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Background: Outcomes of diabetes screening in contemporary, multi-ethnic populations are unknown. We examined the association of prior outpatient diabetes screening with the risks of cardiovascular events and mortality in Ontario, Canada. Methods: We conducted a population-based cohort study using administrative databases among adults aged ≥ 20 years with incident diabetes diagnosed during 2014–2016. The exposure was outpatient diabetes screening performed within 3 years prior to diabetes diagnosis. The co-primary outcomes were (1) a composite of all-cause mortality and hospitalization for myocardial infarction, stroke, coronary revascularization, and (2) all-cause mortality (followed up until 2018). We calculated standardized rates of each outcome and conducted cause-specific hazard modelling to determine the adjusted hazard ratio (HR) of the outcomes, adjusting for prespecified confounders and accounting for the competing risk of death. Results: We included 178,753 Ontarians with incident diabetes (70.2% previously screened). Individuals receiving prior screening were older (58.3 versus 53.4 years) and more likely to be women (49.6% versus 40.0%) than previously unscreened individuals. Individuals receiving prior screening had relatively lower standardized event rates than those without prior screening across all outcomes (composite: 12.8 versus 18.1, mortality: 8.2 versus 11.1 per 1000 patient-years). After multivariable adjustment, prior screening was associated with 34% and 32% lower risks of the composite (HR 0.66, 0.63–0.69) and mortality (0.68, 0.64–0.72) outcomes. Among those receiving prior screening, a result in the prediabetes range was associated with lower risks of the composite (0.82, 0.77–0.88) and mortality (0.71, 0.66–0.78) outcomes than a result in the normoglycemic range. Conclusions: Previously screened individuals with diabetes had lower risks of cardiovascular events and mortality versus previously unscreened individuals. Better risk assessment tools are needed to support wider and more appropriate uptake of diabetes screening, especially among young adults. [ABSTRACT FROM AUTHOR]

Objective: Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sex-specific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K.Research Design and Methods: Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ≥18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ≥35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event.Results: A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA1c, and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors.Conclusions: Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. [ABSTRACT FROM AUTHOR]

Aim: To better understand the healthcare burden of people with type 2 diabetes (T2D) and estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 in Ontario, Canada. Materials and Methods: We used administrative data to evaluate the prevalence of T2D, eGFR < 90 mL/min/1.73 m2 and adverse cardiovascular co‐morbidities in individuals aged ≥ 30 years living in Ontario, Canada. We also examined incremental healthcare costs and healthcare resource utilization (HCRU) for these patients with specific incident cardiovascular and renal outcomes, in comparison with controls without these outcomes. Results: While the prevalence of T2D in the general population aged ≥ 30 years in Ontario increased by 1.8% over a 5‐year period (2011‐2012 to 2015‐2016), the prevalence of eGFR < 90 mL/min/1.73 m2 among people with T2D increased by 35%. In comparison with corresponding controls without these outcomes, the per patient average total costs (Canadian dollars) over a 2‐year analysis period were higher for patients with cardiovascular disease/chronic kidney disease related death ($69 827; n = 32 407), doubling of serum creatinine ($52 260; n = 22 825), those who started dialysis ($150 627; n = 3499) or received a kidney transplant ($50 664; n = 651). Similarly, HCRU was significantly greater for patients with these incident outcomes. Conclusions: This real‐world retrospective study highlights an increasing prevalence of T2D, eGFR < 90 mL/min/1.73 m2, and the substantially higher healthcare costs and HCRU when these patients have adverse cardiovascular and renal outcomes. The existence of such a large economic burden underpins the importance of preventing these diabetes‐related complications. [ABSTRACT FROM AUTHOR]

Introduction: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario. Methods: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014--31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults. Results: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%). Conclusion: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security. [ABSTRACT FROM AUTHOR]

Introduction: The need for up-to-date and high-quality continuing medical education (CME) is growing while the financial investment in CME is shrinking. Despite online technology's potential to efficiently deliver electronic CME (eCME) to large numbers of users, it has not yet displaced traditional CME. The purpose of this study was to explore what health care providers want in eCME and how they want to use it. Methods: This was a qualitative study. Two 3-hour focus groups were held with physicians in both academic and community practices as well as trainees knowledgeable in the hypertension clinical practice guidelines with a willingness to discuss eCME. Content/thematic analysis was used to examine the data. Results: Three main themes emerged: credibility, content/context, and control. Credibility was the most consistent and dominant theme. Affiliations with medical organizations and accreditation were suggested as methods by which eCME can gain credibility. The content and need for discussion of the content emerged as a key pivot point between eCME and traditional CME: a greater need for discussion was linked to a preference for traditional face-to-face CME. Control over the content and how it was accessed was an emergent theme, giving learners the ability to control the depth of learning and the time spent. They valued the ability to quickly find information that was in a format (podcast, video, mobile device) that best suited their learning needs or preferences at the time. Discussion: This study provides insight into physician preferences for eCME and hypotheses that can be used to guide further research. [ABSTRACT FROM AUTHOR]

Background: Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups., Methods: Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease)., Results: Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population ( p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension., Interpretation: We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing., Competing Interests: Competing interests: Catherine Yu reports receiving research grants from the St. Michael’s Hospital Medical Services Association, St. Michael’s Hospital (Unity Health Toronto), the Ontario SPOR SUPPORT Unit and the Royal College of Physicians and Surgeons of Canada. Kim Connelly reports receiving research grants and payment for presentations from AstraZeneca, Servier, Boehringer Ingelheim, Eli Lilly, Novartis, Novo Nordisk and Merck. Dr. Connelly also reports serving on a Data Safety Monitoring Board or Advisory Board for AstraZeneca, Servier, Boehringer Ingelheim, Eli Lilly, Novartis, Novo Nordisk and Merck. Gillian Booth reports receiving grants or contracts from the Canadian Institutes of Health Research (CIHR), Juvenile Diabetes Research Foundation and the Thistledown Foundation. Karen Tu reports receiving payments (to institutions) from CIHR, St. Michael’s Hospital Foundation, The College of Family Physicians of Canada, Foundation for Advancing Family Medicine, Canadian Medical Association Foundation, North York General Hospital, Heart and Stroke Foundation of Canada, Heart and Stroke Foundation of Ontario, Department of Defense (United States), University of Toronto (Department of Family and Community Medicine), MaRS Innovation Fund, Canadian Dermatology Foundation, Canadian Rheumatology Association (Canadian Initiative for Outcomes in Rheumatology Care), PSI Foundation, Cancer Care Ontario, Toronto Rehabilitation Institute Chair Fund, University of Toronto Practice-Based Research Network, Arthritis Society, MS Society of Canada, The Canadian Vascular Network and the Ontario SPOR SUPPORT Unit Targeted IMPACT Award. Sheldon Tobe reports receiving a KMH clinic unrestricted grant and in-kind support for the Zero to Five study, and consulting fees from AstraZeneca (all paid to Sunnybrook Research Institute). Dr. Tobe also reports receiving payment from Amgen, Astra-Zeneca, Bristol Myers Squibb, Bayer, Boehringer Ingelheim, Janssen, Lilly, Novartis, Novo Nordisk, Pfizer and Sanofi Genzyme for the CHEPPLUS education program. Dr. Tobe has worked on a volunteer basis with the American Hypertension Specialists Certification Program. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Aim: To better understand the healthcare burden of people with type 2 diabetes (T2D) and estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m 2 in Ontario, Canada., Materials and Methods: We used administrative data to evaluate the prevalence of T2D, eGFR < 90 mL/min/1.73 m 2 and adverse cardiovascular co-morbidities in individuals aged ≥ 30 years living in Ontario, Canada. We also examined incremental healthcare costs and healthcare resource utilization (HCRU) for these patients with specific incident cardiovascular and renal outcomes, in comparison with controls without these outcomes., Results: While the prevalence of T2D in the general population aged ≥ 30 years in Ontario increased by 1.8% over a 5-year period (2011-2012 to 2015-2016), the prevalence of eGFR < 90 mL/min/1.73 m 2 among people with T2D increased by 35%. In comparison with corresponding controls without these outcomes, the per patient average total costs (Canadian dollars) over a 2-year analysis period were higher for patients with cardiovascular disease/chronic kidney disease related death ($69 827; n = 32 407), doubling of serum creatinine ($52 260; n = 22 825), those who started dialysis ($150 627; n = 3499) or received a kidney transplant ($50 664; n = 651). Similarly, HCRU was significantly greater for patients with these incident outcomes., Conclusions: This real-world retrospective study highlights an increasing prevalence of T2D, eGFR < 90 mL/min/1.73 m 2 , and the substantially higher healthcare costs and HCRU when these patients have adverse cardiovascular and renal outcomes. The existence of such a large economic burden underpins the importance of preventing these diabetes-related complications., (© 2020 The Authors. Diabetes, Obesity and Metabolism published by John Wiley & Sons Ltd.)

Introduction: First Nations communities are known to have high rates of diabetes. The rural First Nations communities in northwest (NW) Ontario are particularly affected. Regional studies in 1985 and 1994 found a high prevalence of diabetes. More recently, they are estimated to have the highest prevalence in Ontario at 19%, double the provincial norm. The purpose of this study is to examine the epidemiology and prevalence of diabetes in the total population and cardiovascular comorbidities in the adult population of 25 First Nations communities in NW Ontario., Methods: This retrospective diabetes prevalence study used primary care electronic medical record data for a 3-year period, 1 August 2014-31 July 2017. Diabetes prevalence was calculated for both the total and the adult (18+) populations and comorbid hypertension and dyslipidaemia were identified in adults., Results: The age-adjusted diabetes prevalence for the total population was 15.1% versus a Canadian prevalence of 8.8%. The age-adjusted adult prevalence was 14.1%, double Canada's average of 7.1%. The average age of adults with diabetes was 52 years (±14.9); 57% were female. Comorbid hypertension (58%) and dyslipidaemia (73%) were common. Metformin was the most commonly used medication (58%), followed by insulin/analogues (23%) and sulphonylureas (13%)., Conclusion: The diabetes prevalence in the First Nations population of NW Ontario is double Canada's norm. Addressing it will require addressing relevant social determinants of health, including poverty and food security., Competing Interests: None

Background: Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South., Methods: We examined 30-day and 1-year mortality and readmissions for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF), or stroke in Northern compared with Southern Ontario, using the Canadian Institute for Health Information Discharge Abstract Database (2005-2016). Northern patients were defined as those residing and hospitalized in the Northwest or Northeast Local Health Integration Network regions. We used multiple Cox proportional hazards regression analysis for time-to-first event and Prentice-Williams-Peterson method to evaluate repeat and multiply admitted patients., Results: A total of 47,745 Northern and 465,353 Southern patients hospitalized with AMI (n = 182,158), HF (n = 130,770), AF (n = 72,326), or stroke (n = 127,844) were studied. Rates of first readmission were higher among Northern patients for AMI (adjusted hazard ratio [HR], 1.32), HF (HR, 1.16), AF (HR, 1.21), and stroke (HR, 1.27) compared with Southern patients (all P < 0.001). Repeat readmission rates among Northern patients for AMI (HR, 1.23), HF (HR, 1.13), AF (HR, 1.18), and stroke (HR, 1.22) were also increased (all P < 0.001 vs Southern). Thirty-day mortality did not differ significantly between Northern and Southern patients., Conclusions: Readmissions were increased in those residing and hospitalized in the North. To reduce readmissions in the North, the quality of postacute transitional care should be examined further., (Copyright © 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The goal of the Hypertension Management Initiative (HMI) is to improve the management and control of hypertension by both primary care providers and patients. The HMI was in effect in 11 primary care sites across the province of Ontario, Canada. This was a qualitative study. Focus groups and a lobby survey were completed with a total of 199 of the 3934 patients enrolled in the study. Interviews with 41 participating health care providers from all sites were performed. A qualitative description approach was used to give a rich description of each informant's experiences. Patients expressed motivation and engagement in their own health care and became more knowledgeable about hypertension and how to manage it with their health care providers. Most reported satisfaction with the discipline of regular appointments and ongoing monitoring and counseling of the program including identifying and working on goals for their modifiable risk factors. Their health care providers felt the HMI program had a positive impact on the treatment and management of hypertension and also that it improved the functioning of the interprofessional team. The HMI helped to improve patient self-empowerment and self-management and also improved physicians' and nurses' confidence in diagnosing accurately and in hypertension management. Physician buy-in is key to maintaining clinical hypertension management. Interprofessional collaboration was improved for physicians and nurses but less so for pharmacists. Greater confidence among the nurses to manage hypertension more independently reduced demands on physician time., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: STARRT recently demonstrated that many patients experience suboptimal dialysis starts (defined as initiation as an inpatient and/or with a central venous catheter), even when followed by a nephrologist for >12 months (NDT 2011). However, STARRT did not identify the factors associated with suboptimal initiation of dialysis. The objectives of this study were to extend the results of STARRT by ascertaining the factors leading to suboptimal initiation of dialysis in patients who were referred at least 12 months prior to commencement of dialysis., Methods: At each of the three Toronto centers, charts of consecutive incident RRT patients were identified from 1 January 2009 to 31 December 2010, with predetermined data extracted., Results: A total of 436 incident RRT patients were studied; 52.4% were followed by a nephrologist for >12 months prior to the initiation of dialysis. Suboptimal starts occurred in 56.4% of these patients. No attempt at arteriovenous fistula (AVF) or arteriovenous graft (AVG) prior to initiation was made in 65% of these starts. Factors contributing to suboptimal starts despite early referral included patient-related delays (31.25%), acute-on-chronic kidney disease (31.25%), surgical delays (16.41%), late decision-making (8.59%) and others (12.50%). The percentage of optimal starts with early referral among 14 nephrologists ranged from 33 to 72%., Conclusions: Most patients started dialysis in a suboptimal manner, despite an extended period of pre-dialysis care. Nephrologists should take responsibility for suboptimal initiation of dialysis despite early referral and test methods that attempt to prevent this.

Aims: More than 90% of cases of renovascular disease (RVD) are caused by atherosclerosis; thus patients with this condition are at high risk for vascular events. We examined the association of statins with prognosis in patients with RVD., Methods and Results: We performed a population-based cohort study in 4040 patients with RVD older than 65 years using province-wide health data in Ontario, Canada. The primary outcome was time to first cardiorenal event, specifically myocardial infarction, stroke, heart failure, acute renal failure, dialysis or death; the primary analysis used a time-dependent covariate for statin exposure. Despite having a greater burden of cardiovascular and renal comorbidity, the risk of the primary outcome was significantly lower in statin users than in non-users [unadjusted hazard ratio (HR) 0.51, 95% confidence interval (CI) 0.47-0.57; P < 0.0001]. This association was materially unchanged after adjusting for demographic characteristics, cardiovascular risk factors, other comorbidities, measures of health-care utilization, screening, and concomitant medications (adjusted HR 0.51, 95% CI 0.46-0.57). An analysis using the same endpoint in a propensity-matched cohort without time-dependent statin exposure revealed a lower risk of the primary outcome in statin-treated patients but with a substantially more conservative point estimate (HR 0.82, 95% CI 0.71-0.95)., Conclusion: These data suggest that statins are associated with improved prognosis in elderly patients with RVD.

Background: Achieving control of hypertension prevents target organ damage at both the micro and macrovascular level and is a highly cost effective means of lowering the risk for heart attack and stroke particularly in people with diabetes. Clinical trials demonstrate that blood pressure control can be achieved in a large proportion of people. Translating this knowledge into widespread practice is the focus of the Hypertension Management Initiative, which began in 2004 with the goal of improving the management of this chronic health condition by primary care providers and patients in the community., Methods: This study will test the effect of a systems change on the management of high blood pressure in real world practice in primary care in Ontario, Canada. The systems change intervention involves an interprofessional educational program bringing together physicians, nurses and pharmacists with tools for both providers and patients to facilitate blood pressure management. Each of two waves of subjects were enrolled over a 6 month period with the initial enrollment between waves separated by 9 months. Blood pressure will be measured with the BpTru automated blood pressure device. To determine the effectiveness of the intervention, a before and after analysis within all subjects will compare blood pressure at baseline to annual measurements for the three year study. To assess whether the intervention has an impact on blood pressure control independent of community trends, a betwen group comparison of baseline blood pressures in the delayed wave will be made with the immediate wave during the same time period, so that the immediate wave has experienced the intervention for at least 9 months. The total enrollment goal is 5,000 subjects. The practice locations include 10 Family Health Teams (FHTs) and 1 Community Health Centre (CHC) and approximately 49 primary care physicians, 15 nurse practitioners, 37 registered nurses and over 150 community pharmacists across the 11 communities throughout the province of Ontario. The 11 primary care sites will be divided into immediate and delayed groups based on geography and the use of an electronic versus a traditional chart patient record., Discussion: Initial consideration was given to randomizing the groups, however, for a number of reasons, this was deemed to not be possible. In order to ensure that the sites in the immediate intervention and delayed intervention groups are not different from each other, the sites will be assigned to the intervention groups manually to ensure a distribution of the variables as evenly as possible. Given that HSFO approached this particular group of health care providers to participate in a program relating to hypertension, this may have heightened their awareness of the issue and affected their management of patients with hypertension. Thus, data will be collected to allow an assessment of previous practice patterns and determine any impact of the Hawthorne Effect., Trial Registration: Clinicaltrials.gov NCT00425828.

Background: Psychosocial stressors such as job strain and marital stress have been associated with a sustained increase in blood pressure (BP)., Methods: We evaluated whether job strain and marital cohesion were associated with ambulatory BP in workers with normal or untreated elevated BP using baseline data from the Double Exposure study. The study population included 248 male and female volunteers who were nonmedicated, employed, and living with a significant other, all for a minimum of 6 months. Blood pressure was measured with an ambulatory BP monitor and participants completed a diary that recorded time during work, spousal contact, and sleep. Job strain and marital cohesion were calculated from the Job Content Questionnaire and the Dyadic Adjustment Scale, respectively., Results: Of the subjects, 54.4% were female with a mean age of 50.8 years (6.6, SD). In all, 21.3% reported job strain. Significant assocations were found between 24-h systolic BP (SBP) and alcohol consumption (P = .033), job strain (P = .007), male gender (P = .004), and age (P = .039) and was inversely associated with exercise (P = .037). An interaction between 24-h SBP, job strain, and marital cohesion was found such that greater marital cohesion was associated with lower SBP in subjects with job strain., Conclusions: Psychosocial factors may influence the development of early hypertension. This should be clarified by the cohort phase of the Double Exposure study.