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Background Droplet+contact (DC) precautions are used to prevent the spread of acute respiratory infections. Clinicians at London Health Sciences Centre, an academic tertiary care organization in Ontario, Canada, have reported that many patients remain isolated longer than necessary. Research suggests that prolonged isolation may negatively impact patient outcomes, experience, and costs. Objectives Reduce unnecessary DC precautions on general medicine units by 30% by March 31, 2020. Methods Our multi-disciplinary team designed this project using the Model for Improvement. We identified barriers to precaution removal through surveys, chart reviews, process mapping (figure 1), and fishbone diagramming (figure 2). Our change drivers focussed on motivation, precaution identification, reassessment cues, and standardized decision-making (figure 3). In a series of PDSA cycles, we tested and implemented new discontinuation criteria and a decision-support tool across two hospitals (figure 4). Outcomes measures were: (1) % unnecessary DC precautions, collected by weekly physician audits, and (2) DC precautions lasting >5 days, collected from electronic medical records. Our process measures were: (1) user test fidelity, and (2) physician awareness. Our balance measure was physician satisfaction with new criteria. Statistical analysis was performed using Student’s t-test, run charts, and process control charts (QI Macros, IHI Rules). Results We completed eight appropriateness audits (n=212 patients) at two hospitals between December 2019 – March 2020. During user testing, eight physicians applied the new criteria and decision-support tool to five mock cases at 92% (37/40) fidelity. After implementing changes, mean precaution appropriateness increased from 30% (24/80) to 64% (85/132), (p 5 days. Conclusions Discontinuing prolonged DC precautions is important to conserve vital resources, especially during the COVID-19 pandemic. We reduced these incidents by implementing standard discontinuation criteria and a decision support tool. Our next step is to adapt these tools to standardize precaution removal for COVID-19 patients.

Background Nursing home (NH) residents are frequent users of emergency departments (ED) and while prior research suggests that repeat visits are common, there is little data describing this phenomenon. Our objectives were to describe repeat ED visits over one year, identify risk factors for repeat use, and characterize “frequent” ED visitors. Methods Using provincial administrative data from Ontario, Canada, we identified all NH residents 65 years or older who visited an ED at least once between January 1 and March 31, 2010 and then followed them for one year to capture all additional ED visits. Frequent ED visitors were defined as those who had 3 or more repeat ED visits. We used logistic regression to estimate risk factors for any repeat ED visit and for being a frequent visitor and Andersen-Gill regression to estimate risk factors for the rate of repeat ED visits. Results In a cohort of 25,653 residents (mean age 84.5 (SD = 7.5) years, 68.2% female), 48.8% had at least one repeat ED visit. Residents who experienced a repeat ED visit were generally similar to others but they tended to be slightly younger, have a higher proportion male, and a higher proportion with minimal cognitive or physical impairment. Risk factors for a repeat ED visit included: being male (adjusted odds ratio 1.27, (95% confidence interval 1.19–1.36)), diagnoses such as diabetes (AOR 1.28 (1.19–1.37)) and congestive heart failure (1.26 (1.16–1.37)), while severe cognitive impairment (AOR 0.92 (0.84–0.99)) and 5 or more chronic conditions (AOR 0.82 (0.71–0.95)) appeared protective. Eleven percent of residents were identified as frequent ED visitors, and they were more often younger then 75 years, male, and less likely to have Alzheimer’s disease or other dementias than non-frequent visitors. Conclusions Repeat ED visits were common among NH residents but a relatively small group accounted for the largest number of visits. Although there were few clear defining characteristics, our findings suggest that medically complex residents and younger residents without cognitive impairments are at risk for such outcomes. Electronic supplementary material The online version of this article (10.1186/s12877-018-0854-8) contains supplementary material, which is available to authorized users.

Background Nursing home (NH) residents are frequently transferred to the emergency department (ED) but there is little data on inter-facility variation, which has implications for intervention planning and implementation. Objectives To describe variation in ED transfer rates (TRs) across NHs and the association with NH characteristics. Design/setting Retrospective cohort study using linked administrative data from Ontario. Participants 71,780 residents of 604 NHs in 2010 and followed for one year. Measurements Funnel plots were used to identify high transfer NHs and logistic regression to test the association with NH location, size, ownership and historical ED transfer rate. Results One-year ED transfer rates ranged from 4.3% to 58.6% (mean 28.4%); 115 (19%) NHs were considered high. Being within five minutes of an ED, larger size and high historical ED transfer rate were associated with being a high ED transfer home. Conclusion There was substantial variation across NHs. Consideration of characteristics such as proximity to an ED may be important in the development and targeting of different interventions for NHs.

Objective To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics. Research Design and Methods Observational, population-based cohort study of youth with type 1 diabetes (

The study evaluated the association between physician follow-up within 30 days after hospital discharge and psychiatric readmission within the subsequent 180 days.Among inpatients with schizophrenia who were discharged between 2007 and 2012 in Ontario (N=19,132), those who had a 30-day follow-up visit with a primary care physician (PCP) only, a psychiatrist only, or both were compared with a no-follow-up group. The primary outcome was psychiatric readmission in the subsequent 180 days. Secondary analyses stratified the sample on the basis of readmission risk at discharge.About 65% of patients had follow-up care within 30 days postdischarge. Psychiatric readmission rates were similar among patients with any physician follow-up and significantly lower than among those with no follow-up (26%): PCP only: 22%; adjusted hazard ratio [aHR]=.88, 95% confidence interval [CI]=.81-.96; psychiatrist only, 22%; aHR=.84, CI=.77-.90; both, 21%, aHR=.82, CI=.75-.90). In stratified analyses, 66% of patients were in the category at highest risk of psychiatric readmission, and the effect of follow-up with any physician was significant for these patients, compared with high-readmission risk patients with no follow-up, who had a 29% readmission rate (PCP only, 20% readmission rate, aHR=.85, CI=.77-.94; psychiatrist only, 29%, aHR=.84, CI=.77-.92; both, 17%, aHR=.81, CI=.73-.90).Timely physician follow-up was associated with reduced risk of psychiatric readmissions, with the greatest reduction among patients at high risk of readmission. Because more than one-third of patients had no physician visit within 30 days postdischarge, improving physician follow-up may help reduce psychiatric readmission rates.

Objective More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia. Design Retrospective cohort study. Setting Population based in Ontario, Canada, from 2002 to 2011. Population Ontario women aged 15–49 years who gave birth to a liveborn or stillborn singleton infant. Methods Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy. Main outcome measures The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators. Results Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28–2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04–2.85), preterm birth (aOR 1.75, 95% CI 1.46–2.08), SGA (aOR 1.49, 95% CI 1.19–1.86), and LGA (aOR 1.53, 95% CI 1.17–1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity. Conclusions Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

Objective To describe adverse events in pediatric insulin pump users since universal funding in Ontario and to explore the role of socioeconomic status and 24-hour support. Research design and methods Population-based cohort study of youth (

Inhaled, long-acting anticholinergic medication (LAA), commonly used for moderate-to-severe chronic obstructive pulmonary disease (COPD), has been shown to decrease COPD hospitalizations, emergency department visits, and acute exacerbations but has also been associated with urinary tract infection (UTI) in a prior meta-analysis. The objective of this study was to verify if there was an association between LAA and UTI in older individuals with COPD. A population-based, real-world cohort study using health administrative data from Ontario, Canada was conducted. Incidence of UTI was compared between older people with physician-diagnosed COPD, who were new users of inhaled long-acting anticholinergics and new users of inhaled corticosteroids–a reference medication used in similar clinical settings that has no known association with UTI. Propensity score matching was used to minimize the effects of confounding. An overall association between LAA and various measures of UTI in older individuals was not found. However, in a priori defined stratified analyses, men newly initiated on LAA were 75% more likely to develop a UTI than men newly started on an inhaled corticosteroid (hazard ratio 1.75; 95% confidence interval 1.05–2.92). No significant association was seen in women. In conclusion, older men with COPD newly started on LAA are at increased risk of UTI. Men considering an inhaled LAA should be informed of this risk and, if they decide to take it, be provided with appropriate monitoring.

Objective: As the numbers of older adults in Canada increases, there will be a growing need for mental health services for this population. Acute psychiatric units (APUs) provide inpatient psychiatric services for the management of serious mental illness. Understanding the characteristics of older adults in APUs is necessary to determine the range of inpatient services required for this population. Method: We conducted a population-based study of all adults discharged from APUs in Ontario in a 2-year period, 2008-2010, using administrative databases. We compared the characteristics of older adults (aged 66 years and older) in APUs to those of younger adults (aged 18 to 65 years), including sociodemographics, psychiatric and medical diagnoses, and measures of cognition and functioning. Results: There were a total of 79 352 discharges from APUs, with older adults accounting for 8.8% of all discharges. Depressive disorder was the most common diagnosis, both in older and in younger populations (32.1% and 29.9%, respectively), while dementia accounted for 19.5% of discharges for older adults. Older adults, compared with younger adults, were more likely to have 2 or more chronic medical conditions (83.8% and 20.5%, respectively), significant cognitive impairment (47.0% and 14.5%, respectively), and moderate-to-severe functional impairment (21.8% and 3.3%, respectively). Conclusions: Older adults in APUs are a complex group, with mental health and medical care needs that differ from younger adults. APUs must be able to provide adequate psychiatric, medical, and interprofessional services to achieve optimal outcomes. Future studies are required to understand the quality of care and outcomes for older adults in APUs. Objectif : Comme le nombre d'adultes âges augmente au Canada, il y aura un besoin croissant de services de sante mentale pour cette population. Les unites de soins psychiatriques actifs (USPA) offrent des services psychiatriques a des patients hospitalises pour la prise en charge de maladies mentales graves. Il est necessaire de comprendre les caracteristiques des adultes âges afin de determiner la gamme des services aux patients hospitalises requis pour cette population. Key Words: geriatric, elderly, hospitalization, inpatient, health service utilization, mental health Methode : Nous avons mene une etude dans la population de tous les adultes ayant eu leur conge d'une USPA en Ontario dans une periode de 2 ans, de 2008 a 2010, a l'aide des bases de donnees administratives. Nous avons compare les caracteristiques des adultes âges (de 66 ans et plus) dans des USPA avec celles d'adultes plus jeunes (de 18 a 65 ans), y compris les donnees sociodemographiques, les diagnostics psychiatriques et medicaux, et des mesures de la cognition et du fonctionnement. Resultats : Il y avait un total de 79 352 conges des USPA, les adultes âges representant 8,8 % de tous les conges. Le trouble depressif etait le diagnostic le plus commun, tant chez les populations âgees que chez les plus jeunes (32,1 % et 29,9 %, respectivement), tandis que la demence representait 19,5 % des conges des adultes âges. Les adultes âges, compares aux adultes plus jeunes, etaient plus susceptibles d'avoir 2 affections medicales chroniques ou plus (83,8 % et 20,5 %, respectivement), une deficience cognitive significative (47,0 % et 14,5 %, respectivement), et une incapacite fonctionnelle de moderee a grave (21 ,8 % et 3,3 %, respectivement). Conclusions : Les adultes âges dans les USPA sont un groupe complexe, dont les besoins de soins de sante mentale et medicaux different de ceux des adultes plus jeunes. Les USPA doivent etre en mesure de dispenser des services psychiatriques, medicaux et interprofessionnels adequats pour atteindre des resultats optimaux. Il faut plus d'etudes pour comprendre la qualite des soins et les resultats pour les adultes âges dans les USPA. Abbreviations AD antidepressant ADL activity of daily living APU acute psychiatric unit BD bipolar disorder BDZ benzodiazepine CIHI-DAD Canadian Institutes of Health Information - Discharge Abstract Database CIHI-NACRS Canadian Institutes of Health InformationNational Ambulatory Care Reporting System CPS Cognitive Performance Scale DSM Diagnostic and Statistical Manual of Mental Disorders GAF Global Assessment of Functioning ICES Institute for Clinical Evaluative Sciences LOS length of stay MHCC Mental Health Commission of Canada MMSE mini mental status examination ODB Ontario Drug Benefits OHIP Ontario Health Insurance Program OMHRS Ontario Mental Health Reporting System RAI-M H Resident Assessment I nstrumentMental Health RPDB Registered Persons Database Adults aged 66 years and older comprise 12% to 14% of the Canadian population,1·2 and this group is projected to double in the next 25 years. …

Acute angle-closure glaucoma (AACG) is an ocular emergency that may be precipitated by certain types of medications. Antidepressant drugs can affect a number of neurotransmitters, which are involved in the regulation of the iris, which may precipitate AACG. We used a case-crossover study design to investigate the association between recent exposure to antidepressant drugs and AACG. We identified patients with AACG among adults aged 66 years or older between 1998 and 2010 in Ontario using linked population-based administrative databases. We identified intermittent users of antidepressant medications through prescription drug claims in the year preceding AACG. We determined antidepressant exposure in the period immediately before AACG and compared it with antidepressant exposure in 2 earlier control periods. We used conditional logistic regression to determine the odds ratio for antidepressant exposure in the hazard period compared with the control periods. A total of 6470 patients with AACG occurred during the study period. The mean age of the patients was 74.3 years, and 66% were female. Overall, 5.6% of individuals were intermittent users of antidepressant drugs in the year preceding AACG. The odds ratio for any antidepressant exposure in the period immediately preceding AACG was 1.62 (95% confidence interval, 1.16-2.26). An increased risk of AACG was also observed in several subgroups. We conclude that recent exposure to antidepressant drugs is associated with an increased risk of AACG. Clinicians should remain vigilant for the development of this uncommon but potentially serious adverse event after initiating antidepressant therapy.

Administrative health care databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions and exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. There is a paucity of validated methods to ascertain comorbidities for risk-adjustment in ambulatory populations of subjects with schizophrenia using administrative health care databases. Our objective was to examine the ability of th\e Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict 1-year mortality in a population-based cohort of subjects with schizophrenia. We used a retrospective cohort constructed using population-based administrative data that consisted of all 94,466 residents of Ontario, Canada between the ages of 20 and 100 years who were alive on January 1, 2007 and who had been diagnosed with schizophrenia prior to this date. Subjects were randomly divided into derivation and validation samples. A logistic regression model consisting of age, sex, and indicator variables for 14 of the 32 ADG categories had excellent discrimination: the c-statistic (equivalent to the area under the ROC curve) was 0.845 and 0.836 in the derivation and validation samples, respectively. Furthermore, the model demonstrated very good calibration.

Evaluation and optimization of antibiotic use (antibiotic stewardship) is being increasingly promoted as a means to reduce antibiotic resistance, adverse events, treatment complications and costs within institutions. Our goal was to examine the prevalence of antibiotic use among long-term care facility residents and the extent of variability across these institutions.We conducted a population-based, point-prevalence study of antibiotic use among elderly individuals (n = 37,371) residing in long-term care facilities (n = 363 institutions) in Ontario between April and June 2009, using linked healthcare databases from Canada's largest province. Facilities were grouped into quintiles according to their mean antibiotic dispensing rates and variation was compared across quintiles.There were 2190 (5.9%) long-term care residents receiving antibiotic prescriptions on the study date. The three most prevalent antibiotics were agents most commonly used for the treatment of urinary tract infections, including nitrofurantoin (365, 15.4%), trimethoprim/sulfamethoxazole (338, 14.3%) and ciprofloxacin (304, 12.8%). The majority of treatment courses were at least 10 days in duration (1482, 62.6%), and many exceeded 90 days (495, 20.9%), suggesting chronic prophylaxis. There was substantial variability in antibiotic use across facilities, with a 5-fold variation from the highest-use quintile (10.8%) to the lowest-use quintile (2.2%). This variation persisted after adjustment for multiple facility-level and resident-level factors, including demographic characteristics, healthcare utilization statistics, co-morbidity prevalence, functional status and device dependence.Antibiotic use is common among long-term care residents, variable across institutions, and may benefit from focused antimicrobial stewardship interventions to standardize treatment indications and duration.

ObjectiveWe sought to examine the short-term and long-term impacts of psychiatric hospitalisations among patients of Chinese and South Asian origin.DesignRetrospective population-based cohort study using linked health administrative data.SettingWe examined all adult psychiatric inpatients discharged between 1 April 2006 and 31 March 2014 in Ontario, Canada, who were classified as Chinese, South Asian and all other ethnicities (ie, ‘general population’) using a validated algorithm. We identified 2552 Chinese, 2439 South Asian and 127 142 general population patients.Primary and secondary outcome measuresWe examined psychiatric severity measures at admission and discharge and performed multivariable logistic regression analyses to examine 30-day, 180-day and 365-day postdischarge service utilisation and outcomes, comparing each of the ethnic groups with the reference population, after adjustment for age, sex, income, education, marital status, immigration status, community size and discharge diagnosis.ResultsDespite presenting to hospital with greater illness severity, Asian psychiatric inpatients had shorter lengths of hospital stay and greater absolute improvements in mental health and functional status at discharge compared with other inpatients. After hospitalisation, Chinese patients were more likely to visit psychiatrists and South Asian patients were more likely to seek mental healthcare from general practitioners. They were also less likely to have a psychiatric readmission or die 1 year following hospitalisation (adjusted ORChinese=0.87; 95% CI 0.79 to 0.97; adjusted ORSouth Asian=0.82, 95% CI 0.73 to 0.91). Findings were consistent across genders, psychiatric diagnoses and immigrant groups.ConclusionOnce hospitalised, patients of Chinese and South Asian origin fared as well as or better than general population patients at discharge and following discharge, and had a positive trajectory of psychiatric service utilisation.

BACKGROUND Drug-reimbursement policies may have an adverse effect on patient outcomes if they interfere with timely access to efficacious medications for acute medical conditions. Clopidogrel in combination with aspirin is the recommended standard of care for patients receiving coronary stents to prevent thrombosis. We examined the population-level effect of a change by a Canadian provincial government in a pharmacy-benefits program from a prior-authorization policy to a less restrictive, limited-use policy on access to clopidogrel among patients undergoing percutaneous coronary intervention (PCI) with stenting after acute myocardial infarction. METHODS We conducted a population-based, retrospective, time-series analysis from April 1, 2000, to March 31, 2005, of all patients 65 years of age or older with acute myocardial infarction who underwent PCI with stenting in Ontario, Canada. The primary outcome was the composite rate of death, recurrent acute myocardial infarction, PCI, and coronary-artery bypass grafting at 1 year, with adjustment for sex and age. The secondary outcome was major bleeding. RESULTS The rate of clopidogrel use within 30 days after hospital discharge following myocardial infarction increased from 35% in the prior-authorization period to 88% in the limited-use period. The median time to the first dispensing of a clopidogrel prescription decreased from 9 days in the first period to 0 days in the second period. The 1-year composite cardiovascular outcome significantly decreased from 15% in the prior-authorization group to 11% in the limited-use group (P=0.02). Rates of bleeding in the two groups did not change. CONCLUSIONS The removal of a prior-authorization program led to improvement in timely access to clopidogrel for coronary stenting and improved cardiovascular outcomes.

Heart failure (HF) with preserved systolic function (ejection fraction [EF]50%) is common, yet no proven therapies exist. Large registries could shed light on what medications may or may not be useful to reduce hospitalization and mortality. The EFFECT Registry, which prospectively enrolled 9,943 patients admitted to the hospital for HF from 1999 to 2001 in 103 hospitals in Ontario, Canada, was used. Patients discharged alive were divided into those with EF50% and EF50%. Discharge medications (angiotensin-converting enzyme [ACE] inhibitors, beta blockers [BBs], spironolactone, and digoxin) were examined for their association with HF rehospitalization or death during 1 year. In the HF group with EF50% (n = 1,026), 199 patients died within 1 year and 349 patients died or were hospitalized for HF within 1 year. In the HF group with EF50% (n = 1,898), 427 patients died and 720 patients died or were hospitalized for HF. In the HF group with EF50%, 67% were administered an ACE inhibitor; 32%, a BB; 37%, digoxin; and 12%, spironolactone. No differences were seen in adjusted survival for any medications (ACE inhibitors, BBs, digoxin, or spironolactone) examined in the HF group with EF50% despite an adjusted survival benefit with ACE inhibitors (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.77 to 0.94), BBs (HR 0.80, 95% CI 0.72 to 0.89), and spironolactone (HR 0.80, 95% CI 0.66 to 0.98) in patients with low EF. In conclusion, none of the medications proved to improve outcomes in patients with HF with low EF showed an association with outcomes in patients with HF and EF50%, highlighting the need for randomized trial evidence to define therapies that will be beneficial in patients with HF and preserved systolic function.

To determine if elevations of adhesion molecules in acute coronary syndrome (ACS) are useful for risk stratification.A cell adhesion array (Randox Ltd.) and NT-proBNP were measured in 216 ACS patients.Kaplan-Meier and Cox models indicate early elevations of NT-proBNP but not the adhesion molecules are predictive of future death/myocardial infarction.Elevations of adhesion molecules early after pain onset in ACS are not useful for long-term risk stratification.

Background While health service use appears to be positively correlated with resource availability, no study has explored the interactions among health service supply, cardiovascular disease burden and health service use. The objective of the present study was to examine the relationship among cardiovascular evaluation and management intensity, physician supply and cardiovascular disease burden in the Canadian population. Methods The present cross-sectional, population-based study consisted of adult residents in Ontario in 2001. Cardiac evaluation and management intensity, the main outcome measure, was measured at the individual level, and consisted of receiving one or more of the following services: noninvasive cardiac testing, coronary angiography and statin use (the latter among individuals 65 years of age and older). Mortality was the secondary outcome measure. Cardiovascular disease burden, and cardiologist and primary care physician supply were measured at the regional (ie, county) level. Analyses were adjusted for age and sex using Poisson regression, accounting for regional clustering. Results Regional per capita cardiologist supply varied more than twofold across regions, but was inversely related to the regional cardiovascular disease burden (r=−0.34, P=0.01). Primary care physician supply was relatively evenly distributed across regions. Residents in areas with more cardiologists were more likely to receive some form of cardiac intervention (RR=1.074, 95% CI 1.066 to 1.082 per additional cardiologist per 100,000). Those in areas with more primary care physicians were also more likely to receive noninvasive cardiac testing (RR=1.056, 95% CI 1.051 to 1.061 per six additional primary care physicians per 100,000). However, the intensity of provision of cardiac health services was unrelated to regional cardiovascular disease burden and was not associated with improved survival. Conclusions The mismatch between physician supply and cardiac disease burden may explain why cardiovascular health service use is neither concordant with the cardiovascular disease burden nor associated with mortality in the population. These results underscore the importance of physician service maldistribution and supply-sensitive care on the appropriateness of cardiac health service use.

Background: Inflammation in acute coronary syndrome (ACS) can identify those at greater long-term risks for heart failure (HF) and death. The present study assessed the performance of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1) (cytokines involved in the activation and recruitment of leukocytes) in addition to known biomarkers [e.g., N-terminal pro-brain natriuretic peptide (NT-proBNP)] for predicting HF and death in an ACS population. Methods: In a cohort of 216 ACS patients, NT-proBNP (Elecsys®; Roche) and IL-6, IL-8, and MCP-1 (evidence investigator™; Randox) were measured in serial specimens collected early after symptom onset (n = 723). We collected at least 2 specimens from each participant: an early specimen (median 2 h; interquartile range 2–4 h) and a later specimen (9 h; 9–9 h), and used the later specimens’ biomarker concentrations for risk stratification. Results: An increase in both IL-6 and NT-proBNP was observed but not for IL-8 or MCP-1 early after pain onset. Kaplan–Meier analysis demonstrated that individuals with increased NT-proBNP (>183 ng/L) or cytokines (IL-6 > 6.4 ng/L; above upper limit of normal for IL-8 or MCP-1) had a greater probability of death or HF in the following 8 years (P Conclusion: IL-6, MCP-1, and NT-proBNP are independent predictors of long-term risk of death or HF, highlighting the importance of identifying leukocyte activation and recruitment in ACS patients.

Objectives: To assess the ability of C-reactive protein (CRP) to predict long-term outcomes in a chest pain population. Design and methods: CRP was measured at presentation in 446 emergency department patients with acute coronary syndromes. All-cause mortality and hospital discharges for acute myocardial infarction (AMI) and congestive heart failure (CHF) were obtained for up to 8 years following the event. Results: Kaplan–Meier analyses indicated that patients with CRP concentrations above the American Heart Association scientific statement cut-off had a higher rate for death and CHF admissions. After adjusting for troponin concentrations, in a Cox proportional hazard model, only CRP concentrations indicative of an acute phase response (i.e., > 7.44 mg/L) were associated with a significant risk for death after 5 years and CHF readmission after 2 years. Conclusions: Patients presenting early with chest pain with elevated CRP concentrations have a greater long-term risk for death and heart failure.

Background: Recent data suggest that older men with detectable cardiac troponin I (cTnI) concentrations that remain below the 99th percentile concentration cutoff are at increased risk for subsequent cardiovascular events. We designed this study to extend this observation by examining risk prediction in both men and women presenting to an emergency department with chest discomfort. Methods: We obtained data for all-cause mortality and hospital discharges associated with either acute myocardial infarction (AMI) or congestive heart failure (CHF) for up to 8 years after the initial presentation in 448 patients who originally presented in 1996 with acute coronary syndrome (ACS). We performed retrospective analysis for cTnI (AccuTnI™; Beckman Coulter) in frozen plasma samples based on the patients’ reported time from onset of symptoms. Peak cTnI concentration was used for risk assessment. Results: Patients with cTnI concentrations ≥0.02 μg/L (i.e., limit of detection), including those whose peak values remained below the 99th percentile (0.04 μg/L), were at greater risk for death and AMI/CHF readmissions at 2, 5, and 8 years of follow-up compared with those with peak cTnI Conclusion: Both men and women who present with possible ACS with detectable cTnI concentrations that remain below the 99th percentile are at a greater risk for future adverse events.

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 P P 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 The Thrombolysis In Myocardial Infarction (TIMI) risk index for the prediction of 30-day mortality was developed and validated in patients with ST-segment elevation myocardial infarction (STEMI) who were being treated with thrombolytics in randomized clinical trials. When tested in clinical registries of patients with STEMI, the index performed poorly in an older (65 years and older) Medicare population, but it was a good predictor of early death among the more representative population on the National Registry of Myocardial Infarction-3 and -4 databases. It has not been tested in a population outside the United States or among non-STEMI patients. Methods The TIMI risk index was applied to the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study cohort of 11,510 acute MI patients from Ontario. The model's discriminatory capacity and calibration were tested in all patients and in subgroups determined by age, sex, diagnosis and reperfusion status. Results The TIMI risk index was strongly associated with 30-day mortality for both STEMI and non-STEMI patients. The C statistic was 0.82 for STEMI and 0.80 for non-STEMI patients, with overlapping 95% CI. The discriminatory capacity was somewhat lower for patients older than 65 years of age (0.74). The model was well calibrated. Conclusions The TIMI risk index is a simple, valid and moderately accurate tool for the stratification of risk for early death in STEMI and non-STEMI patients in the community setting. Its routine clinical use is warranted.

To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics.Observational, population-based cohort study of youth with type 1 diabetes (19 yr) who received pump funding from 2006 to 2013 (n = 3700). We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. We tested the relationship between center-level pump uptake and center characteristics (center type, physician model, and availability of 24-h support) using an adjusted negative binomial model; we studied center- and patient-level factors (socioeconomic status and baseline glycemic control) associated with discontinuation using a Cox proportional hazards model with generalized estimating equations.Pump users were more likely to be in the highest income quintile than non-pump users (29.6 vs. 19.1%, p0.0001). In 2012, mean percent pump use was 38.0% with variability across centers. There was no association between uptake and center characteristics. Discontinuation was low (0.42/100 person-yr) and was associated with being followed at a small community center [hazard ratio (HR): 2.24 (1.05-4.76)] and being more deprived [HR: 2.36 (1.14-1.48)]. Older age was associated with a lower rate of discontinuation [HR: 0.31 (0.14-0.66)].Rates of pump use have increased since 2006 and discontinuation is rare. Large variation in uptake across centers was not explained by the factors we examined but may reflect variation in patient populations or practice patterns, and should be further explored.

To measure the health-related quality of life (HRQOL) and functional status of children with cardiomyopathy and to determine whether they are correlated with sociodemographics, cardiac status, and clinical outcomes.Parents of children in the Pediatric Cardiomyopathy Registry completed the Child Health Questionnaire (CHQ; age ≥ 5 years) and Functional Status II (Revised) (age ≤ 18 years) instruments. Linear and Cox regressions were used to examine hypothesized associations with HRQOL.The 355 children evaluated at ≥ 5 years (median 8.6 years) had lower functioning (CHQ Physical and Psychosocial Summary Scores 41.7 ± 14.4 and 47.8 ± 10.7) than that of healthy historical controls. The most extreme CHQ domain score, Parental Impact-Emotional, was one SD below normal. Younger age at diagnosis and smaller left ventricular end-diastolic dimension z score were associated independently with better physical functioning in children with dilated cardiomyopathy. Greater income/education correlated with better psychosocial functioning in children with hypertrophic and mixed/other types of cardiomyopathy. In the age ≥ 5 year cohort, lower scores on both instruments predicted earlier death/transplant and listing for transplant in children with dilated and mixed/other types of cardiomyopathy (P.001). Across all ages (n = 565), the Functional Status II (Revised) total score was 87.1 ± 16.4, and a lower score was associated with earlier death/transplant for all cardiomyopathies.HRQOL and functional status in children with cardiomyopathy is on average impaired relative to healthy children. These impairments are associated with older age at diagnosis, lower socioeconomic status, left ventricular size, and increased risk for death and transplant. Identification of families at risk for functional impairment allows for provision of specialized services early in the course of disease.ClinicalTrials.gov: NCT00005391.

OBJECTIVE: Little is known about the sociocultural determinants of mental illness at hospital presentation. Our objective was to examine ethnic differences in illness severity at hospital admission among Chinese, South Asian, and the general population living in Ontario, Canada. METHODS: We conducted a large, population-based, cross-sectional study of psychiatric inpatients aged from 19 to 105 years who were discharged between 2006 and 2014. A total of 133,588 patients were classified as Chinese (n = 2,582), South Asian (n = 2,452), or the reference group (n = 128,554) using a validated surnames algorithm (specificity: 99.7%). Diagnoses were based on DSM-IV criteria. We examined the association between ethnicity and 4 measures of disease severity: involuntary admissions, aggressive behaviors, and the number and frequency of positive symptoms (ie, hallucinations, command hallucinations, delusions, and abnormal thought process) (Positive Symptoms Scale, Resident Assessment Instrument-Mental Health [RAI-MH]). RESULTS: After adjusting for sociodemographic characteristics, immigration status, and discharge diagnosis, Chinese patients had greater odds of involuntary admissions (odds ratio [OR] = 1.79; 95% CI, 1.64-1.95) and exhibiting severe aggressive behaviors (OR = 1.36; 95% CI, 1.23-1.51) and ≥ 3 positive symptoms (OR = 1.39; 95% CI, 1.24-1.56) compared to the general population. South Asian ethnicity was also an independent predictor of most illness severity measures. The association between Chinese ethnicity and illness severity was consistent across sex, diagnostic and immigrant categories, and first-episode hospitalization. CONCLUSIONS: Chinese and South Asian ethnicities are independent predictors of illness severity at hospital presentation. Understanding the role of patient, family, and health system factors in determining the threshold for hospitalization is an important future step in informing culturally specific care for these large and growing populations worldwide.© Copyright 2016 Physicians Postgraduate Press, Inc. Language: en

Background— Critics remain skeptical about the long-term sustainability of Medicare in Canada because of the proliferation of health technology and escalating expenditures. The objective of this study was to examine the temporal trends in the utilization and costs of cardiovascular technologies for the evaluation and/or management of patients with ischemic heart disease in Canada. Methods and Results— This repeated cross-sectional population-based study of Ontario residents examined the temporal trends in the utilization and costs associated with echocardiography, stress (imaging and nonimaging) testing, coronary angiography, percutaneous coronary intervention (PCI), and bypass surgery between 1992 and 2001. Annual costs increased by nearly 2-fold over the 10-year study period and cumulatively accounted for more than $2.8 billion (Canadian) in expenditures. The proliferation in use of cardiac testing/interventions over time outstripped both demographic shifts and changes in the prevalence of coronary artery disease. Annual increases were widespread for all procedures ( P Conclusions— Although definitive conclusions about the appropriateness of temporal patterns cannot be ascertained, the proliferation of cardiac testing challenges the sustainability of Medicare in Canada, especially given uncertainty as to whether the accompanying incremental rise in total expenditures translates into significant outcome benefits in the population.

Clinical guidelines recommend lipid testing in all hospitalized acute myocardial infarction (AMI) patients. Inhospital lipid testing has also been proposed as a quality indicator for AMI care, but little is known about its use or importance. We sought to examine rates of inhospital lipid testing and its association with statin therapy at hospital discharge.We performed an analysis using medical chart abstraction data that included demographic and comprehensive clinical information for patients hospitalized in Ontario, Canada, with an AMI from 1999 to 2001.Among 11,468 patients, inhospital lipid testing was performed in 6,019 (52.5%) patients and in 4,169 (36.4%) patients within 24 hours of admission. Patients who had lipid testing were significantly more likely to be discharged on statin therapy compared with patients not tested (41.4% vs 23.0%, P.001). In addition, inhospital lipid testing was strongly associated (odds ratio 3.61, 95% CI 3.15-4.14) with statin therapy prescription at hospital discharge after adjusting for other clinical, physician, and hospital factors.Despite endorsements from practice guidelines, less than half of all admitted AMI patients received lipid testing within 24 hours of hospital admission. Because inhospital lipid testing was strongly associated with the initiation of statin therapy at discharge, many opportunities to initiate statin therapy were lost. Efforts to increase the use of lipid testing in hospitalized AMI patients may translate into higher rates of lipid-lowering therapy and improved patient outcomes.

Objective Elevated rates of mood and anxiety disorders among high utilizers of health care have been suggested as one driver of increased service use. We compared the impact of Mindfulness Based Cognitive Therapy (MBCT), a structured group treatment, on the rates of health care utilization with matched control participants receiving non-MBCT group therapy. Methods Using Ontario health administrative data, we created a retrospective cohort of population-based patients receiving MBCT and an age- and gender-matched (3:1) cohort of non-MBCT group therapy controls. Subjects were recruited between 2003 and 2010 and stratified according to high/low rates of primary care utilization, with the high utilization cohort being the cohort of interest. The primary outcome was a reduction in an aggregate measure of non-mental health utilization comprising Emergency Department, non-mental health primary care, and non-psychiatrist specialist visits. Results There were 10,633 MBCT recipients, 4851 (46%) of whom were high utilizers. The proportion of high utilizers was 13,274 (45%, N = 29,795) for non-MBCT group therapy controls. Among high utilizers, there was a significant reduction in non-mental health utilization among MBCT recipients compared to non-MBCT group therapy recipients (0.55 (0.21–0.89)) suggesting that for every two MBCT patients treated, there is a reduction in 1 non-mental health visit. Conclusion Among high utilizers of primary care, MBCT reduced non-mental health care utilization 1 year post-therapy compared to non-MBCT, group therapy controls. The reductions suggest that MBCT, an established treatment modality for a variety of mental illnesses, has the added benefit of reducing distress-related high health care utilization.

Normal values in adults for ultrasonic tissue characterization by integrated backscatter have been reported previously and subsequently applied to patients with specific diseases. Factors influencing integrated backscatter values in a pediatric population are not clearly defined. To obtain normal values for myocardial ultrasonic integrated backscatter in a pediatric population, we studied 72 children with normal cardiac anatomy using an ultrasonic integrated backscatter imaging system. The parameters measured were at peak, nadir, and end-diastole in eight different regions with two different settings: fixed and variable. We subsequently calculated cyclic variation, the ratios of cyclic variation to end-diastole and to peak. Age ranged from 1 day to 17.4 years (median 4.4 years). More than 90% of data curves from the two regions in the left ventricular posterior wall in long-axis view had normal patterns, whereas more than 50% of curves for the other regions had abnormal patterns. Comparing the two posterior wall positions, there were no differences in cyclic variation between the two regions, with little effect of setting. Less effect of regions and settings was noted for the ratios of cyclic variation to end-diastole or peak. There was no relation between backscatter variables and age, gender, or height, and some variables correlated weakly with body surface area. The assessment of integrated backscatter in children is optimal with interrogation of the left ventricular posterior wall imaged in the long-axis view. More stable estimates are obtained when the cyclic variation is related to the peak or end-diastolic value.

Objectives. We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. Methods. We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. Results. Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%–20%) in LTC and 28% (27%–29%) in the community. Results for hospital admissions were comparable. Conclusions. We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Serotonergic antidepressants (SAds) are associated with bleeding-related adverse events. An increased risk of bleeding with SAds may have important implications in surgical settings. Our study evaluates the risk of red blood cell (RBC) transfusions and postoperative complications associated with SAds among older adults undergoing hip fracture surgery. We conducted a retrospective cohort study of individuals 66 years or older who underwent hip fracture surgery in Ontario, Canada. The risk of RBC transfusion among current users of SAds and nonserotonergic antidepressants (NSAds) was compared with recent former SAd users. Secondary outcomes included measures of postoperative morbidity and mortality. Subgroup analyses were undertaken in groups who were coprescribed other medications known to effect bleeding. Multivariable logistic regression was utilized to determine the odds ratios (ORs) for antidepressants and postoperative outcomes. A total 11,384 individuals were included in the study sample. Current SAd users had an increased risk of RBC transfusion compared with recent former users of SAds (OR, 1.28; 95% confidence interval, 1.14-1.43) as did current NSAd users (OR, 1.17; 95% confidence interval, 1.03-1.33). The risk of RBC transfusion with SAds or NSAds was further increased among individuals receiving antiplatelet agents. However, postoperative morbidity and mortality were not increased among either group of antidepressant users. In conclusion, SAds are associated with an increased risk of RBC transfusions, although this does not appear to result in major postoperative complications. Clinicians should be aware of this increased risk, although routine discontinuation of antidepressants before surgery is likely unwarranted in most cases.

Importance Given that most common bacterial infections can be treated with antibiotic courses of 7 or fewer days, reducing standard antibiotic treatment durations may be an avenue to curtailing antibiotic overuse in long-term care. Objectives To describe the variability in the duration of antibiotic treatment courses in long-term care across resident recipients and prescribing physicians and to determine whether this variability is influenced by prescriber preference. Design and Setting Province-wide retrospective analysis of residents of Ontario, Canada, long-term care facilities in 2010. Participants All adults aged 66 years or older who received an incident treatment course with a systemic antibiotic while residing in an Ontario long-term care facility. Main Outcome Measure Antibiotic treatment duration was examined across residents and prescribing physicians. The proportion of a physician's treatment courses that exceeded 7 days was used to classify short-, average-, and long-duration prescribers. Results Of 66 901 long-term care residents from 630 long-term care facilities, 50 061 (77.8%) received an incident antibiotic treatment course (with 51 540 antibiotic courses prescribed). The most commonly selected antibiotic treatment course was 7 days (in 21 136 courses [41.0%]), but 23 124 (44.9%) exceeded 7 days. Among the 699 physicians responsible for 20 or more antibiotic treatment courses, the median (interquartile range) proportion of treatment courses beyond 7 days was 43.5% (26.9%-62.9%) (range, 0%-97.1%). Twenty-one percent of prescribers had a higher-than-expected proportion of prescriptions beyond the 7-day threshold. Patient characteristics were similar across short-, average-, and long-duration prescribers. A mixed logistic model confirmed that prescribers were an important determinant of treatment duration (P Conclusions and Relevance Antibiotic treatment courses in long-term care facilities are often prescribed for long durations, and this appears to be influenced by prescriber preference more than patient characteristics. Future trials should evaluate antibiotic stewardship interventions targeting prescriber preferences to systematically shorten average treatment durations to reduce the complications, costs, and resistance associated with antibiotic overuse.

Purpose Administrative healthcare databases are used for health services research, comparative effectiveness studies, and measuring quality of care. Adjustment for comorbid illnesses is essential to such studies. Validation of methods to account for comorbid illnesses in administrative data for patients with chronic obstructive pulmonary disease (COPD) has been limited. Our objective was to compare the ability of the Charlson index, the Elixhauser method, and the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict outcomes in patients with COPD. Methods Retrospective cohorts constructed using population-based administrative data of patients with incident (n = 216,735) and prevalent (n = 638,926) COPD in Ontario, Canada, were divided into derivation and validation datasets. The primary outcome was all-cause death within 1 year. Secondary outcomes included all-cause hospitalization, COPD-specific hospitalization, non-COPD hospitalization, and COPD exacerbations. Results In both the incident and prevalent COPD cohorts, the three methods had comparable discrimination for predicting mortality (c-statistics in the validation sample of incident patients of 0.819 for the Charlson method versus 0.822 for the Elixhauser method versus 0.830 for the ADG method). All three methods had lower predictive accuracy for predicting nonfatal outcomes. Conclusions In a disease-specific cohort of COPD patients, all three methods allowed for accurate prediction of mortality, with the Johns Hopkins ADGs having marginally higher discrimination.

Pancreatic cancer (PC) is one of the most lethal malignancies and disease-specific biomarkers are desperately needed for better diagnosis, prognosis, monitoring treatment efficacy and for accelerating the development of novel targeted therapeutics. Being an advanced stage manifestation and a proximal fluid in contact with cancer tissues, the ascitic fluid presents itself as a promising rich source of biomarkers. Herein, we present a comprehensive proteomic analysis of pancreatic ascitic fluid. To fractionate the complex ascites proteome, we adopted a multi-dimensional chromatographic approach that included size-exclusion, ion-exchange and lectin-affinity chromatographic techniques. Our detailed proteomic analysis with high-resolution Orbitrap(®) mass spectrometer resulted in the identification of 816 proteins. We followed rigorous filtering criteria that consisted of PC-specific information obtained from three publicly available databases (Oncomine, Protein Atlas and Unigene) to segregate 20 putative biomarker candidates for future validation. Since these proteins are of membranous and extra-cellular origin, most are glycosylated, and many of them are over-expressed in cancer tissues, the probability of these proteins entering the peripheral blood circulation is high. Their validation as serological PC biomarkers in the future is highly warranted.

Administrative healthcare databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions, or exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. Similarly, when conducting healthcare provider profiling, adequate risk-adjustment is necessary for conclusions about provider performance to be valid. There are limited validated methods for risk adjustment in ambulatory populations using administrative healthcare databases.To examine the ability of the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict mortality in a general ambulatory population cohort.Retrospective cohort constructed using population-based administrative data.All 10,498,413 residents of Ontario, Canada between the ages of 20 and 100 years who were alive on their birthday in 2007. Subjects were randomly divided into derivation and validation samples.Death within 1 year of the subject's birthday in 2007.A logistic regression model consisting of age, sex, and indicator variables for 28 of the 32 ADG categories had excellent discrimination: the c-statistic (equivalent to the area under the receiver operating characteristic curve) was 0.917 in both derivation and validation samples. Furthermore, the model showed very good calibration. In comparison, the use of the Charlson comorbidity index or the Elixhauser comorbidities resulted in a minor decrease in discrimination compared with the use of the ADGs.Logistic regression models using age, sex, and the John Hopkins ADGs were able to accurately predict 1-year mortality in a general ambulatory population of subjects.

Background Acute coronary syndrome (ACS) is one of the most frequent reasons for hospitalization worldwide. Although substantial advances have been made in the prevention and treatment of coronary artery disease, their impact on the rates of ACS hospitalization is unclear. Methods Data from the Canadian Institute for Health Information Discharge Abstract Database were used to estimate secular trends in ACS hospitalization. A total of 1.3 million ACS hospitalizations in Canada from April 1, 1994, to March 31, 2006, were examined. Overall hospitalization rates were standardized for age and sex using 1991 Canadian census data, and hospitalization rates were also stratified by age group, sex and Canadian province to assess trends in each subgroup. Results The Canadian age- and sex-standardized ACS hospitalization rate was 508 per 100,000 persons in 1994, and 317 per 100,000 persons in 2005 – a relative reduction of 37.8% and an average annual relative reduction of 3.9% per year. Declines in ACS hospitalization rates were observed among men (annual relative reduction 3.9%, relative reduction 39.0%) and women (annual relative reduction 3.8%, relative reduction 35.8%). Declining trends were also observed among patients of different age groups and among patients hospitalized across all Canadian provinces. Interpretation Over the past decade, a substantial decline in ACS hospitalization rates occurred, which has not been previously observed. This finding is likely due to improvements in primary and secondary prevention of coronary artery disease. The present study's data should provide important insights and guidance for future health care planning in Canada.

Previous qualitative and survey studies have suggested women with spinal cord injury (SCI) are screened less often for cervical cancer compared with the general population. We investigated whether cervical cancer screening rates differ between population-based women with and without traumatic SCI, matched for age and geography.A double cohort design was used, comparing women with SCI to the general population (1:4) using administrative data for Ontario, Canada. Women with SCI, identified using the Discharge Abstract Database for the fiscal years 1995-1996 to 2001-2002, were female residents of Ontario between the ages of 25 and 66, admitted to an acute care facility with a traumatic SCI (ICD-9 CM code 806 or 952). Women in the general Ontario population were randomly matched by age and geography. Screening rates were calculated from fee codes related to Papanicolaou (Pap) smear tests for a 3-year period preinjury and postinjury.There were 339 women with SCI matched to 1506 women in the general Ontario population. Screening rates pre-SCI were 55% for women with SCI and 57% during this same time period for matched women in the general population; post-SCI rates were 58% for both the two groups. Factors predicting the likelihood of receiving a Pap test for SCI cases included younger age and higher socioeconomic status.Utilization data suggest that there are no significant differences in screening rates for women with SCI compared with the general population. However, screening rates for women with SCI were significantly influenced by age as well as income.

From 1974 through 1991, a total of 583 children with Kawasaki disease were seen at the Hospital for Sick Children, in Toronto, of whom 80 (13.7%) had coronary artery involvement. There were 55 boys and 25 girls, whose mean age at onset was 2.9±2.5 years, followed for a mean period of 4.0±3.6 years. Giant aneurysms (maximum diameter ≥8 mm) were found in 22 children, moderate-sized aneurysms (≥4 to 80% of small or moderate-sized aneurysms regressed within 5 years, giant aneurysms did not regress during the follow-up period. In patients who received immune globulin therapy, coronary lesions tended to resolve more rapidly than in those treated with salicylate therapy alone, because 91% of the lesions in the former were small or moderate. These findings suggest that the severity of coronary artery involvement during the initial stages of Kawasaki disease influences the regression of these lesions, and that immune globulin treatment may improve outcome by reducing the incidence of severe lesions.

Objective: To determine if a cytokine panel could be informative regarding subsequent heart failure(HF)/death. Design and methods: In 216 subjects presenting with chest pain to an emergency department in 1996, EDTA plasma (− 70 °C) was thawed for IL-6, MCP-1, IL-10, VEGF, EGF measurement. Results: Subjects with any three cytokines elevated were at higher risk for HF/death compared to those with ≤ two cytokines elevated. Discussion: A cytokine panel might be useful for risk stratification for HF/death.

Background Percutaneous coronary intervention (PCI) is increasingly being offered to patients with coronary artery disease. The purpose of this study was to determine the impact of this change in coronary revascularization strategy on PCI and coronary artery bypass grafting (CABG) utilization across Canada. Methods All cases of PCI and isolated CABG between years 1994 and 2005 were identified through the Canadian Institute for Health Information. Age- and sex-standardized rates of PCI and CABG per 100,000 population as well as PCI-toCABG ratios were calculated by year and province and across age, sex, income, diabetes, and recent acute coronary syndrome subgroups. In addition, risk-adjusted rates of in-hospital mortality after PCI and CABG were reported by year. Results Between 1994 and 2005, PCI rates increased from 85.6/100,000 to 186.7/100,000 (P b .001), whereas CABG rates remained stable (75.6/100,000-70.8/100,000; P = .43), resulting in an increase in PCI-to-CABG ratio (1.132.64; P b .001). Significant increases in PCI-to-CABG ratios were seen across all provinces (except Newfoundland and Alberta), as well as across all age, sex, income, diabetes, and recent acute coronary syndrome categories. Decline in riskadjusted in-hospital mortality was seen after both CABG (3.9%-2.2%; P b .001) and PCI (1.6%-1.3%; P b .001) but appeared larger after CABG. Conclusions Since 1994, rates of PCI have increased significantly as compared to CABG. During the same period, greater declines in risk-adjusted rates of in-hospital mortality were seen among CABG versus PCI patients. Further study is needed to determine the appropriateness of PCI and CABG rates in terms of clinical outcomes and resource utilization. (Am Heart J 2010;160:958-65.)

Background: Guidelines for treatment of acute coronary syndrome (ACS) recommend observing a rise or fall in cardiac troponin (cTn) concentrations for assessing acute injury. It is unknown whether a rising pattern presages a more adverse long-term prognosis than elevations that do not change. The present study assessed whether a rising pattern of cardiac biomarkers was more prognostic than simple elevations. Methods: We measured N-terminal pro-brain natriuretic peptide (NT-proBNP) (Roche), cTnT (Roche) and cTnI (Beckman Coulter) in 212 ACS patients. These biomarkers were measured in coincident EDTA and heparin plasma samples available from at least 2 different time points, an early first specimen obtained a median of 2 hours after onset of symptoms, interquartile range (IQR) 2–4 hours, and a later second specimen obtained at 9 hours, IQR 9–9 hours. The cTn concentration in the second specimen was used to classify myocardial necrosis (cTnI >0.04 ug/L; cTnT >0.01 ug/L). Outcomes [death, myocardial infarction (MI), heart failure (HF)] were obtained >8 years after the initial presentation. For patients with myocardial necrosis and a cTn concentration ratio (second/first measured concentrations) ≥1.00, the concentration ratios and the absolute concentrations in the second specimen were used to assess prognosis after 4 years. Results: In myocardial necrosis, the relative change (cTn2/cTn1) was greater for cTnI than for cTnT (P Conclusions: A rise in cardiac troponin or NT-proBNP concentration in ACS patients presenting early after onset of pain is not helpful for long-term prognosis.

For patients presenting with acute coronary syndrome (ACS) to the emergency department, early identification of those that are at high risk for subsequent myocardial necrosis or adverse outcomes would allow earlier or more aggressive treatment. We determined if a panel of biomarkers can be used to identify high risk patients.A cohort (84 females/132 males) from our 1996 ACS study population that had EDTA specimens stored (-70 degrees C) was selected and the earliest available specimen was analyzed for 11 biomarkers (IL-6, IL-8, MCP-1, VEGF, L-selectin, P-selectin, E-selectin, ICAM-1, VCAM-1, NT-proBNP, cTnT). These data were linked to the existing cTnI and health outcome databases for this population. ROC curve analysis for myocardial necrosis (i.e., peak cTnI0.04 microg/l) identified 3 candidate biomarkers. These 3 biomarkers were applied together to generate a panel test (2 of the 3 biomarkers increased for a positive result) and assessed for its ability to identify patients at risk for myocardial necrosis and the combined endpoint of death, myocardial infarction (MI) and heart failure (HF).The panel test (IL-6, NT-proBNP, E-selectin) alone detected 60% (95% CI: 49-69; false positive rate: 26%) of subjects that would be classified with myocardial necrosis. Kaplan-Meier and Cox proportional analyses indicated that patients positive by the biomarker panel (including those with cTnIor =0.04 microg/l) had significantly worse outcomes (death/MI/HF) as compared to those negative by both cTnI and the panel test.A biomarker panel analyzed early after pain onset can identify individuals at risk for both myocardial necrosis and the combined endpoint of death/MI/HF. Additional prospective studies are required to assess this panel for both early MI detection and to further refine which health outcomes (death, MI, HF) are associated with positive panel results.

Importance Antibiotics are frequently and often inappropriately prescribed to patients in nursing homes. These antibiotics pose direct risks to recipients and indirect risks to others residing in the home. Objective To examine whether living in a nursing home with high antibiotic use is associated with an increased risk of antibiotic-related adverse outcomes for individual residents. Design, Setting, and Participants In this longitudinal open-cohort study performed from January 1, 2010, through December 31, 2011, we studied 110 656 older adults residing in 607 nursing homes in Ontario, Canada. Exposures Nursing home–level antibiotic use was defined as use-days per 1000 resident-days, and facilities were classified as high, medium, and low use according to tertile of use. Multivariable logistic regression modeling was performed to assess the effect of nursing home–level antibiotic use on the individual risk of antibiotic-related adverse outcomes. Main Outcomes and Measures Antibiotic-related harms included Clostridium difficile , diarrhea or gastroenteritis, antibiotic-resistant organisms (which can directly affect recipients and indirectly affect nonrecipients), allergic reactions, and general medication adverse events (which can affect only recipients). Results Antibiotics were provided on 2 783 000 of 50 953 000 resident-days in nursing homes (55 antibiotic-days per 1000 resident-days). Antibiotic use was highly variable across homes, ranging from 20.4 to 192.9 antibiotic-days per 1000 resident-days. Antibiotic-related adverse events were more common (13.3%) in residents of high-use homes than among residents of medium-use (12.4%) or low-use homes (11.4%) ( P P = .003). A sensitivity analysis examining nursing home–level antibiotic use as a continuous variable confirmed an increased risk of resident-level antibiotic-related harms (adjusted odds ratio, 1.004 per additional day of nursing home antibiotic use; 95% CI, 1.001-1.006; P = .01). Conclusions and Relevance Antibiotic use is highly variable across nursing homes; residents of high-use homes are exposed to an increased risk of antibiotic-related harms even if they have not directly received these agents. Antibiotic stewardship is needed to improve the safety of all nursing home residents.

Objective More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia. Design Retrospective cohort study. Setting Population based in Ontario, Canada, from 2002 to 2011. Population Ontario women aged 15–49 years who gave birth to a liveborn or stillborn singleton infant. Methods Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy. Main outcome measures The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators. Results Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28–2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04–2.85), preterm birth (aOR 1.75, 95% CI 1.46–2.08), SGA (aOR 1.49, 95% CI 1.19–1.86), and LGA (aOR 1.53, 95% CI 1.17–1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity. Conclusions Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

The 2003 American Heart Association (AHA) definition for myocardial infarction (MI) requires an "adequate set" (i.e. at least 6 h between measurements) of biomarkers and specifically troponin for the diagnosis of MI. The aim of the present study was to assess the performance of myoglobin, the CKMB isoforms, and cardiac troponin I (cTnI) in specimens earlier than the requisite 6 h after presentation, in a population originally characterized using World Health Organization (WHO) criteria.In 1996, 228 acute coronary syndrome patients with an "adequate sample set" had their specimens assayed for CKMB isoforms and myoglobin. In 2003, the same specimens were analyzed with the AccuTnI troponin I assay and myoglobin (Beckman Coulter Access immunoassay).The clinical sensitivities for both myoglobin and the CKMB isoforms were90% when the population was classified by WHO criteria. However the sensitivities were70% when the ESC/ACC MI definition was used. Analyzing cTnI at earlier time points as long as there was at least 3 h between specimens or at least 1 specimen 6 h from pain onset did not misclassify subjects based on adverse outcomes in the year following their presentation.Contemporary assays for cTnI with increased analytical sensitivity reduce the utility of myoglobin and CKMB isoforms to rule-out an AMI.

Aims To determine the relative impact of time to hospital arrival, baseline cardiovascular risk (i.e.TIMI mortality risk index), intracerebral haemorrhage risk, and comorbid disease burden on the likelihood of not receiving reperfusion therapy among ST-segment elevation myocardial infarction (STEMI) patients without contraindications to treatment. Methods and results Retrospective population-based cohort of 3994 patients admitted to 103 acute care hospitals with chest pain and STEMI within 12 h of symptom onset in Ontario, Canada, between 1999 and 2001. Patients with one or more documented absolute or relative contraindication ( n =909) were excluded from the analyses. Reperfusion therapy was defined as the receipt of either fibrinolysis or primary percutaneous coronary intervention. Multivariable analysis and likelihood χ 2 was used to quantify the importance of each factor in predicting the non-utilization of therapy. In total, 23.1% of patients received no reperfusion therapy. Listed in order from greatest to least importance, predictors of non-utilization of reperfusion therapy included increasing time to hospital presentation (likelihood χ 2 31.6, P