Peter C. Austin

Longer Wait Times Increase Overall Mortality in Patients With Bladder Cancer

PURPOSE We used population level data to determine the impact of extended wait times on the survival of patients who underwent radical cystectomy for bladder cancer. MATERIALS AND METHODS We identified 2,535 patients who underwent cystectomy for bladder cancer in Ontario, Canada between 1992 and 2004 using administrative databases. A Cox proportional hazards model accounting for patient, pathological and health services variables that could affect wait times was created to assess the impact of wait time on survival. The tumor stage specific impact of waiting for cystectomy was also assessed. Cox regression analysis that modeled wait time using cubic splines was used to determine a maximum wait time within which optimal care can be provided. RESULTS Median wait time from transurethral bladder resection to cystectomy was 50 days. Unadjusted and adjusted analyses demonstrated that prolonged wait times were significantly associated with a lower overall survival rate. The relative hazard of death with increasing wait times appeared greater for low stage vs high stage cancers. The cubic splines regression analysis revealed that the risk of death began to increase after 40 days. CONCLUSIONS Treatment delay between transurethral bladder tumor resection and radical cystectomy resulted in worse overall survival. The effect of wait time was greatest in lower stage lesions. The suggested maximum wait time from transurethral bladder tumor resection to cystectomy was 40 days. Further studies assessing disease-free survival are required to corroborate these findings.

Presentation blood glucose and death, hospitalization, and future diabetes risk in patients with acute heart failure syndromes.

Purpose The prognostic implications of blood glucose on a wide range of outcomes including early mortality, hospitalizations, and incident diabetes diagnoses have not been fully elucidated in acute heart failure syndromes (AHFS). Methods In a population-based cohort of 16 524 AHFS patients presenting to the emergency department (ED) in Ontario, Canada between 2004 and 2007, we performed a competing risk analysis for 30-day mortality, new diabetes diagnoses, and hospitalization outcomes. Presentation blood glucose concentrations were categorized as follows: 3.9–6.1 [referent], >6.1–7.8, >7.8–9.4, >9.4–11.1, and >11.1 mmol/L. Results Among AHFS patients without diabetes presenting to the ED (n = 9275), blood glucose >6.1 mmol/L (n = 5252, 56.6%) was associated with increased risks of all-cause death [hazard ratio (HR) range: 1.26 (95% CI 1.05–1.50) to 1.50 (95% CI 1.11–2.02)], and cardiovascular death [HR range: 1.28 (95% CI 1.03–1.59) to 1.64 (95% CI 1.16–2.33)]. Among AHFS patients with diabetes (n = 7249), presenting blood glucose >11.1 mmol/L (n = 2286, 31.5%) was associated with increased risks of all-cause death (HR 1.48, 95% CI 1.10–2.00) and diabetes-related hospitalizations (HR 1.39, 95% CI; 1.20–1.61). Presentation blood glucose >9.4 mmol/L was associated with increased risks of hospitalization for HF or cardiovascular causes [HR range: 1.09 (95% CI 1.02–1.17) to 1.15 (95% CI 1.07–1.24)] in all patients. With higher presentation blood glucose, the risk of incident diabetes diagnosis increased, with adjusted HRs of 1.61 (>6.1–7.8 mmol/L) to 3.61 (>11.1 mmol/L) among those without the condition at baseline (all P < 0.001). Conclusions Mildly elevated presentation blood glucose was associated with early death, future diabetes, and hospitalizations for diabetes, HF, and cardiovascular causes among patients with AHFS.

Incident atrial fibrillation in the emergency department in Ontario: a population-based retrospective cohort study of follow-up care

BACKGROUND Continuity of care has been shown to be poor following in-hospital discharge, and there are substantially fewer resources to facilitate follow-up care arrangements after discharge from an emergency department. Our objective was to assess the frequency, timeliness and predictors for obtaining follow-up care following discharge from an emergency department in Ontario with a new diagnosis of atrial fibrillation. METHODS We conducted a retrospective cohort study involving all patients discharged from the 157 nonpediatric emergency departments in Ontario, who received a new diagnosis of atrial fibrillation between 2007 and 2012. We determined the frequency of follow-up care with a family physician, cardiologist or internist within 7 (timely) and 30 days of the emergency department visit, and assessed the association of emergency and family physician characteristics, including primary care model type, with obtaining timely follow-up care. RESULTS Among 14 907 patients discharged from Ontario emergency departments with a new, primary diagnosis of atrial fibrillation, half (n = 7473) had timely follow-up care. At 30 days, 2678 patients (18.0%) still had not obtained follow-up care. Among emergency and family physician factors, lack of a family physician had the largest independent association with acquiring timely follow-up care (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.50-0.69). Using patients with a family physician belonging to a primarily fee-for-service remuneration model as the comparison group, patients with a family physician belonging to a capitation-based Family Health Network, as part of a Family Health Team, were less likely to receive timely follow-up care (OR 0.73, 95% CI 0.62-0.86), as were those whose family physician belonged to the same model type that was not part of a Family Health Team (OR 0.77, 95% CI 0.60-0.97). INTERPRETATION Only half of the patients who were discharged from an emergency department in Ontario with a new diagnosis of atrial fibrillation were seen within 7 days of discharge. The most influential factor was having a family physician; patients with a family physician being remunerated via primarily fee-for-service methods were more likely to be seen within 7 days than those who were reimbursed through a primarily capitation model. Systems-wide solutions are needed to ensure timely follow-up care is available for all patients with chronic diseases.

Effect of time to electrocardiogram on time from electrocardiogram to fibrinolysis in acute myocardial infarction patients.

OBJECTIVE The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to-ECG time. METHODS This retrospective cohort study used a population-based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time. RESULTS In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%. CONCLUSIONS Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less.

The impact of opioid medications on subsequent fractures in discharged emergency department patients with peripheral vertigo

BACKGROUND Vertigo is common in the emergency department (ED). Most aetiologies are peripheral and do not require hospitalization, but many patients still fear falling. Some patients may be taking opioid analgesic medications (for other reasons); the risk of falls leading to fractures among patients with vertigo could be potentiated by the simultaneous use of opioids. OBJECTIVES To examine the risk of fractures in discharged ED patients with peripheral vertigo who were being prescribed opioids during the same time period. METHODS Linked administrative databases from Ontario were used to compare discharged ED patients aged ≥65 with peripheral vertigo to patients with urinary tract infection (UTI) from 2006 to 2011. We used Cox regression analysis with an interaction term to estimate the modifying effect of an opioid prescription on the hazard of fracture within 90 days. RESULTS There were 13,012 patients with a peripheral vertigo syndrome and 76,885 with a UTI. Thirteen percent of the vertigo cohort and 25% of the UTI cohort had access to a filled opioid prescription. Compared to vertigo patients who did not fill an opioid prescription, the adjusted hazard of fracture among vertigo patients who did fill a prescription was 3.59 (95% CI 1.97-6.13). Among UTI patients who filled an opioid prescription the hazard ratio was 1.68 (95% CI 1.43-1.97) compared to UTI patients who did not. CONCLUSIONS Patients discharged from the ED with peripheral vertigo who were also being prescribed opioids had a higher hazard of subsequent fracture compared to those who were not, and the effect was much greater than among UTI patients. These results suggest that in the acutely vertiginous older patient, opioid analgesic medications should be modified, where possible.