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Case selection and appropriateness of coronary angiography and coronary artery bypass graft surgery in British Columbia and Ontario.

https://arctichealth.org/en/permalink/ahliterature209152
Source
Can J Cardiol. 1997 Mar;13(3):246-52
Publication Type
Article
Date
Mar-1997
Author
G M Anderson
S P Pinfold
J E Hux
C D Naylor
Author Affiliation
Institute for Clinical Evaluative Sciences, North York, Ontario. geoff@ices.on.ca
Source
Can J Cardiol. 1997 Mar;13(3):246-52
Date
Mar-1997
Language
English
Publication Type
Article
Keywords
Aged
British Columbia
Confounding Factors (Epidemiology)
Coronary Angiography - standards
Coronary Artery Bypass - standards
Female
Humans
Male
Medical Records
Middle Aged
Ontario
Patient Selection
Retrospective Studies
Abstract
To compare the types of patients selected for coronary angiography (CA) and coronary artery bypass graft (CABG) surgery, and the appropriateness of the procedures performed on these patients in a random sample of cases in British Columbia and Ontario.
Retrospective randomized medical record review.
All hospitals performing CA and/or CABG in British Columbia and Ontario in fiscal year 1989/90.
For CA, 395 randomly selected patients in Ontario and 139 randomly selected patients in British Columbia; for CABG, 431 randomly selected patients in Ontario and 125 randomly selected patients in British Columbia.
Case selection was measured in terms of the demographic and clinical characteristics of patients undergoing the procedures. Appropriateness was measured by comparing the clinical characteristics of patients undergoing the procedures with explicit criteria established by a panel of Canadian physicians. The yield from CA was measured as the proportion of patients who were found to have insignificant anatomical disease.
Analysis of patients selected for CA showed that sample patients from Ontario were less likely than those from British Columbia to be female (25% versus 37%, respectively, P = 0.012) and less likely to have undergone a previous revascularization (12% versus 24%, respectively, P = 0.005). The distribution of main indications for CA differed between the two provinces (P = 0.002), with Ontario patients more likely to have chronic stable angina (45% versus 24%) and less likely to have unstable angina (16% versus 26%). For CABG, sample patients from Ontario were less likely to be 65 years of age or older (32% versus 45%, P = 0.016) and more likely to have an ejection fraction less than 35% (14% versus 5%, P = 0.006). The distribution of the main indications for CABG differed (P
PubMed ID
9117912 View in PubMed
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Coronary artery bypass graft surgery and primary percutaneous coronary intervention choices in patients with similar coronary anatomy: A computer-based simulation examines the sex gap.

https://arctichealth.org/en/permalink/ahliterature147495
Source
Can J Cardiol. 2009 Nov;25(11):649-53
Publication Type
Article
Date
Nov-2009
Author
B M Meyers
T. Vira
Chi- Ming Chow
B L Abramson
Author Affiliation
St Michael's Hospital, University of Toronto, Toronto, Canada.
Source
Can J Cardiol. 2009 Nov;25(11):649-53
Date
Nov-2009
Language
English
Publication Type
Article
Keywords
Aged
Angioplasty, Balloon, Coronary - standards - trends
Attitude of Health Personnel
Cardiology - standards - trends
Computer simulation
Confidence Intervals
Coronary Artery Bypass - standards - trends
Coronary Artery Disease - mortality - radiography - therapy
Female
Health Care Surveys
Hospitals, University
Humans
Male
Middle Aged
Ontario
Physician's Practice Patterns - standards - trends
Pilot Projects
Probability
Quality of Health Care
Questionnaires
Risk assessment
Severity of Illness Index
Sex Factors
Survival Analysis
Treatment Outcome
Abstract
Sex differences (or a 'sex gap') exist in the rates of cardiac revascularization. It was evaluated whether physician preference contributes to this difference.
To obtain information on how cardiac specialists manage male and female patients being evaluated for coronary artery disease.
A computer-based patient simulation program was developed. Six sex-matched clinical vignettes (three pairs) with uninterpreted coronary angiograms were shown to specialists, who were blinded to the purpose of the study. The sex-matched scenarios were balanced with respect to symptoms, comorbidities and coronary anatomy. Physicians were surveyed on management and rationale.
Fifty physicians were surveyed, consisting mainly of cardiologists from tertiary cardiac centres in Ontario. Among the three sexmatched pairs, the frequencies at which percutaneous coronary intervention (including drug-eluting stents), bypass surgery and medical therapy were chosen did not differ across sexes. The means for men and women, respectively, were 47% and 50% for percutaneous coronary intervention, 32% and 26% for bypass surgery, and 21% and 24% for medical treatment.
In the present pilot study, cardiac specialists chose similar rates of medical, interventional and surgical procedures independent of a patient's sex. Although large registry trials show that sex differences in management exist, the present data suggest that cardiac specialist preference is less likely to be a factor if coronary angiography was performed. Further research is required to explore the causes of sex discrepancies in cardiac care.
Notes
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PubMed ID
19898697 View in PubMed
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Coronary artery bypass graft surgery in Newfoundland and Labrador.

https://arctichealth.org/en/permalink/ahliterature205621
Source
CMAJ. 1998 May 5;158(9):1137-42
Publication Type
Article
Date
May-5-1998
Author
G A Fox
J. O'Dea
P S Parfrey
Author Affiliation
Patient Research Center, General Hospital, Memorial University of Newfoundland, St. John's, Nfld.
Source
CMAJ. 1998 May 5;158(9):1137-42
Date
May-5-1998
Language
English
Publication Type
Article
Keywords
Cohort Studies
Coronary Angiography
Coronary Artery Bypass - standards - statistics & numerical data
Coronary Disease - radiography - surgery
Decision Making
Delivery of Health Care - organization & administration - standards
Female
Humans
Male
Middle Aged
Newfoundland and Labrador
Patient Selection
Reproducibility of Results
Retrospective Studies
Rural Population
Time Factors
Waiting Lists
Abstract
Newfoundland and Labrador, like other health care jurisdictions, is faced with widening gaps between the demands for health care and a strained ability to supply the necessary resources. The authors carried out a study to determine the rates of appropriate and inappropriate coronary artery bypass grafting (CABG) in the province and the waiting times for this surgery.
This retrospective cohort study was performed in the tertiary care hospital that receives all referrals for coronary angiography and coronary artery revascularization for Newfoundland and Labrador. By reviewing the hospital records, the authors identified 2 groups of patients: those in whom critical coronary artery disease was diagnosed on the basis of coronary angiography and who were referred for CABG between Apr. 1, 1994, and Mar. 31, 1995, and those who actually underwent the procedure during that period. By applying specific criteria developed by the RAND Corporation, the authors determined the appropriateness and necessity of CABG in each case. They also compared waiting times for CABG with optimal waiting times; as determined by a consensus-based priority score.
A total of 338 patients underwent CABG during the study period. The cases were characterized by multivessel disease and late-stage angina symptoms. Almost all of the patients had high appropriateness scores (7-9), and nearly 95% had high necessity scores (7-9). However, during the study period, the waiting list increased by about 20%, because a total of 391 patients were referred by the weekly cardiovascular surgery conference; the authors identified these and an additional 31 patients as having necessity scores of 7 or more. Only 7 (23%) of 31 patients for whom CABG was considered very urgent underwent surgery within the recommended 24 hours, and only 30 (24%) of the 122 patients for whom CABG was considered urgent underwent surgery within the recommended 72 hours.
These results provide evidence that the cardiac surgery program in Newfoundland and Labrador is performing CABG in patients for whom surgical revascularization is highly appropriate and necessary. Access to CABG is less than ideal, however, since the waiting list continues to expand, and many patients wait beyond the recommended time for surgery.
Notes
Cites: Ann Intern Med. 1996 Jul 1;125(1):8-188644996
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Comment In: CMAJ. 1998 May 5;158(9):1151-39597966
PubMed ID
9597964 View in PubMed
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Do operator volumes relate to clinical outcomes after percutaneous coronary intervention in the Canadian health care system?

https://arctichealth.org/en/permalink/ahliterature170017
Source
Am Heart J. 2006 Apr;151(4):902-8
Publication Type
Article
Date
Apr-2006
Author
Warren J Cantor
Ruth Hall
Jack V Tu
Author Affiliation
University of Toronto, Toronto, Ontario, Canada. cantorw@smh.toronto.on.ca
Source
Am Heart J. 2006 Apr;151(4):902-8
Date
Apr-2006
Language
English
Publication Type
Article
Keywords
Aged
Angioplasty, Balloon, Coronary - standards - utilization
Clinical Competence
Comorbidity
Coronary Artery Bypass - standards - utilization
Coronary Disease - epidemiology - therapy
Female
Hospital Mortality
Humans
Logistic Models
Male
Middle Aged
National Health Programs - standards - utilization
Ontario
Outcome Assessment (Health Care)
Abstract
Many US studies have documented an association between operator volume and outcomes after percutaneous coronary intervention (PCI). No study has assessed whether this relationship exists in Canada, where PCI is performed only at a limited number of regional centers and operator volumes are higher.
All PCI procedures performed in the province of Ontario from 1995 to 2001 were analyzed using administrative databases. The outcomes of interest were coronary artery bypass graft during the same hospitalization, mortality at 30 days, or the combined end point.
A total of 38,561 PCI procedures were performed by 65 physicians at 8 centers. Over the study period, risk-adjusted coronary artery bypass graft rates fell from 2.0% in 1995 to 0.7% in 2000 (P 195 cases) volume, there were no significant linear relationships between risk-adjusted outcomes and operator terciles. No significant correlations were seen between individual PCI volume and risk-adjusted rates of mortality, bypass surgery, or the combined end point (P = .2, P = .35, and P = .95, respectively).
In contrast to US studies, there does not appear to be an association between PCI volume and outcomes in Ontario. These findings may be related to the high annual volumes of most operators and institutions within Ontario.
PubMed ID
16569560 View in PubMed
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Effect of specialty and nationality on panel judgments of the appropriateness of coronary revascularization: a pilot study.

https://arctichealth.org/en/permalink/ahliterature53936
Source
Med Care. 2001 May;39(5):513-20
Publication Type
Article
Date
May-2001
Author
S J Bernstein
P. Lázaro
K. Fitch
M D Aguilar
J P Kahan
Author Affiliation
Health Services Research Unit, Instituto de Salud Carlos III, Madrid, Spain. sbernste@umich.edu
Source
Med Care. 2001 May;39(5):513-20
Date
May-2001
Language
English
Publication Type
Article
Keywords
Angioplasty, Transluminal, Percutaneous Coronary - standards - utilization
Attitude of Health Personnel
Cardiology
Coronary Artery Bypass - standards - utilization
Coronary Disease - classification - diagnosis - therapy
Cross-Cultural Comparison
Great Britain
Health Services Misuse
Humans
Netherlands
Patient Selection
Practice Guidelines
Quality of Health Care
Regression Analysis
Research Support, Non-U.S. Gov't
Residence Characteristics
Severity of Illness Index
Spain
Sweden
Switzerland
Thoracic Surgery
Utilization Review
Abstract
BACKGROUND: Appropriateness criteria are frequently used to assess quality of care. However, assessing care in one country with criteria developed in another may be misleading. One approach to measuring care across countries would be to develop common standards using physicians from different countries and specialties. OBJECTIVE: To identify the degree to which appropriateness ratings for coronary revascularization developed by a multinational panel differ by panelist specialty and nationality. METHODS: A 13-member panel of cardiothoracic surgeons and cardiologists from the Netherlands, Spain, Sweden, Switzerland, and the United Kingdom was convened to rate the appropriateness of 842 indications for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft surgery (CABG) on a 1 (extremely inappropriate) to 9 (extremely appropriate) scale. MEASURES: Mean appropriateness ratings by panelist specialty and nationality. RESULTS: Surgeons' mean ratings for PTCA indications ranged from 0.64 points lower than the corresponding ratings of the cardiologists for acute myocardial infarction indications to 1.22 points lower for chronic stable angina indications. Conversely, their ratings for bypass surgery indications ranged from 0.59 points higher for chronic stable angina indications to 0.69 points higher for unstable angina indications. Although Spanish panelists' ratings were significantly higher than the mean for 3 of the 4 clinical conditions treated by PTCA, their ratings were similar for bypass surgery indications. No specific patterns were observed in the ratings of the panelists from the other countries. CONCLUSIONS: These findings support the use of physicians from multiple specialties on appropriateness panels because they represent more divergent views than physicians from a single specialty. Finding no systematic difference in beliefs regarding the appropriateness of PTCA and CABG among physicians from different countries will require confirmation before multinational panels supplant single country panels in future studies.
PubMed ID
11317099 View in PubMed
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Ethics of queuing for coronary artery bypass grafting in Canada.

https://arctichealth.org/en/permalink/ahliterature217133
Source
CMAJ. 1994 Oct 1;151(7):949-53
Publication Type
Article
Date
Oct-1-1994
Author
Jafna L Cox
Author Affiliation
Division of Cardiology, Victoria General Hospital, Dalhousie University, Halifax.
Source
CMAJ. 1994 Oct 1;151(7):949-53
Date
Oct-1-1994
Language
English
Publication Type
Article
Keywords
Canada
Consensus
Coronary Artery Bypass - standards - utilization
Costs and Cost Analysis
Decision Making
Delivery of Health Care
Diagnosis
Ethics, Medical
General Surgery
Guidelines as Topic
Health Care Rationing
Health Services Accessibility - standards
Heart diseases
Humans
Moral Obligations
Morbidity
Mortality
Patient Advocacy
Patient Selection
Peer Review
Physician's Role
Physicians
Prognosis
Public Policy
Resource Allocation
Risk
Risk assessment
Risk factors
Social Justice
Social Responsibility
Stress, Psychological
Triage
Waiting Lists
Notes
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PubMed ID
11652836 View in PubMed
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[Mortality, recurrent angina pectoris and late myocardial infarction in patients surgically treated for coronary heart disease]

https://arctichealth.org/en/permalink/ahliterature54316
Source
Tidsskr Nor Laegeforen. 1998 Oct 20;118(25):3939-43
Publication Type
Article
Date
Oct-20-1998
Author
O. Risum
J L Svennevig
S. Nitter-Hauge
K. Levorstad
M. Abdelnoor
Author Affiliation
Kirurgisk avdeling A, Rikshospitalet, Oslo.
Source
Tidsskr Nor Laegeforen. 1998 Oct 20;118(25):3939-43
Date
Oct-20-1998
Language
Norwegian
Publication Type
Article
Keywords
Angina Pectoris - diagnosis - etiology - mortality - surgery
Cohort Studies
Coronary Artery Bypass - standards
Coronary Disease - complications - diagnosis - mortality - surgery
English Abstract
Female
Humans
Male
Myocardial Infarction - diagnosis - etiology
Myocardial Revascularization
Norway
Prognosis
Quality Assurance, Health Care
Recurrence
Risk factors
Abstract
This cohort study includes 1,025 patients operated between 1982 and 1986 at Rikshospitalet, the National Hospital of Norway, 912 men and 113 women. The closing date was 1 January 1993. A total of 31 patients (3%) died within 30 days of operation. Independent risk factors were atrial fibrillation, previous heart surgery, mitral insufficiency, left main stem stenosis, unstable angina pectoris and elevated end-diastolic pressure. Among the 164 patients (16%) who died more than 30 days after operation, the independent risk factors of total mortality were atrial fibrillation, concomitant resection of left ventricular aneurysm, left main stem stenosis, NYHA functional class IV on admission, elevated end-diastolic pressure and prolonged cross-clamping time. Recurrent angina pectoris was experienced by 146 patients (14.2%) while 102 patients had non-fatal myocardial infarction. The cumulative incidence of these conditions was initially low, but began to increase four year after operation. The independent risk factor for these two end-points was hypertension. The study suggests that stratification of independent risk factors facilitates comparison of mortality in different centres and permits improved quality control.
PubMed ID
9830339 View in PubMed
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Quality of care of international and Canadian medical graduates in acute myocardial infarction.

https://arctichealth.org/en/permalink/ahliterature175989
Source
Arch Intern Med. 2005 Feb 28;165(4):458-63
Publication Type
Article
Date
Feb-28-2005
Author
Dennis T Ko
Peter C Austin
Benjamin T B Chan
Jack V Tu
Author Affiliation
Division of Cardiology and Schulich Heart Centre, Sunnybrook and Women's College Health Sciences Centre, Ontario, Canada.
Source
Arch Intern Med. 2005 Feb 28;165(4):458-63
Date
Feb-28-2005
Language
English
Publication Type
Article
Keywords
Adult
Aged
Aged, 80 and over
Angioplasty, Balloon, Coronary - standards - statistics & numerical data
Angiotensin-Converting Enzyme Inhibitors - therapeutic use
Cardiac Catheterization - standards - statistics & numerical data
Cardiology - education - standards
Cohort Studies
Coronary Artery Bypass - standards - statistics & numerical data
Female
Foreign Medical Graduates - standards
Humans
Male
Middle Aged
Multivariate Analysis
Myocardial Infarction - mortality - therapy
Ontario
Physician's Practice Patterns - standards
Quality of Health Care
Retrospective Studies
Risk Adjustment - statistics & numerical data
Survival Analysis
Survival Rate
Abstract
International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established.
We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians' service payments, hospital discharge abstracts, and patients' vital status. We included 127,275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates.
Of the 127,275 admitted AMI patients, 28,061 (22.0%) were treated by IMGs and 99,214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate-treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year.
The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients.
PubMed ID
15738378 View in PubMed
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[Rational transfusion therapy. A study of transfusion practice and possibilities of optimization in elective coronary bypass surgery].

https://arctichealth.org/en/permalink/ahliterature210362
Source
Ugeskr Laeger. 1996 Dec 9;158(50):7237-40
Publication Type
Article
Date
Dec-9-1996
Author
K. Højlund
L I Andersen
M S Hüttel
C. Lahrmann
T. Kristensen
J. Georgsen
Author Affiliation
Odense Universitetshospital, Klinisk immunologisk afdeling.
Source
Ugeskr Laeger. 1996 Dec 9;158(50):7237-40
Date
Dec-9-1996
Language
Danish
Publication Type
Article
Keywords
Adult
Aged
Blood Transfusion - standards
Coronary Artery Bypass - standards
Denmark
Female
Humans
Male
Middle Aged
Physician's Practice Patterns
Questionnaires
Surgical Procedures, Elective
Abstract
The objective of the study was to evaluate the effect of intervention on physicians' transfusion behavior in elective coronary artery bypass grafting (CABG). We analyzed transfusion data on 176 patients who underwent primary elective CABG during two periods, either before (phase one, n = 102) or after (phase two, n = 74) intervention. The intervention was based on cooperation with the involved department of cardiac surgery, interviews of the surgeons and anaesthesiologists ordering blood, and concurrent audit of transfusion practice using a blood order form. The proportion af patients receiving allogenic transfusions decreased from 90% in phase one to 58% in phase two and the total use of blood components was reduced from an average of 6.3 units/patient to 2.7 units/patient, p
PubMed ID
9012040 View in PubMed
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13 records – page 1 of 2.