard care. Participants in the SDM group received a decision aid following cardiac catheterization, populated with individualized risk assessment, personal profile and comorbidity status. Both groups were assessed before surgery on comprehension, decisional conflict, decisional quality, anxiety and depression. RESULTS: We included 98 patients in the SDM group and 97 in the non-SDM group. Patients who received decision aids through a formalized SDM approach scored higher in comprehension (median 15.0, interquartile range [IQR] 12.0-18.0) than those who did not (median 9.0, IQR 7.0-12.0, p < 0.001). Decisional quality was greater in the SDM group (median 82.0, IQR 73.0-91.0) than in the non-SDM group (median 76.0, IQR 62.0-82.0, p < 0.05). Decisional conflict scores were lower in the SDM group (mean 1.76, standard deviation [SD] 1.14) than in the non-SDM group (mean 5.26, SD 1.02, p < 0.05). Anxiety and depression scores showed no significant difference between groups. CONCLUSION: Institution of a formalized SDM process including individualized decision aids improved comprehension of risks, benefits and alternatives to cardiac surgery, as well as decisional quality, and did not result in increased levels of anxiety.

Frailty Is Associated With Decreased Time Spent at Home After Critical Illness: A Population-Based Study.

BACKGROUND: Frailty is characterized by vulnerability to stressors due to an accumulation of multiple functional deficits. Frailty is increasingly recognized as a risk factor for accelerated functional decline, increasing dependency, and risk of mortality. The objective of this study was to examine the association of frailty, at the time of critical care admission, with days alive at home and health care costs post-discharge. METHODS: This retrospective cohort study used linked administrative data (2010-2016) in Ontario, Canada. We identified all patients admitted at the intensive care unit (ICU), aged 19 years and above, assessed using the Resident Assessment Instrument for Home Care (RAI-HC), within 6 months prior to index hospitalization including an ICU stay. Patients were stratified as robust, pre-frail, or frail based on a validated Frailty Index. The primary outcome was days alive at home in the year after admission. Secondary outcomes included mortality, health care-associated costs, ICU interventions, long-term care admissions, and hospital readmissions. RESULTS: Frail patients spent significantly fewer days at home within 1 year of index hospitalization (mean 159 days vs 223 days in robust cohort, P < .001). Mortality was higher among frail patients at 1 year (59.6% in the frail cohort vs 45.9% in robust patients; odds ratio for death 1.59 [1.49-1.69]). Frail patients also had higher rates of long-term care admission within 1 year (30.1% vs 10.6% in robust patients). Total health care-associated costs per person alive were $30 450 higher the year after admission in the frail cohort. CONCLUSIONS: Frailty prior to ICU admission among patients who were eligible for RAI-HC assessment was associated with higher mortality and fewer days spent at home following admission. Frail patients had markedly higher rates of long-term care admission and increased costs per life saved following critical illness. These findings add to the discussion of risk-benefit trade-offs for ICU admission.

Patterns of cesarean birth among women living with HIV in Ontario: A cross-sectional, population-level study.

BACKGROUND: In Canada, as is found globally, women of reproductive age are a growing demographic of persons living with HIV. Combination antiretroviral therapy (cART) treatment enables women living with HIV (WLWH) to become pregnant without perinatal transmission, and they are increasingly planning to become pregnant. Since 2014, Canadian guidelines no longer recommend routine elective cesarean birth (CB) for women who are virally suppressed and receiving cART. It is unknown whether their obstetric care has changed since this update. Our objective was to describe trends in cesarean births among WLWH in Ontario, Canada, over a 12-year period. METHODS: Our research is co-led and codesigned with WLWH. We conducted a retrospective population-level cohort study using linked health administrative databases at ICES (formally, the Institute for Clinical and Evaluative Sciences). Participants were all women who gave birth in Ontario, between 2006/07 and 2017/18. We assessed their intrapartum characteristics and used multivariable regression to determine an association between HIV status and CB, controlling for sociodemographic and clinical variables. RESULTS: Since 2014, the overall proportion of CB among WLWH remained stable and was higher than among women without HIV (39.9% vs 29.0%, P < 0.001). In addition, the proportion of primary CB decreased between 2006 and 2010 and between 2014 and 2018 (28.5%-19.3%), whereas the proportion of repeat CB increased (13.1%-20.5%, P = 0.013). CONCLUSIONS: Because of decreasing HIV-related indications for CB, more practitioners may be following the guidelines for first-time mothers. Currently, no guidelines exist for care of WLWH with a previous CB, and opportunities for vaginal birth may be missed in this population.

Introduction of anti-TNF therapy has not yielded expected declines in hospitalisation and intestinal resection rates in inflammatory bowel diseases: a population-based interrupted time series study.

OBJECTIVES: To better understand the real-world impact of biologic therapy in persons with Crohn's disease (CD) and ulcerative colitis (UC), we evaluated the effect of marketplace introduction of infliximab on the population rates of hospitalisations and surgeries and public payer drug costs. DESIGN: We used health administrative data to study adult persons with CD and UC living in Ontario, Canada between 1995 and 2012. We used an interrupted time series design with segmented regression analysis to evaluate the impact of infliximab introduction on the rates of IBD-related hospitalisations, intestinal resections and public payer drug costs over 10 years among patients with CD and 5 years among patients with UC, allowing for a 1-year transition. RESULTS: Relative to what would have been expected in the absence of infliximab, marketplace introduction of infliximab did not produce significant declines in the rates of CD-related hospitalisations (OR at the last observation quarter 1.06, 95% CI 0.811 to 1.39) or intestinal resections (OR 1.10, 95% CI 0.810 to 1.50), or in the rates of UC-related hospitalisations (OR 1.22, 95% CI 1.07 to 1.39) or colectomies (OR 0.933, 95% CI 0.54 to 1.61). The findings were similar among infliximab users, except that hospitalisation rates declined substantially among UC patients following marketplace introduction of infliximab (OR 0.515, 95% CI 0.342 to 0.777). There was a threefold rise over expected trends in public payer drug cost among patients with CD following infliximab introduction (OR 2.98,95% CI 2.29 to 3.86), suggesting robust market penetration in this group, but no significant change among patients with UC (OR 1.06, 95% CI 0.955 to 1.18). CONCLUSIONS: Marketplace introduction of infliximab has not yielded anticipated reductions in the population rates of IBD-related hospitalisations or intestinal resections, despite robust market penetration among patients with CD. Misguided use of infliximab in CD patients and underuse of infliximab in UC patients may largely explain our study findings.

Recovery free of heart failure after acute coronary syndrome and coronary revascularization.

AIMS: Previous studies have examined risk factors for the development of heart failure (HF) subsequent to acute coronary syndrome (ACS). Our study seeks to clarify the clinical variables that best characterize patients who remain free from HF after coronary artery bypass grafting (CABG) surgery for ACS to determine novel biological factors favouring freedom from HF in prospective translational studies. METHODS AND RESULTS: Nova Scotia residents (1995-2012) undergoing CABG within 3 weeks of ACS were included. The primary outcome was freedom from readmission to hospital due to HF. Descriptive statistics were generated, and a Cox proportional hazards model assessed outcome with adjustment for clinical characteristics. Of 11 936 Nova Scotians who underwent isolated CABG, 3264 (27%) had a recent ACS and were included. Deaths occurred in 210 (6%) of subjects prior to discharge. A total of 3054 patients were included in the long-term analysis. During follow-up, HF necessitating readmission occurred in 688 (21%) subjects with a hazard ratio of 12% at 2 years. The adjusted Cox model demonstrated significantly better freedom from HF for younger, male subjects without metabolic syndrome and no history of chronic obstructive pulmonary disease, renal insufficiency, atrial fibrillation, or HF. CONCLUSIONS: Our findings have outlined important clinical variables that predict freedom from HF. Furthermore, we have shown that 12% of patients undergoing CABG after ACS develop HF (2 years). Our findings support our next phase in which we plan to prospectively collect blood and tissue specimens from ACS patients undergoing CABG in order to determine novel biological mechanism(s) that favour resolution of post-ACS inflammation.

Cardiac troponin T is an important predictor of mortality after cardiac surgery.

PURPOSE: Serum troponin (cTnT) levels, a commonly measured biomarker of myocardial injury, has rarely been considered in risk models after cardiac surgery. MATERIALS AND METHODS: Retrospective study of patients undergoing any cardiac surgery between 2004 and 2012. Patients with a history of recent myocardial injury (<21 days) were excluded. The minimum P value approach was used to determine categories of peak cTnT associated with in-hospital death. A multivariable analysis was performed to identify independent predictors of mortality. RESULTS: A total of 5318 patients without evidence of preoperative ischemia underwent a number of cardiac surgical interventions ranging from isolated coronary revascularization to combined valve coronary artery bypass grafting. The unadjusted in-hospital mortality rate was 3.3% (n = 175 patients). Four categories of peak cTnT were identified using the minimum P value approach: less than or equal to 0.6 ng/mL, 0.7 to 1.9 ng/mL, 2.0 to 3.1 ng/mL, and greater than 3.1 ng/mL with unadjusted mortality rates of 1.0%, 3.6%, 10.1%, and 33.1%, respectively. Multivariate logistic regression demonstrated that all peak cTnT levels greater than 0.6 ng/mL were independent predictors of in-hospital mortality in a dose-dependent manner. CONCLUSIONS: We demonstrate that in patients without preoperative myocardial ischemia, the demonstration of myocardial injury (>0.6 ng/mL) in the postoperative period is highly predictive of in-hospital death.

Molecular versus conventional methods: clinical evaluation of different methods for the diagnosis of tuberculosis in Bangladesh.

BACKGROUND: The diagnosis of tuberculosis (TB) in developing countries, such as Bangladesh, is based mainly on microscopic detection of acid-fast bacilli in smears from clinical specimens. On the other hand, the detection of TB by polymerase chain reaction (PCR) is quite new in Bangladesh. In this study, we compared the molecular method with the conventional diagnosis procedures, where Lowenstein-Jensen medium culture results have been used as the "gold standard." METHODS: A total of 135 sputum samples were collected from clinically suspected patients with pulmonary TB. A direct smear was made from each sputum specimen and stained by the Ziehl-Neelsen (Z-N) method. The sputum samples were then processed, and the pellet was used for both Z-N (concentration) and auramine O fluorescence staining or resuspended in phosphate buffered saline to inoculate Lowenstein-Jensen medium or processed for PCR detection of Mycobacterium tuberculosis. RESULTS: The direct smear staining yielded 44 (32.6%) sputum samples that were acid-fast positive, which increased after concentration, yielding 60 (44.4%) acid-fast-positive samples. Fluorescence microscopy using auramine O staining further increased the number of positive samples to 67 (49.6%). The biochemical tests showed 75 (55.6%) sputum samples to be culture positive, and the MB/BacT system increased the recovery up to 90 (66.7%) culture positives. On the other hand, PCR yielded 93 (68.9%) positive results, 20 (21.5%) of which were culture-negative sputum specimens. CONCLUSION: It is suggested that the Z-N direct microscopy on its own is the best method (with high specificity) for confirming the diagnosis of acid-fast bacilli. Although the PCR diagnosis of TB appears to be a rapid and sensitive method, the results should be interpreted with care in the clinical settings.