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Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study.

https://arctichealth.org/en/permalink/ahliterature145763
Source
BMJ. 2010;340:b5526
Publication Type
Article
Date
2010
Author
Duminda N Wijeysundera
W Scott Beattie
Peter C Austin
Janet E Hux
Andreas Laupacis
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ontario M4N 3M5, Canada. d.wijeysundera@utoronto.ca
Source
BMJ. 2010;340:b5526
Date
2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Exercise Test - methods - mortality
Female
Heart Diseases - diagnosis - mortality
Humans
Intraoperative Complications - mortality - prevention & control
Length of Stay
Male
Middle Aged
Ontario
Preoperative Care - methods - mortality
Retrospective Studies
Stress, Physiological
Survival Analysis
Abstract
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
Notes
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Comment In: BMJ. 2010;340:b540120083544
PubMed ID
20110306 View in PubMed
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Outcomes and processes of care related to preoperative medical consultation.

https://arctichealth.org/en/permalink/ahliterature141659
Source
Arch Intern Med. 2010 Aug 9;170(15):1365-74
Publication Type
Article
Date
Aug-9-2010
Author
Duminda N Wijeysundera
Peter C Austin
W Scott Beattie
Janet E Hux
Andreas Laupacis
Author Affiliation
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. d.wijeysundera@utoronto.ca
Source
Arch Intern Med. 2010 Aug 9;170(15):1365-74
Date
Aug-9-2010
Language
English
Publication Type
Article
Keywords
Adult
Aged
Case-Control Studies
Chronic Disease
Comorbidity
Confidence Intervals
Confounding Factors (Epidemiology)
Female
Humans
Internal Medicine
Length of Stay - statistics & numerical data
Male
Middle Aged
Odds Ratio
Ontario - epidemiology
Outcome and Process Assessment (Health Care)
Preoperative Care - methods - standards - statistics & numerical data
Referral and Consultation - statistics & numerical data
Retrospective Studies
Risk assessment
Sensitivity and specificity
Surgical Procedures, Operative - mortality
Abstract
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.
Notes
Comment In: Arch Intern Med. 2011 Feb 28;171(4):368; author reply 368-921357818
Comment In: Arch Intern Med. 2011 Feb 28;171(4):367-8; author reply 368-921357817
PubMed ID
20696963 View in PubMed
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Outcomes of acute myocardial infarction in Canada.

https://arctichealth.org/en/permalink/ahliterature184367
Source
Can J Cardiol. 2003 Jul;19(8):893-901
Publication Type
Article
Date
Jul-2003
Author
Jack V Tu
Peter C Austin
Woganee A Filate
Helen L Johansen
Susan E Brien
Louise Pilote
David A Alter
Author Affiliation
Sunnybrook and Women's College Health Sciences Centre, Toronto, Canada. tu@ices.on.ca
Source
Can J Cardiol. 2003 Jul;19(8):893-901
Date
Jul-2003
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Aged
Aged, 80 and over
Angina Pectoris - epidemiology - therapy
Canada - epidemiology
Cohort Studies
Female
Heart Failure - epidemiology - ethnology
Hospital Mortality
Humans
Length of Stay
Male
Middle Aged
Myocardial Infarction - epidemiology - therapy
Patient Readmission
Quality of Health Care
Severity of Illness Index
Sex Factors
Treatment Outcome
United States - epidemiology
Abstract
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.
PubMed ID
12876609 View in PubMed
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A population-based description of atrial fibrillation in the emergency department, 2002 to 2010.

https://arctichealth.org/en/permalink/ahliterature112630
Source
Ann Emerg Med. 2013 Dec;62(6):570-577.e7
Publication Type
Article
Date
Dec-2013
Author
Clare L Atzema
Peter C Austin
Eli Miller
Alice S Chong
Lingsong Yun
Paul Dorian
Author Affiliation
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: clare.atzema@ices.on.ca.
Source
Ann Emerg Med. 2013 Dec;62(6):570-577.e7
Date
Dec-2013
Language
English
Publication Type
Article
Keywords
Age Factors
Aged
Aged, 80 and over
Atrial Fibrillation - epidemiology - therapy
Emergency Service, Hospital - statistics & numerical data
Female
Humans
Length of Stay
Male
Middle Aged
Ontario - epidemiology
Retrospective Studies
Severity of Illness Index
Sex Factors
Triage - statistics & numerical data
Abstract
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.
Notes
Comment In: Ann Emerg Med. 2013 Dec;62(6):578-923948746
PubMed ID
23810031 View in PubMed
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A population-based study of anesthesia consultation before major noncardiac surgery.

https://arctichealth.org/en/permalink/ahliterature151906
Source
Arch Intern Med. 2009 Mar 23;169(6):595-602
Publication Type
Article
Date
Mar-23-2009
Author
Duminda N Wijeysundera
Peter C Austin
W Scott Beattie
Janet E Hux
Andreas Laupacis
Author Affiliation
Department of Anesthesia, Toronto General Hospital and University of Toronto, ON, Canada. d.wijeysundera@utoronto.ca
Source
Arch Intern Med. 2009 Mar 23;169(6):595-602
Date
Mar-23-2009
Language
English
Publication Type
Article
Keywords
Aged
Anesthesia - mortality
Anesthesiology - organization & administration - statistics & numerical data
Cohort Studies
Female
Hospital Mortality
Humans
Length of Stay - statistics & numerical data
Male
Middle Aged
Ontario - epidemiology
Referral and Consultation
Retrospective Studies
Abstract
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
PubMed ID
19307523 View in PubMed
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A population-based study to evaluate the effectiveness of multidisciplinary heart failure clinics and identify important service components.

https://arctichealth.org/en/permalink/ahliterature118222
Source
Circ Heart Fail. 2013 Jan;6(1):68-75
Publication Type
Article
Date
Jan-2013
Author
Harindra C Wijeysundera
Gina Trubiani
Xuesong Wang
Nicholas Mitsakakis
Peter C Austin
Dennis T Ko
Douglas S Lee
Jack V Tu
Murray Krahn
Author Affiliation
Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Ontario, Canada. wijeysundera@gmail.com
Source
Circ Heart Fail. 2013 Jan;6(1):68-75
Date
Jan-2013
Language
English
Publication Type
Article
Keywords
Aged
Community Health Centers - organization & administration
Female
Follow-Up Studies
Heart Failure - epidemiology - therapy
Humans
Length of Stay - statistics & numerical data
Male
Morbidity - trends
Ontario - epidemiology
Patient Admission - statistics & numerical data
Quality Assurance, Health Care - trends
Registries
Retrospective Studies
Abstract
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
PubMed ID
23230307 View in PubMed
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Processes and outcomes of care for diabetic acute myocardial infarction patients in Ontario: do physicians undertreat?

https://arctichealth.org/en/permalink/ahliterature185663
Source
Diabetes Care. 2003 May;26(5):1427-34
Publication Type
Article
Date
May-2003
Author
David A Alter
Yaariv Khaykin
Peter C Austin
Jack V Tu
Janet E Hux
Author Affiliation
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. david.alter@ices.on.ca
Source
Diabetes Care. 2003 May;26(5):1427-34
Date
May-2003
Language
English
Publication Type
Article
Keywords
Aged
Databases, Factual
Delivery of Health Care - standards
Diabetic Angiopathies - therapy
Female
Follow-Up Studies
Geography
Hospitals, Teaching
Humans
Income
Length of Stay
Male
Myocardial Infarction - epidemiology - mortality - therapy
Ontario - epidemiology
Quality Assurance, Health Care
Reproducibility of Results
Survival Analysis
Time Factors
Treatment Outcome
Abstract
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
PubMed ID
12716800 View in PubMed
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The real-world outcomes of off-pump coronary artery bypass surgery in a public health care system.

https://arctichealth.org/en/permalink/ahliterature164491
Source
Can J Cardiol. 2007 Mar 15;23(4):281-6
Publication Type
Article
Date
Mar-15-2007
Author
Veena Guru
Kevin W Glasgow
Stephen E Fremes
Peter C Austin
Kevin Teoh
Jack V Tu
Author Affiliation
Institute for Clinical Evaluative Sciences, Division of Cardiovascular Surgery, University of Toronto, Ontario. veena.guru@utoronto.ca
Source
Can J Cardiol. 2007 Mar 15;23(4):281-6
Date
Mar-15-2007
Language
English
Publication Type
Article
Keywords
Aged
Aged, 80 and over
Coronary Artery Bypass - statistics & numerical data
Coronary Artery Bypass, Off-Pump - statistics & numerical data
Female
Heart Diseases - surgery
Humans
Length of Stay - statistics & numerical data
Male
Middle Aged
Multivariate Analysis
Odds Ratio
Ontario
Retrospective Studies
Risk Adjustment
Treatment Outcome
Abstract
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.
Notes
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PubMed ID
17380221 View in PubMed
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8 records – page 1 of 1.