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Background: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. Methods: We performed a retrospective serial cross‐sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population‐representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30‐day readmission rates, and time‐to‐surgery. Results: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30‐day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%–45%) and THA (0.2%–10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%–60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30‐day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). Conclusions: We observed substantial between‐country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence‐based surgical approaches. [ABSTRACT FROM AUTHOR]

The article discusses a study which investigated trends in and economic implications of the use of fibrates in the U.S. and Canada. The researchers also examined the relationship between differences in the availability and use of brand-name versus generic formulations of fenofibrate in both countries. The population-level, observational cohort study utilized IMS Health data from both countries between January 2002 and December 2009. It was found that there has been an increase in prescriptions for fibrates in the U.S., while prescriptions in Canada remained stable.

Background: Cardiac catheterization is substantially underused among higher-risk patients with acute myocardial infarction (AMI) with appropriate indications but overused among patients with inappropriate indications. We sought to determine the importance of anticipated benefit and anticipated harm on the use of cardiac catheterization among older patients with AMI.Methods and Results: We performed an analysis of Medicare fee-for-service beneficiaries hospitalized with an AMI between 1998 and 2001. Multivariate models were developed to determine relative importance of anticipated benefit (baseline cardiovascular risk), anticipated harm (bleeding risk, comorbidities), and demographic factors (age, sex, race, regional invasive intensity) in predicting cardiac catheterization use within 60 days of AMI admission. Analyses were stratified by American College of Cardiology/American Heart Association class I or II as appropriate, and class III as inappropriate. Determinants of reduced likelihood of cardiac catheterization among 42 241 AMI patients with appropriate indications included (in order of importance) older age (likelihood chi(2)=1309.5), higher bleeding risk score (likelihood chi(2)=471.2), more comorbidities (likelihood chi(2)=276.6), female sex (likelihood chi(2)=162.9), hospitalization in low (likelihood chi(2)=67.9) or intermediate intensity invasive regions (likelihood chi(2)=22.4) (all P<0.001), and baseline cardiovascular risk (likelihood chi(2)=6.4, P=0.01). Among 2398 AMI patients with inappropriate indications, significant determinants of greater procedure likelihood included younger age, male sex, lower bleeding risk score, and fewer comorbidities.Conclusions: Regardless of the procedure indication, the decision to perform cardiac catheterization in this population appears largely driven by demographic factors and potential harm rather than potential benefit of the procedure. [ABSTRACT FROM AUTHOR]

Background: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists. Methods: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality. Results: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia. Conclusions: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality. N Engl J Med 2010;362:1110-8. [ABSTRACT FROM AUTHOR]

Background: Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries., Methods: We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality., Results: Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI., Conclusions: We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies., Competing Interests: Disclosures None.

Background Despite improved outcomes associated with ticagrelor compared with clopidogrel in acute coronary syndrome (ACS), many studies have demonstrated slow adoption of ticagrelor in the United States because of its increased cost. Less is known about how ticagrelor is adopted when there is no added cost consideration. Our objectives were to determine patterns of use of ticagrelor, hospital-level adoption of ticagrelor use, and factors associated with its use after ACS in a publicly funded health care system. Methods and Results We conducted a population-based cohort study including patients (≥65 years) hospitalized with their first ACS from April 2014 to March 2018 in Ontario, Canada. We determined temporal trends in ticagrelor use and hospital-level adoption of its use post-ACS discharge. Using hierarchical regression models, we identified significant predictors of ticagrelor use. There were 23 962 patients with ACS (mean age 76.3 years, 59.7% men) hospitalized in 156 hospitals. Overall ticagrelor use increased from 32.6% in 2014/2015 to 51.8% in 2017/2018. There was substantial variation in ticagrelor use post-ACS across hospitals, with hospital-specific prescribing rates ranging from 0% to 83.6%. Lower odds of ticagrelor use was associated with advanced age and the presence of comorbidities. Besides patient factors, being admitted to a rurally located hospital more than halved the odds of being prescribed ticagrelor (odds ratio [OR], 0.49; 95% CI, 0.32-0.77). Being managed by a cardiologist during the index ACS hospitalization was associated with higher odds of having a ticagrelor prescription after ACS (OR, 2.80; 95% CI, 2.36-3.33). Conclusions Ticagrelor use rates varied substantially across hospitals and were strongly associated with physician and hospital factors independent of patient characteristics.

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions., Methods: In this retrospective cohort study, we followed adults aged 66-99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality)., Results: We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%)., Interpretation: Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI., Competing Interests: Competing interests: None declared., (Copyright 2020, Joule Inc. or its licensors.)

Background: In 2007, the American Heart Association recommended antibiotic prophylaxis for the prevention of infective endocarditis (IE) for only the highest-risk patients. Whether this change affected the use of antibiotic prophylaxis and the incidence of IE is unclear., Methods: IE-related hospitalizations were identified from 2002 to 2014 among all adults and those at high and moderate risk for IE, stratified by age. Prescriptions for antibiotic prophylaxis were obtained from the Ontario Drug Benefit database for adults ≥65 years of age. Outcomes were antibiotic prophylaxis prescription rates and incidence of IE-related hospitalization. Trends in patient and pathogen characteristics were analyzed. Time series analyses were performed with segmented regression and change-point analyses., Results: Prescriptions for antibiotic prophylaxis decreased substantially in the moderate-risk cohort after the guideline revision (mean quarterly prescriptions, 30 680 versus 17 954 [level change, -6,481; P=0.0004] per 1 million population) with a minimal, yet significant, decrease followed by a slow increase in the high-risk group. There were 7551 IE-related hospitalizations among 6884 adults ≥18 years of age. Among adults ≥65 years of age, the mean IE rate increased from 872 to 1385 and 229 to 283 per 1 million population at risk per quarter in the high- and moderate-risk groups, respectively. Change-point analyses indicated that this increase occurred in the second half of 2010 in adults ≥65 years of age, 3 years after the American Heart Association guideline revision. Staphylococcus aureus and streptococcal species accounted for 30.3% and 26.4% of all IE, with a decrease in streptococcal infections over time., Conclusions: Antibiotic prophylaxis decreased significantly in the moderate-risk group with minimal change in the high-risk group after the American Heart Association guideline revision in 2007. However, IE-related hospitalizations increased among both high- and moderate-risk patients 3 years after the revision. Our study provides support for the cessation of antibiotic prophylaxis in the moderate-risk population.

Background: We previously found that the use of ezetimibe increased rapidly with different patterns between the United States (US) and Canada prior to the landmark Ezetimibe and Simvastatin in Hypercholesterolemia Enhance Atherosclerosis Regression (ENHANCE) trial, which was reported in January 2008, and failed to show that the drug slowed the progression of atherosclerosis. What is not known is how practice in the 2 countries changed after the ENHANCE trial. We examined ezetimibe use trends in the US and Canada before and after the reporting of the ENHANCE trial., Methods: We conducted a population-based, retrospective, time-series analysis using the data collected by IMS Health in the US and CompuScript in Canada from January 1, 2002, to December 31, 2009. The main outcome measure was monthly number of prescriptions for ezetimibe-containing products., Results: The monthly number of ezetimibe prescriptions/100,000 population rose from 6 to 1,082 in the US from November 2002 to January 2008, then significantly declined to 572/100,000 population by December 2009 after the release of the ENHANCE trial, a decrease of 47.1% (P < .001). In contrast, in Canada, use continuously rose from 2 to 495/100,000 population from June 2003 to December 2009 (P = .2). United States expenditures totaled $2.24 billion in 2009., Conclusions: Ezetimibe remains commonly used in both the US and Canada. Ezetimibe use has decreased in the US post-ENHANCE, whereas use has gradually but steadily increased in Canada. The diverging patterns of ezetimibe use in the US and Canada require further investigation, as they reveal that a common evidence base is eliciting very different utilization patterns in neighboring countries., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: Ethnic minority groups in the United States are at increased risk of developing cardiovascular diseases, experiencing adverse outcomes, and receiving suboptimal treatment. Such discrepancies may be related to a difference in race-specific outcomes in the management of cardiovascular diseases. However, little is known about the reporting and representation of ethnic minorities in major cardiovascular trials., Methods: A systematic review of major cardiovascular randomized controlled trials published in The Journal of the American Medical Association, The Lancet, and The New England Journal of Medicine between 1997 and 2010 was performed. We determined the reporting rate of the following ethnic minority groups in studies that enrolled American patients: whites, African Americans, Asians, and Hispanics., Results: A total of 250 randomized controlled trials that enrolled 1,103,694 patients were included in the systematic review. Among them, 56% (n = 140) of the trials reported information on race. No significant temporal changes in racial reporting were observed during the study period (P = .21). The median enrollment rate in trials for whites, African Americans, Hispanics, and Asians was 86%, 7%, 6%, and 4%, respectively. When compared with the population prevalence of disease burden, we found that whites were overrepresented (88% vs 78%, P < .001), whereas African Americans were underrepresented (3% vs 11%, P < .001), in trials of coronary artery disease., Conclusions: Despite significant changes in the ethnic composition of the United States, we found that only about half of all major cardiovascular trials reported any racial information. Underrepresentation of ethnic minority groups in cardiovascular trials was observed., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Ezetimibe lowers low-density lipoprotein cholesterol, but current lipid-lowering guidelines in the United States and Canada do not recommend it as a first option for either primary or secondary prevention. We sought to describe the adoption of ezetimibe relative to that of other lipid-lowering agents and compare its use in the two countries., Methods: We conducted a population-level, cohort study using data from January 2002 to December 2006, provided by IMS Health, to describe prescribing practices and expenditures for lipid-lowering agents and ezetimibe in the United States and Canada., Results: From 2002 to 2006, the monthly number of prescriptions for lipid-lowering agents rose from 3719 to 7401 per 100,000 population in Canada and from 3927 to 6827 per 100,000 population in the United States. Of these prescriptions, the proportion for ezetimibe rose from 0.2% in 2003 to 3.4% in 2006 in Canada and from 0.1% in 2002 to 15.2% in 2006 in the United States. Statin use was relatively constant between 2002 and 2006 in Canada, whereas the proportion of statin prescriptions decreased from 86.5 to 80.8% in the United States. In 2006, the ratio of prescriptions for statins to those for ezetimibe was 26:1 in Canada and 5:1 in the United States. In 2006, expenditures for ezetimibe per 100,000 population were higher in the United States than in Canada by a factor of more than 4., Conclusions: Distinct patterns of use of ezetimibe emerged in the United States and Canada from 2002 to 2006, a difference that markedly altered the approach to the treatment of hyperlipidemia in the United States. The U.S. pattern increased overall costs, but the effect on clinical outcomes is uncertain., (Copyright 2008 Massachusetts Medical Society.)

Objectives: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions., Background: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S., Methods: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission., Results: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions., Conclusions: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients' appropriateness or their baseline risks.

Background: Previous comparisons of acute myocardial infarction (AMI) treatment between the United States and Canada are limited because they compared selected patients from randomized trials, used administrative data that lacked clinical detail, or did not consider regional differences in AMI treatment., Methods and Results: We compared medication use, invasive cardiac procedure use, and 30-day risk-standardized mortality rates of 38,886 fee-for-service Medicare beneficiaries hospitalized with AMI in the United States and 5634 similarly aged patients in Ontario, Canada, from 1998 and 2001. Baseline characteristics and illness severity across the US regions and Ontario were not substantially different. Cardiac catheterization use in AMI patients was significantly higher in the United States compared with Ontario (38.7% versus 16.8%, P<0.001), but significant regional variations existed, in which the northeastern United States had significantly lower utilization rates (25.6%) compared with other US regions. Beta-blocker use among ideal candidates was highest in the northeastern United States (77.6% versus 69.7% in the United States as a whole, P<0.001) and angiotensin-converting enzyme inhibitor use was highest in Ontario (69.1% versus 58.2% in the United States, P<0.001). Risk-standardized mortality rates at 30 days were not substantially different across the regions., Conclusions: Previous studies have suggested a clear divergence in invasive cardiac therapy for AMI patients between the United States and Canada on the basis of health care financing and structural differences. Our findings of similar treatment patterns in the northeastern United States and Ontario suggest that regional practices may have a greater impact on treatment patterns than the respective health care delivery systems.

Background: Although statins reduce the risk of cardiovascular events, concerns about adverse effects may deter physicians from prescribing these agents. We performed a systematic overview of randomized statin trials to quantify the risks of musculoskeletal, renal, and hepatic complications associated with therapy., Methods and Results: Major statin trials were identified by electronic search of the MEDLINE database from 1966 to December 2005. We included English language reports of adults with documented hyperlipidemia; double-blind, random allocation of > or = 100 patients to statin monotherapy versus placebo; and reports of myalgia, creatine kinase elevations, rhabdomyolysis, transaminase elevations, and discontinuation due to adverse events. Among 74,102 subjects enrolled in 35 trials (follow-up range, 1 to 65 months), statin therapy (excluding cerivastatin) did not result in significant absolute increases in risks of myalgias (risk difference/1000 patients [RD], 2.7; 95% CI, -3.2 to 8.7), creatine kinase elevations (RD, 0.2; 95% CI, -0.6 to 0.9), rhabdomyolysis (RD, 0.4; 95% CI, -0.1 to 0.9), or discontinuation due to any adverse event (RD, -0.5; 95% CI, -4.3 to 3.3). The absolute risk of transaminase elevations was significantly higher with statin therapy (RD, 4.2; 95% CI, 1.5 to 6.9)., Conclusions: On the basis of data available from published clinical trials, statin therapy is associated with a small excess risk of transaminase elevations, but not of myalgias, creatine kinase elevations, rhabdomyolysis, or withdrawal of therapy compared with placebo. Further study is necessary to determine whether the results from these published clinical trials are similar to what occurs in routine practice, particularly among patients who are older, have more severe comorbid conditions, or receive higher statin doses than most patients in these clinical trials.

Background: Health care expenditure per person is significantly higher in the United States compared with Canada, but whether there are differences in quality of care of many conditions is unknown. We compared the process of care and outcomes of patients with heart failure, the most common cause of hospitalization for individuals 65 years and older in both countries., Methods: We compared processes of care and 30-day and 1-year risk-standardized mortality rates among 28,521 US Medicare beneficiaries and 8180 similarly aged patients in Ontario, Canada, hospitalized with heart failure from 1998 to 2001., Results: More US patients underwent left ventricular ejection fraction assessment during hospitalization compared with Canadian patients (61.2% vs 41.7%, P<.001). At discharge, patients in the United States were prescribed beta-blockers more frequently (28.7% vs 25.4%, P<.001) but angiotensin-converting enzyme inhibitors less frequently (54.3% vs 63.4%, P<.001). Among ideal candidates, prescription of beta-blockers (32.5% vs 29.7%, P = .08) or angiotensin-converting enzyme inhibitors (78.3% vs 77.6%, P = .68) was not significantly different between the 2 countries. The US patients had lower risk characteristics on admission and lower crude mortality rates at 30 days and 1 year. Thirty-day risk-standardized mortality was significantly lower for the US patients (8.9% vs 10.7%, P<.001), but 1-year risk-standardized mortality was no longer significantly different (32.2% vs 32.3%, P = .98)., Conclusion: Patients with heart failure who are hospitalized in the United States had lower short-term mortality at 30 days, but 1-year mortality rates were not significantly different between the United States and Canada.