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Background: Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers., Results: The APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system., Conclusion: Both patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD., (© 2024. The Author(s).)

Objective: A beta version (2018) of International Classification of Diseases, 11th Revision for MMS (ICD-11), needed testing. Field-testing involves real-world application of the new codes to examine usability. We describe creating a dataset and characterizing the usability of ICD-11 code set by coders. We compare ICD-11 against ICD-10-CA (Canadian modification) and a reference standard dataset of diagnoses. Real-world usability encompasses code selection and time to code a complete inpatient chart using ICD-11 compared with ICD-10-CA., Methods and Results: A random sample of inpatient records previously coded using ICD-10-CA was selected from hospitals in Calgary, Alberta (N = 2896). Nurses examined these charts for conditions and healthcare-related harms. Clinical coders re-coded the same charts using ICD-11 codes. Inter-rater reliability (IRR) and coding time improved with ICD-11 coding experience (23.6 to 9.9 min average per chart). Code structure comparisons and challenges encountered are described. Overall, 86.3% of main condition codes matched. Coder comments regarding duplicate codes, missing codes, code finding issues enabled improvements to the ICD-11 Browser, Coding Tool, and Reference Guide. Training is essential for solid IRR with 17,000 diagnostic categories in the new ICD-11. As countries transition to ICD-11, our coding experiences and methods can inform users for implementation or field testing., (© 2022. The Author(s).)

Background: Measurement of care quality and safety mainly relies on abstracted administrative data. However, it is well studied that administrative data-based adverse event (AE) detection methods are suboptimal due to lack of clinical information. Electronic medical records (EMR) have been widely implemented and contain detailed and comprehensive information regarding all aspects of patient care, offering a valuable complement to administrative data. Harnessing the rich clinical data in EMRs offers a unique opportunity to improve detection, identify possible risk factors of AE and enhance surveillance. However, the methodological tools for detection of AEs within EMR need to be developed and validated. The objectives of this study are to develop EMR-based AE algorithms from hospital EMR data and assess AE algorithm's validity in Canadian EMR data., Methods: Patient EMR structured and text data from acute care hospitals in Calgary, Alberta, Canada will be linked with discharge abstract data (DAD) between 2010 and 2020 (n~1.5 million). AE algorithms development. First, a comprehensive list of AEs will be generated through a systematic literature review and expert recommendations. Second, these AEs will be mapped to EMR free texts using Natural Language Processing (NLP) technologies. Finally, an expert panel will assess the clinical relevance of the developed NLP algorithms. AE algorithms validation: We will test the newly developed AE algorithms on 10,000 randomly selected EMRs between 2010 to 2020 from Calgary, Alberta. Trained reviewers will review the selected 10,000 EMR charts to identify AEs that had occurred during hospitalization. Performance indicators (e.g., sensitivity, specificity, positive predictive value, negative predictive value, F1 score, etc.) of the developed AE algorithms will be assessed using chart review data as the reference standard., Discussion: The results of this project can be widely implemented in EMR based healthcare system to accurately and timely detect in-hospital AEs., Competing Interests: The authors have declared that no competing interests exist.

Strategic Clinical Networks (SCNs) in Alberta include multidisciplinary teams that work toward health system innovation and improvement; however, what contributes to team effectiveness is unclear. This theory-informed longitudinal survey (n = 826) evaluated team effectiveness within SCNs and predictors of effectiveness. Satisfaction, inter-team relationships and seven predictors including team inputs and team and leadership processes improved over two years. Attitudinal outputs were predicted by the same factors over time, whereas performance outputs were predicted by different factors. This innovative study emphasizes that SCN teams and their effectiveness evolve over time and that team-based research can refine network evaluations., (Copyright © 2022 Longwoods Publishing.)

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., Competing Interests: Competing interests: Karen Tang and William Ghali report a grant from the Canadian Institutes of Health Research for another project related to patient navigation. No other competing interests were declared., (© 2021 CMA Joule Inc. or its licensors.)

Background: The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina., Methods and Results: Data are from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, a population-based registry of patients who received cardiac catheterization in Alberta, Canada. The cohort consists of 4052 patients undergoing cardiac catheterization for stable angina and completed the SAQ within 2 weeks. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess the factorial structure of the SAQ. Internal and test-retest reliabilities of a new measure (i.e., SAQ-CAN) was measured using Cronbach α and intraclass correlation coefficient, respectively. CFA model fit was assessed using the root mean square error of approximation (RMSEA) and comparative fit index (CFI). Construct validity of the SAQ-CAN was assessed in relation to Hospital Anxiety and Depression Scales (HADS), Euro Quality of life 5 dimension (EQ5D), and original SAQ. Of the 4052 patients included in this analysis, 3281 (80.97%) were younger than 75 years old, while 3239 (79.94%) were male. Both exploratory and confirmatory factor analyses revealed a four-factorial structure consisting of 16 items that provided a better fit to the data (RMSEA = 0.049 [90% CI = (0.047, 0.052)]; CFI = 0.975). The 16-item SAQ demonstrated good to excellent internal reliability (Cronbach's α range from 0.77 to 0.90), moderate to strong correlation with the Original SAQ and EQ5D but negligible correlations with HADS., Conclusion: The SAQ-CAN has acceptable psychometric properties that are comparable to the original SAQ. We recommend its use for assessing coronary health outcomes in Canadian patients with Coronary Artery Disease.

Background: In studies showing associations between ambient air pollution and myocardial infarction (MI), data have been lacking on the inherent spatial variability of air pollution. The aim of this study was to determine whether the long-term spatial distribution of air pollution influences short-term temporal associations between air pollution and admission to hospital for MI., Methods: We identified adults living in Calgary who were admitted to hospital for an MI between 2004 and 2012. We evaluated associations between short-term exposure to air pollution (ozone [O 3 ], nitrogen dioxide [NO 2 ], sulfur dioxide [SO 2 ], carbon monoxide [CO], particulate matter < 10 μm in diameter [PM 10 ] and particulate matter < 2.5 μm in diameter [PM 2.5 ]), and hospital admissions for MI using a time-stratified, case-crossover study design. Air Quality Health Index (AQHI) scores were calculated from a composition of O 3 , NO 2 and PM 2.5 . Conditional logistic regression models were stratified by low, medium and high levels of neighbourhood NO 2 concentrations derived from land use regression models; results of these analyses are presented as odds ratios (ORs) with 95% confidence intervals (CIs)., Results: From 2004 to 2012, 6142 MIs were recorded in Calgary. Individuals living in neighbourhoods with higher long-term air pollution concentrations were more likely to be admitted to hospital for MI after short-term elevations in air pollution (e.g., 5-day average NO 2 : OR 1.20, 95% CI 1.03-1.40, per interquartile range [IQR]) as compared with regions with lower air pollution (e.g., 5-day average NO 2 : OR 0.90, 95% CI 0.78-1.04, per IQR). In high NO 2 tertiles, the AQHI score was associated with MI (e.g., 5-day average OR 1.13, 95% CI 1.02-1.24, per IQR; 3-day average OR 1.13, 95% CI 1.04-1.23, per IQR)., Interpretation: Our results show that the effect of air pollution on hospital admissions for MI was stronger in areas with higher NO 2 concentrations than that in areas with lower NO 2 concentrations. Individuals living in neighbourhoods with higher traffic-related pollution should be advised of the health risks and be attentive to special air quality warnings., Competing Interests: Competing interests: Michael Hill reports personal fees from Sun Pharma; nonfinancial support from Hoffmann–La Roche Canada; grants from Covidien (Medtronic), Boehringer–Ingelheim, Stryker, Medtronic and NoNO; and the patent “Systems and Methods for Assisting in Decision-Making and Triaging for Acute Stroke Patients.” Michael Hill owns stock in Calgary Scientific, a company that focuses on medical imaging software, is a director of the Canadian Neurological Sciences Federation, a not-for-profit group, is a director of Circle NeuroVascular, and has received grant support from Alberta Innovates Health Solutions, Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and the National Institute of Neurological Disorders and Stroke. Gilaad Kaplan has received honoraria for speaking or consultancy from AbbVie, Janssen, Pfizer and Takeda. He has received research support from Ferring, Janssen, AbbVie, GlaxoSmithKline, Merck and Shire. He has been a consultant for Gilead. He shares ownership of a patent: Treatment of Inflammatory Disorders, Autoimmune Disease, and PBC. UTI Limited Partnership, assignee. Patent WO2019046959A1. PCT/CA2018/051098. 7 Sept. 2018. No other competing interests were declared., (Copyright 2020, Joule Inc. or its licensors.)

Background: Although suggested by practice guidelines, the need for pre-exercise stress testing in asymptomatic people with diabetes remains controversial. We examined the utility of screening with pre-exercise stress testing in patients with diabetes., Methods: We completed a cohort study, evaluating patients with diabetes who attended an exercise program intake session between 2007 and 2012. The exposure of interest was referral for pre-exercise stress testing determined by an algorithm requiring sedentary patients with diabetes and ≥ 1 cardiac risk factor to undergo testing. Outcomes included cardiac catheterization, revascularization, cardiovascular-related admissions, mortality, and change in care., Results: Among 1705 people with diabetes, 676 (40%) were referred for pre-exercise stress testing. In patients who were referred for stress testing compared with those who were not, there was no difference in the composite of cardiovascular outcomes (revascularization, cardiovascular-related admissions, and cardiovascular-related death) within 1 year (2.8% vs 1.9%, P = 0.250), or subsequent to the first year (3.1% vs 4.6%, P = 0.164). Within 1 year, more revascularizations were performed in patients referred for stress testing compared with those who were not (2.1% vs 0.8%, P = 0.027) but not during longer-term follow-up (mean 3.4 years)., Conclusions: The rates of cardiovascular outcomes in both tested and untested patients were low. Patients undergoing stress testing had no difference in adverse cardiovascular outcomes over the follow-up periods. Referral for stress testing did not result in a change in care for most patients. Our findings suggest stress testing before beginning an exercise program is not necessary for most asymptomatic patients with diabetes., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD., Methods and Results: Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups., Conclusions: This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD., (© 2018 American Heart Association, Inc.)

Background: Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system., Methods and Results: We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30-day and 1-year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11-0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30-day mortality (P=0.008) but no significant difference for 1-year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients., Conclusion: Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30-day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low-income nonmetropolitan communities., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Interface pressure is a key risk factor in the development of pressure ulcers. Visual feedback of continuous interface pressure between the body and support surface could inform clinicians on repositioning strategies and play a key role in an overall strategy for the prevention and management of pressure ulcers., Methods/design: A parallel two-group randomized controlled clinical trial will be conducted to study the effect of continuous pressure imaging on reducing interface pressure and on the incidence of pressure ulcers in vulnerable hospital patients. A total of 678 eligible consenting inpatients at risk of pressure ulcer development in a tertiary acute care institution will be randomly allocated to either having the ForeSite PT™ system with the liquid-crystal display monitor turned on to provide visual feedback to the clinicians while also collecting continuous interface pressure data (intervention group) or to having the ForeSite PT™ system with monitor turned off (that is, not providing visual feedback) but still collecting continuous interface pressure data (control group), in a ratio of 1:1. Continuous interface pressure data will be collected in both groups for 3 days (72 h). Data collection will continue until discharge for a subset of approximately 60 patients. The primary outcome will be the differences in the two groups' interface pressure analysis. Interface pressure readings will be collected through hourly samplings of continuous interface pressure recordings. Secondary outcomes will be the differences between the two groups in pressure-related skin and soft tissue changes in areas at risk of pressure ulcer (obtained at baseline within 24 h of admission) and on the third day of the trial or at discharge and perceptions of the intervention by patients and clinicians (obtained on the third day or at discharge)., Discussion: This will be the first randomized controlled trial to investigate the effect of visual feedback with continuous interface pressure of vulnerable hospital patients across different care settings, and the association between interface pressure and development of pressure-related skin and soft tissue changes. The results could provide important information to guide clinical practice in the prevention and management of pressure ulcers., Trials Registration: ClinicalTrials.gov NCT02325388 (date of registration: 24 December 2014).

Unlabelled: CONSTRUCT: The 25-item Stanford Faculty Development Program Tool on Clinical Teaching Effectiveness assesses clinical teaching effectiveness., Background: Valid and reliable rating of teaching effectiveness is helpful for providing faculty with feedback. The 25-item Stanford Faculty Development Program Tool on Clinical Teaching Effectiveness was intended to evaluate seven dimensions of clinical teaching. Confirmation of the structure of this tool has not been previously performed., Approach: This study sought to validate this tool using a confirmatory factor analysis, testing a 7-factor model and compared its goodness of fit with a modified model. Acceptability of the use of the tool was assessed using a 6-item survey, completed by final year medical students (N = 119 of 156 students; 76%)., Results: The testing of the goodness of fit indicated that the 7-factor model performed poorly, χ(2)(254) = 457.4, p < .001 (root mean square error of approximation [RMSEA] = 0.08, comparative fit index [CFI] = 0.91, non-normed fit index [NNFI] = 0.89). Only standardized root mean square residual (SRMR) indicated acceptable fit (0.06). Further exploratory analysis identified 10 items that cross-loaded on 2 factors. The remainder of the items loaded on factors as originally intended. By removing these 10 items, repeat confirmatory factor analysis on the modified 15-item, 5-factor model demonstrated a better fit than the original model: SRMR = 0.075, NNFI = 0.91, χ(2)(80) = 150.1, p < .001; RMSEA = 0.09; CFI = 0.93. Although 75% of the participants stated they were willing to fill the tool on their preceptors on a biweekly basis, only 25% were willing to do so on a weekly basis., Conclusions: Our study failed to confirm factor structure of the 25-item tool. A modified tool with fewer, more conceptually distinct items was best fit by a 5-factor model. Further, the acceptability of use for the 25-item tool may be poor for rotations with a new preceptor weekly. The abbreviated tool may be preferable in that setting.

Objective: The purpose of this study was to assess the relationship between diabetic ketoacidosis (DKA) hospitalization and driving distance from home to outpatient diabetes care in adults with type 1 diabetes mellitus., Methods: We identified adults with type 1 diabetes using clinical and administrative databases living in Calgary, Alberta. The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, codes were used to identify DKA hospitalizations, and geographic information systems were used to obtain road distance. Multivariate logistic regression was used to assess the association between driving distance (exposure) to diabetes care sites and the outcome of DKA hospitalization., Results: We identified 1467 patients (151 patients with DKA) with type 1 diabetes. Patients with DKA hospitalizations were younger (35.6 vs. 41.0 years), had shorter duration of diabetes (13.6 vs. 18.7 years) and higher glycated hemoglobin (9.2% vs. 8.4%). Driving distance from home to diabetes centre 1 (adjusted odds ratio 1.02 per 1 km; 95% confidence interval, 0.96 to 1.07), diabetes centre 2 (adjusted odds ratio 1.01; 95% confidence interval, 0.99 to 1.04) or closest general practitioner (adjusted odds ratio 0.9; 95% confidence interval, 0.63 to 1.25) was not associated with DKA hospitalization. Driving distance was also not associated with glycemic control., Conclusions: Within a large urban city, driving distance to diabetes centres does not appear to be protective of DKA hospitalization. However, this work does not preclude the role of local travel distance and diabetes outcomes. More research is required to explore the role of other individual, neighbourhood and community factors that influence DKA hospitalization., (Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Patients with ACS often present to community hospitals without on-site cardiac catheterization and revascularization therapies. Transfer to specialized cardiac procedural centers is necessary to provide access to these procedures. We evaluated process of care within a regional care model by comparing cardiac catheterization and revascularization rates and outcomes in ACS patients presenting to community and interventional hospitals., Methods: We evaluated a total of 6154 patients with ACS admitted to Southern Alberta hospitals (where a distinct regional care model for ACS exists) between January 1, 2005 and December 31, 2009. We compared cardiac catheterization and revascularization rates during index hospitalization among patients admitted to community and interventional hospitals. Thirty day and 1-year survival were also evaluated., Results: Catheterization was performed more often in patients presenting to community hospitals compared to the interventional facility (respectively 69.5% and 51.4%, p < 0.0001). Catheterization within 72 hours of admission occurred in 48% of patients presenting to the interventional center and in 68.3% of community patients (P < 0.0001). In patients undergoing catheterization, revascularization (PCI and/or CABG) was also performed more frequently in the community group (74.5% vs 56.1%, P < 0.0001). Risk adjusted mortality rates were the same for patients undergoing cardiac catheterization regardless of hospital of initial presentation., Conclusion: ACS patients presenting to community centers associated with a regional care model had effective access to cardiac catheterization and revascularization. These findings support the importance of regional initiatives and processes of care that facilitate access to cardiac catheterization for all ACS patients.

Background: Previous research suggests that the early benefit from revascularization with drug-eluting stents might diminish over time., Methods: We performed an extended analysis of a previously identified cohort of 6440 patients who underwent percutaneous coronary intervention between April 1, 2003 and March 31, 2005 using a prospective provincial clinical registry in Alberta, Canada. We compared rates of death, and of death or repeat revascularization among the 6440 patients receiving either drug-eluting (sirolimus- and paclitaxel) stents or bare-metal stents. We determined risk-adjusted hazard ratios at moments in time with a spline analysis using Cox proportional hazards modelling., Results: During the 8 years of observation, the relative risks for death or the composite outcome of death or repeat revascularization varied over time. There was an early finding of better outcomes associated with drug-eluting stents in the first year after implantation. Thereafter, there was no significant benefit associated with drug-eluting stents compared with bare-metal stents with 8 years of follow-up. At 30 days, the adjusted hazard ratio was 0.38 (95% confidence interval [CI], 0.18-0.81) for death and 0.27 (95% CI, 0.14-0.54) for the composite outcome of death or repeat revascularization. By 8 years, the adjusted hazard ratio of death or the composite outcome was 1.15 (95% CI, 0.97-1.36) and 1.01 (95% CI, 0.87-1.17), respectively., Conclusions: Revascularization with first-generation drug-eluting stents is associated with better outcomes within the first year only. Thereafter, the risk of death or repeat revascularization is similar between drug-eluting stents and bare-metal stents., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Prior Canadian studies of cardiac procedure rates showed changes over time and regional variability, but more recent Canadian cardiac procedure rates are unknown., Methods: We performed a study using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry to evaluate the temporal trends and geographic distribution of cardiac procedures in Alberta from April 1, 2003 through March 31, 2010. Rates were age- and sex-standardized by means of the 1996 Canadian census., Results: While the raw number of cardiac catheterizations in Alberta was nearly uniform through the study period, age- and sex-standardized cardiac catheterizations declined from a rate of 480 per 100,000 in 2003 to a rate of 430 per 100,000 in 2010. The percutaneous coronary intervention (PCI) rates also declined, from a rate of 186 per 100,000 in 2003 to 170 per 100,000 in 2010. The rates for coronary artery bypass grafts declined from 84 per 100,000 in 2003 to 42 per 100,000 in 2010. There was geographic variability, with northern regions characterized by rates that were higher than the provincial average rates, and southern regions characterized by rates lower than the provincial average., Conclusion: During the study period, age- and sex-standardized rates of cardiac catheterization and PCI in Alberta declined, reversing previous trends of increasing PCI rates. The rates of coronary artery bypass grafts in Alberta declined significantly, suggesting a change in practice consistent with that seen elsewhere. There are geographic differences in rates of cardiac procedures. These data have implications for other regions of Canada, for which registry data may not be available., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Evaluating geographic access to health services often requires determining the patient travel time to a specified service. For urgent care, many research studies have modeled patient pre-hospital time by ground emergency medical services (EMS) using geographic information systems (GIS). The purpose of this study was to determine if the modeling assumptions proposed through prior United States (US) studies are valid in a non-US context, and to use the resulting information to provide revised recommendations for modeling travel time using GIS in the absence of actual EMS trip data., Methods: The study sample contained all emergency adult patient trips within the Calgary area for 2006. Each record included four components of pre-hospital time (activation, response, on-scene and transport interval). The actual activation and on-scene intervals were compared with those used in published models. The transport interval was calculated within GIS using the Network Analyst extension of Esri ArcGIS 10.0 and the response interval was derived using previously established methods. These GIS derived transport and response intervals were compared with the actual times using descriptive methods. We used the information acquired through the analysis of the EMS trip data to create an updated model that could be used to estimate travel time in the absence of actual EMS trip records., Results: There were 29,765 complete EMS records for scene locations inside the city and 529 outside. The actual median on-scene intervals were longer than the average previously reported by 7-8 minutes. Actual EMS pre-hospital times across our study area were significantly higher than the estimated times modeled using GIS and the original travel time assumptions. Our updated model, although still underestimating the total pre-hospital time, more accurately represents the true pre-hospital time in our study area., Conclusions: The widespread use of generalized EMS pre-hospital time assumptions based on US data may not be appropriate in a non-US context. The preference for researchers should be to use actual EMS trip records from the proposed research study area. In the absence of EMS trip data researchers should determine which modeling assumptions more accurately reflect the EMS protocols across their study area.

Real-time locating systems (RTLS) have the potential to enhance healthcare systems through the live tracking of assets, patients and staff. This study evaluated a commercially available RTLS system deployed in a clinical setting, with three objectives: (1) assessment of the location accuracy of the technology in a clinical setting; (2) assessment of the value of asset tracking to staff; and (3) assessment of threshold monitoring applications developed for patient tracking and inventory control. Simulated daily activities were monitored by RTLS and compared with direct research team observations. Staff surveys and interviews concerning the system's effectiveness and accuracy were also conducted and analyzed. The study showed only modest location accuracy, and mixed reactions in staff interviews. These findings reveal that the technology needs to be refined further for better specific location accuracy before full-scale implementation can be recommended.

Purpose: To measure the effect of including a clinical librarian in the health care team on medical residents and clinical clerks., Method: In 2009, medical residents and clinical clerks were preassigned to one of two patient care teams (intervention and control). Each team had a month-long rotation on the general medicine teaching unit. The clinical librarian joined the intervention team for morning intake, clinical rounding, or an afternoon patient list review, providing immediate literature searches, formal group instruction, informal bedside teaching, and/or individual mentoring for use of preappraised resources and evidence-based medicine search techniques. Both intervention and control teams completed pre and post surveys comparing their confidence levels and awareness of resources as well as their self-reported use of evidence for making patient care decisions. The nonintervention team was surveyed as the control group., Results: The clinical librarian intervention had a significant positive effect on medical trainees' self-reported ability to independently locate and evaluate evidence resources to support patient care decisions. Notably, 30 of 34 (88%) reported having changed a treatment plan based on skills taught by the clinical librarian, and 27 of 34 (79%) changed a treatment plan based on the librarian's mediated search support., Conclusions: Clinical librarians on the care team led to positive effects on self-reported provider attitudes, provider information retrieval tendencies, and, notably, clinical decision making. Future research should evaluate economic effects of widespread implementation of on-site clinical librarians.

Background: There is variation in cardiac catheterization utilization across jurisdictions. Previous work from Alberta, Canada, showed no evidence of a plateau in the yield of high-risk disease at cardiac catheterization rates as high as 600 per 100,000 population suggesting that the optimal rate is higher. This work aims 1) To determine if a previously demonstrated linear relationship between the yield of high-risk coronary disease and cardiac catheterization rates persists with contemporary data and 2) to explore whether the linear relationship exists in other jurisdictions., Methods: Detailed clinical information on all patients undergoing cardiac catheterization in 3 Canadian provinces was available through the Alberta Provincial Project for Outcomes Assessment in Coronary Heart (APPROACH) disease and partner initiatives in British Columbia and Nova Scotia. Population rates of catheterization and high-risk coronary disease detection for each health region in these three provinces, and age-adjusted rates produced using direct standardization. A mixed effects regression analysis was performed to assess the relationship between catheterization rate and high-risk coronary disease detection., Results: In the contemporary Alberta data, we found a linear relationship between the population catheterization rate and the high-risk yield. Although the yield was slightly less in time period 2 (2002-2006) than in time period 1(1995-2001), there was no statistical evidence of a plateau. The linear relationship between catheterization rate and high-risk yield was similarly demonstrated in British Columbia and Nova Scotia and appears to extend, without a plateau in yield, to rates over 800 procedures per 100,000 population., Conclusions: Our study demonstrates a consistent finding, over time and across jurisdictions, of linearly increasing detection of high-risk CAD as population rates of cardiac catheterization increase. This internationally-relevant finding can inform country-level planning of invasive cardiac care services.

Background: In order to reduce the delays encountered through patient transfer, regional care models have been developed that directly transport subsets of acute myocardial infarction (AMI) patients to hospitals with percutaneous coronary intervention (PCI) facilities. Calgary is a Canadian city that implemented this type of model in 2004., Methods: The study population included 9768 AMI patients admitted to Calgary hospitals between 1997 and 2007. Administrative data were used to define patients who were directly admitted to the PCI hospital and those transferred there after initial admission to a hospital without specialized cardiac care. The differences in clinical characteristics and mortality trends of patients grouped by hospital delivery site and transfer practice are described., Results: The proportion of patients directly admitted to a PCI hospital has increased with the implementation of a regional care model. Among patients admitted to non-PCI facilities, the patients who are transferred are younger, more likely to be male, have a shorter length of stay, and have lower proportions of several comorbid conditions. The risk-adjusted in-hospital mortality odds ratio for patients who received care at the PCI hospital postmodel relative to those treated at non-PCI hospitals premodel was 0.38 (95% confidence interval, 0.31-0.47). The corresponding adjusted odds ratio was 0.60 (0.47-0.76)., Conclusions: Our results suggest changing care over time and trends toward improved outcomes. Patients' clinical characteristics appear to play a major role in the decision to transfer. Avoidance of the risk treatment paradox through refinement of regional transfer protocols ought to be a priority., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Although bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) is associated with low morbidity and good long-term results, controversy exists about the age after which BITA grafting is no longer beneficial. We sought to determine if such an age cutoff point exists., Methods: The study cohort consisted of 5,601 consecutive patients from a cardiac surgery registry who underwent isolated CABG (1,038 [19%] BITA grafts, 4,029 [72%] single internal thoracic artery [SITA] grafts, 534 [10%] vein-only grafts) between 1995 and 2008. A Cox model was used to compare survival by use of bilateral, single, or no internal thoracic artery (ITA) grafts, adjusting for baseline clinical and demographic characteristics., Results: Mean follow-up was 7.1 years. Patients undergoing BITA grafting had the lowest 1-year mortality (2.4% versus 4.3% SITA grafting and 8.2% vein-only grafting; p < 0.0001). Relative to SITA grafting, a crude survival benefit of 54% existed for BITA grafting (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.37 to 0.57; p < 0.0001) with worse survival for vein-only grafts (HR, 1.16; 95% CI, 0.99 to 1.37; p = 0.07). After adjustment, the benefit of BITA grafting was no longer statistically significant (HR, 0.87; 95% CI, 0.69 to 1.08; p = 0.2). However age may be an effect modifier: a spline analysis plotting HR (BITA grafting versus SITA grafting) against age suggested a potential survival advantage associated with BITA grafting in patients younger than 69.9 years., Conclusions: Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to age 70 years. As benefits of arterial grafting become more obvious over time, a longer period of follow-up will be needed to confirm the advantage of a BITA grafting strategy. In the meantime the BITA grafting advantage for patients older than 70 years is not clear., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward., Methods: We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction., Results: During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently "lost" to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were 7.9±1.1, 8.1±1.0, and 7.9±1.7, respectively., Conclusion: The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The Seattle Angina Questionnaire (SAQ), a descriptive quality of life instrument, is often used in coronary artery disease studies. In its current form, however, it cannot be used in economic evaluations. The investigators sought to create a mapping algorithm that would allow translation of SAQ scores into EQ-5D utility scores., Methods: Data from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database were used to examine the relationship between scores in each of the 5 domains of the SAQ (physical limitation, anginal stability, anginal frequency, treatment satisfaction, and disease perception) and the EQ-5D utility score. The cohort was divided into 80% derivation and 20% validation sets. Mapping algorithms were developed using simple linear regression and Tobit models. To account for the skewed distribution of the EQ-5D scores and the presence of heteroscedasticity, Bayesian extensions were applied to each model by specifying a nonconstant variance for the error term. Model performance was assessed by comparing predicted and observed mean EQ-5D scores in the validation set, and the unadjusted R2., Results: The cohort consisted of 1992 patients. The simple linear regression model had the best predictive performance, with an R2 of 0.38. The nonconstant variance term did not improve overall performance for any of the models. The linear regression model accurately estimated the mean EQ-5D score in the validation set (predicted score 0.81 v. observed score 0.81)., Conclusions: Mean EQ-5D utility weights can be accurately estimated from the SAQ using a simple linear regression mapping algorithm.

Background: Acute kidney injury (AKI) is associated with early mortality after percutaneous coronary revascularization procedures, but its prognostic relevance to long-term clinical outcomes remains controversial., Methods and Results: We conducted a retrospective study of 14782 adults who received coronary angiography in the province of Alberta, Canada, between 2004 and 2006. AKI was identified on the basis of changes in serum creatinine concentration within 7 days of the procedure according to AKI Network criteria. The associations between AKI and long-term outcomes, including mortality, end-stage renal disease, and cardiovascular and renal hospitalizations, were studied with the use of Cox regression of multiple failure times. The adjusted risk of death increased with increasing severity of AKI; compared with no AKI, the adjusted hazard ratio for death was 2.00 (95% confidence interval, 1.69 to 2.36) with stage 1 AKI and 3.72 (95% confidence interval, 2.92 to 4.76) with stage 2 or 3 AKI. The adjusted risk of end-stage renal disease requiring renal replacement therapy also increased according to the severity of AKI (hazard ratio, 4.15 [95% confidence interval, 2.32 to 7.42] and 11.74 [95% confidence interval, 6.38 to 21.59], respectively), as did the risks of subsequent hospitalizations for heart failure and acute renal failure., Conclusions: These findings inform the controversy surrounding AKI after angiography, demonstrating that it is a significant risk factor for long-term mortality, end-stage renal disease, and hospitalization for cardiovascular and renal events after coronary angiography.

Background: During daytime working hours, outcomes may be worse when percutaneous coronary intervention (PCI) is performed later in the day because of operator fatigue and differences in process of care., Methods: Using the APPROACH database, we analyzed 2,492 consecutive nonurgent PCI procedures performed during working hours. Patients undergoing PCI for acute coronary syndromes were excluded. Patients were separated into 2 groups based on whether PCI was started in the morning (7:00 am-12:00 pm, n = 1,446) or after noon (12:01 pm-6:00 pm, n = 1,037). Outcomes included procedural complications; target vessel revascularization (TVR); and death at 7 days, 30 days, and 1 year., Results: Patients undergoing PCI in the afternoon were more likely to have heart failure, reduced ejection fraction, and Canadian Cardiovascular Society class IV or atypical angina symptoms; more likely to be inpatients; less likely to have stable angina; and less likely to receive glycoprotein IIb/IIIa inhibitors. Patients undergoing PCI in the afternoon had significantly higher unadjusted rates of the composite of death and TVR at 7 days (0.9% vs 0.3%, P = .04) and 30 days (2.0% vs 1.0%, P = .04) and death at 1 year (2.2% vs 1.1%, P = .03) compared with PCI performed in the morning. After multivariate adjustment, the differences in the composite of death and TVR at 30 days and at 1 year were not statistically significant., Conclusion: Patients undergoing nonurgent PCI during working hours after noon had higher rates of TVR in the first 30 days and death at 1 year. Further study is required to determine whether patient characteristics, operator fatigue, differences in process of care, or a combination of these factors accounts for the difference in outcomes., (Copyright 2010 Mosby, Inc. All rights reserved.)

Objectives: This study assessed the validity of a widely-accepted administrative data surveillance methodology for identifying individuals with diabetes relative to three laboratory data reference standard definitions for diabetes., Methods: We used a combination of linked regional data (hospital discharge abstracts and physician data) and laboratory data to test the validity of administrative data surveillance definitions for diabetes relative to a laboratory data reference standard. The administrative discharge data methodology includes two definitions for diabetes: a strict administrative data definition of one hospitalization code or two physician claims indicating diabetes; and a more liberal definition of one hospitalization code or a single physician claim. The laboratory data, meanwhile, produced three reference standard definitions based on glucose levels +/- HbA1c levels., Results: Sensitivities ranged from 68.4% to 86.9% for the administrative data definitions tested relative to the three laboratory data reference standards. Sensitivities were higher for the more liberal administrative data definition. Positive predictive values (PPV), meanwhile, ranged from 53.0% to 88.3%, with the liberal administrative data definition producing lower PPVs., Conclusions: These findings demonstrate the trade-offs of sensitivity and PPV for selecting diabetes surveillance definitions. Centralized laboratory data may be of value to future surveillance initiatives that use combined data sources to optimize case detection.

We validated the accuracy of case definitions for hypertension derived from administrative data across time periods (year 2001 versus 2004) and geographic regions using physician charts. Physician charts were randomly selected in rural and urban areas from Alberta and British Columbia, Canada, during years 2001 and 2004. Physician charts were linked with administrative data through unique personal health number. We reviewed charts of approximately 50 randomly selected patients >35 years of age from each clinic within 48 urban and 16 rural family physician clinics to identify physician diagnoses of hypertension during the years 2001 and 2004. The validity indices were estimated for diagnosed hypertension using 3 years of administrative data for the 8 case-definition combinations. Of the 3,362 patient charts reviewed, the prevalence of hypertension ranged from 18.8% to 33.3%, depending on the year and region studied. The administrative data hypertension definition of "2 claims within 2 years or 1 hospitalization" had the highest validity relative to the other definitions evaluated (sensitivity 75%, specificity 94%, positive predictive value 81%, negative predictive value 92%, and kappa 0.71). After adjustment for age, sex, and comorbid conditions, the sensitivities between regions, years, and provinces were not significantly different, but the positive predictive value varied slightly across geographic regions. These results provide evidence that administrative data can be used as a relatively valid source of data to define cases of hypertension for surveillance and research purposes.

Objective: We aimed to analyze trends in drug-eluting stents (DES) use in four international health care and regulatory settings., Background: Accounts suggest a differential approach to DES internationally and recent reductions in use following reports of late stent thrombosis. Current studies of clinical practice are limited in their scope., Methods: Data were pooled from angioplasty registries in Alberta (Canada), Belgium, Mayo Clinic (Rochester, MN), and Scotland (UK) that have routinely recorded consecutive patients treated since 2003. Trend analysis was performed to examine variations in DES use over time and by clinical subgroup., Results: A total of 178,504 lesions treated between January 2003 and September 2007 were included. In the Mayo Clinic Registry, rapid adoption to a peak of 91% DES use for all lesions by late 2004 was observed. In contrast, Alberta and Scotland showed delayed adoption with lower peak DES use, respectively, 56% and 58% of lesions by early 2006. Adoption of DES in Belgium was more gradual and peak use of 35% lower than other registries. Reductions in DES use were seen in all data sets during 2006, although this varied in absolute and relative terms and by clinical subgroup., Conclusion: Adoption and use of DES showed wide variation in four countries. The determinants of use are complex, and it is likely that nonclinical factors predominate. Recent reductions in use may be as a consequence of publicity and concerns regarding late stent thrombosis. The optimum application of DES in clinical practice is unclear and is reflected in the degree of international variation demonstrated.

Objective: To determine the proportion of consultations requested by general internal medicine services that communicate key components of the consultation process to medical subspecialists., Design: Retrospective chart review by two researchers, using a standardised chart abstraction instrument (93.1% agreement, kappa 0.85)., Setting: Calgary, Alberta, Canada., Sample: A random sample of medical consultations was selected from those generated on two medical teaching units (MTUs) from 2003 to 2004., Measurements: The primary measure of interest was whether a "clear clinical question" was posed to the subspecialist, a binary variable., Results: Two hundred consultations were sampled from the 2885 subspecialty consultations. Of the selected consultations, 94.0% (188/200) were available for review. A clear clinical question was posed in 69.7% (131/188) of consultations (CI 0.63 to 0.74). In a secondary analysis involving a larger sample permitting comparison across subspecialties, 95.1% (368/387) of the consultations, representative of the subspecialties, were available for review. An MTU member contacted the subspecialist for 74.2% of consultations. If a consultation was urgent, a member of the MTU contacted the subspecialist in 81.0% of consultations. Of these urgent consultations, 63.3% had a clear clinical question., Conclusion: More than one in four consultations does not contain a clear clinical question, illustrating suboptimal communication between physicians. Innovative strategies that provide a sustainable solution for overcoming barriers to communication could have a significant impact on quality of care.

Background: Ethnic disparities in access to health care and health outcomes are well documented. It is unclear whether similar differences exist between Aboriginal and non-Aboriginal people with chronic kidney disease in Canada. We determined whether access to care differed between status Aboriginal people (Aboriginal people registered under the federal Indian Act) and non-Aboriginal people with chronic kidney disease., Methods: We identified 106 511 non-Aboriginal and 1182 Aboriginal patients with chronic kidney disease (estimated glomerular filtration rate less than 60 mL/min/1.73 m(2)). We compared outcomes, including hospital admissions, that may have been preventable with appropriate outpatient care (ambulatory-care-sensitive conditions) as well as use of specialist services, including visits to nephrologists and general internists., Results: Aboriginal people were almost twice as likely as non-Aboriginal people to be admitted to hospital for an ambulatory-care-sensitive condition (rate ratio 1.77, 95% confidence interval [CI] 1.46-2.13). Aboriginal people with severe chronic kidney disease (estimated glomerular filtration rate < 30 mL/min/1.73 m(2)) were 43% less likely than non-Aboriginal people with severe chronic kidney disease to visit a nephrologist (hazard ratio 0.57, 95% CI 0.39-0.83). There was no difference in the likelihood of visiting a general internist (hazard ratio 1.00, 95% CI 0.83-1.21)., Interpretation: Increased rates of hospital admissions for ambulatory-care-sensitive conditions and a reduced likelihood of nephrology visits suggest potential inequities in care among status Aboriginal people with chronic kidney disease. The extent to which this may contribute to the higher rate of kidney failure in this population requires further exploration.

Objective: The goal of this study was to assess the validity of the International Classification of Disease, 10th Version (ICD-10) administrative hospital discharge data and to determine whether there were improvements in the validity of coding for clinical conditions compared with ICD-9 Clinical Modification (ICD-9-CM) data., Methods: We reviewed 4,008 randomly selected charts for patients admitted from January 1 to June 30, 2003 at four teaching hospitals in Alberta, Canada to determine the presence or absence of 32 clinical conditions and to assess the agreement between ICD-10 data and chart data. We then re-coded the same charts using ICD-9-CM and determined the agreement between the ICD-9-CM data and chart data for recording those same conditions. The accuracy of ICD-10 data relative to chart data was compared with the accuracy of ICD-9-CM data relative to chart data., Results: Sensitivity values ranged from 9.3 to 83.1 percent for ICD-9-CM and from 12.7 to 80.8 percent for ICD-10 data. Positive predictive values ranged from 23.1 to 100 percent for ICD-9-CM and from 32.0 to 100 percent for ICD-10 data. Specificity and negative predictive values were consistently high for both ICD-9-CM and ICD-10 databases. Of the 32 conditions assessed, ICD-10 data had significantly higher sensitivity for one condition and lower sensitivity for seven conditions relative to ICD-9-CM data. The two databases had similar sensitivity values for the remaining 24 conditions., Conclusions: The validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions was generally similar though validity differed between coding versions for some conditions. The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM. Future assessments like this one are needed because the validity of ICD-10 data may get better as coders gain experience with the new coding system.

Background: The best therapeutic strategy for patients with double-vessel coronary artery disease and proximal left anterior descending artery involvement (2VD + pLAD) is not clear., Objectives: To compare the survival experience of a cohort of cardiac catheterization patients with 2VD + pLAD based on chosen therapeutic strategy (medical management versus percutaneous coronary intervention [PCI] versus coronary artery bypass graft surgery [CABG])., Methods: The authors identified and studied a total of 603 patients with 2VD + pLAD from all patients who underwent diagnostic coronary angiography in Alberta between January 1997 and May 1999. The primary end point was five-year survival from index catheterization for each of the treatment groups and from time of revascularization when the two revascularization strategies were compared., Results: Risk-adjusted hazard ratios (HR) comparing cumulative five-year survival rates of patients treated medically, or with PCI or CABG indicated a survival benefit for patients treated with CABG (HR 0.24, 95% CI 0.11 to 0.54; P<0.001) and PCI (HR 0.43, 95% CI 0.24 to 0.77; P=0.003) compared with medical management. Meanwhile, a risk-adjusted comparison of revascularization strategies suggested a possible trend toward higher mortality for PCI-treated patients versus CABG-treated patients (HR 1.56, 95% CI 0.65 to 3.72; P=0.125)., Conclusions: The results of this registry-based observational study suggest a survival benefit from revascularization compared with medical management in patients with 2VD + pLAD. Furthermore, the authors found a trend toward better survival in CABG-treated patients compared with PCI-treated patients.

Background: Hospital discharge data are used extensively in health research. Given the clinical differences between ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI), it is important that these entities be distinguishable in a medical record. The authors sought to determine the extent to which the type of MI is recorded in medical records, as well as the consistency of this designation within individual records., Methods: Records of all MI patients admitted to a tertiary care centre in Canada from April 1, 2000, to March 31, 2001, were reviewed. Documentation and consistency of the use of the terms STEMI (Q wave, ST elevation or transmural MI) or NSTEMI (non-Q wave, subendocardial or nontransmural MI) were assessed in the admission history, progress notes, coronary care unit summary and discharge summary sections of each record., Results: Missing data were common; each chart section mentioned MI type in fewer than one-half of charts. When information was combined, it was possible to determine the type of MI in 81.1% of cases. MI type was consistently described as STEMI in 48.7% of cases, and as NSTEMI in 32.4%. Of concern, MI type was discrepant across sections in 10.5% of cases and missing entirely in 8.4% of cases., Conclusions: The designation of MI cases as STEMI or NSTEMI is both incomplete and inconsistent in hospital records. This has implications for health services research conducted retrospectively using medical record data, because it is difficult to comprehensively study processes and outcomes of MI care if the type cannot be retrospectively determined.

Background: We have previously described a method for dealing with missing data in a prospective cardiac registry initiative. The method involves merging registry data to corresponding ICD-9-CM administrative data to fill in missing data 'holes'. Here, we describe the process of translating our data merging solution to ICD-10, and then validating its performance., Methods: A multi-step translation process was undertaken to produce an ICD-10 algorithm, and merging was then implemented to produce complete datasets for 1995-2001 based on the ICD-9-CM coding algorithm, and for 2002-2005 based on the ICD-10 algorithm. We used cardiac registry data for patients undergoing cardiac catheterization in fiscal years 1995-2005. The corresponding administrative data records were coded in ICD-9-CM for 1995-2001 and in ICD-10 for 2002-2005. The resulting datasets were then evaluated for their ability to predict death at one year., Results: The prevalence of the individual clinical risk factors increased gradually across years. There was, however, no evidence of either an abrupt drop or rise in prevalence of any of the risk factors. The performance of the new data merging model was comparable to that of our previously reported methodology: c-statistic = 0.788 (95% CI 0.775, 0.802) for the ICD-10 model versus c-statistic = 0.784 (95% CI 0.780, 0.790) for the ICD-9-CM model. The two models also exhibited similar goodness-of-fit., Conclusion: The ICD-10 implementation of our data merging method performs as well as the previously-validated ICD-9-CM method. Such methodological research is an essential prerequisite for research with administrative data now that most health systems are transitioning to ICD-10.

Globally, it is known that the incidence of end-stage renal disease is higher among Aboriginals, but it is unknown whether this is due to an increased prevalence of chronic kidney disease or other unidentified factors. We studied 658,664 people of non-First Nations and 14,989 people of First Nations and found that the age- and sex-adjusted prevalence of chronic kidney disease was significantly higher among those of non-First Nations compared to those of First Nations (67.5 versus 59.5 per 1000 population; P < 0.0001). However, severe chronic kidney disease (estimated glomerular filtration rate <30 ml/min per 1.73 m2) was almost two-fold higher among people of First Nations (P < 0.0001). Cox proportional hazards models suggested that compared to people of non-First Nations, those of First Nations with chronic kidney disease had a 77% increased risk of death after adjusting for age, gender, diabetes and baseline eGFR. In conclusion, whether the higher incidence of end-stage renal disease among people of First Nations is due to suboptimal management of chronic kidney disease and its associated comorbidities, more rapid loss of kidney function, or other unidentified factors remains to be determined.

Background: This study uses geographic information systems (GIS) as a tool to evaluate and visualize the general accessibility of areas within the province of Alberta (Canada) to cardiac catheterization facilities. Current American and European guidelines suggest performing catheterization within 90 minutes of the first medical contact. For this reason, this study evaluates the populated places that are within a 90 minute transfer time to a city with a catheterization facility. The three modes of transport considered in this study are ground ambulance, rotary wing air ambulance and fixed wing air ambulance., Methods: Reference data from the Alberta Chart of Call were interpolated into continuous travel time surfaces. These continuous surfaces allowed for the delineation of isochrones: lines that connect areas of equal time. Using Dissemination Area (DA) centroids to represent the adult population, the population numbers were extracted from the isochrones using Statistics Canada census data., Results: By extracting the adult population from within isochrones for each emergency transport mode analyzed, it was found that roughly 70% of the adult population of Alberta had access within 90 minutes to catheterization facilities by ground, roughly 66% of the adult population had access by rotary wing air ambulance and that no population had access within 90 minutes using the fixed wing air ambulance. An overall understanding of the nature of air vs. ground emergency travel was also uncovered; zones were revealed where the use of one mode would be faster than the others for reaching a facility., Conclusion: Catheter intervention for acute myocardial infarction is a time sensitive procedure. This study revealed that although a relatively small area of the province had access within the 90 minute time constraint, this area represented a large proportion of the population. Within Alberta, fixed wing air ambulance is not an effective means of transporting patients to a catheterization facility within the 90 minute time frame, though it becomes advantageous as a means of transportation for larger distances when there is less urgency.

Patients who were moved from a traditional medical ward to a new state-of-the-art medical ward were surveyed regarding their perceptions of quality during their hospitalization. Respondents rated the environment of the state-of-the-art facility, as well as the overall quality of their hospital stay, more positively. However, fewer differences in perceptions of the quality of the broader hospital environment and little difference in the perceived quality of staff-patient interactions were found. Findings indicated that enhancing the facilities of the patient care environment improved patients' overall perceptions of the quality of their hospital stay.

This study assessed the extent of use of the subcutaneous insulin sliding scale (ISS) with hospitalized medical patients and examined the association between ISS use and glucose control. Despite some concerns about efficacy and suitability, the ISS is often used in the hospital studied. Researchers reviewed records of patients with a secondary diagnosis of diabetes who were admitted to the medical teaching unit of a tertiary care hospital. On day 1, 45.2% of patients were on an ISS alone. Patients on an ISS were more likely to experience hyperglycemia compared with patients on scheduled regimens, but they also had fewer hypoglycemic episodes.

Background: Missing data present a challenge to many research projects. The problem is often pronounced in studies utilizing self-report scales, and literature addressing different strategies for dealing with missing data in such circumstances is scarce. The objective of this study was to compare six different imputation techniques for dealing with missing data in the Zung Self-reported Depression scale (SDS)., Methods: 1580 participants from a surgical outcomes study completed the SDS. The SDS is a 20 question scale that respondents complete by circling a value of 1 to 4 for each question. The sum of the responses is calculated and respondents are classified as exhibiting depressive symptoms when their total score is over 40. Missing values were simulated by randomly selecting questions whose values were then deleted (a missing completely at random simulation). Additionally, a missing at random and missing not at random simulation were completed. Six imputation methods were then considered; 1) multiple imputation, 2) single regression, 3) individual mean, 4) overall mean, 5) participant's preceding response, and 6) random selection of a value from 1 to 4. For each method, the imputed mean SDS score and standard deviation were compared to the population statistics. The Spearman correlation coefficient, percent misclassified and the Kappa statistic were also calculated., Results: When 10% of values are missing, all the imputation methods except random selection produce Kappa statistics greater than 0.80 indicating 'near perfect' agreement. MI produces the most valid imputed values with a high Kappa statistic (0.89), although both single regression and individual mean imputation also produced favorable results. As the percent of missing information increased to 30%, or when unbalanced missing data were introduced, MI maintained a high Kappa statistic. The individual mean and single regression method produced Kappas in the 'substantial agreement' range (0.76 and 0.74 respectively)., Conclusion: Multiple imputation is the most accurate method for dealing with missing data in most of the missind data scenarios we assessed for the SDS. Imputing the individual's mean is also an appropriate and simple method for dealing with missing data that may be more interpretable to the majority of medical readers. Researchers should consider conducting methodological assessments such as this one when confronted with missing data. The optimal method should balance validity, ease of interpretability for readers, and analysis expertise of the research team.

Background: Census-based measures of income derived from median income of a geographic area are often used in health research. Many national census surveys gather information on both the respondent's individual income and the income for the entire household, giving researchers a choice of census income measures. We compared the extent to which individual respondent income and household income (both obtained from census data) are associated with outcomes in a cohort of patients with cardiac disease., Methods: We used data from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), where postal codes were linked to the Postal Code Conversion File (PCCF) to determine each patient's census Dissemination Areas (DA). DA-derived median household income and median individual income were obtained from the 2001 Canadian Census and survival outcomes were then directly determined for income groupings defined by quintile. Two-year survival adjusted for age and sex was described with a proportional hazards analysis., Results: There were 9,397 patients undergoing cardiac catheterization between January 1, 2001 and March 31, 2002, with complete DA-level median income measures. Household income quintiles yielded a wider spread of survival across quintiles (range of 2-year estimated survival, 91.8% to 95.9% for household income versus 92.8% to 95.6% for respondent income), as well as a more progressive decline in survival as income decreased. This progressive decline was not seen for the respondent income measure., Conclusions: The greater spread and progressive decline of survival for household income relative to respondent income leads us to conclude that household income is the better socio-economic determinant of health in our data and for the outcome measure we studied.

Background: Snowfall can cause chaos in urban centres and put considerable stress on health care systems. Given that myocardial infarction (MI) is a condition that may be triggered or aggravated by stress, and that health system stress could influence the typical care provided to patients with MI, a study was conducted comparing 'snow days' with 'nonsnow days', specifically assessing the incidence of MI, the use of acute procedures and in-hospital mortality., Methods: Hospital discharge data were used on all patients discharged after MI. These data were merged with data from Environment Canada to determine the amount of snowfall that occurred on any given day. The use of acute procedures was determined by linking to data from the Alberta Provincial PRoject for Outcomes Assessment in Coronary Heart disease (APPROACH). Snow days were defined as days when at least 5 cm of snow fell, and the two subsequent days were included because of the lingering effect of 'urban chaos' that can ensue after significant snowfall. The average incidence of MIs on snow days versus nonsnow days was then determined. Risk-adjusted odds ratios for the use of direct percutaneous coronary intervention and in-hospital mortality were also determined., Results: There were 61 snow days and 575 nonsnow days. The incidence of MI (incidence density ratio of 1.08, 95% CI 0.82 to 3.10) and the use of direct percutaneous coronary intervention (adjusted OR=1.07, 95% CI 0.74 to 1.54) were slightly higher on snow days. In-hospital mortality trended toward being lower (adjusted OR=0.54, 95% CI 0.28 to 1.04) for patients admitted on snow days, although none of these differences were statistically significant., Conclusion: Despite the potential for the significant adverse effects of snow days on the incidence of MI, the use of acute procedures and outcomes, these findings suggest only minor effects, if any.

Background: Census-based measures of income often are used as proxies for individual-level income. Yet, the validity of such area-based measures relative to 'true' individual-level income has not been fully characterized., Objectives: The objectives of this study were (1) to determine whether area-based measures of household income are a suitable proxy for self-reported household income and (2) to assess whether these measures are associated with outcomes in a cardiac disease cohort., Research Design: We used a prospective cohort from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) cardiac catheterization registry., Subjects: A total of 4372 patients having undergone cardiac catheterization and who also completed a 1-year follow-up questionnaire on self-reported income level were studied., Measures: Our measurements were survival to 2.5 years after catheterization and health-related quality of life (EuroQoL)., Results: Agreement between the 2 income measures generally was poor (unweighted Kappa = 0.07), particularly for the low-income patients. Despite this poor agreement, both income measures were positively associated with survival and EuroQoL scores. An outcome analysis that simultaneously considered individual level income and area-based income revealed that low-income individuals have poorer survival and lower quality of life scores if they live in low income neighborhoods, but not if they live in high income neighborhoods., Conclusions: The area-based estimates of household income in these data demonstrate poor agreement with self-reported household income at the level of individual patients, particularly for low-income patients. Despite this, both income measures appear to be prognostically relevant, perhaps because individual and neighborhood income measure different constructs.

Background: The structure of the Canadian health care system lends itself to health services and health outcomes research. It is possible to track hospital admissions and discharges, physician billings and prescriptions using administrative databases. In addition, several provinces have developed registries that provide detailed clinical and procedural information. Using the unique personal health numbers assigned to all Canadian residents, linkage between administrative databases and population-based clinical registries provides important information regarding the use of health services and health outcomes., Objective: To determine the extent of cross-border (British Columbia-Alberta border) use of cardiac services by British Columbia residents., Methods: Population rates of cardiac procedures were calculated using two prospective clinical registries (British Columbia Cardiac Registries and Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease [APPROACH]), as well as administrative databases (the British Columbia Ministry of Health's hospitalization and Medical Services Plan databases)., Results: Analyses using only British Columbia data suggest low cardiac procedure rates for patients living in eastern British Columbia. By accessing APPROACH data, it was determined that more than 80% of British Columbia cardiac patients living along the British Columbia-Alberta border access procedural services in Alberta., Conclusions: While residents of eastern British Columbia appear to have reduced access to cardiac services when data from British Columbia are analyzed in isolation, they are actually accessing care in Alberta. Analyses based solely on single province data sources will underestimate cardiac procedures rates.

This study on patients undergoing coronary angiography for acute myocardial infarction demonstrated that 2.8% of patients had angiographically normal coronary arteries and that these patients have a better prognosis than patients with angiographically verified coronary artery disease. The trend toward a higher prevalence of malignancy in this unique patient group raises the possibility of malignancy-induced hypercoagulability or inflammation as an underlying etiologic factor.

Background: Alberta and British Columbia have comprehensive cardiac databases that provide detailed demographic, clinical and procedural data, including coronary anatomy, on all patients undergoing cardiac catheterization., Objectives: To examine the baseline clinical characteristics of patients undergoing cardiac catheterization, describe the use of revascularization treatments (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) following catheterization, and describe survival after cardiac catheterization, stratified by treatment strategy received and proposed, using cardiac databases from Alberta and British Columbia., Patients and Methods: All patients between 20 and 105 years of age, admitted to hospital for their first coronary angiography between April 1, 1995, and March 31, 2001, with angiographic evidence of coronary disease were included in the study. Procedure volumes, baseline characteristics and therapy received within one year of cardiac catheterization are described by province. Stepwise, multivariate logistic regression analysis was used to model determinants of the revascularization modality. Kaplan-Meier curves of one-year survival after index cardiac catheterization were estimated for the therapy received (Alberta and British Columbia) and the therapy proposed (British Columbia only)., Results: Patients were predominantly men (70%), commonly presented with two- or three-vessel disease, and frequently had hypertension, a history of myocardial infarction and dyslipidemia. Within one year of catheterization, 21% to 26% underwent CABG and 32% to 42% underwent PCI. Emergency or urgent status at the time of catheterization was associated with receiving PCI, while three-vessel and left main disease were associated with receiving CABG. Patients who did not undergo revascularization within one year (presumed medical therapy) had the lowest one-year survival rate (93.4%; 95% CI 92.1% to 94.7%); this group comprised patients receiving medical therapy as proposed (one-year survival rate of 95.7%, 95% CI 94.6% to 96.8%), as well as patients receiving medical therapy at variance with the proposal for revascularization (84.6%; 95% CI 80.5% to 88.9%)., Conclusions: Between 53.1% and 67.5% of patients presenting for cardiac catheterization undergo revascularization within one year. Urgent status increased the probability of PCI, and anatomy (ie, three-vessel and left main) increased the probability of CABG. Patients not undergoing proposed revascularization by one year had poorer outcomes, in contrast with those proposed for medical therapy, who had excellent outcomes.

Purpose: The benefits of cardiac rehabilitation (CR) for patients with coronary artery disease are extensive and compelling, demonstrating reductions in mortality. However, some reports suggest that only 10% to 20% of eligible patients currently participate in formal CR programs. The purpose of this study was to identify the proportion of patients referred to CR in a large Canadian city, and to determine their statistically adjusted survival rates relative to patients not referred to CR., Methods: Subjects eligible for this study included all adult residents with coronary artery disease from 1995 to 1999 in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. All 5,081 patients who survived 6 months or more after catheterization were included in the analysis. Survival data were adjusted using a Cox proportional hazards model., Results: Referral to a CR program (28.9% of patients) was significantly more likely for young male patients who had undergone a prior revascularization procedure, presented with an ejection fraction exceeding 50%, and did not report cerebrovascular, peripheral vascular, or renal disease. Crude hazard ratios indicated that referral to a CR program remained significantly associated with lower mortality after control was used for clinical, anatomic, treatment and comorbid conditions recorded at catheterization (hazard ratio, 0.68; 95% confidence interval, 0.51-0.90; P = .005)., Conclusions: Despite the proven efficacy of CR in clinical trials, fewer than one third of the patients undergoing cardiac catheterization are referred to a CR program. The better survival outcomes noted for patients referred to CR suggests that there is an opportunity to improve care and outcomes through increased referral of patients to such programs.

Background: The optimal approach to revascularization in patients with kidney disease has not been determined. We studied survival by treatment group (CABG, percutaneous coronary intervention [PCI], or no revascularization) for patients with 3 categories of kidney function: dialysis-dependent kidney disease, non-dialysis-dependent kidney disease, and a reference group (serum creatinine <2.3 mg/dL)., Methods and Results: Data were derived from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), which captures information on all patients undergoing cardiac catheterization in Alberta, Canada. Characteristics and patient survival in 662 dialysis patients (1.6%) and 750 non-dialysis-dependent kidney disease patients (1.8%) were compared with the remainder of the 40,374 patients (96.6%). For the reference group, the adjusted 8-year survival rates for CABG, PCI, and no revascularization (NR) were 85.5%, 80.4%, and 72.3%, respectively (P<0.001 for CABG versus NR; P<0.001 for PCI versus NR). Adjusted survival rates were 45.9% for CABG, 32.7% for PCI, and 29.7% for NR in the nondialysis kidney disease group (P<0.001 for CABG versus NR; P=0.48 for PCI versus NR) and 44.8% for CABG, 41.2% for PCI, and 30.4% for NR in the dialysis group (P=0.003 for CABG versus NR; P=0.03 for PCI versus NR)., Conclusions: Compared with no revascularization, CABG was associated with better survival in all categories of kidney function. PCI was also associated with a lower risk of death than no revascularization in reference patients and dialysis-dependent kidney disease patients but not in patients with non-dialysis-dependent kidney disease. The presence of kidney disease or dependence on dialysis should not be a deterrent to revascularization, particularly with CABG.

Background: Coronary artery bypass grafting (CABG) is indicated in patients with coronary artery disease and impaired ventricular function. However, earlier studies have suggested that prognosis of patients with severe left ventricular dysfunction is extremely poor. We used the APPROACH registry to derive contemporary estimates of prognosis associated with CABG for this high-risk patient population., Methods and Results: The study group consisted of 7841 patients who had isolated CABG in the province of Alberta, Canada between 1996 and 2001. Patients with markedly reduced left ventricular function (ejection fraction [EF] <30%, Lo EF, n =430) were compared with those with moderate reduction in ventricular function (EF 30% to 50%, Med EF, n =2581) and those with normal left ventricular function (EF >50%, normal [Nl] EF, n=4830). The operative mortality was higher in the patient group with Lo EF (4.6%) compared with Med EF and Nl EF groups (3.4% and 1.9%, respectively, P<0.001). At 5 years, survival was 77.7% for Lo EF patients compared with 85.5% and 91.2% for Med EF and Nl EF patients, respectively (P<0.001). After controlling for other independent variables, the adjusted hazard ratio for death was 1.98 (95% CI, 1.49 to 2.62) for Lo EF relative to Nl EF. The mortality rate at 1 year was significantly lower for Lo EF patients who underwent CABG than it was for nonrevascularized Lo EF patients (risk-adjusted odds ratio, 0.36; 95% CI, 0.24 to 0.55)., Conclusions: In the modern era of cardiac surgery, CABG can be performed in Lo EF cases with an acceptable perioperative mortality risk. Our estimate of 5-year survival in this high-risk group is better than previously reported in the literature from earlier periods.