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Canadian Journal of Cardiology

Comparison of Readmission and Death Among Patients With Cardiac Disease in Northern vs Southern Ontario

      Abstract

      Background

      Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South.

      Methods

      We examined 30-day and 1-year mortality and readmissions for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF), or stroke in Northern compared with Southern Ontario, using the Canadian Institute for Health Information Discharge Abstract Database (2005-2016). Northern patients were defined as those residing and hospitalized in the Northwest or Northeast Local Health Integration Network regions. We used multiple Cox proportional hazards regression analysis for time-to-first event and Prentice-Williams-Peterson method to evaluate repeat and multiply admitted patients.

      Results

      A total of 47,745 Northern and 465,353 Southern patients hospitalized with AMI (n = 182,158), HF (n = 130,770), AF (n = 72,326), or stroke (n = 127,844) were studied. Rates of first readmission were higher among Northern patients for AMI (adjusted hazard ratio [HR], 1.32), HF (HR, 1.16), AF (HR, 1.21), and stroke (HR, 1.27) compared with Southern patients (all P < 0.001). Repeat readmission rates among Northern patients for AMI (HR, 1.23), HF (HR, 1.13), AF (HR, 1.18), and stroke (HR, 1.22) were also increased (all P < 0.001 vs Southern). Thirty-day mortality did not differ significantly between Northern and Southern patients.

      Conclusions

      Readmissions were increased in those residing and hospitalized in the North. To reduce readmissions in the North, the quality of postacute transitional care should be examined further.

      Résumé

      Contexte

      Des facteurs géographiques peuvent influer sur l’issue de maladies cardiovasculaires au Canada. Les maladies du système circulatoire constituent une raison majeure du taux de mortalité élevé dans le nord de l’Ontario, mais on ne sait pas si les patients hospitalisés pour une maladie cardiovasculaire connaissent des issues différentes par rapport aux personnes vivant dans le sud.

      Méthodologie

      Nous avons examiné les taux de mortalité et de réadmissions à 30 jours et à 1 an des patients hospitalisés pour un infarctus aigu du myocarde (IAM), une insuffisance cardiaque (IC), une fibrillation auriculaire (FA) ou un accident vasculaire cérébral (AVC) dans le nord de l’Ontario comparativement à ceux observés dans le sud de la province, à partir de la base de données sur les congés des patients de l’Institut canadien d’information sur la santé (2005-2016). Les patients du nord étaient ceux qui résidaient et étaient hospitalisés dans les régions nord-ouest et nord-est du réseau local d’intégration des services de santé (RLISS). Nous avons fait appel à la méthode de régression multiple à risque proportionnel de Cox pour calculer le temps écoulé avant le premier événement et à la méthode Prentice-Williams-Peterson pour évaluer les patients hospitalisés de façons répétées ou plusieurs fois.

      Résultats

      Un total de 47 745 patients du nord et 465 353 patients du sud hospitalisés pour un IAM (n = 182 158), une IC (n = 130 770), une FA (n = 72 326) ou un AVC (n = 127 844) ont été inclus dans l’étude. Les taux de première réadmission ont été plus élevés chez les patients du nord pour l'IAM aigu (rapport des risques instantanés corrigé [RRI], 1,32), l'IC (RRI, 1,16), la FA (RRI, 1,21) et l’AVC (RR, 1,27) comparativement aux patients du sud (p < 0,001 dans tous les cas). Les taux de réadmissions répétées des patients du nord pour l'IAM (RRI, 1,23), l'IC (RRI, 1,13), la FA (RRI, 1,18) et l’AVC (RRI, 1,22) étaient également élevés (p < 0,001 vs sud dans tous les cas). La mortalité à trente jours n’était pas considérablement différente entre le nord et le sud.

      Conclusions

      Les réadmissions étaient accrues chez les patients résidants et hospitalisés dans le nord. Pour réduire les réadmissions dans le nord, la qualité des soins transitionnels après un épisode aigu devrait être examinée davantage.
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      References

        • GBD Causes of Death Collaborators
        Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: a systematic analysis for the Global Burden of Disease Study 2016.
        Lancet. 2017; 390: 1151-1210
      1. Statistics Canada. Statistics Canada Table 102-0551: deaths and mortality rate, by selected group causes, age group and sex, Canada, CANSIM database. Available at: http://www5.statcan.gc.ca/cansim/a26?lang=eng&id=1020551. Accessed August 18, 2018.

        • Roth G.A.
        • Johnson C.
        • Abajobir A.
        • et al.
        Global, regional, and national burden of cardiovascular diseases for 10 causes, 1990 to 2015.
        J Am Coll Cardiol. 2017; 70: 1-25
      2. Centers for Disease Control and Prevention. Healthcare Cost and Utilization Project (HCUP): National Inpatient Survey. Updated February 27, 2018. Available at: https://chronicdata.cdc.gov/Heart-Disease-Stroke-Prevention/Healthcare-Cost-and-Utilization-Project-HCUP-Natio/ntny-77fx. Accessed August 18, 2018.

        • Tu J.V.
        • Nardi L.
        • Fang J.
        • et al.
        • Canadian Cardiovascular Outcomes Research Team
        National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke, 1994-2004.
        CMAJ. 2009; 180: E118-E125
      3. Glazier R, Gozdyra P, Yeritsyan N. Geographic access to primary care and hospital services for rural and northern communities: report to the Ontario Ministry of Health and Long-Term Care. Toronto: ICES, 2011.

        • Bhatia R.S.
        • Austin P.C.
        • Stukel T.A.
        • et al.
        Outcomes in patients with heart failure treated in hospitals with varying admission rates: population-based cohort study.
        BMJ Qual Saf. 2014; 23: 981-988
      4. Health Quality Ontario. Health in the North: a report on geography and health of people in Ontario’s two northern regions. August 13, 2017. Toronto: Health Quality Ontario, 2016.

        • Lee D.S.
        • Stukel T.A.
        • Austin P.C.
        • et al.
        Improved outcomes with early collaborative care of ambulatory heart failure patients discharged from the emergency department.
        Circulation. 2010; 122: 1806-1814
        • Krumholz H.M.
        • Wang Y.
        • Mattera J.A.
        • et al.
        An administrative claims model suitable for profiling hospital performance based on 30-day mortality rates among patients with heart failure.
        Circulation. 2006; 113: 1693-1701
        • Keenan P.S.
        • Normand S.L.
        • Lin Z.
        • et al.
        An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure.
        Circ Cardiovasc Qual Outcomes. 2008; 1: 29-37
        • Tu K.
        • Campbell N.R.
        • Chen Z.L.
        • Cauch-Dudek K.J.
        • McAlister F.A.
        Accuracy of administrative databases in identifying patients with hypertension.
        Open Med. 2007; 1: e18-e26
        • Hux J.E.
        • Ivis F.
        • Flintoft V.
        • Bica A.
        Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm.
        Diabetes Care. 2002; 25: 512-516
        • Schultz S.E.
        • Rothwell D.M.
        • Chen Z.
        • Tu K.
        Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records.
        Chronic Dis Inj Can. 2013; 33: 160-166
        • Tu J.V.
        • Chu A.
        • Rezai M.R.
        • et al.
        The incidence of major cardiovascular events in immigrants to Ontario, Canada: The CANHEART Immigrant Study.
        Circulation. 2015; 132: 1549-1559
        • Goldraich L.
        • Austin P.C.
        • Zhou L.
        • et al.
        Care setting intensity and outcomes after emergency department presentation among patients with acute heart failure.
        J Am Heart Assoc. 2016; 5e003232
        • Joynt K.E.
        • Orav E.J.
        • Jha A.K.
        The association between hospital volume and processes, outcomes, and costs of care for congestive heart failure.
        Ann Intern Med. 2011; 154: 94-102
        • Sud M.
        • Yu B.
        • Wijeysundera H.C.
        • et al.
        Associations between short or long length of stay and 30-day readmission and mortality in hospitalized patients with heart failure.
        JACC Heart Fail. 2017; 5: 578-588
        • Wijeysundera H.C.
        • Trubiani G.
        • Wang X.
        • et al.
        A population-based study to evaluate the effectiveness of multidisciplinary heart failure clinics and identify important service components.
        Circ Heart Fail. 2013; 6: 68-75
        • Braga J.R.
        • Tu J.V.
        • Austin P.C.
        • et al.
        Recurrent events analysis for examination of hospitalizations in heart failure: insights from the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) trial.
        Eur Heart J Qual Care Clin Outcomes. 2018; 4: 18-26
        • Rhudy Jr., J.P.
        • Alexandrov A.W.
        • Hyrkas K.E.
        • et al.
        Geographic access to interventional cardiology services in one rural state.
        Heart Lung. 2016; 45: 434-440
        • Joynt K.E.
        • Harris Y.
        • Orav E.J.
        • Jha A.K.
        Quality of care and patient outcomes in critical access rural hospitals.
        JAMA. 2011; 306: 45-52
        • Kulshreshtha A.
        • Goyal A.
        • Dabhadkar K.
        • Veledar E.
        • Vaccarino V.
        Urban-rural differences in coronary heart disease mortality in the United States: 1999-2009.
        Public Health Rep. 2014; 129: 19-29
        • Wu J.R.
        • Moser D.K.
        • Rayens M.K.
        • et al.
        Rurality and event-free survival in patients with heart failure.
        Heart Lung. 2010; 39: 512-520
        • Ibrahim A.M.
        • Hughes T.G.
        • Thumma J.R.
        • Dimick J.B.
        Association of hospital critical access status with surgical outcomes and expenditures among Medicare beneficiaries.
        JAMA. 2016; 315: 2095-2103
        • Kociol R.D.
        • Greiner M.A.
        • Fonarow G.C.
        • et al.
        Associations of patient demographic characteristics and regional physician density with early physician follow-up among Medicare beneficiaries hospitalized with heart failure.
        Am J Cardiol. 2011; 108: 985-991
        • Ayanian J.Z.
        • Landrum M.B.
        • Guadagnoli E.
        • Gaccione P.
        Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction.
        N Engl J Med. 2002; 347: 1678-1686
        • Radzimanowski M.
        • Gallowitz C.
        • Muller-Nordhorn J.
        • Rieckmann N.
        • Tenckhoff B.
        Physician specialty and long-term survival after myocardial infarction - A study including all German statutory health insured patients.
        Int J Cardiol. 2018; 251: 1-7
        • Czarnecki A.
        • Chong A.
        • Lee D.S.
        • et al.
        Association between physician follow-up and outcomes of care after chest pain assessment in high-risk patients.
        Circulation. 2013; 127: 1386-1394
        • O’Neill D.E.
        • Southern D.A.
        • Norris C.M.
        • et al.
        Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment & outcome.
        BMC Health Serv Res. 2017; 17: 354
        • Atzema C.L.
        • Dorian P.
        • Ivers N.M.
        • Chong A.S.
        • Austin P.C.
        Evaluating early repeat emergency department use in patients with atrial fibrillation: a population-based analysis.
        Am Heart J. 2013; 165: 939-948
        • Smith M.A.
        • Liou J.I.
        • Frytak J.R.
        • Finch M.D.
        30-day survival and rehospitalization for stroke patients according to physician specialty.
        Cerebrovasc Dis. 2006; 22: 21-26
        • Feltner C.
        • Jones C.D.
        • Cene C.W.
        • et al.
        Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.
        Ann Intern Med. 2014; 160: 774-784