Comparison of Readmission and Death Among Patients With Cardiac Disease in Northern vs Southern Ontario

Exploring the personal stroke and rehabilitation experiences of older adults with chronic stroke during the COVID-19 pandemic: a qualitative descriptive study

PURPOSE

The purpose of this study was to explore the personal stroke and rehabilitation experiences of older adults with chronic stroke living in a mid-sized Northwestern Ontario city in Canada during the COVID-19 pandemic.

METHODS

A qualitative descriptive approach with a constructivist worldview was used. In addition, a semi-structured interview guide was used to gather the participants' perspectives on their experiences throughout stroke recovery. Ten participants were interviewed, including six males and four females. The interviews were completed, transcribed, and analysed using inductive and deductive content analysis. Multiple steps were taken to enhance data trustworthiness.

RESULTS

Six main themes and eight related subthemes emerged. These included: getting help is complex, the effects of stroke are multifaceted, losing rehabilitation services during the COVID-19 pandemic, overcoming hardships but not alone, "If you don't use it, you lost it": rehabilitative success is based on one's actions, and "look at me now": the importance of taking pride in one's successes.

CONCLUSIONS

One unique finding was that the participants used this study as an opportunity to teach and advocate for future stroke survivors which is not often seen in qualitative stroke rehabilitation research. Future stroke research should place emphasis on both the positive and negative experiences of this population.

Uptake of SGLT2i and Outcomes in Patients with Diabetes and Heart Failure: A Population-Based Cohort and a Specialized Clinic Cohort

BACKGROUND

Sodium-glucose cotransporter-2 (SGLT2) inhibitors are effective in adults with diabetes mellitus (DM) and heart failure (HF) based on randomized clinical trials. We compared SGLT2 inhibitor uptake and outcomes in two cohorts: a population-based cohort of all adults with DM and HF in Alberta, Canada and a specialized heart function clinic (HFC) cohort.

METHODS

The population-based cohort was derived from linked provincial healthcare datasets. The specialized clinic cohort was created by chart review of consecutive patients prospectively enrolled in the HFC between February 2018 and August 2022. We examined the association between SGLT2 inhibitor use (modeled as a time-varying covariate) and all-cause mortality or deaths/cardiovascular hospitalizations.

RESULTS

Of the 4,885 individuals from the population-based cohort, 64.2% met the eligibility criteria of the trials proving the effectiveness of SGLT2 inhibitors. Utilization of SGLT2 inhibitors increased from 1.2% in 2017 to 26.4% by January 2022. In comparison, of the 530 patients followed in the HFC, SGLT2 inhibitor use increased from 9.8% in 2019 to 49.1 % by March 2022. SGLT2 inhibitor use in the population-based cohort was associated with fewer all-cause mortality (aHR 0.51, 95%CI 0.41-0.63) and deaths/cardiovascular hospitalizations (aHR 0.65, 95%CI 0.54-0.77). However, SGLT2 inhibitor usage rates were far lower in HF patients without DM (3.5% by March 2022 in the HFC cohort).

CONCLUSIONS

Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2 inhibitors in patients with HF and DM remains low, even in the specialized HFC. Clinical care strategies are needed to enhance the use of SGLT2 inhibitors and improve implementation.

Utilization of Shock Team and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in the Management of Cardiogenic Shock in Northern Ontario

Background

Despite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown.

Methods

This retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality.

Results

The outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization.

Conclusions

This analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Heart Health Begins With Community: Community-Based Research Exploring Innovative Strategies to Support First Nations Heart Health

Background

Indigenous people have displayed their strength through their holistic practices and spiritual connection to the land. Despite overcoming the impact of discriminatory and disempowering policies within Western institutions, Indigenous people continue to experience a higher risk of cardiovascular disease, compared to the general population. To move toward improving Indigenous health outcomes, researchers need to work in partnership with communities to develop heart health strategies centred on their experienced barriers and sources of healing. We conducted a community-based explorative study in Moosonee, Ontario to explore the local community's needs and priorities regarding heart health and wellness.

Methods

A convenience sample of community members and healthcare professionals were invited to participate in a sharing circle. Qualitative data were analyzed using conventional content analysis and the Indigenous method of two-eyed seeing.

Results

Eight community members and 5 healthcare professionals participated in the sharing circle. Four dominant themes were identified: (1) heart health is more than metrics; (2) honouring our traumas; (3) destigmatizing care through relationship building; and (4) innovative solutions start with community. With the history of mistreatment among Indigenous people, strength-based solutions involved rebuilding clinical relationships. To bring care closer to home, digital health tools were widely accepted, but the design of these tools needs to integrate both Western and Indigenous approaches to healing.

Conclusions

Indigenous health upholds the physical, emotional, psychological, and spiritual needs of an individual as being of equal importance. To improve community heart health, strategies should start by strengthening broken bonds and bridging multiple worldviews of healing.

Global Comparison of Readmission Rates for Patients With Heart Failure

BACKGROUND

Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes.

OBJECTIVES

This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression.

RESULTS

In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient.

CONCLUSIONS

Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.

The Safety of Early Discharge Following Transcatheter Aortic Valve Implantation Among Patients in Northern Ontario and Rural Areas Utilizing the Vancouver 3M TAVI Study Clinical Pathway

Background

Early hospital ( < 48 hours) discharge following transcatheter aortic valve implantation (TAVI) is an increasingly adopted practice; however, data on the safety of such an approach among patients residing in North Ontario, including remote and medically underserved areas, are lacking.

Methods

This retrospective study included patients who underwent TAVI in Sudbury, Ontario. The safety of early discharge after implementation of the Vancouver 3M (multidisciplinary, multimodality, but minimalist) clinical pathway was assessed. The primary endpoint was 30-day mortality. Resource utilization before vs after 3M clinical pathway implementation was also compared.

Results

A total of 291 patients who underwent TAVI between 2012 and 2021 were included in the study. One in-hospital death (0.6%) occurred after the 3M clinical pathway implementation, with no mortality observed beyond hospital discharge. Eleven patients (6.7%) required rehospitalization within 30 days. The need for mechanical ventilation and surgical vascular cut-down declined from 100% and 97%, respectively, at baseline, to 6% and 2%. The number of patients receiving TAVI on a given procedural day increased from 2 to 3 patients. The median post-TAVI hospital length of stay decreased from 5 days (2-6 days) to 1 day (1-3 days) after 3M clinical pathway implementation.

Conclusions

Following TAVI, early discharge of selected patients residing in Northern Ontario, including rural areas, using the Vancouver 3M clinical pathway was associated with favourable outcomes, short length of stay, and more-efficient resource utilization. These data can help improve healthcare efficiency and bridge variations in TAVI funding and accessibility in underserved locations.

Trends in glucose testing among individuals without diabetes in Ontario between 2010 and 2017: a population-based cohort study

BACKGROUND

Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups.

METHODS

Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease).

RESULTS

Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population (p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension.

INTERPRETATION

We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing.

National Interhospital Transfer for Patients With Acute Cardiovascular Conditions

Background

Treatment of ST-elevation myocardial infarction (STEMI) in Canada is protocolized, and timely patient transfer can improve outcomes. Population-based processes of care in Canada for other cardiovascular conditions remain less clear. We aimed to describe the interhospital transfer of Canadian patients with acute cardiovascular disease.

Methods

We reviewed the Canadian Institute for Health Information Discharge Abstract Database for adult patients hospitalized with acute cardiovascular disease between 2013 and 2018. We compared patient characteristics and clinical outcomes based on transfer status (transferred, nontransferred) and presenting hospital (teaching, large community, medium community, and small community hospitals). The primary outcome of interest was in-hospital mortality.

Results

There were 476,753 patients with primary acute cardiovascular diagnoses, 48,579 (10.2%) of whom were transferred. Transferred patients were more frequently younger, male, and had fewer comorbidities. The most common diagnoses among transferred patients were non-STEMI (44.2%), STEMI (29.0%), and congestive heart failure (9.4%). Using teaching hospitals as a reference, transfer to large and medium community hospitals was associated with lower hospital mortality (adjusted odds ratio: 0.83, 95% confidence interval: 0.75-0.91 and 0.45, 95% confidence interval: 0.39-0.52, respectively).

Conclusions

Approximately 10% of patients with acute cardiovascular conditions are transferred to another hospital. Patient transfer may be associated with lower in-hospital mortality, with possible variability based on diagnosis, comorbidities, hospital of origin, and destination hospital. Further investigation into the optimization of care for patients with acute cardiovascular disease, including transfer practices, is warranted as regionalized care models continue to develop.

Trends in the Use of Cardiac Imaging for Patients With Heart Failure in Canada

IMPORTANCE

Cardiac imaging is a component of the provision of medical care for patients with heart failure that has experienced a broad expansion in past decades. However, there is a paucity of studies examining the patterns of use of cardiac imaging modalities in real-world clinical practice.

OBJECTIVES

To investigate temporal trends in the use and costs of cardiac imaging for the examination of patients with heart failure in Canada and to examine the association between the institution of an accreditation program and the use of echocardiography.

DESIGN, SETTING, AND PARTICIPANTS

A repeated cross-sectional study based on population-based administrative databases in Ontario, Canada, of individuals with heart failure identified using a validated algorithm based on hospital admissions and ambulatory physician claims was conducted between April 1, 2002, and March 31, 2017.

MAIN OUTCOMES AND MEASURES

The incidence and prevalence of heart failure and the age- and sex-adjusted rate of use and costs of cardiac imaging, including resting and stress echocardiography, myocardial perfusion scintigraphy, invasive coronary angiography, computed tomography, magnetic resonance imaging, and positron emission tomography.

RESULTS

A total of 882 355 adults (50.1% women; median age, 76 years [interquartile range, 66-83 years]) with prevalent heart failure were identified. The age- and sex-standardized prevalence of heart failure remained stable during the study (2.4% [95% CI, 2.4%-2.4%] in 2002 and 2.0% [95% CI, 2.0%-2.0%] in 2016). There was an increase in the rate of use of resting echocardiography, from 386 tests (95% CI, 373-398) per 1000 patients with heart failure in 2002 to 533 (95% CI, 519-547) per 1000 patients in 2011. Coinciding with the initiation of an accreditation program for echocardiography in 2012, there was an immediate reduction in the rate of use (-59.5 tests per 1000 patients with heart failure; P < .001), which was followed by a plateau in subsequent years. At the same time, there was a 10.8% relative reduction in the use of myocardial perfusion scintigraphy and an 11.2% relative reduction in the use of invasive coronary angiography from 2011 to 2016 and the incorporation of newer modalities after they became publicly insured health services.

CONCLUSIONS AND RELEVANCE

These findings suggest that resting echocardiography remains the most used imaging technique for patients with heart failure, exceeding the use of and the cost spent on other modalities. Stabilization in the use of traditional imaging modalities coincided temporally with the emergence of advanced techniques and provincewide quality improvement policy initiatives.