Brenda R. Hemmelgarn

Outcomes After Acute Myocardial Infarction in South Asian, Chinese, and White Patients

Background— Cardiac mortality rates vary substantially between countries and ethnic groups. It is unclear, however, whether South Asian, Chinese, and white populations have a variable prognosis after acute myocardial infarction (AMI). To clarify this association, we compared mortality, use of revascularization procedures, and risk of recurrent AMI and hospitalization for heart failure between these ethnic groups in a universal-access healthcare system. Methods and Results— We used a population cohort study design using hospital administrative data linked to cardiac procedure registries from British Columbia and the Calgary Health Region Area in Alberta (1994 to 2003) to identify AMI cases. Patient ethnicity was categorized using validated surname algorithms. There were 2190 South Asian, 946 Chinese, and 38479 white patients with AMI identified. There was no significant difference in use of revascularization procedures between ethnic groups at 30 d and 1 year. Short-term (30-day) mortality was higher among Chinese relative to white patients (odds ratio, 1.23; 95% confidence interval, 1.02 to 1.48). There was no significant difference in 30-day mortality between South Asian and white patients. South Asian patients had a 35% lower relative risk of long-term mortality compared with white patients (hazard ratio, 0.65; 95% confidence interval, 0.57 to 0.72). There was no significant difference in long-term mortality between Chinese and white patients. Among AMI survivors, Chinese patients had a lower risk of recurrent AMI, whereas there was no difference between South Asian and white patients. Conclusion— The ethnic groups studied have striking differences in outcomes after AMI, with South Asian patients having significantly lower long-term mortality after AMI.

Association Between Incretin-Based Drugs and the Risk of Acute Pancreatitis

ImportancenThe association between incretin-based drugs, such as dipeptidyl peptidase 4 (DPP-4) inhibitors and glucagon-like peptide 1 (GLP-1) agonists, and acute pancreatitis is controversial.nnnObjectivenTo determine whether the use of incretin-based drugs, compared with the use of 2 or more other oral antidiabetic drugs, is associated with an increased risk of acute pancreatitis.nnnDesign, Setting, and ParticipantsnA large, international, multicenter, population-based cohort study was conducted using combined health records from 7 participating sites in Canada, the United States, and the United Kingdom. An overall cohort of 1u202f532u202f513 patients with type 2 diabetes initiating the use of antidiabetic drugs between January 1, 2007, and June 30, 2013, was included, with follow-up until June 30, 2014.nnnExposuresnCurrent use of incretin-based drugs compared with current use of at least 2 oral antidiabetic drugs.nnnMain Outcomes and MeasuresnNested case-control analyses were conducted including hospitalized patients with acute pancreatitis matched with up to 20 controls on sex, age, cohort entry date, duration of treated diabetes, and follow-up duration. Hazard ratios (HRs) and 95% CIs for hospitalized acute pancreatitis were estimated and compared current use of incretin-based drugs with current use of 2 or more oral antidiabetic drugs. Secondary analyses were performed to assess whether the risk varied by class of drug (DPP-4 inhibitors and GLP-1 agonists) or by duration of use. Site-specific HRs were pooled using random-effects models.nnnResultsnOf 1u202f532u202f513 patients included in the analysis, 781u202f567 (51.0%) were male; mean age was 56.6 years. During 3u202f464u202f659 person-years of follow-up, 5165 patients were hospitalized for acute pancreatitis (incidence rate, 1.49 per 1000 person-years). Compared with current use of 2 or more oral antidiabetic drugs, current use of incretin-based drugs was not associated with an increased risk of acute pancreatitis (pooled adjusted HR, 1.03; 95% CI, 0.87-1.22). Similarly, the risk did not vary by drug class (DPP-4 inhibitors: pooled adjusted HR, 1.09; 95% CI, 0.86-1.22; GLP-1 agonists: pooled adjusted HR, 1.04; 95% CI, 0.81-1.35) and there was no evidence of a duration-response association.nnnConclusions and RelevancenIn this large population-based study, use of incretin-based drugs was not associated with an increased risk of acute pancreatitis compared with other oral antidiabetic drugs.

Patient, family physician and community pharmacist perspectives on expanded pharmacy scope of practice: a qualitative study

BACKGROUNDnThe RxEACH trial was a randomized trial to evaluate the efficacy of community pharmacy-based case finding and intervention in patients at high risk for cardiovascular (CV) events. Community-dwelling patients with poorly controlled risk factors were identified and their CV risk reduced through patient education, prescribing and follow-up by their pharmacist. Perspectives of patients, family physicians and community pharmacists were obtained regarding pharmacists identification and management of patients at high risk for CV events, to identify strategies to facilitate implementation of the pharmacists expanded role in routine patient care.nnnMETHODSnWe used a qualitative methodology (individual semistructured interviews) with conventional qualitative content analysis to describe perceptions about community pharmacists care of patients at high risk for CV events. Perceptions were categorized into macro (structure), meso (institution) and micro (practice) health system levels, based on a conceptual framework of care for optimizing scopes of practice.nnnRESULTSnWe interviewed 48 participants (14 patients, 13 family physicians and 21 community pharmacists). Patients were supportive of the expanded scope of practice of pharmacists. All participant groups emphasized the importance of communication, ability to share patient information, trust and better understanding of the roles, responsibilities, accountabilities and liabilities of the pharmacist within their expanded role.nnnINTERPRETATIONnDespite support from patients and changes to delivery of care in primary care settings, ongoing efforts are needed to understand how to best harmonize family physician and community pharmacist roles across the health system. This will require collaboration and input from professional associations, regulatory bodies, pharmacists, family physicians and patients.

Implementation of an intervention to reduce population-based screening for vitamin D deficiency: a cross-sectional study

BACKGROUNDnWe describe the implementation of an intervention in Alberta in support of the Choosing Wisely Canada recommendation against population screening for vitamin D deficiency (as determined by serum total 25-hydroxyvitamin D testing). We hypothesized that the introduction of a specialized requisition for vitamin D testing would reduce the annual number of vitamin D tests performed.nnnMETHODSnWe performed a cross-sectional observational study that included all vitamin D tests ordered in Alberta between Apr. 1, 2015, and Mar. 31, 2016. There were no exclusion criteria. A special requisition for ordering vitamin D tests in Alberta was introduced on Apr. 1, 2015. Using an interrupted time series model, we compared predicted versus observed vitamin D test volumes for the 12-month period following the introduction of the new requisition. The sole outcome measure was the monthly change in volume of vitamin D testing. In addition, we calculated any cost savings as a result of reduced testing.nnnRESULTSnOver the first 12 months of the intervention, there was a reduction in the number of tests ordered from a predicted 342u202f477 tests to 29u202f525 tests (91.4% reduction). This decrease represented a direct spending decrease of Can

Development of a conceptual framework for understanding financial barriers to care among patients with cardiovascular-related chronic disease: a protocol for a qualitative (grounded theory) study

938u202f856-

Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study

1u202f564u202f760 per year in Alberta.nnnINTERPRETATIONnA provincially led implementation of a Choosing Wisely Canada recommendation resulted in a large and sustained reduction in serum total 25-hydroxyvitamin D testing in Alberta. This study shows that provincially led interventions based on Choosing Wisely Canada recommendations can result in substantial reductions in laboratory tests.

Association Between Glycemic Control and Adverse Outcomes in People With Diabetes Mellitus and Chronic Kidney Disease

BACKGROUNDnPatients with cardiovascular-related chronic diseases may face financial barriers to accessing health care, even in Canada, where universal health care insurance is in place. No current theory or framework is adequate for understanding the impact of financial barriers to care on these patients or how they experience financial barriers. The overall objective of this study is to develop a framework for understanding the role of financial barriers to care in the lives of patients with cardiovascular-related chronic diseases and the impact of such barriers on their health.nnnMETHODSnWe will perform an inductive qualitative grounded theory study to develop a framework to understand the effect of financial barriers to care on patients with cardiovascular-related chronic diseases. We will use semistructured interviews (face-to-face and telephone) with a purposive sample of adult patients from Alberta with at least 1 of hypertension, diabetes, heart disease or stroke. We will analyze interview transcripts in triplicate using grounded theory coding techniques, including open, focused and axial coding, following the principle of constant comparison. Interviews and analysis will be done iteratively to theoretical saturation. Member checking will be used to enhance rigour.nnnINTERPRETATIONnA comprehensive framework for understanding financial barriers to accessing health care is instrumental for both researchers and clinicians who care for patients with chronic diseases. Such a framework would enable a better understanding of patient behaviour and nonadherence to recommended medical therapies and lifestyle modifications.

Comparison of survival among older adults with kidney failure treated versus not treated with chronic dialysis

BACKGROUNDnThere are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary.nnnMETHODSnWe conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value.nnnRESULTSnOf 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment.nnnINTERPRETATIONnOverall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.