To determine the association of non-invasive cardiac stress testing before elective intermediate to high risk non-cardiac surgery with survival and hospital stay.
Population based retrospective cohort study.
Acute care hospitals in Ontario, Canada, between 1 April 1994 and 31 March 2004.
Patients aged 40 years or older who underwent specific elective intermediate to high risk non-cardiac surgical procedures.
Non-invasive cardiac stress testing performed within six months before surgery.
Postoperative one year survival and length of stay in hospital.
Of the 271 082 patients in the entire cohort, 23 991 (8.9%) underwent stress testing. After propensity score methods were used to reduce important differences between patients who did or did not undergo preoperative stress testing and assemble a matched cohort (n=46 120), testing was associated with improved one year survival (hazard ratio (HR) 0.92, 95% CI 0.86 to 0.99; P=0.03) and reduced mean hospital stay (difference -0.24 days, 95% CI -0.07 to -0.43; P
Institute for Clinical Evaluative Sciences, Keenan Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, 200 Elizabeth St, Toronto, ON M5G 2C4, Canada. firstname.lastname@example.org
Preoperative consultations by internal medicine physicians facilitate documentation of comorbid disease, optimization of medical conditions, risk stratification, and initiation of interventions intended to reduce risk. Nonetheless, the impact of these consultations, which may be performed by general internists or specialists, on outcomes is unclear.
We used population-based administrative databases to conduct a cohort study of patients 40 years or older who underwent major elective noncardiac surgery in Ontario, Canada, between 1994 and 2004. Propensity scores were used to assemble a matched-pairs cohort that reduced differences between patients who did and did not undergo preoperative consultation by general internists or specialists. The association of consultation with mortality and hospital stay was determined within this matched cohort. As a sensitivity analysis, we evaluated the association of consultation with an outcome for which no difference would be expected: postoperative wound infection.
Of 269,866 patients in the cohort, 38.8% (n=104,695) underwent consultation. Within the matched cohort (n=191,852), consultation was associated with increased 30-day mortality (relative risk [RR], 1.16; 95% confidence interval [CI], 1.07-1.25; number needed to harm, 516), 1-year mortality (1.08; 1.04-1.12; number needed to harm, 227), mean hospital stay (difference, 0.67 days; 0.59-0.76), preoperative testing, and preoperative pharmacologic interventions. Notably, consultation was not associated with any difference in postoperative wound infections (RR, 0.98; 95% CI, 0.95-1.02). These findings were stable across subgroups as well as sensitivity analyses that tested for unmeasured confounding.
Medical consultation before major elective noncardiac surgery is associated with increased mortality and hospital stay, as well as increases in preoperative pharmacologic interventions and testing. These findings highlight the need to better understand mechanisms by which consultation influences outcomes and to identify efficacious interventions to decrease perioperative risk.
Little information is available on recent population-based trends in the outcomes of patients who have had an acute myocardial infarction (AMI) in Canada.
Data were analyzed from the Discharge Abstract Database and Hospital Morbidity Database of the Canadian Institute for Health Information. All new cases of AMI in Canada between fiscal 1997/98 and fiscal 1999/2000 of patients at least 20 years old were examined. Data were also analyzed from these databases for hospital readmissions for a second AMI, angina and congestive heart failure (CHF).
There were 139,523 new AMI cases. The overall crude in-hospital AMI mortality rate in Canada was 12.3%. In-hospital mortality rate after an AMI was worse for women than for men in Canada (16.7% and 9.9%, respectively). The age- and sex-standardized in-hospital mortality rate varied from a low of 10.5% (95% CI 8.4% to 12.6%) in Prince Edward Island to a high of 13.1% (95% CI 12.8% to 13.5%) in Quebec. Among AMI survivors, 12.5% were readmitted within one year for angina, 7.7% for a second AMI and 7.5% for CHF. There were wide interregional differences in age- and sex-standardized mortality rates and one-year readmission rates.
AMI is associated with a substantial acute mortality rate in Canada, especially in the elderly and female patients. Identifying the causes of interregional differences in patient outcomes should be a priority for future research.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. Electronic address: email@example.com.
We aimed to describe the demographics, care, and outcomes of patients with atrial fibrillation in the emergency department (ED), as well as temporal changes over time.
In this retrospective cohort study, we used a province-wide database to identify all adult patients who were treated in a nonpediatric ED in the province of Ontario with a primary diagnosis of atrial fibrillation, April 2002 to March 2010. We determined the frequency and rate of ED visits and assessed patient demographics, ED care, and outcomes, both overall and by year.
During the 8-year study period, 113,786 patients made 143,003 ED visits for atrial fibrillation, accounting for 0.5% of all ED visits. The annual number of ED visits increased from 15,931 to 20,168 (29.4%; 95% confidence interval [CI] 28.7% to 30.1%) between 2002 and 2010, whereas the crude rate increased from 172 per 100,000 to 195 per 100,000 persons. Median age was 72.0 years (Interquartile range 61.0 to 80.0 years) and 50.8% were women, which did not change significantly during the study period. The percentage of index ED visits with a physician billing for cardioversion increased from 6.3% (95% CI 5.9% to 6.7%) to 11.8% (95% CI 11.3% to 12.3%). Although the percentage of patients with a CHADS2 score greater than or equal to 2 increased from 49.3% (95% CI 48.4% to 50.2%) to 53.6% (95% CI 52.9% to 54.4%) and high-acuity ED triage scores increased from 41.1% (95% CI 40.2% to 42.0%) to 62.5% (95% CI 61.7% to 63.2%), hospital admissions decreased from 48.1% (95% CI 47.3% to 49.0%) to 38.4% (95% CI 37.6% to 39.2%). Thirty-day mortality was 3.3% (95% CI 3.2% to 3.4%) and showed a slight downward trend during the study period (P=.05), whereas subsequent hospitalizations within 30 days for atrial fibrillation or stroke (2.8%; 95% CI 2.7% to 2.9%) and repeated ED visits (7.3%; 95% CI 7.1% to 7.4%) remained unchanged.
The number of ED visits for atrial fibrillation increased markedly during an 8-year period. Although it appears that slightly higher-risk patients are being treated in the province's EDs, fewer patients are being admitted to the hospital, and mortality rates have not increased.
Comment In: Ann Emerg Med. 2013 Dec;62(6):578-923948746
In single-center studies, consultation by an anesthesiologist days to weeks before surgery was associated with reduced patient anxiety, case cancellations on the day of surgery, and duration of hospitalization. Nonetheless, the impact of anesthesia consultation on outcomes in the population remains unclear.
We used population-based, linked, administrative databases to conduct a cohort study of patients, aged 40 years and older, who underwent selected elective intermediate- to high-risk noncardiac surgical procedures in Ontario, Canada, between April 1, 1994, and March 31, 2004. Propensity-score methods were used to construct a matched-pairs cohort that resolved important differences between patients who underwent consultation and those who did not. We then determined the association of consultation (within 60 days before surgery) with hospital length of stay and postoperative mortality (30-day and 1-year) rates within the matched pairs.
Of the 271 082 patients in the entire cohort, 39% (n = 104 716) underwent anesthesia consultation. The proportion of patients who underwent consultation increased from 19% in 1994 to 53% in 2003. Within the matched-pairs (n = 180 254), consultation was associated with reduced mean hospital length of stay (8.17 days vs 8.52 days; difference, -0.35 days; 95% confidence interval [CI], -0.27 to -0.43; P
Multidisciplinary heart failure (HF) clinics are efficacious in clinical trials. Our objectives were to compare real-world outcomes of patients with HF treated in HF clinics versus usual therapy and identify HF clinic features associated with improved outcomes.
The service components at all HF clinics in Ontario, Canada, were quantified using a validated instrument and categorized as high/medium/low intensity. We used propensity-scores to match HF clinic and control patients discharged alive after a HF readmission in 2006-2007. Outcomes were mortality, and both all-cause and HF readmission. Cox-proportional hazard models were used to evaluate HF clinic-level characteristics associated with improved outcomes. We identified 14 468 patients with HF, of whom 1288 were seen in HF clinics. Within 4 years of follow-up, 52.1% of patients treated at a HF clinic died versus 54.7% of control patients (P=0.02). Patients treated at HF clinics had increased readmissions (87.4% versus 86.6% for all-cause [P=0.009]; 58.7% versus 47.3% for HF related [P4 contacts of significant duration for 6 months) were associated with lower mortality (hazard ratio, 0.14; P
To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario.
We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Multivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics.
Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P
The population-based results of off-pump coronary artery bypass surgery (OPCAB) in a public health care system have not been reported.
The study objective was to compare the one-year outcomes of OPCAB with those of the standard on-pump coronary artery bypass surgery (ONCAB) in the province of Ontario.
The present study was a retrospective, population-based study (n=15,172, with 1660 OPCAB patients) undertaken in fiscal years 2000 and 2001 using clinical and administrative data. Multivariate regression modelling for risk adjustment and propensity matching were used to compare OPCAB with ONCAB for one-year outcomes, including death, repeat revascularization and cardiac readmission.
The rate of OPCAB was 11%, with institutional rates ranging from 3% to 51%. OPCAB patients were more likely to be female and older than 79 years of age, with peripheral vascular disease and higher socioeconomic status. OPCAB patients were less likely to have surgically significant coronary disease, poor left ventricular function, an urgent status, congestive heart failure and diabetes. The risk-adjusted one-year composite outcome was higher for OPCAB (11.8%, 95% CI 10.40% to 13.29%) than ONCAB (10.8%, 95% CI 10.23% to 11.27%); however, this difference was eliminated with propensity matching. OPCAB patients had shorter hospital lengths of stay and lower blood product transfusion rates than ONCAB patients.
Despite the minimal use of OPCAB in Canada's public health care system, outcome rates are similar to those of ONCAB. The benefits of OPCAB observed in randomized trials, including shorter hospital lengths of stay and lower transfusion rates, remained true in the investigators' real-world experience. The results OPCAB were at least equivalent to those of ONCAB.