Search

Background: Gradients that link socioeconomic status and cardiovascular mortality have been observed in many populations, including those of countries that provide publicly funded comprehensive medical coverage. The intermediary causes of such gradients remain poorly elucidated.Objective: To examine the relationships among socioeconomic status, other health factors, and 2-year mortality rates after acute myocardial infarction (MI).Design: Prospective cohort study.Setting: Ontario, Canada.Patients: 3407 patients who were hospitalized for acute MI in 53 large-volume hospitals in Canada from December 1999 to February 2003.Measurements: The authors obtained self-reported measures of income and education and developed profiles of the patients' prehospitalization cardiac risks and comorbid conditions. To create these profiles, the authors used the patients' self-reports and retrospectively linked no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, ethnicity, social support, cardiovascular history and risk, comorbid conditions, and selected in-hospital process factors.Results: Income was strongly and inversely correlated with 2-year mortality rate (crude hazard ratio for high-income vs. low-income tertile, 0.45 [95% CI, 0.35 to 0.57]; P < 0.001). However, after adjustment for age and preexisting cardiovascular events or conventional vascular risk factors, the effect of income was greatly attenuated (adjusted hazard ratio for high-income vs. low-income tertile, 0.77 [CI, 0.54 to 1.10]; P = 0.150). Noncardiovascular comorbid conditions and in-hospital process factors had negligible explanatory effect.Limitations: Previous cardiovascular risks were ascertained through self-report or retrospectively through the longitudinal tracking of the hospitals' administrative databases. The study began with a cohort of patients who had an index cardiac event rather than with asymptomatic individuals.Conclusions: Age, past cardiovascular events, and current vascular risk factors accounted for most of the income-mortality gradient after acute MI. This observation suggests that the "wealth-health gradient" in cardiovascular mortality may be partially ameliorated by more rigorous management of known risk factors among less affluent persons. *For a list of members of the SESAMI Study Group, see the Appendix. [ABSTRACT FROM AUTHOR]

Objectives: The goal of our study was to examine how age and gender affect the use of coronary angiography and the intensity of cardiac follow-up care within the first year after acute myocardial infarction (AMI). Another objective was to evaluate the association of age, gender and treatment intensity with five-year survival after AMI.Background: Utilization rates of specialized cardiac services inversely correlate with age. Gender-specific practice patterns may also vary with age in a manner similar to known age-gender survival differences after AMI.Methods: Using linked population-based administrative data, we examined the association of age and gender with treatment intensity and long-term survival among 25,697 patients hospitalized with AMI in Ontario between April 1, 1992, and December 31, 1993. A Cox proportional hazards model was used to adjust for socioeconomic status, illness severity, attending physician specialty and admitting hospital characteristics.Results: After adjusting for baseline differences, the relative rates of angiography and follow-up specialist care for women relative to men, respectively, fell 17.5% (95% confidence interval [CI], 13.6 to 21.3, p < 0.001) and 10.2% (95% CI, 7.1 to 13.2, p < 0.001) for every 10-year increase in age. Conversely, long-term AMI survival rates in women relative to men improved with increasing age, such that the relative survival in women rose 14.2% (95% CI, 10.1 to 17.5, p < 0.001) for every 10-year age increase.Conclusions: Gender differences in the intensity of invasive testing and follow-up care are strongly age-specific. While care becomes progressively less aggressive among older women relative to men, survival advantages track in the opposite direction, with older women clearly favored. These findings suggest that biology is likely to remain the main determinant of long-term survival after AMI for women. [ABSTRACT FROM AUTHOR]

This series provides clinicians with strategies and tools to interpret and integrate evidence from published research in their care of patients. The 2 key principles for applying all the articles in this series to patient care relate to the value-laden nature of clinical decisions and to the hierarchy of evidence postulated by evidence-based medicine. Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused on management recommendations. An evidence-based practitioner must also understand the patient's circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; conduct an efficient literature search; critically appraise the research evidence; and apply that evidence to patient care. However, treatment judgments often reflect clinician or societal values concerning whether intervention benefits are worth the cost. Many unanswered questions concerning how to elicit preferences and how to incorporate them in clinical encounters constitute an enormously challenging frontier for evidence-based medicine. Time limitation remains the biggest obstacle to evidence-based practice but clinicians should seek evidence from as high in the appropriate hierarchy of evidence as possible, and every clinical decision should be geared toward the particular circumstances of the patient. [ABSTRACT FROM AUTHOR]

Clinicians rely on knowledge about the clinical manifestations of disease to make clinical diagnoses. Before using research on the frequency of clinical features found in patients with a disease, clinicians should appraise the evidence for its validity, results, and applicability. For validity, 4 issues are important-how the diagnoses were verified, how the study sample relates to all patients with the disease, how the clinical findings were sought, and how the clinical findings were characterized. Ideally, investigators will verify the presence of disease in study patients using credible criteria that are independent of the clinical manifestations under study. Also, ideally the study patients will represent the full spectrum of the disease, undergo a thorough and consistent search for clinical findings, and these findings will be well characterized in nature and timing. The main results of these studies are expressed as the number and percentages of patients with each manifestation. Confidence intervals can describe the precision of these frequencies. Most clinical findings occur with only intermediate frequency, and since these frequencies are equivalent to diagnostic sensitivities, this means that the absence of a single finding is rarely powerful enough to exclude the disease. Before acting on the evidence, clinicians should consider whether it applies to their own patients and whether it has been superseded by new developments. Detailed knowledge of the clinical manifestations of disease should increase clinicians' ability to raise diagnostic hypotheses, select differential diagnoses, and verify final diagnoses. JAMA. 2000;284:869-875 [ABSTRACT FROM AUTHOR]

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84 [ABSTRACT FROM AUTHOR]

Driven by fiscal pressures in the 1990s, Canada's provincial Medicare systems cut inpatient care, expanded community services, and consolidated hospitals under regional authorities in nine of ten provinces. Public confidence has been badly shaken by the transition. No province has successfully integrated services across the continuum of care. Home care and prescription drug coverage vary from province to province. Efforts to reform physician payment have stalled, and capacity to measure and manage the quality of care is generally underdeveloped. Thus, for the next few years, policymakers must stabilize the acute care sector, while cautiously pursuing an agenda of piece-meal reforms. [ABSTRACT FROM AUTHOR]

Objectives: To examine the relationship between birth weight and mode of delivery among women with untreated borderline gestational diabetes mellitus (GDM), treated overt GDM, and normoglycemia.Design: Prospective cohort study.Setting: Three Toronto, Ontario teaching hospitals.Patients: A total of 3778 volunteers aged 24 years or older.Interventions: Subjects underwent a 3-hour long, 100-g oral glucose tolerance test at 28 weeks' gestation, regardless of screening test results. Usual care was provided to 143 women who met the National Diabetes Data Group criteria for GDM. Physicians were blinded to glucose tolerance test results for all others, including 115 untreated women with borderline GDM by the broader criteria of Carpenter and Coustan.Main Outcome Measures: Crude and adjusted rates of cesarean delivery and neonatal macrosomia (birth weight >4000 g).Results: Compared with normoglycemic controls, the untreated borderline GDM group had increased rates of macrosomia (28.7% vs 13.7%, P<.001) and cesarean delivery (29.6% vs 20.2%, P=.02). Cesarean delivery in this subgroup was associated with macrosomia (45.5% vs 23.5%, P=.03). Usual care of known GDM normalized birth weights, but the cesarean delivery rate was about 33% whether macrosomia was present or absent. A clearly increased risk of cesarean delivery among treated patients compared with normoglycemic controls persisted after adjustment for multiple maternal risk factors (adjusted odds ratio, 2.1; 95% confidence interval, 1.3 to 3.6).Conclusions: Infant macrosomia was a mediating factor in high cesarean delivery rates for women with untreated borderline GDM. While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment. [ABSTRACT FROM AUTHOR]

Objectives: To review the evidence regarding indications for pulmonary artery catheterization (PAC) in critically ill patients, and to propose a guideline-generating process that would encourage randomized controlled trials of PAC.Data Sources: Computerized and manual search for randomized trials involving PAC as an integral part of the protocol, published as of October 1992. Manual search for guidelines endorsed by specialty societies and/or proposed by expert panels following an explicit group process.Data Synthesis: Four trials suggest benefit from PAC for pre- or perioperative management of high-risk surgical patients. Two others indicate that PAC for low-risk aortic aneurysm surgery confers no advantages. Use of PAC to guide therapy aimed at improved mixed venous oxygen saturation was beneficial compared with usual care with PAC in two small trials among patients with septic shock and severe trauma. Other PAC indications are either untested or inadequately tested by small trials. Large trials are needed, but trials to date have been impeded by clinicians' uncertainty about PAC and unwillingness to randomize critically ill patients. No published guidelines for PAC have used a formal group process and/or a hierarchical review of evidence to demarcate proven from unproven indications.Conclusions: We propose a research-promoting expert panel on indications for PAC. Aided by a critical literature review, experts would rate case scenarios on the need for routine PAC with or without a specified intervention strategy. Future trials should test indications where there is either consensus about the uncertainty of need for PAC, or interpanelist disagreement owing to inconclusive evidence. This process could facilitate practice guideline development, utilization management, and large trials of PAC and related interventions. [ABSTRACT FROM AUTHOR]

Objectives: This study was designed to determine whether admission to a Canadian hospital with on-site revascularization (invasive hospital) affected revascularization choice, timing, and outcome compared with community (non-invasive) hospitals.Background: Health care systems in Canada are characterized by relative restraint in diffusion of tertiary cardiovascular services, with capacity for revascularization procedures concentrated in large regional referral centers.Methods: We used linked administrative data and a clinical registry to follow-up 15,166 Ontario patients who underwent revascularization within the year after their index acute myocardial infarction (MI). Outcomes included recurrent urgent cardiac hospitalization, hospital bed-days, and death within the same year after the index admission. We adjusted for age, gender, socioeconomic status, illness severity, attending physician specialty, and academic hospital affiliation.Results: After adjusting for baseline factors, patients admitted to invasive hospitals were more likely to receive angioplasty than bypass surgery (adjusted odd ratio: 1.85; 95% confidence interval: 1.68 to 2.04, p < 0.001). The converse pattern was seen for patients admitted to community hospitals. Median revascularization waiting times were significantly shorter at invasive hospitals (12 vs. 48 days, p < 0.001). Patients admitted to invasive hospitals had fewer cardiac re-admissions (41.5 vs. 68.9 events per 100 patients, p < 0.001) before their first revascularization and consumed fewer hospital bed-days (379 vs. 517 per 100 patients, p < 0.001). There were no differences in outcomes beyond revascularization.Conclusions: Outcome advantages associated with timely post-MI revascularization highlight the importance of organizing revascularization referral networks and facilitating access to revascularization for patients with acute coronary syndromes admitted to community hospitals in Canada. [ABSTRACT FROM AUTHOR]

Objective: In the United States, clear partisan differences in responses to COVID-19 have been shown in leadership and elite cueing at the state level as well as in perspectives and behaviours of the citizenry. This study probes differences in political values-particularly the prevalence of laissez-faire attitudes-that might explain the stronger social consensus on pandemic countermeasures seen in Canada., Methods: Data were obtained from temporally aligned waves of cross-sectional surveys of Canadian and US adults in the first year of the pandemic. Survey questions were used to construct an index of laissez-faire attitudes (LFA) which, along with demographic variables and measures of partisanship, was incorporated into regression models to predict three outcomes: practice of personal mitigation measures (e.g. mask wearing), level of worry about the pandemic, and likeliness to get a vaccine., Results: LFA scores had a strong negative relationship to all three outcomes for Canadians and Americans, albeit with larger effects among the Americans on two outcomes. Overall differences in LFA scores between Americans and Canadians were modest (0.04 on a 0-1 scale). However, Republican Party stalwarts had considerably higher LFA scores and were proportionally more numerous than Conservative loyalists in Canada. While there were partisan differences in LFA scores within Canada, the largest gap by far was between Republicans and Democrats in the USA. Respondents from Canada's Prairie provinces had slightly higher average LFA scores but there were no significant residence effects on outcomes., Conclusion: Laissez-faire attitudes that may conflict with public health values and measures are much more prevalent in the USA than in Canada. This difference underpins the limited effects of political partisanship and broad consensus in the Canadian public's responses to the pandemic., (© 2023. The Author(s) under exclusive license to The Canadian Public Health Association.)

Competing Interests: Competing interests: Fahad Razak is Scientific Director and Arthur Slutsky is a member of the Ontario COVID-19 Science Advisory Table. Fahad Razak reports holding a salary award as the Graham Farquharson Knowledge Translation Fellow from the PSI Foundation and is an employee of Ontario Health and Public Health Ontario. Dr. Razak has also received grants (outside the current article) to study COVID-19 from the Canadian Institute of Health Research, Canadian Frailty Network, the University of Toronto (including the Department of Medicine, St. Michael’s Hospital and the Sunnybrook Health Sciences Centre), the Digital Research Alliance of Canada (Data Champions Pilot Project) and the Royal College of Physicians and Surgeons of Canada. David Naylor is volunteer Co-Chair of Canada’s COVID-19 Immunity Task Force, a federally funded and mandated group. Dr. Naylor reports receiving salary support from the Department of Medicine, University of Toronto. Arthur Slutsky is Chair of the International ECMO Network. Dr. Slutsky reports receiving consulting fees regarding the development of drugs to treat COVID-19 from Altimmune, Apeiron, GSK, Cellenkos, Edesa, Exvastat and Translate Bio. Dr. Slutsky also reports membership of safety committees in relation to treatments for COVID-19, from Diffusion Pharmaceuticals and Faron. No other competing interests were declared.

Competing Interests: Intérêts concurrents: Aucun déclaré.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.