Canadian Journal of Cardiology

Recent Trends in Hospitalizations for Cardiovascular Disease, Stroke, and Vascular Cognitive Impairment in Canada

Open AccessPublished:July 01, 2020DOI:https://doi.org/10.1016/j.cjca.2020.03.007

      Abstract

      Background

      We analyzed hospitalization rates for a broad set of cardiovascular diseases, stroke, and vascular cognitive impairment (VCI) between 2007 and 2016 in Canada to characterize population-level trends and demographic and provincial/territorial variation in inpatient health care utilization.

      Methods

      Record-level administrative hospitalization data from April 1, 2007 to March 31, 2017 for individuals aged 0-105 years were obtained from the Canadian Institute for Health Information Discharge Abstract Database. Data were available for all provinces and territories, except Quebec. Using the International Classification of Diseases (10th Revision, Canada) diagnostic coding standards, we identified disease categories related to cardiovascular disease, stroke, or VCI. Hospitalizations, crude and standardized, for age and sex (direct method) were calculated using the 2011 Census as the standard population.

      Results

      Between 2007 and 2016, percent decreases in standardized hospitalization rates were relatively small for heart failure and stroke (−2.4% and −4.7%, respectively), whereas those for coronary artery and vascular disease and heart rhythm disorders were moderate (−27.4% and −16.8%, respectively). Percent increases were relatively small for congenital heart disease (+7.2%) and moderate for acquired valvular heart disease (+31.1%) and VCI (+23.4%). There were notable age- and sex-specific differences along with provincial/territorial variation.

      Conclusions

      Between 2007 and 2016, there was an overall decrease in standardized hospitalization rates for coronary artery and vascular disease, heart failure, heart rhythm disorders, and stroke, and an increase in hospitalization rates for structural heart disease (congenital heart disease and acquired valvular heart disease) and VCI in Canada.

      Résumé

      Contexte

      Nous avons analysé les taux des hospitalisations liées à un grand éventail de maladies cardiovasculaires, aux accidents vasculaires cérébraux (AVC) et au déficit cognitif d’origine vasculaire (DCOV) survenues entre 2007 et 2016 au Canada afin de dégager des tendances relatives à certaines populations et à certaines caractéristiques démographiques, ainsi que les variations entre provinces ou territoires quant à l’utilisation des soins hospitaliers.

      Méthodologie

      Nous avons extrait de la Base de données sur les congés des patients de l’Institut canadien d’information sur la santé toutes les données administratives sur les hospitalisations au niveau de l’enregistrement, relatives aux personnes âgées de 0 à 105 ans hospitalisées entre le 1er avril 2007 et le 31 mars 2017. Des données étaient accessibles pour l’ensemble des provinces et territoires, sauf le Québec. À l’aide des normes de codification de la Classification internationale des maladies (10e révision, Canada), nous avons recensé les catégories de maladies liées aux maladies cardiovasculaires, à l’AVC et au DCOV. Les taux d’hospitalisations, bruts et normalisés pour tenir compte de l’âge et du sexe (méthode directe), ont été calculés en utilisant la population du Recensement de 2011.

      Résultats

      Entre 2007 et 2016, les diminutions en pourcentage des taux d’hospitalisations normalisés étaient relativement faibles dans le cas de l’insuffisance cardiaque (-2,4 %) et de l’AVC (-4,7 %), et à mo-dérées dans le cas de la coronaropathie et des autres maladies vasculaires (-27,4 %) ainsi que des arythmies (-16,8 %). Les augmentations en pourcentage étaient relativement faibles dans le cas de la cardiopathie congénitale (+7,2 %) et modérées dans le cas de la cardiopathie valvulaire acquise (+31,1 %) et le DCOV (+23,4 %). Des différences importantes entre les groupes d’âge et les sexes ainsi qu’entre provinces ou territoires ont été relevées.

      Conclusions

      Les taux d’hospitalisations normalisés pour cause de coronaropathie et autres maladies vasculaires, insuffisance cardiaque, arythmie et AVC ont globalement diminué au Canada de 2007 à 2016, tandis qu’ils ont augmenté dans le cas des cardiopathies structurelles (cardiopathie congénitale et cardiopathie valvulaire acquise) et du DCOV.
      Cardiovascular and cerebrovascular diseases are leading causes of death in Canada.
      Statistics Canada
      Leading causes of death, total population, by age group.
      Co-occurrence of disease and common risk factors link many types of cardiovascular disease, stroke, and cognitive impairment.
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      vascular cognitive impairment (VCI), and dementia.
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      Likewise, stroke,
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      and vascular dementia
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      are associated with increased risk of cardiovascular disease. With the growing body of literature establishing the heart-brain connection,
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      population-level analyses of health indicators should strive to include comprehensive sets of diagnoses that span the heart-brain axis to better appreciate disease interconnectedness, common etiology, and multimorbidity.
      Temporal trends in hospitalizations provide important insight into changing patterns of inpatient health care utilization and can inform health care policy, prevention strategy, and system planning. Hospitalization rates are a key indicator of inpatient health care utilization
      World Health Organization
      Global Reference List of 100 Core Health Indicators.
      and complement the Canadian Cardiovascular Society-led development of quality indicators for assessing cardiovascular care in Canada.
      Canadian Cardiovascular Society
      CCS Data Definitions & Quality Indicators.
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      Analyses of recent trends in hospitalizations have been conducted for stroke at the national and provincial/territorial levels,
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      Ten-year trends in stroke admissions and outcomes in Canada.
      for congenital heart disease at the national level,
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      Congenital heart disease hospitalizations in Canada: a 10-year experience.
      for atherosclerotic cardiovascular diseases
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      and sudden cardiac death
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      in Ontario and for heart failure in Alberta.
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      Heart failure in young adults is associated with high mortality: a contemporary population-level analysis.
      In a 2003 study, temporal trends in national and regional hospitalizations for a small set of cardiovascular diseases (myocardial infarction, heart failure, angina, and chest pain) were examined in Canada from 1994 and 1999,
      • Hall R.E.
      • Tu J.V.
      Canadian Cardiovascular Outcomes Research Team
      Hospitalization rates and length of stay for cardiovascular conditions in Canada, 1994 to 1999.
      but there has been no recent comprehensive analysis encompassing cardiovascular disease, stroke, and VCI.
      Thus, we sought to examine hospitalization rates in Canada over the past decade for a large set of cardiovascular diseases, stroke, and VCI to characterize population-based health care utilization trends and sex-specific and provincial/territorial variation.

      Methods

       Data sources and study population

      Record-level hospitalization data from April 1, 2007 to March 31, 2017 were obtained from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database (DAD). The DAD contains demographic, administrative, and clinical data on all hospital discharges from acute inpatient care facilities for all provinces and territories, except Quebec. Data from the Northwest Territories, Yukon, and Nunavut were aggregated. Hospitalizations for all individuals 0-105 years of age were included in this retrospective population-level cohort study. There were 10 fiscal periods during this time period, each beginning April 1 and ending March 31. Analyses were conducted at the level of hospital encounter—1 patient could have more than 1 encounter throughout the decade examined. Multiple hospitalizations for the same individual within a given fiscal year were counted as separate hospitalizations to assess total burden of hospitalizations. Provincial/territorial hospitalizations were determined using the submitting province, regardless of where the patient resides. This allowed us to assess the burden of hospitalizations specific to a province or territory. Administrative data obtained from CIHI were analyzed by the Heart and Stroke Foundation of Canada (HSFC). Parts of this report are on the basis of data and information provided by CIHI. However, the analyses, conclusions, opinions, and statements expressed herein are those of the authors and not those of CIHI.
      The type of hospitalization was identified using the International Classification of Diseases (10th revision, Canada) diagnostic coding standards
      Canadian Institute for Health Information
      Canadian Coding Standards for Version 2018 ICD-10-CA and CCI.
      for the “most responsible diagnosis,” (MRDx) which refers to the condition with the highest resource use during the hospitalization. Each hospitalization included was identified as having an MRDx from 1 of the diagnostic codes for cardiovascular disease, stroke, or VCI as listed in Supplemental Table S1. MRDx were categorized within 6 disease cohorts for ease of data visualization and analysis and to align with the 6 Mission Critical Areas identified and prioritized by the HSFC: (1) coronary artery and vascular disease; (2) heart failure; (3) heart rhythm disorders; (4) structural heart disease (includes congenital heart disease and acquired valvular heart disease); (5) stroke; and (6) VCI. The structural heart disease cohort was split into its 2 components for all analyses in this study. The diagnostic codes used to identify hospitalizations for VCI included a range of codes which included vascular dementia, mild cognitive impairment, and Alzheimer disease-related diagnostic codes to capture dementia of possible or probable vascular contribution.
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      Vascular contributions to cognitive impairment and dementia: a statement for health care professionals from the American Heart Association/American Stroke Association.
      ,
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      • Fang J.
      • Swartz R.H.
      • Smith E.E.
      Outcomes in hospitalized ischemic stroke patients with dementia on admission: a population-based cohort study.
      This is in line with recent coding standards
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      • Swartz R.H.
      • Smith E.E.
      Outcomes in hospitalized ischemic stroke patients with dementia on admission: a population-based cohort study.
      and with research supporting cognitive impairment and dementia as frequently a combination of Alzheimer pathology and microvascular damage.
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      Mixed brain pathologies account for most dementia cases in community-dwelling older persons.

       Statistical analyses

      Analyses were conducted using SAS version 9.4 (SAS Institute Inc, Cary, NC).

       Crude number of hospitalizations

      The crude number of hospitalizations for each of the disease cohorts was quantified over the 10-year period to assess changes in total burden of hospitalizations. Percent change in crude number of hospitalizations from fiscal year 2007-2008 to 2016-2017 was calculated for each disease cohort to characterize relative change over time.

       Age- and sex-specific hospitalization rates

      Five age groups were defined (0-19 years, 20-39 years, 40-59 years, 60-79 years, and 80 years and older) to assess age- and sex-specific trends in hospitalization rates per hundred thousand for each of the disease cohorts over the 10-year period. The number of hospitalizations in the age-sex group in the fiscal year of interest was calculated and divided by the population in the corresponding age-sex group. Percent change in hospitalization rates between fiscal year 2007-2008 and 2016-2017 was calculated for each age-sex group across all disease cohorts to characterize relative change in hospitalizations rates. Negative binomial regression analysis was used to test the significance (P < 0.05) of age- and sex-specific relative changes in hospitalization rates between fiscal year 2007 and fiscal year 2016.

       Standardized hospitalization rates

      Age- and sex-standardized hospitalization rates per hundred thousand were calculated to remove the effect of possible differences in the age and sex structure of the population. The direct standardization method was used, with the 2011 Canadian Census as the standard population.
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      • Wong L.
      An introduction to health care administrative data.
      Percent change in standardized hospitalization rates between fiscal year 2007-2008 and 2016-2017 was calculated for each disease cohort to characterize relative change in standardized hospitalizations rates. The Mantel-Haenszel rate ratio Z test (SAS procedure stdrate) was used to test the significance (P < 0.05) of the relative changes in standardized hospitalization rates between fiscal year 2007 and fiscal year 2016.

      Results

       Temporal trends in crude number and standardized rates of hospitalizations

      We identified 2,609,279 hospitalizations (1,559,535 were for males; 1,049,744 were for females) with an MRDx of a cardiovascular disease, stroke, or VCI within the 10-year period. The percent change in crude number of hospitalizations and age- and sex-standardized hospitalization rates for each of the disease cohorts between fiscal year 2007-2008 and 2016-2017 (refer to Table 1 for absolute values) are illustrated in Figure 1. There were relative increases in the crude number of hospitalizations for heart failure (+24.8%), heart rhythm disorders (+4.9%), congenital heart disease (+12.1%), acquired valvular heart disease (+68.0%), stroke (+20.4%), and VCI (+57.5%), and a relative decrease for coronary artery and vascular disease (−9.0%) between 2007 and 2016. A different pattern emerged for standardized hospitalizations: there were relative decreases for all disease cohorts except for structural heart disease (congenital heart disease and acquired valvular heart disease) and VCI, which yielded relative increases in standardized hospitalizations between 2007 and 2016. The percent change in standardized hospitalization rates between 2007 and 2016 was relatively small for heart failure, congenital heart disease, and stroke (−2.4%, +7.2%, and −4.7%, respectively), and moderate for coronary artery and vascular disease (−27.4%), heart rhythm disorders (−16.8%), acquired valvular heart disease (+31.1%), and VCI (+23.4%). These trends in age- and sex-standardized hospitalization rates over the 10-year period for each disease cohort are illustrated in Figure 2.
      Table 1Percent change in hospitalizations between 2007 and 2016 in Canada
      Coronary artery and vascular diseaseHeart failureHeart rhythm disordersCongenital heart disease
      Congenital heart disease and valvular heart disease (acquired) are components of the structural heart disease cohort.
      Valvular heart disease (acquired)
      Congenital heart disease and valvular heart disease (acquired) are components of the structural heart disease cohort.
      StrokeVascular cognitive impairment
      Crude number of hospitalizations

      2007: 131,3702007: 40,7032007: 38,3182007: 32732007: 69022007: 35,8692007: 1359
      2016: 119,6122016: 50,7842016: 40,1392016: 36692016: 11,5952016: 43,1322016: 2141
      %Δ: −9.0%Δ: +24.8%Δ: +4.9%Δ: +12.1%Δ: +68.0%Δ: +20.4%Δ: +57.5
      Standardized hospitalization rate2007: 553.82007: 173.52007: 161.82007: 12.62007: 29.22007: 151.82007: 5.8
      2016: 401.82016: 169.32016: 134.62016: 13.62016: 38.52016: 144.72016: 7.2
      %Δ: −27.4%Δ: −2.4%Δ: −16.8%Δ: +7.2%Δ: +31.1%Δ: −4.7%Δ: +23.4
      P < 0.0001P < 0.001P < 0.0001P < 0.01P < 0.0001P < 0.0001P < 0.0001
      2007 corresponds to fiscal year 2007-2008; 2016 corresponds to fiscal year 2016-2017. Age- and sex-standardized hospitalization rates are per 100,000. Quebec data were not accessible for this study. Data rounded to 1 decimal point.
      Congenital heart disease and valvular heart disease (acquired) are components of the structural heart disease cohort.
      Figure thumbnail gr1
      Figure 1Percent change in hospitalizations between 2007 and 2016 in Canada. Percent change in crude number of hospitalizations and age- and sex-standardized hospitalization rates between 2007 and 2016 for each of the disease cohorts. Refer to for International Classification of Diseases, 10th revision diagnostic codes included in analyses. Refer to for absolute values. Quebec data were not accessible for this study. 2007 corresponds to fiscal year 2007-2008; 2016 corresponds to fiscal year 2016-2017. CHD and VHD are components of the structural heart disease cohort. CAVD, coronary artery and vascular disease; CHD, congenital heart disease; HF, heart failure; HRD, heart rhythm disorders; VCI, vascular cognitive impairment; VHD, valvular heart disease (acquired).
      Figure thumbnail gr2
      Figure 2Temporal trends in standardized hospitalization rates in Canada. (A) Trends in age- and sex-standardized hospitalization rates for all disease cohorts over the 10-year period. Closer examination shows a decrease in standardized hospitalization rates over time for (B) coronary artery and vascular disease (CAVD), (C) heart failure (HF), heart rhythm disorders (HRD), and stroke, and an increase in hospitalization rates over time for (D) structural heart disease [congenital heart disease (CHD), acquired valvular heart disease (VHD)], and (E) vascular cognitive impairment (VCI). Refer to for International Classification of Diseases, 10th revision diagnostic codes included in analyses. Quebec data were not accessible for this study. Each year corresponds to a fiscal period beginning April 1 and ending March 31 (for example, the year 2007 includes data from April 1, 2007 to March 31, 2008).

       Temporal trends in age- and sex-specific hospitalization rates

      Trends in age- and sex-specific hospitalization rates over the 10-year period for each of the disease cohorts is illustrated in Figure 3. A summary of the percent change in age- and sex-specific hospitalization rates between fiscal year 2007-2008 and 2016-2017 is provided in Supplemental Table S2. Some diseases were determined to affect the population at earlier life stages than they were 10 years ago. The percent increase in heart failure hospitalization rates within the 20- to 39-year-old age group was +55.5% for men and +25.1% for women, and among the 40- to 59-year-old age group was +17.2% for men and +11.1% for women between 2007 and 2016. The percent increase in hospitalization rates for acquired valvular heart disease was much more pronounced for women (+65.7%) than for men (+15.9%) aged 20-39 years. Notably, women aged 20-39 years were the only adult (20 years of age and older) age group that did not yield a statistically significant percent decrease in hospitalization rate for coronary artery and vascular disease between 2007 and 2016, with a statistically nonsignificant 1.6% marginal decrease in hospitalization rate. There was a 25% relative increase in the stroke hospitalization rate for women aged 20-39 years between 2007 and 2016. This was not true for men of the same age group, who showed a statistically nonsignificant relative decrease in stroke hospitalization rate. Overall, there were relative increases in hospitalization rates for stroke in men and women aged 40-59 years (9.3% and 19.7%, respectively) between 2007 and 2016, and relative decreases for those aged 60 and older.
      Figure thumbnail gr3
      Figure 3Temporal trends in age- and sex-specific hospitalization rates in Canada. Trends in age- and sex-specific hospitalization rates for each of the disease cohorts over the 10-year period: (A) coronary artery and vascular disease (CAVD), (B) heart failure (HF), (C) heart rhythm disorders (HRD), structural heart disease [(D) congenital heart disease (CHD), (E) acquired valvular heart disease (VHD)], (F) stroke, and (G) vascular cognitive impairment (VCI). Refer to for corresponding summary of the percent change in age- and sex-specific hospitalization rates between 2007 and 2016. Refer to for International Classification of Diseases, 10th revision diagnostic codes included in analyses. Quebec data were not accessible for this study. Each year corresponds to a fiscal period beginning April 1 and ending March 31 (for example, the year 2007 includes data from April 1, 2007 to March 31, 2008). yrs, years.

       Provincial/territorial variation

      Provincial/territorial variation in age- and sex-standardized hospitalization rates for the 2016-2017 fiscal year are illustrated in Figure 4, with diagnoses grouped into 3 broader disease cohorts for ease of visualization: cardiovascular disease (all diagnostic codes for coronary artery and vascular disease, heart failure, heart rhythm disorders, and structural heart disease listed in Supplemental Table S1), stroke, and VCI. In fiscal year 2015-2016, Newfoundland and Labrador, New Brunswick, Manitoba, and Saskatchewan had the highest rates of hospitalization for cardiovascular disease. The Northwest Territories, Yukon, Nunavut, and Prince Edward Island (PEI) had the lowest. PEI, Newfoundland and Labrador, New Brunswick, and Saskatchewan had the highest hospitalization rates for stroke. British Columbia, Manitoba, Alberta, and New Brunswick had the highest hospitalization rates for VCI. A summary of the percent change in provincial/territorial standardized hospitalization rates between fiscal year 2007-2008 and 2016-2017 for each of the disease cohorts is provided in Supplemental Table S3. There was notable provincial/territorial variation: standardized hospitalization rates for heart failure significantly decreased for all regions except Alberta, British Columbia, the Northwest Territories, Yukon, and Nunavut, where relative increases were observed. For stroke, a statistically significant relative increase in hospitalization rate was found for British Columbia.
      Figure thumbnail gr4
      Figure 4Provincial/territorial variation in 2016 standardized hospitalization rates. Heat map illustrating provincial/territorial variation in age- and sex-standardized hospitalization rates for the 2016-2017 fiscal year with diagnoses grouped into 3 broader disease cohorts for ease of visualization: (A) cardiovascular disease, (B) stroke, and (C) vascular cognitive impairment (VCI). Darker shades of red correspond to higher rates of hospitalization. Grey refers to no accessible data (ie, Quebec). Data from the Northwest Territories, Nunavut, and Yukon were aggregated, and the rates presented correspond to the 3 areas as a whole. Data rounded to the nearest integer. The 2016-2017 fiscal year includes data from April 1, 2016 to March 31, 2017. Refer to for International Classification of Diseases, 10th revision diagnostic codes included in analyses. The cardiovascular disease cohort included all diagnostic codes for coronary artery and vascular disease, heart failure, heart rhythm disorders, and structural heart disease (congenital heart disease and acquired valvular heart disease) listed in .

      Discussion

      In this retrospective population-level cohort study we examined temporal trends in inpatient hospitalizations in Canada across a large set of cardiovascular diseases, stroke, and VCI. Between 2007 and 2016, there were relative increases in the crude number of hospitalizations in Canada for heart failure, heart rhythm disorders, structural heart disease (congenital heart disease and acquired valvular heart disease), stroke, and VCI, and a relative decrease for coronary artery and vascular disease. This assessment of crude hospitalization burden illustrates an overall net increase in the volume of inpatient care utilization over the past decade for this broad set of diseases with the exception of coronary artery and vascular disease. Analyses of trends in age- and sex-standardized hospitalization rates indicate that the relative increases in crude hospitalizations observed over time are associated with a growing and aging population. We determined that there was an overall relative decline in standardized hospitalization rates for coronary artery and vascular disease, heart failure, heart rhythm disorders, and stroke, and an increase for structural heart disease (congenital heart disease and acquired valvular heart disease), and VCI.
      The relative decrease in standardized hospitalization rates observed for coronary artery and vascular disease, heart failure, heart rhythm disorders, and stroke is consistent with the global trend of declining cardiovascular
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      might contribute to declining associated hospitalization rates.
      Canada’s population is aging
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      In 2018, the proportion of the population 65 years of age and older was greater than the proportion 14 years of age and younger.
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      Population estimates on July 1st, by age and sex.
      The effect of an aging population is reflected in the sizeable percent increase (+57.5%) in the crude number of hospitalizations we observed for VCI between the years 2007 and 2016. This is consistent with models predicting a significant increase in the prevalence of dementia in the next 10 years in Canada.
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      • Rahme E.
      • Pilote L.
      Congenital heart disease in the general population: changing prevalence and age distribution.
      ,
      • Khairy P.
      • Ionescu-Ittu R.
      • Mackie A.S.
      • et al.
      Changing mortality in congenital heart disease.
      The prevalence of acquired valvular heart disease is known to increase with age because of the degenerative etiology of most cases in industrialized countries.
      • Kodali S.K.
      • Velagapudi P.
      • Hahn R.T.
      • Abbott D.
      • Leon M.B.
      Valvular heart disease in patients ≥80 years of age.
      ,
      • Iung B.
      • Vahanian A.
      Epidemiology of acquired valvular heart disease.
      Moreover, the increasing uptake of recently developed catheter-based replacement/intervention procedures for valvular heart disease commonly found in aging patients (eg, aortic stenosis, mitral regurgitation) currently necessitate hospitalization.
      • Asgar A.W.
      • Ouzounian M.
      • Adams C.
      • et al.
      2019 Canadian Cardiovascular Society position statement for transcatheter aortic valve implantation.
      ,
      • Wan B.
      • Rahnavardi M.
      • Tian D.H.
      • et al.
      A meta-analysis of MitraClip system versus surgery for treatment of severe mitral regurgitation.
      Consistent with this epidemiological trend and the effect of an aging population, the percent increase in the rate of hospitalization for acquired valvular heart disease in individuals 80 years of age and older was 104.6% and 85.9% for men and women, respectively, between 2007 and 2016.
      We found that some diseases are affecting the population at earlier life stages than they were 10 years ago. For instance, although the overall percent decrease in hospitalization rate for heart failure was 2.4% over the decade, younger age groups showed marked relative increases in heart failure hospitalization, consistent with trends reported in a recent study on health care utilization in Alberta.
      • Wong C.M.
      • Hawkins N.M.
      • Ezekowitz J.A.
      • et al.
      Heart failure in young adults is associated with high mortality: a contemporary population-level analysis.
      In our cohort, the percent increase in heart failure hospitalization rates within the 20- to 39-year-old age group was +55.5% for men and +25.1% for women, and among the 40- to 59-year-old age group was +17.2% for men and +11.1% for women between 2007 and 2016. The percent increase in hospitalization rates for acquired valvular heart disease was more pronounced for women (+65.7%) than men (+15.9%) aged 20-39 years. Notably, women aged 20-39 years were the only adult age group that did not yield a statistically significant percent decrease in hospitalization rate for coronary artery and vascular disease between 2007 and 2016. Further analyses are needed to determine which specific diagnoses are contributing most to hospitalizations of women in this age group. Certainly, an increasing awareness of acute coronary syndromes more commonly seen in younger women such as spontaneous coronary artery disease and myocardial infarction with no obstructive coronary arteries, as well as an alarming increase in obesity and metabolic-related cardiovascular risk factors might be contributing factors.
      • Norris C.M.
      • Yip C.Y.Y.
      • Nerenberg K.A.
      • et al.
      State of the science in women’s cardiovascular disease: a Canadian perspective on the influence of sex and gender.
      There was a 25% relative increase in the stroke hospitalization rate for women aged 20-39 years between 2007 and 2016. This was not true for men of the same age group, who showed a statistically nonsignificant relative decrease in stroke hospitalization rate. This likely reflects the increase in stroke risk during pregnancy, which is approximately 3 times higher than the risk of stroke in young adults.
      • Swartz R.H.
      • Cayley M.L.
      • Foley N.
      • et al.
      The incidence of pregnancy-related stroke: a systematic review and meta-analysis.
      Overall, there were relative increases in hospitalization rates for stroke in men and women aged 40-59 years (9.3% and 19.7%, respectively) between 2007 and 2016, and relative decreases for those aged 60 years and older. This is consistent with recent Canadian trends reported by Kamal et al.
      • Kamal N.
      • Lindsay M.P.
      • Côté R.
      • et al.
      Ten-year trends in stroke admissions and outcomes in Canada.
      There was notable provincial/territorial variation in standardized hospitalization rates. Examination of percent changes in standardized hospitalization rates between 2007 and 2016 revealed that hospitalization rates for heart failure significantly decreased for all regions except Alberta, British Columbia, and the Northwest Territories, Yukon, and Nunavut, where relative increases were observed. For stroke, a statistically significant relative increase in hospitalization rate was shown for British Columbia, consistent with trends in provincial hospitalizations reported by Kamal et al.
      • Kamal N.
      • Lindsay M.P.
      • Côté R.
      • et al.
      Ten-year trends in stroke admissions and outcomes in Canada.
      In 2016, PEI as well as the Northwest Territories, Yukon, and Nunavut combined had the 2 lowest rates of hospitalization for cardiovascular disease (all diagnostic codes for coronary artery and vascular disease, heart failure, heart rhythm disorders, and structural heart disease listed in Supplemental Table S1). This could potentially be explained by out-of-province hospitalizations—PEI and the territories have the highest percentages of patients hospitalized in neighbouring provinces, resulting in lower rates of hospitalizations per capita.
      Have Health Card
      Will Travel: Out-of-Province/-Territory Patients.
      Resource limitations of smaller provinces or territories necessitate the transfer of patients to neighbouring provinces to access services (eg, cardiac catheterization laboratory) for acute in-patient procedural performance and care.

       Limitations

      This study has several limitations. First, hospital administrative data are subject to variation in the consistency and accuracy of coding of the MRDx
      • Cadarette S.M.
      • Wong L.
      An introduction to health care administrative data.
      ,
      • Masri A.
      • Althouse A.D.
      • McKibben J.
      • Lee J.S.
      • Mulukutla S.R.
      Limitations of administrative data for studying patients hospitalized with heart failure.
      and they are contingent on the accuracy of patient records and diagnoses made by the responsible physicians. Second, data from Quebec were not accessible, and as a result the hospitalization data are incomplete and do not reflect the influence of the second largest province in Canada, which had a population of more than 8 million people in 2016 and accounted for 23% of the total population of Canada. Third, changes in patients’ interactions with primary care, ambulatory care, rehabilitation, and community-based care were not accounted for because they were not within the scope of the current study. Some of the decreases in standardized rates of hospitalizations are reflective of better prevention and changes in how the health of patients living with the effects of cardiovascular disease, stroke, and VCI are managed in the community. For example, a large proportion of patients with transient ischemic attack (unpublished data analyzed by HSFC) or minor ischemic stroke
      • Kapral M.K.
      • Hall R.
      • Fang J.
      • et al.
      Predictors of hospitalization in patients with transient ischemic attack or minor ischemic stroke.
      are provided care in an ambulatory setting and were not captured by the DAD data set used in this study. Last, it is important to recognize the potential effect of the evolving diagnostic understanding of disease on diagnostic code usage over time. For example, with the expanded use of brain imaging, diagnostic clarity has improved for VCI, likely resulting in an observed increase in hospitalization rates.

       Conclusions

      Between 2007 and 2016, there was an overall decrease in standardized hospitalization rates for coronary artery and vascular disease, heart failure, heart rhythm disorders, and stroke, and an increase in hospitalization rates for structural heart disease (congenital heart disease and acquired valvular heart disease) and VCI in Canada. Our findings provide important insight into changing patterns of inpatient health care utilization, including sex, age, and provincial/territorial-specific observations, and are a first step in developing data to inform health care policy, prevention strategy, and system planning. Notably, heart failure, acquired valvular heart disease, and stroke are affecting the population at earlier life stages than they were 10 years ago, especially for women. Future analyses will focus on elucidating the interconnections among these diseases that span the heart-brain vascular axis and the effect on hospitalizations—patients admitted to hospital with cardiovascular disease and then readmitted for stroke or VCI and vice versa.

      Funding Sources

      The authors have no funding sources to declare.

      Disclosures

      L.C.P.B., M.P.L., C.G., M.M.-R., and C.Y.Y.Y. are employees of the HSFC. The remaining authors have no conflicts of interest to disclose.

      Acknowledgements

      The authors thank Bradley Bonitatibus and Adrienne Kasiban for assistance with data analysis and graphical presentation, and Cindy Chiu for help with table data entry. The authors also thank CIHI for the use of their database in this study.

      Supplementary Material

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