Abstract Atrial fibrillation (AF) is an extremely common clinical problem with an important population morbidity and mortality burden. The management of AF is complex and fraught with many uncertain ...and contentious issues, which are being addressed by extensive ongoing basic and clinical research. The Canadian Cardiovascular Society AF Guidelines Committee produced an extensive set of evidence-based AF management guidelines in 2010 and updated them in the areas of anticoagulation and rate/rhythm control in 2012. In late 2013, the committee judged that sufficient new information regarding AF management had become available since 2012 to warrant an update to the Canadian Cardiovascular Society AF Guidelines. After extensive evaluation of the new evidence, the committee has updated the guidelines for: (1) stroke prevention principles; (2) anticoagulation of AF patients with chronic kidney disease; (3) detection of AF in patients with stroke; (4) investigation and management of subclinical AF; (5) left atrial appendage closure in stroke prevention; (6) emergency department management of AF; (7) periprocedural anticoagulation management; and (8) rate and rhythm control including catheter ablation. This report presents the details of the updated recommendations, along with their background and rationale. In addition, a complete set of presently applicable recommendations, those that have been updated and those that remain in force from previous guideline versions, is provided in the Supplementary Material.
Summary Background The effectiveness of quality improvement (QI) strategies on diabetes care remains unclear. We aimed to assess the effects of QI strategies on glycated haemoglobin (HbA1c ), ...vascular risk management, microvascular complication monitoring, and smoking cessation in patients with diabetes. Methods We identified studies through Medline, the Cochrane Effective Practice and Organisation of Care database (from inception to July 2010), and references of included randomised clinical trials. We included trials assessing 11 predefined QI strategies or financial incentives targeting health systems, health-care professionals, or patients to improve management of adult outpatients with diabetes. Two reviewers independently abstracted data and appraised risk of bias. Findings We reviewed 48 cluster randomised controlled trials, including 2538 clusters and 84 865 patients, and 94 patient randomised controlled trials, including 38 664 patients. In random effects meta-analysis, the QI strategies reduced HbA1c by a mean difference of 0·37% (95% CI 0·28–0·45; 120 trials), LDL cholesterol by 0·10 mmol/L (0·05–0.14; 47 trials), systolic blood pressure by 3·13 mm Hg (2·19–4·06, 65 trials), and diastolic blood pressure by 1·55 mm Hg (0·95–2·15, 61 trials) versus usual care. We noted larger effects when baseline concentrations were greater than 8·0% for HbA1c , 2·59 mmol/L for LDL cholesterol, and 80 mm Hg for diastolic and 140 mm Hg for systolic blood pressure. The effectiveness of QI strategies varied depending on baseline HbA1c control. QI strategies increased the likelihood that patients received aspirin (11 trials; relative risk RR 1·33, 95% CI 1·21–1·45), antihypertensive drugs (ten trials; RR 1·17, 1·01–1·37), and screening for retinopathy (23 trials; RR 1·22, 1·13–1·32), renal function (14 trials; RR 128, 1·13–1·44), and foot abnormalities (22 trials; RR 1·27, 1·16–1·39). However, statin use (ten trials; RR 1·12, 0·99–1·28), hypertension control (18 trials; RR 1·01, 0·96–1·07), and smoking cessation (13 trials; RR 1·13, 0·99–1·29) were not significantly increased. Interpretation Many trials of QI strategies showed improvements in diabetes care. Interventions targeting the system of chronic disease management along with patient-mediated QI strategies should be an important component of interventions aimed at improving diabetes management. Interventions solely targeting health-care professionals seem to be beneficial only if baseline HbA1c control is poor. Funding Ontario Ministry of Health and Long-term Care and the Alberta Heritage Foundation for Medical Research (now Alberta Innovates—Health Solutions).
Abstract Background Identifying patients with atrial fibrillation (AF) using administrative data is important for epidemiologic and outcomes research. Although administrative data cover large ...populations, it is necessary to assess their validity in identifying AF patients. Methods We used Ontario family physician electronic medical records from the E lectronic M edical R ecord A dministrative data L inked D atabase (EMRALD) as a reference standard to assess the accuracy of administrative data algorithms in identifying patients with AF. From a random sample of 7500 adult patients, patients with AF as recorded in family physician records were identified. Results The optimal algorithm consisted of any of: hospitalization or an emergency room code for AF or prescription for an AF-specific antiarrhythmic agent or billing code for cardioversion, or prescription for an anticoagulant that was accompanied by a physician billing code. for arrhythmia. The algorithm sensitivity was 80.7% (95% confidence interval CI, 75.1-86.3), specificity 99.1% (95% CI, 98.9-99.3), positive predictive value 71.1% (95% CI, 65.1-77.1), and negative predictive value 99.5% (95% CI, 99.3-99.7). This algorithm, applied to the Ontario population, resulted in a calculated increase in AF prevalence from 1.68% to 2.36% over the years 2000-2014. Anticoagulation rates for AF patients increased from 53% in 2011 to 60% in 2014. Among AF patients receiving anticoagulants, novel oral anticoagulant utilization increased from < 5% in 2011 to > 50% in 2014. Conclusions Identifying patients with AF can be done using administrative data, and the algorithm can be used to assess trends in disease burden over time and patterns of care in large populations.
ABSTRACT INTRODUCTION More than half of older adults (age ≥ 65 yr) have 2 or more high-burden multimorbidity conditions (i.e., highly prevalent chronic diseases, which are associated with increased ...health care utilization; these include diabetes DM, dementia, depression, chronic obstructive pulmonary disease COPD, cardiovascular disease CVD, arthritis, and heart failure HF), yet most existing interventions for managing chronic disease focus on a single disease or do not respond to the specialized needs of older adults. We conducted a systematic review and meta-analysis to identify effective multimorbidity interventions compared with a control or usual care strategy for older adults. METHODS We searched bibliometric databases for randomized controlled trials (RCTs) evaluating interventions for managing multiple chronic diseases in any language from 1990 to December 2017. The primary outcome was any outcome specific to managing multiple chronic diseases as reported by studies. Reviewer pairs independently screened citations and full-text articles, extracted data and assessed risk of bias. We assessed statistical and methodological heterogeneity and performed a meta-analysis of RCTs with similar interventions and components. RESULTS We included 25 studies (including 15 RCTs and 6 cluster RCTs) (12 579 older adults; mean age 67.3 yr). In patients with depression + COPD or CVD + DM, care-coordination strategies significantly improved depressive symptoms (standardized mean difference −0.41; 95% confidence interval CI −0.59 to −0.22; I2 = 0%) and reduced glycosylated hemoglobin (HbA1c ) levels (mean difference −0.51; 95% CI −0.90 to −0.11; I2 = 0%), but not mortality (relative risk RR 0.79; 95% CI 0.53 to 1.17; I2 = 0%). Among secondary outcomes, care-coordination strategies reduced functional impairment in patients with arthritis + depression (between-group difference −0.82; 95% CI −1.17 to −0.47) or DM + depression (between-group difference 3.21; 95% CI 1.78 to 4.63); improved cognitive functioning in patients with DM + depression (between-group difference 2.44; 95% CI 0.79 to 4.09) or HF + COPD ( p = 0.006); and increased use of mental health services in those with DM + (CVD or depression) (RR 2.57; 95% CI 1.90 to 3.49; I2 = 0%). INTERPRETATION Subgroup analyses showed that older adults with diabetes and either depression or cardiovascular disease, or with coexistence of chronic obstructive pulmonary disease and heart failure, can benefit from care-coordination strategies with or without education to lower HbA1c , reduce depressive symptoms, improve health-related functional status, and increase the use of mental health services. Protocol registration PROSPERO-CRD42014014489
Abstract There is considerable variation in the quality of colonoscopy, attributable in part to endoscopist performance. Audit and feedback (A&F) provides health professionals with a summary of their ...performance over a period of time and is a common strategy used to improve provider performance. In this review, we discuss current understanding of the mechanism of A&F and describe specific features of effective A&F. To date, trials of A&F to improve colonoscopy performance report heterogeneous results, in part because colonoscopy is a complex procedural skill but also because the quality improvement interventions were sub-optimally implemented or inadequately evaluated. Nonetheless, evidence from a wide range of literature suggests that A&F has the potential to improve endoscopist performance. We discuss future directions for research in this area and provide guidance for providers or health system planners wishing to implement A&F to address quality of colonoscopy in their practice and/or jurisdiction.
To help health providers identify and close the gaps between ideal evidence-based practices and the care routinely received by patients, health systems often use audit and feedback, which involves ...reporting to health providers on their performance to highlight where improvement efforts may be needed. Little is known about how best to involve patients in the development of such initiatives. Here, Ivers et al discuss their Health Quality Ontario project which aims to ensure that audit and feedback initiatives were aligned with patient priorities.
Abstract Background Surveillance for stroke/transient ischemic attack (TIA) using administrative data has traditionally been limited to reporting patients who had an acute event and were ...hospitalized. This underestimates the true prevalence because many events do not result in hospitalization. We examined whether the accuracy of administrative data for identifying prevalent stroke/TIA could be improved by using data from both inpatient and outpatient visits. Methods An administrative data validation reference standard was developed through chart abstraction of 5000 adult patients randomly sampled from 73,014 patients of 83 family physicians who participate in the Electronic Medical Record Administrative Data Linked Database (EMRALD), in Ontario, Canada. Results The prevalence of stroke/TIA in our adult population was 3.0%. An algorithm of 1 hospital record had a sensitivity of 35.3% (27.7%-43.0%) and specificity of 99.8% (99.7%-99.9%), whereas an algorithm of 2 physician billings within 1 year or 1 hospitalization had a sensitivity of 68.0% (95% confidence interval CI, 60.5%-75.5%) and specificity of 98.9% (95% CI, 98.6%-99.2%) for the identification of patients who had ever had a stroke/TIA. We found that hospitalization data underestimated the prevalence of stroke by > 50% and TIA by > 66% compared with using both hospitalization and physician claims data. Conclusions The use of outpatient physician claims data in addition to hospitalization data improves the sensitivity of administrative data for the identification of prevalent stroke/TIA and may be used to estimate the prevalence of cerebrovascular events in large populations and over time.
ABSTRACT BACKGROUND The 1-year mortality rate in patients with heart failure who are discharged from an emergency department is 20%. We sought to determine whether early follow-up after discharge ...from the emergency department was associated with decreased mortality or subsequent admission to hospital. METHODS This retrospective cohort study conducted in Ontario, Canada, included adult patients who were discharged from 1 of 163 emergency departments between April 2007 and March 2014 with a primary diagnosis of heart failure. Using a propensity score–matched landmark analysis, we assessed follow-up in relation to mortality and admissions to hospital for cardiovascular conditions. RESULTS Of 34 519 patients, 16 274 (47.1%) obtained follow-up care within 7 days and 28 846 (83.6%) within 30 days. Compared with follow-up between day 8 and 30, patients with follow-up care within 7 days had a lower rate of mortality over 1 year (hazard ratio HR 0.92; 95% confidence interval CI 0.87–0.97), and a reduced rate of admission to hospital over 90 days (HR 0.87, 95% CI 0.80–0.94) and 1 year (HR 0.92; 95% CI 0.87–0.97); the mortality rate over 90 days in this group trended to a lower rate (HR 0.90, 95% CI 0.10–1.00). Follow-up care within 30 days, compared with patients without 30-day follow-up, was associated with a reduction in 1-year mortality (HR 0.89, 95% CI 0.82–0.97) but not admission to hospital (HR 1.02, 95% CI 0.94–1.10). In this group, there was a trend toward an increase in 90-day admission to hospital (HR 1.14, 95% CI 1.00–1.29). INTERPRETATION Follow-up care within 7 days of discharge from the emergency department was associated with lower rates of long-term mortality, as well as subsequent hospital admissions, and a trend to lower short-term mortality rates. Timely access to longitudinal care for patients with heart failure who are discharged from the emergency setting should be prioritized.
Background Guidelines recommend cardiac rehabilitation and long-term use of cardiac medications for most patients who have had a myocardial infarction (MI), but adherence to these secondary ...prevention treatments is suboptimal. Methods This is a multicenter, pragmatic, 3-arm randomized trial. Eligible patients (n = 2,742) with obstructive coronary artery disease are randomized post-MI to usual care or 1 of 2 intervention arms. Patients in the first intervention arm receive mail-outs sent on behalf of their cardiologist at 4, 8, 20, 32, and 44 weeks post-MI; content is designed to address determinants of adherence and facilitate discussion between the patient and their health care team. Patients in the second intervention arm receive mail-outs plus automated interactive voice response system telephone calls 2 weeks after each letter, as well as a telephone call by trained lay health workers if the interactive voice response system identifies challenges with adherence. Outcomes are assessed 12 months post-MI via patient self-report and administrative data sources. Co-primary outcomes are adherence to cardiac medications and completion of cardiac rehabilitation. Secondary outcomes include cardiovascular events and mortality. An embedded, theory-informed process evaluation will explore the mechanism of action; an economic evaluation is also planned. Conclusions We describe a complete program evaluation of a highly pragmatic, health-system intervention to support adherence to recommended treatments. Research ethics boards approved waiver of consent for patients enrolled in the trial with provision of multiple opportunities to opt out and a debrief at the time of outcome assessment. The methods used here may provide a model for similar interventions.
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