Wastewater-based surveillance can be used to model COVID-19-associated workforce absenteeism

Wastewater-based surveillance (WBS) of infectious diseases is a powerful tool for understanding community COVID-19 disease burden and informing public health policy. The potential of WBS for understanding COVID-19's impact in non-healthcare settings has not been explored to the same degree. Here we examined how SARS-CoV-2 measured from municipal wastewater treatment plants (WWTPs) correlates with workforce absenteeism. SARS-CoV-2 RNA N1 and N2 were quantified three times per week by RT-qPCR in samples collected at three WWTPs servicing Calgary and surrounding areas, Canada (1.4 million residents) between June 2020 and March 2022. Wastewater trends were compared to workforce absenteeism using data from the largest employer in the city (>15,000 staff). Absences were classified as being COVID-19-related, COVID-19-confirmed, and unrelated to COVID-19. Poisson regression was performed to generate a prediction model for COVID-19 absenteeism based on wastewater data. SARS-CoV-2 RNA was detected in 95.5 % (85/89) of weeks assessed. During this period 6592 COVID-19-related absences (1896 confirmed) and 4524 unrelated absences COVID-19 cases were recorded. A generalized linear regression using a Poisson distribution was performed to predict COVID-19-confirmed absences out of the total number of absent employees using wastewater data as a leading indicator (P < 0.0001). The Poisson regression with wastewater as a one-week leading signal has an Akaike information criterion (AIC) of 858, compared to a null model (excluding wastewater predictor) with an AIC of 1895. The likelihood-ratio test comparing the model with wastewater signal with the null model shows statistical significance (P < 0.0001). We also assessed the variation of predictions when the regression model was applied to new data, with the predicted values and corresponding confidence intervals closely tracking actual absenteeism data. Wastewater-based surveillance has the potential to be used by employers to anticipate workforce requirements and optimize human resource allocation in response to trackable respiratory illnesses like COVID-19.

Optimal medical therapy improves outcomes in patients with diabetes mellitus and acute myocardial infarction

AIMS

We aimed to explored the association between the use of optimal medical therapy (OMT) in patients with myocardial infarction (AMI) and diabetes mellitus (DM) and clinical outcomes.

METHODS

Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) is an international registry that enrolled participants with acute coronary syndrome followed up for at least 1 year across 15 centers from 2003 to 2014. Baseline characteristics and endpoints were analyzed.

RESULTS

Among 3095 (23.2%) patients with AMI and DM, 1898 (61.3%) received OMT at hospital discharge. OMT was associated with significantly reduced mortality (4.3% vs. 10.8%, p < 0.001), re-AMI (4.4% vs. 8.1%, p < 0.001), and composite endpoint of death/re-AMI (8.0% vs. 17.6%, p < 0.001). No difference was observed among regions. Propensity score matching confirmed that OMT significantly associated with lower mortality. After adjusting for confounding variables, OMT, drug-eluting stents, and complete revascularization were independent protective factors of 1-year mortality, whereas left ventricular ejection fraction and age were risk factors.

CONCLUSIONS

Guideline-recommended OMT was prescribed at suboptimal frequencies with geographic variations in this worldwide cohort. OMT can improve long-term clinical outcomes in patients with DM and AMI.

CLINICAL TRIAL REGISTRATION

NCT02466854 June 9, 2015.

Leaving the Walkman and ICD-9 Behind: Modernizing the Disease Classification System Used by Canadian Physicians

The International Classification of Diseases, Ninth Revision (ICD-9) was released in the 1970s and adopted in Canada for physician billing claims in 1979 (CIHI n.d.b.; WHO & International Conference for the Ninth Revision of the International Classification of Diseases 1977). ICD-9 is no longer adequate for representing our modern healthcare environment and patient needs. We summarize the findings from a small survey of ICD-9 users across Canada – such as family physicians, researchers and decision makers – who describe the limitations of ICD-9 and the features that they would desire in a new or updated classification system.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evaluation of optimal medical therapy in acute myocardial infarction patients with prior stroke

Background

Treatment of acute myocardial infarction (AMI) patients with prior stroke is a common clinical dilemma. Currently, the application of optimal medical therapy (OMT) and its impact on clinical outcomes are not clear in this patient population.

Methods

We retrieved 765 AMI patients with prior stroke who underwent percutaneous coronary intervention (PCI) during the index hospitalization from the international multicenter BleeMACS registry. All of the subjects were divided into two groups based on the prescription they were given prior to discharge. Baseline characteristics and procedural variables were compared between the OMT and non-OMT groups. Mortality, re-AMI, major adverse cardiovascular events (MACE), and bleeding were followed-up for 1 year.

Results

Approximately 5% of all patients presenting with AMI were admitted to the hospital for ischemic stroke. Although the prescription rate of each OMT medication was reasonably high (73.3%-97.3%), 47.7% lacked at least one OMT medication. Patients receiving OMT showed a significantly decreased occurrence of mortality (4.5% vs 15.1%, p < 0.001), re-AMI (4.2% vs 9.3%, p = 0.004), and the composite endpoint of death/re-AMI (8.6% vs 20.5%, p < 0.001) compared to those without OMT. No significant difference was observed between the groups regarding bleeding. After adjusting for confounding factors, OMT was the independent protective factor of 1-year mortality, while age was the independent risk factors.

Conclusions

OMT at discharge was associated with a significantly lower 1-year mortality of patients with AMI and prior stroke in clinical practice. However, OMT was provided to just half of the eligible patients, leaving room for substantial improvement.

Clinical Trial Registration

NCT02466854.

Mitigating imperfect data validity in administrative data PSIs: a method for estimating true adverse event rates

QUESTION

Are there ways to mitigate the challenges associated with imperfect data validity in Patient Safety Indicator (PSI) report cards?

FINDINGS

Applying a methodological framework on simulated PSI report card data, we compare the adjusted PSI rates of three hospitals with variable quality of data and coding. This framework combines (i) a measure of PSI rates using existing algorithms; (ii) a medical record review on a small random sample of charts to produce a measure of hospital-specific data validity and (iii) a simple Bayesian calculation to derive estimated true PSI rates. For example, the estimated true PSI rate, for a theoretical hospital with a moderately good quality of coding, could be three times as high as the measured rate (for example, 1.4% rather than 0.5%). For a theoretical hospital with relatively poor quality of coding, the difference could be 50-fold (for example, 5.0% rather than 0.1%).

MEANING

Combining a medical chart review on a limited number of medical charts at the hospital level creates an approach to producing health system report cards with estimates of true hospital-level adverse event rates.

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention

Background:

The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.

Methods:

We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003–2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine–Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.

Results:

Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7–319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01–1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36–8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.

Conclusion:

The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.

Developing a Data Integrated COVID-19 Tracking System for Decision-Making and Public Use

IntroductionThe unprecedented COVID-19 pandemic unveiled a strong need for advanced and informative surveillance tools. The Centre for Health Informatics (CHI) at the University of Calgary took action to develop a surveillance dashboard, which would facilitate the education of the public, and answer critical questions posed by local and national government. ObjectivesThe objective of this study was to create an interactive method of surveillance, or a “COVID-19 Tracker” for Canadian use. The Tracker offers user-friendly graphics characterizing various aspects of the current pandemic (e.g. case count, testing, hospitalizations, and policy interventions). MethodsSix publicly available data sources were used, and were selected based on the frequency of updates, accuracy and types of data, and data presentation. The datasets have different levels of granularity for different provinces, which limits the information that we are able to show. Additionally, some datasets have missing entries, for which the “last observation carried forward” method was used. The website was created and hosted online, with a backend server, which is updated on a daily basis. The Tracker development followed an iterative process, as new figures were added to meet the changing needs of policy-makers. ResultsThe resulting Tracker is a dashboard that visualizes real-time data, along with policy interventions from various countries, via user-friendly graphs with a hover option that reveals detailed information. The interactive features allow the user to customize the figures by jurisdiction, country/region, and the type of data shown. Data is displayed at the national and provincial level, as well as by health regions. ConclusionsThe COVID-19 Tracker offers real-time, detailed, and interactive visualizations that have the potential to shape crucial decision-making and inform Albertans and Canadians of the current pandemic.

Outcome of Patients With Prior Stroke/Transient Ischemic Attack and Acute Coronary Syndromes

The association between prior stroke/transient ischemic attack (TIA) and clinical outcomes in patients with acute coronary syndrome (ACS) has not been well explored. We evaluated the impact of prior stroke/TIA on this specific patient population. We conducted an international multicenter study including 15 401 patients with ACS from the Bleeding Complications in a Multicenter Registry of Patients Discharged With Diagnosis of Acute Coronary Syndrome registry. They were divided into 2 groups: patients with and without prior stroke/TIA. The primary end point was death at 1-year follow-up. Prior stroke/TIA was associated with higher rate of 1-year death (8.7% vs 3.4%; P < .001). It was an independent predictor of 1-year death even after adjustment for confounding variables (odds ratio, 1.705; 95% confidence interval, 1.046-2.778; P = .032). Besides, patients with prior stroke/TIA had significantly increased 1-year reinfarction (5.6% vs 3.8%, P = .015), in-hospital bleeding (8.7% vs 5.8%, P < .001), and 1-year bleeding (5.2% vs 3.0%, P < .001). No difference of antithrombotic therapies or dual antiplatelet therapy (DAPT) types on outcomes was observed in patients with prior stroke/TIA. Prior stroke/TIA was associated with higher 1-year death for patients with ACS who underwent percutaneous coronary intervention. No benefits or harms were observed with different antithrombotic therapies or DAPT types in these patients.

Comparative Prognostic Accuracy of Risk Prediction Models for Cardiogenic Shock

OBJECTIVES

Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock.

METHODS

Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality.

CONCLUSIONS

In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods.

Cost analysis and efficacy of recruitment strategies used in a large pragmatic community-based clinical trial targeting low-income seniors: a comparative descriptive analysis

OBJECTIVE

One of the most challenging parts of running clinical trials is recruiting enough participants. Our objective was to determine which recruitment strategies were effective in reaching specific subgroups.

STUDY DESIGN AND SETTING

We assessed the efficacy and costs of the recruitment strategies used in the Assessing Outcomes of Enhanced Chronic Disease Care Through Patient Education and a Value-based Formulary Study (ACCESS) in Alberta, Canada.

RESULTS

Twenty percent of the study budget ($354,330 CAD) was spent on recruiting 4013 participants, giving an average cost per enrolled of $88 CAD. Pharmacies recruited the most participants (n = 1217), at a cost of $128/enrolled. "Paid media" had the highest cost ($806/enrolled), whereas "word of mouth" and "unpaid media" had the lowest (~$3/enrolled). Participants enrolled from "seniors outreach" had the lowest baseline quality of life and income, while participants from "word of mouth" had the lowest educational attainment.

CONCLUSION

The "health care providers" strategies were especially successful - at a moderate cost per enrolled. The "media" strategies were less effective, short lasting, and more costly. No strategy was singularly effective in recruiting our targeted groups, emphasizing the importance of utilizing a variety of strategies to reach recruitment goals.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02579655 . Registered on 19 October 2015.

Trajectories of Health-Related Quality of Life in Coronary Artery Disease

BACKGROUND

Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD.

METHODS AND RESULTS

Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups.

CONCLUSIONS

This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.

The Effects of Acute Atmospheric Pressure Changes on the Occurrence of ST-Elevation Myocardial Infarction: A Case-Crossover Study

BACKGROUND

Few studies have explored the influence of short-term exposure to atmospheric pressure changes on the abrupt onset of ST-elevation myocardial infarction (STEMI). We sought to evaluate the association between acute atmospheric pressure changes and the occurrence of STEMI.

METHODS

We studied STEMI patients from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) from March 1, 2002 to December 31, 2016 in a case-crossover study design. Each case was matched with control intervals according to the same day of week, month, and year. All STEMI patients were linked with the nearest weather station within a 40-km radius according to residential postal code. The effect of exposure to air pressure changes, rate of air pressure changes, acute air pressure increase, and acute air pressure decrease 1 day to 7 days earlier on the onset of STEMI were analyzed with conditional logistic regression. All models were adjusted with daily average temperature, relative humidity, and average levels of 5 air pollutants.

RESULTS

In 11,379 STEMI patients, positive associations with the onset of STEMI were only found at 7 days after exposure to acute air pressure decrease (odds ratio, 1.12; 95% confidence interval, 1.03-1.21), which was consistent in sensitivity and subgroup analyses. All the other models showed no evidence of statistically significant associations.

CONCLUSIONS

Acute air pressure decrease is associated with higher odds of a STEMI event 7 days after exposure. Weather advisories might be issued when atmospheric pressure decrease occurs.

Impact of renin-angiotensin system blockade on the prognosis of acute coronary syndrome based on left ventricular ejection fraction

INTRODUCTION AND OBJECTIVES

For patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.

METHODS

Data from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.

RESULTS

Among 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P=.012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF> 40% (P value for treatment-by-LVEF interaction=.008). For patients with LVEF> 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P=.031).

CONCLUSION

The benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF> 40% and ST-segment elevation myocardial infarction. In non-ST-segment elevation-ACS patients with LVEF> 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.

The Association between Chronic Obstructive Pulmonary Disease and Coronary Artery Disease in Patients Undergoing Coronary Angiography

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of morbidity and mortality. There are conflicting results regarding the association between COPD and CAD. We sought to measure the association between COPD and angiographically diagnosed CAD in a population-based cohort. We performed a retrospective analysis using data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a prospectively collected registry capturing all patients undergoing coronary angiography in Alberta, Canada, since 1995. We included adult patients who had undergone coronary angiogram between April 1, 2007 and March 31, 2014. CAD was present if at least one coronary artery had a significant stenosis ≥50%. COPD was present if the patient had a documented COPD history and was prescribed bronchodilators or inhaled steroids. We evaluated the association between COPD and CAD using univariable and multivariable logistic regression. There were 26,137 patients included with a mean age of 63.3 ± 12.2 years, and 19,542 (74.8%) were male. The crude odds ratio (OR) of having CAD was 0.83 (95% CI 0.74-0.92) for patients with COPD compared to those without COPD. The adjusted OR was 0.75 (95% CI 0.67-0.84) after controlling for age, sex, smoking history, body mass index, hypertension, diabetes, hyperlipidemia, peripheral artery disease and cardiac family history. In patients undergoing coronary angiography, COPD was negatively associated with CAD with and without the adjustment for classic risk factors. COPD patients should be properly examined for heart disease to reduce premature mortality.

Experiences with Coding using ICD-11: “The Codes Paint a Clearer Picture”

IntroductionA high performing health data classification system requires clear, comprehensive code descriptions and user-friendly coding tools for effective coding. Coding specialists have essential specialized knowledge to contribute to the development and functionality of the 11th version of International Classification of Diseases (ICD-11) that will be released in June of 2018. Objectives and ApproachThe objective was to evaluate coding specialists’ experience of coding using ICD-11 for complete inpatient hospital charts. Mixed methods were employed for a survey and interviews. As part of a large field trial, 6 certified coding specialists underwent training to use the ICD-11 Beta Draft browser and ICD-11 Coding Tool. The coding team completed multiple coding exercises and coded over 60 charts each prior to evaluation of their experience. An electronic survey was used to evaluate ICD-11 knowledge, comprehension, and application of the coding training. Interviews explored the coders’ experience of learning and using the ICD-11 classification system. ResultsThe coding team (3 to 10 years of experience) received 14 hours classroom training and 5-10 hours per week of coding practice over 3 months. After training, perceived confidence in coding with ICD-11 was satisfactory; moderate (n=4), high (n=1), and low (n=1). Coding short scenarios was the most useful resource (n=6) and lack of guidelines was the most frustrating. Learning ICD-11 was deemed moderately (n=2) to somewhat (n=3) difficult but each coder described satisfaction in learning the new system. From the interviews, coders expressed liking the ability to more fully describe health conditions and hospital harms with code clusters. “The codes paint a clearer picture of what happened than with ICD-10”. With practice they achieved speed with the coding tools. Conclusion/ImplicationsCoding specialists learned and proficiently used the Beta Version of ICD-11 coding system with moderate perceived confidence. New ICD-11 codes and clustering functions allowed for more complete description of health scenarios and enhanced coder satisfaction.

Advancing data collection of hospital-related harms: Results from hospital discharges dually coded with ICD-10 and ICD-11

IntroductionHospital safety performance is difficult to monitor when under-coding of hospital harms is common. The beta version of ICD-11 includes a 3-part model for coding harms to enhance adverse event descriptions. This method includes code clusters to detail each condition/event (e.g. bleed), cause (e.g. anticoagulant drug), and mode (over-dose). Objectives and ApproachThe study objective was to compare the proportion of adverse events captured using different classification systems. A large field trial of inpatient charts, previously coded in ICD-10 were coded with ICD-11. Coding training for the new ICD-11 focused on new codes, code clustering, and extension codes for cause and mode of the harm. Sensitivity, Specificity, NPV and PPV were reported for ICD-10 compared to ICD-11. ResultsOf the 1,009 records reviewed and coded using ICD-11 to date, 128 cases were coded as a harm in ICD-10 using our previously published PSI work. Coders identified 88 cases with the new ICD-11. Sensitivity and specificity were as follows: 31.3% and 94.6%. ICD-11 had NPV and PPV of 45.5% and 90.5% respectively compared to ICD-10. Detailed clinical comparison of mismatched codes will be completed. Study case examples will demonstrate advanced features of ICD-11, the coding rules being collaboratively developed by our team, CIHI, and WHO representatives, and potential analytic challenges. Conclusion/ImplicationsThe new ICD-11 found 8% of hospital admission were associated with a harm. Although the sensitivity was modest, specificity is quite high and correctly Identifies those cases without a harm. Clinical review of mismatched codes will provide further detailed code comparisons.

Coding Agreement on Identification of Main Resource Use Using ICD-10 and ICD-11

IntroductionMain condition coding definitions in the International Classification of Disease (ICD) 10th and 11th versions are broadly defined in the current and upcoming versions of ICD, and coding health data can involve subjective coding specialist interpretation. Inconsistent coding can lead to inaccurate reporting, and lower quality data for research use. Objectives and ApproachMain condition coding agreement was compared between ICD-10 and ICD-11. 730 hospital charts were randomly selected from Foothills Medical Centre in Calgary, Alberta. These charts were previously coded using ICD-10, and six professional coding specialists recoded them using ICD-11. To compare frequencies of ICD-10 to ICD-11, we used current WHO crosswalk tables to match codes. For any missing codes, manual comparison by done by a qualified reviewer. In Canada, the “main condition” is the clinically significant reason for the hospital visit. If multiple problems were present, the diagnosis using the greatest amount of resources is coded, “main resource use”. ResultsOverall, 730 ICD-10 coded charts were analyzed. Of these charts, 79% (577) had matching resource coding between ICD-10 and ICD-11, and 21% (153) had mismatching coding. Matching coding was either considered an exact match between definitions (23.2%, 134), or similar but not identical (often one code has greater detail, 76.8%, 443). Mismatching codes were either due to different codes for similar conditions (13.1%, 20), different codes for not similar but related conditions (43.8%, 67), or completely different codes for unrelated conditions (43.1%, 66). Conclusion/ImplicationsICD-10 and ICD-11 main resource codes had a high match frequency indicating consistency between coding practices and ICD definitions (577/730, 79%). Future research will aim to understand underlying causes of mismatched main resource use codes. This research will help us understand issues in coding and contribute to future ICD-11 revisions.

Advancing data collection of hospital-related harms: Validity of the new ICD-11 Quality & Safety Use Case

IntroductionThe beta version of the new ICD-11 includes a 3-part model for coding hospital acquired conditions (harms) to enhance adverse event descriptions. This method includes code clusters for detail each condition/event (e.g. bleed), cause (e.g. anticoagulant drug), and mode (over-dose). Objectives and ApproachTo compare the proportion of adverse events captured in ICD-11 to clinical chart review. A large field trial of 3000 inpatient charts are being coded with ICD-11 and chart review. Hospital admissions were randomly selected between January- June 2015 for adults at 3 Calgary hospitals. Chart reviewers were nurses trained to identify 11 categories of harms. Six coding specialists were trained to code with the ICD-11 3-part model for harm description. Coding decision trees and case examples of hospital-related harms were reviewed extensively by both teams. Coding training focused on new codes, code clustering, and extension codes for cause and mode of the harm. ResultsOf the 1,009 records reviewed and coded using ICD-11 to date, chart reviewers and coding specialists accurately identified 49 (37%) of the same charts with documented hospital harms. Both correctly identified 797 (91\%) of cases with no harm. Detailed analysis will follow. Study case examples will demonstrate advanced features of ICD-11 and the coding rules being collaboratively developed by our team, CIHI, and and WHO representatives. Conclusion/ImplicationsIdentification of hospital-related harms was consistent between coding specialists using ICD-11 principles and clinical chart reviewers. Variation existed in determining the cause and the mode of the harm. Case examples exemplify the new 3-part model for ICD-11 description of hospital-related harms.

Enhancing description of hospital-conditions with ICD-11 cluster coding: Better codes for monitoring and prevention

IntroductionExposure to health care events sometimes has unintended and undesired consequences. Health care and complications arising in the course of care are diverse and complex. Representing them comprehensively in information systems is challenging, and presently beyond the bounds of practicality for routine administrative information systems that include ICD coded data. Objectives and ApproachThe ICD-11 conceptual model for hospital-acquired conditions has 3 components: 1) harm to patient 2) cause or source of harm and 3) mode or mechanism. A key feature of the Quality and Safety (Q\&S) code-set in ICD-11 is that a cluster of codes is required to represent an event or injury. Use of the term ‘cluster’ is novel in ICD-11 and so is the extent and the requirement for post-coordination. The cluster required to code a Q\&S case has three codes, one for each of the three components of the model given above. ResultsThe first component, ‘harm’, is represented by an ICD–11 diagnosis code, from any chapter of the classification. Q\&S causes or sources of harm fall into 4 types that capture events caused by substances (drugs and medicaments, etc.), procedures, devices, and a mix of other types of causes (e.g. problems associated with transfusions, incorrect diagnosis, etc.). Q\&S ‘mode or mechanism’ refers to the main way in which the ‘cause’ leads to the ‘harm’ and are specific to the type of ‘cause’ (Table 1). Table 1 - Examples of corresponding Q\&S Mode or Mechanism Cause or Source of Harm Mode or Mechanism Substance Overdose, under-dose, wrong substance. Procedure Accidental perforation of an organ during a procedure. Device Dislodgement. Malfunction. Other cause Mismatched blood. Patient dropped during transfer from OR table. Conclusion/ImplicationsThis new conceptual model for coding healthcare-related harm, dependent on the clustering of codes, has great potential to improve the clinical detail of adverse event descriptions, and the overall quality of coded health data, for better monitoring and strategies for prevention.

Training Coding Specialists for the Future: Methods and Materials for the Beta Version of ICD-11

IntroductionIn June 2018, the World Health Organization (WHO) will release the 11th Version of International Classification of Diseases (ICD-11). New training methods and materials are required. As a WHO Collaborating Center, with Canadian Institute for Health Information (CIHI) members, we trained 6 coding professionals for testing ICD-11 coding processes. Objectives and ApproachThe objective was to achieve a high level of inter-rater reliability using ICD-11 for acute care chart coding. We used Adult Learning principles with CIHI members and 6 certified coding specialists to co-create presentations, practice materials, and decision trees to teach knowledge and skill with ICD-11 tooling and content. Training involved 14 hours of interactive learning plus additional practice hours. A bank of questions and coding scenarios tested knowledge and application of ICD-11 terminology and principles. Coding was undertaken on a set of 3000 randomly selected inpatient Calgary hospital discharges as part of a large CIHR funded ICD-11 field trial. ResultsThe coding team achieved an average score of 84% on the ICD-11 coding quiz and 0.65 (0.33 -1.0) agreement on parent code of main condition for the coding quiz scenarios.  60 inpatient charts were coded by more than one coder to test inter-rater reliability.  Agreement was ≧ 0.80 for the majority of parent codes for main condition. Coding differences may be due to unfamiliar code choices or training gaps. New code descriptions in ICD-11 enhance code selection. Challenges included training while codes were being built in the ICD-11 browser, and minimal coding rules or standards. Conclusion/ImplicationsRecommendations include more code descriptions in the browser and rules in a reference guide, teaching from simple to complex conditions, and multiple scenarios with ‘gold standard’ codes for practice. Reference Guide, Coding Tool, and Browser recommendations have been shared with members of the WHO Morbidity and Quality & Safety Advisory groups.

Approaches to big data analysis of interface pressure measurements from continuous pressure imaging technology

IntroductionOver 4.5 TB of data will be collected in a randomized clinical trial assessing continuous pressure imaging technology in reducing pressure injuries. To permit efficient analysis we examined different approaches to generating a reduced representation of the data that still produced similar analytical results to the full data set. Objectives and ApproachOur primary objective was to develop an approach for reducing the pressure data to a manageable size, without loss of information. Frame by frame analysis of excluded participant imaging data allows us to identify changes in patient position. We explored different sampling frequencies (q5, 30, 60, 120, \& 240 seconds) for analysis, coalesced frames with periods of stillness, and used correlation coefficients as a measure of similarity between adjacent frames to identify patient position changes. Heat maps and plots were used to evaluate the performance characteristics and usefulness of different sampling frequencies and correlation coefficients to compress the data. ResultsA sampling frequency q60 seconds provided reasonable representation of changes in interface pressure over time. This translates to using only 1.7\% of the collected data in our analyses. When the threshold of correlation coefficient was set at 0.99 for coalescing the information based on position changes, then there was a maximum of 80 position changes detected. Therefore, approximately 160 frames q24 hours is sufficient to represent pressure states of participants at high risk of developing pressure injuries. In total we would require 480 frames (160*3) from 72 hours of collected data for our analyses without loss of position changes and pressure information. This represents approximately 0.185\% of the data collected. Conclusion/ImplicationsDecreasing the sampling frequency significantly reduced our data size without compromising resolution, while the use of correlation coefficients was effective at coalescing the continuous pressure imaging data. These methods of data reduction may be applicable to pre-processing large datasets obtained from other device monitoring technologies.

Automated Referral to Cardiac Rehabilitation following Coronary Artery Bypass Grafting is associated with limited improvements in program completion: a large cohort study

IntroductionCardiac Rehabilitation (CR) reduces residual cardiovascular risk among patients who have received coronary artery bypass grafting (CABG) surgery. However, many patients do not attend and some are never referred. It is unclear whether automated referral is associated with improved CR completion rates. Objectives and ApproachGeographically inclusive databases were linked to assess the impact of automated referral on rates of referral to and completion of CR post-CABG. Automated referral to CR post-CABG was instituted in Calgary on July 1, 2007. All subjects receiving CABG in Calgary between January 1, 1996 and March 31, 2016 were enrolled in the study. The Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) database, TotalCardiology-Rehabilitation (TC-R) database, and provincial vital statistics were linked using the unique Provincial Health Number available for each patient. The association between CR referral, completion, and survival was assessed using proportional hazard models. ResultsThere were 28,100 patients referred to the CR program, of which 26,411 were linked to the APPROACH database for a 93.99\% linkage rate. After excluding patients who did not receive CABG, a total of 8,118 patients were identified as the study population [mean age 66.2 (SD 10.2) years, 18.9\% female] during the study period: 5,103 prior to implementation of automated referral, and 3,015 post-automation. Rates of referral increased from 39.5\% prior to automation to 75.0\% post-automation (p Conclusion/ImplicationsAutomated referral to CR is associated with increased referral rates but less dramatic increases in CR completion rates post-CABG. Given the significant improvement in survival associated with CR completion, further work is needed to improve CR referral, and more importantly, CR completion rates.

Patient-Reported Outcomes Improves the Prediction of In-patient and Emergency Department Readmission Risks in Coronary Artery Disease

IntroductionCoronary Artery Disease (CAD) patients are known to report higher healthcare resource use, such as inpatient [IP] and emergency department [ED] readmissions, than the general population. We investigate if the patient reported outcome measures (PROMs) improve the accuracy of readmissions risk prediction models in CAD. Objectives and ApproachPatients enrolled in the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry between 1995 and 2014 who received catheterization (CATH) and completed baseline PROMs were linked to discharge abstract data and national ambulatory data. Logistic regression (LR) was used to develop 30-day and 1-year readmissions risk prediction models adjusting for patients’ demographic, clinical, and self-reported characteristics. PROM was measured using the 19-item Seattle Angina Questionnaire (SAQ). The discriminatory performance of each prediction model was assessed using the Harrel’s c-statistic for LR. ResultsOf the 13,264 patients who completed baseline SAQ, 59 (0.3%) had IP readmissions or ED visits within 30 days, and up to 356 (1.9%) within 1 year of baseline survey. The C-statistics for one-year readmissions risk prediction models that only adjusted for demographic and clinical variables only ranged between 56.4% and 61.2%. The prognostic improvement in the discrimination of these models ranged between 2% to 10% when patient-reported SAQ was included as predictor. The addition of SAQ improves the model discrimination in all types of admission. Conclusion/ImplicationsThe addition of PROMs improves the moderate accuracy of readmissions risk prediction models. These findings highlight the need for routine collection of PROMs in clinical settings and their potential use for aiding clinical and policy decision-making and post-discharge outcomes monitoring in the management of cardiovascular diseases.

Association of Beta-Blockers with Survival on Patients Presenting with ACS Treated with PCI: A Propensity Score Analysis from the BleeMACS Registry

PURPOSE

The aim was to evaluate prognostic value of beta-blocker (BB) administration in acute coronary syndromes (ACS) patients in the percutaneous coronary intervention (PCI) era.

METHODS AND RESULTS

The BleeMACS project is a multicenter, observational, retrospective registry enrolling patients with ACS worldwide in 15 hospitals. Patients discharged with BB therapy were compared to those discharged without a BB before and after propensity score with matching. The primary endpoint was all-cause mortality at 1 year. Secondary endpoints included in-hospital reinfarction, in-hospital heart failure, 1-year myocardial infarction, 1-year bleeding and 1-year composite of death and recurrent myocardial infarction. After matching, 2935 patients for each group were enrolled. The primary endpoint of 1-year death was significantly lower in the group on BB therapy (4.5 vs 7%, p < 0.05), while only a trend was noted for recurrent acute myocardial infarction (4.5 vs 4.9%, p = 0.54). These results were consistent for patients older than 80 years of age, for ST-elevation myocardial infarction (STEMI) patients, and for those discharged with complete versus incomplete revascularization, but not for non-STEMI/unstable angina patients.

CONCLUSIONS

BB therapy was related to 1-year lower risk of all-cause mortality, independently from completeness of revascularization, admission diagnosis, age and ejection fraction. Randomized controlled trials for patients treated with PCI for ACS should be performed.

Prediction of Post-Discharge Bleeding in Elderly Patients with Acute Coronary Syndromes: Insights from the BleeMACS Registry

BACKGROUND

A poor ability of recommended risk scores for predicting in-hospital bleeding has been reported in elderly patients with acute coronary syndromes (ACS). No study assessed the prediction of post-discharge bleeding in the elderly. The new BleeMACS score (Bleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome), was designed to predict post-discharge bleeding in ACS patients. We aimed to assess the predictive ability of the BleeMACS score in elderly patients.

METHODS

We assessed the incidence and characteristics of severe bleeding after discharge in ACS patients aged ≥ 75 years. Bleeding was defined as any intracranial bleeding or bleeding leading to hospitalization and/or red blood transfusion, occurring within the first year after discharge. We assessed the predictive ability of the BleeMACS score according to age by Fine-Gray proportional hazards regression analysis, calculating receiver-operating characteristic (ROC) curves and the area under the ROC curves (AUC).

RESULTS

The BleeMACS registry included 15,401 patients of whom 3,376/15,401 (21.9%) were aged ≥ 75 years. Elderly patients were more commonly treated with clopidogrel and less often treated with ticagrelor or prasugrel. Of 3,376 elderly patients, 190 (5.6%) experienced post-discharge bleeding. The incidence of bleeding was moderately higher in elderly patients (hazard ratio [HR], 2.31, 95% confidence interval [CI], 1.92-2.77). The predictive ability of the BleeMACS score was moderately lower in elderly patients (AUC, 0.652 vs. 0.691, p = 0.001).

CONCLUSION

Elderly patients with ACS had a significantly higher incidence of post-discharge bleeding. Despite a lower predictive ability in older patients, the BleeMACS score exhibited an acceptable performance in these patients.

Prevalence and outcome of patients with cancer and acute coronary syndrome undergoing percutaneous coronary intervention: a BleeMACS substudy

BACKGROUND

The prevalence and outcome of patients with cancer that experience acute coronary syndrome (ACS) have to be determined.

METHODS AND RESULTS

The BleeMACS project is a multicentre observational registry enrolling patients with acute coronary syndrome undergoing percutaneous coronary intervention worldwide in 15 hospitals. The primary endpoint was a composite event of death and re-infarction after one year of follow-up. Bleedings were the secondary endpoint. 15,401 patients were enrolled, 926 (6.4%) in the cancer group and 14,475 (93.6%) in the group of patients without cancer. Patients with cancer were older (70.8±10.3 vs. 62.8±12.1 years, P<0.001) with more severe comorbidities and presented more frequently with non-ST-segment elevation myocardial infarction compared with patients without cancer. After one year, patients with cancer more often experienced the composite endpoint (15.2% vs. 5.3%, P<0.001) and bleedings (6.5% vs. 3%, P<0.001). At multiple regression analysis the presence of cancer was the strongest independent predictor for the primary endpoint (hazard ratio (HR) 2.1, 1.8-2.5, P<0.001) and bleedings (HR 1.5, 1.1-2.1, P=0.015). Despite patients with cancer generally being undertreated, beta-blockers (relative risk (RR) 0.6, 0.4-0.9, P=0.05), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (RR 0.5, 0.3-0.8, P=0.02), statins (RR 0.3, 0.2-0.5, P<0.001) and dual antiplatelet therapy (RR 0.5, 0.3-0.9, P=0.05) were shown to be protective factors, while proton pump inhibitors (RR 1, 0.6-1.5, P=0.9) were neutral.

CONCLUSION

Cancer has a non-negligible prevalence in patients with acute coronary syndrome undergoing percutaneous coronary intervention, with a major risk of cardiovascular events and bleedings. Moreover, these patients are often undertreated from clinical despite medical therapy seems to be protective. Registration:The BleeMACS project (NCT02466854).

Discharge Communication and Patient Involvement are Associated with Unplanned Hospital Readmissions: Results from a Validated Hospital Experience Survey

ABSTRACTObjectivesUnplanned hospital readmissions are an indicator of quality of care, and are associated with significant costs to healthcare systems. Previous research has shown that poor communication and discharge experiences are associated with higher readmission rates. This, however, has only been examined in the short-term, and in many instances, at the hospital-level. The purpose of the study was to examine the relationship between aspects of inpatient communication and discharge instructions and unplanned readmissions at the individual-level up to one-year post-discharge. ApproachThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) telephone survey was completed by patients within 6 weeks of hospital discharge in Alberta, Canada. Survey data were linked to corresponding inpatient records using personal health number, discharge date, and facility codes. Unplanned readmissions (yes vs. no; all causes) from 43 to 365 days post-hospital discharge comprised the outcome variable. Independent variables included selected demographic characteristics, clinical variables, and five survey questions: a) patient involvement in their care decisions, b) receiving written information at discharge, c) understanding the purpose of taking medications, d) understanding responsibility for one’s health, and e) discussing help needed when returning home. Multivariate logistic regression was used to examine each question in the presence of the other predictors. Odds ratios and 95% confidence intervals were calculated. ResultsFrom April 2011 to March 2014, 24,868 patients completed a survey which was successfully linked to the corresponding inpatient record. The cohort had a mean age of 52.8±19.8 years of age (range=18-100), and was predominantly female (65.4%). 18.6% of patients (n=4,620) experienced an unplanned hospital readmission within 43 to 365 days post-discharge. Patients who felt that they were not involved in their care decisions were more likely to be readmitted (OR=1.79; 95%CI: 1.59-2.01), as were patients who did not receive written information at discharge (OR=1.96; 95%CI: 1.83-2.11). Odds of unplanned readmissions did not differ according to understanding of medications (OR=1.08; 95%CI: 0.90-1.30), understanding responsibility for one’s health (OR=1.02; 95%CI: 0.86-1.20), or discussion of help needed when returning home (OR=1.03; 95%CI: 0.93-1.14). ConclusionOur results demonstrate that a lack of patient involvement in their care and not receiving written information at discharge is associated with increased unplanned readmission rate up to one-year post-discharge. This present study provides an example of how patient-reported measures may be linked to individual-level administrative data to drive healthcare improvements. Future research examining patient-reported hospital experience and other health system measures is warranted.

A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.

Validity of Canadian discharge abstract data for hypertension and diabetes from 2002 to 2013

BACKGROUND

Surveillance using coded administrative health data has shown that the prevalence of hypertension and diabetes in Canada increased substantially between 1998 to 2008. These findings require an assumption that the validity of hypertension and diabetes coding is stable over time. We tested this assumption by examining temporal trends in the validity of coding for hypertension and diabetes in the Canadian hospital Discharge Abstract Database.

METHODS

We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database, a clinical registry, as the reference standard to evaluate the validity of the Discharge Abstract Database in recording hypertension and diabetes in Alberta. The APPROACH database contains data for all Alberta residents who have undergone cardiac catheterization and includes prospective ascertainment of comorbid conditions before each procedure. We linked patient data between the 2 databases for 2002 to 2013 using patient provincial health number. Temporal trends in sensitivity, specificity, positive predictive value, negative predictive value and Cohen κ were calculated for both hypertension and diabetes in the Discharge Abstract Database.

RESULTS

We matched 63 483 patients between the APPROACH database and the Discharge Abstract Database. The validity of the Discharge Abstract Database for hypertension and diabetes remained mostly consistent over time. Between 2002 and 2013, sensitivity, specificity, positive predictive value and negative predictive value ranged from 66% to 87% for hypertension and from 81% to 98% for diabetes; the corresponding κ scores ranged from 0.50 to 0.62 and from 0.80 to 0.89. No significant differences in the validity of coding were found across age, sex or hospital location subgroups.

INTERPRETATION

The validity of coding for hypertension and diabetes in the Discharge Abstract Database remained fairly consistent between 2002 and 2013. Our findings support the use of the Discharge Abstract Database for hypertension and diabetes surveillance in hospital settings.

The effect of a regional care model on cardiac catheterization rates in patients with Acute Coronary Syndromes

BACKGROUND

Patients with ACS often present to community hospitals without on-site cardiac catheterization and revascularization therapies. Transfer to specialized cardiac procedural centers is necessary to provide access to these procedures. We evaluated process of care within a regional care model by comparing cardiac catheterization and revascularization rates and outcomes in ACS patients presenting to community and interventional hospitals.

METHODS

We evaluated a total of 6154 patients with ACS admitted to Southern Alberta hospitals (where a distinct regional care model for ACS exists) between January 1, 2005 and December 31, 2009. We compared cardiac catheterization and revascularization rates during index hospitalization among patients admitted to community and interventional hospitals. Thirty day and 1-year survival were also evaluated.

RESULTS

Catheterization was performed more often in patients presenting to community hospitals compared to the interventional facility (respectively 69.5% and 51.4%, p < 0.0001). Catheterization within 72 hours of admission occurred in 48% of patients presenting to the interventional center and in 68.3% of community patients (P < 0.0001). In patients undergoing catheterization, revascularization (PCI and/or CABG) was also performed more frequently in the community group (74.5% vs 56.1%, P < 0.0001). Risk adjusted mortality rates were the same for patients undergoing cardiac catheterization regardless of hospital of initial presentation.

CONCLUSION

ACS patients presenting to community centers associated with a regional care model had effective access to cardiac catheterization and revascularization. These findings support the importance of regional initiatives and processes of care that facilitate access to cardiac catheterization for all ACS patients.