First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario.
Methods:
Using linked administrative databases, we identified annual cohorts of people aged 20–105 years in Ontario with prevalent diabetes between Apr. 1, 1995, and Mar. 31, 2015. We identified Status First Nations people in Ontario from the Indian Register. We compared age- and sex-standardized rates of hospital admission for stroke or TIA, processes of care and case fatality among First Nations versus other people in Ontario with diabetes.
Results:
Overall, 28 874 people with diabetes (of whom 536 were First Nations people) were admitted to hospital with a stroke or TIA between Apr. 1, 2011, and Mar. 31, 2016. Admission rates for stroke or TIA declined over the study period but were higher among First Nations people than other Ontarians in most years after 2005/06. First Nations people admitted with stroke or TIA were as likely as other Ontarians to undergo neuroimaging within 24 hours (94.6% v. 96.0%), be discharged to inpatient rehabilitation (31.8% v. 34.8%) and receive carotid revascularization (1.4% v. 2.7%), but were less likely to receive thrombolysis (6.3% v. 11.0%). Age- and sex-standardized stroke case fatality was similar in First Nations people and other Ontarians at 7 days (12.0% v. 8.5%), 30 days (19.2% v. 16.0%) and 1 year (33.8% v. 28.1%).
Interpretation:
Rates of hospital admission for stroke or TIA were higher among First Nations people than other people with diabetes in Ontario. Future work should focus on determining Indigenous-specific determinants of health related to this disparity and implementing appropriate interventions to mitigate the risks and sequelae of stroke in First Nations people.
The reliability of diagnostic coding of acute stroke and transient ischemic attack (TIA) in administrative data is uncertain. The purpose of this study is to determine the agreement between administrative data sources and chart audit for the identification of stroke type, stroke risk factors, and the use of hospital-based diagnostic procedures in patients with stroke or TIA.Medical charts for a population-based sample of patients (n = 14,508) with ischemic stroke, intracerebral hemorrhage (ICH), or TIA discharged from inpatient and emergency departments (ED) in Ontario, Canada, between April 1, 2012 and March 31, 2013, were audited by trained abstractors. Audited data were linked and compared with hospital administrative data and physician billing data. The positive predictive value (PPV) of hospital administrative data and kappa agreement for the reporting of stroke type were calculated. Kappa agreement was also determined for stroke risk factors and for select stroke-related procedures.The PPV for stroke type in inpatient administrative data ranged from 89.5% (95% CI 88.0-91.0) for TIA, 91.9% (95% CI 90.2-93.5) for ICH, and 97.3% (95% CI 96.9-97.7) for ischemic stroke. For ED administrative data, PPV varied from 78.8% (95% CI 76.3-81.2) for ischemic, 86.3% (95% CI 76.8-95.7) for ICH, and 95.3% (95% CI 94.6-96.0) for TIA. The chance-corrected agreement between the audited and administrative data was good for atrial fibrillation (k = 0.60) and very good for diabetes (k = 0.86). Hospital administrative data combined with physician billing data more than doubled the observed agreement for carotid imaging (k = 0.65) and echocardiography (k = 0.66) compared to hospital administrative data alone.Inpatient and ED administrative data were found to be reliable in the reporting of the International Classification of Diagnosis, 10th revision, Canada (ICD-10-CA)-coded ischemic stroke, ICH and TIA, and for the recording of atrial fibrillation and diabetes. The combination of physician billing data with hospital administrative data greatly improved the capture of some diagnostic services provided to inpatients.
Administrative data validation is essential for identifying biases and misclassification in research. The objective of this study was to determine the accuracy of diagnostic codes for acute stroke and transient ischemic attack (TIA) using the Ontario Stroke Registry (OSR) as the reference standard.We identified stroke and TIA events in inpatient and emergency department (ED) administrative data from eight regional stroke centres in Ontario, Canada, from April of 2006 through March of 2008 using ICD-10-CA codes for subarachnoid haemorrhage (I60, excluding I60.8), intracerebral haemorrhage (I61), ischemic (H34.1 and I63, excluding I63.6), unable to determine stroke (I64), and TIA (H34.0 and G45, excluding G45.4). We linked administrative data to the Ontario Stroke Registry and calculated sensitivity and positive predictive value (PPV).We identified 5,270 inpatient and 4,411 ED events from the administrative data. Inpatient administrative data had an overall sensitivity of 82.2% (95% confidence interval [CI 95%]=81.0, 83.3) and a PPV of 68.8% (CI 95%=67.5, 70.0) for the diagnosis of stroke, with notable differences observed by stroke type. Sensitivity for ischemic stroke increased from 66.5 to 79.6% with inclusion of I64. The sensitivity and PPV of ED administrative data for diagnosis of stroke were 56.8% (CI 95%=54.8, 58.7) and 59.1% (CI 95%=57.1, 61.1), respectively. For all stroke types, accuracy was greater in the inpatient data than in the ED data.The accuracy of stroke identification based on administrative data from stroke centres may be improved by including I64 in ischemic stroke type, and by considering only inpatient data.
To compare complications, disability, and long-term mortality of patients who received direct enteral tube vs nasogastric tube feeding alone after acute stroke.We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (DET; gastrostomy or jejunostomy) or temporary nasogastric tubes (NGT) alone during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003, to March 31, 2013. We used propensity matching to compare groups from discharge and evaluated discharge disability, institutionalization, complications, and mortality, with follow-up over 2 years, and with cumulative incidence functions used to account for competing risks.Among 1,448 patients with DET placement who survived until discharge, 1,421 were successfully matched to patients with NGT alone. Patients with DET had reduced risk of death within 30 days after discharge (9.7% vs 15.3%; hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.49-0.75), but this difference was eliminated after matching on length of stay and discharge disability (HR 0.90, 95% CI 0.70-1.17). Patients with DET had higher rates of severe disability at discharge (modified Rankin Scale score 4-5; 89.6% vs 78.4%), discharge to long-term care (38.0% vs 16.1%), aspiration pneumonia (14.4% vs 5.1%) and other complications, and mortality at 2 years (41.1% vs 35.9%).Patients with DET placement after acute stroke have more severe disability at discharge compared to those with NGT placement alone, and associated higher rates of institutionalization, medical complications, and long-term mortality. These findings may inform goals of care discussions and decisions regarding long-term tube feeding after acute stroke.
Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial decreased major adverse cardiovascular events with very low-dose rivaroxaban and aspirin in patients with coronary artery disease and peripheral artery disease. We examined the eligibility and potential real-world impact of this strategy on the COMPASS-eligible population. Methods and Results COMPASS eligibility criteria were applied to the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) registry, a population-based cohort of Ontario adults. We compared 5-year major adverse cardiovascular events and major bleeding rates stratified by COMPASS eligibility and by clinical risk factors. We applied COMPASS trial rivaroxaban/aspirin arm hazard ratios to estimate the potential impact on the COMPASS-eligible cohort. Among 362 797 patients with coronary artery disease or peripheral artery disease, 38% were deemed eligible, 47% ineligible, and 15% indeterminate. Among eligible patients, a greater number of risk factors was associated with higher rates of cardiovascular outcomes, whereas bleeding rates increased minimally. Over 5 years, applying COMPASS treatment effects to eligible patients resulted in a 2.4% absolute risk reduction of major adverse cardiovascular events and a number needed to treat of 42, and a 1.3% absolute risk increase of major bleeding and number needed to harm (NNH) of 77. Those with at least 2 risk factors had a 3.0% absolute risk reduction of major adverse cardiovascular events (number needed to treat =34) and a 1.6% absolute risk increase of major bleeding (number needed to harm =61). Conclusions Implementation of very-low-dose rivaroxaban therapy would potentially impact ≈$$ \approx $$2 in 5 patients with atherosclerotic disease in Ontario. Eligible individuals with ≥$$ \ge $$2 comorbidities represent a high-risk subgroup that may derive the greatest benefit-to-risk ratio. Selection of patients with high-risk predisposing factors appears appropriate in routine practice.
Objective: Practice guidelines indicate that patients who have months to weeks left to live should not be offered chemotherapy. We examined factors associated with clinician-reported poor performance status as determined by the Palliative Performance Scale (PPS) and subsequent initiation of intravenous (IV) chemotherapy in an ambulatory cancer population in Ontario, Canada. Methods: In this retrospective study, patients who had at least one PPS assessment indicating poor performance status (a PPS score of 50 or lower) comprised the study cohort. Using linked administrative databases, we observed the cohort for initiation of IV chemotherapy within 30 days of the first (index) poor PPS assessment. Results: We excluded patients for whom IV or oral chemotherapy was on going or recently completed or whose performance status improved following the index assessment. Of the remaining cohort, 9.3 percent (264/2,842) received IV chemotherapy within 30 days of the index PPS. Conclusion: A small number of cancer patients with poor performance status began IV chemotherapy in the month following assessment. Objectif: Les directives de pratiques cliniques recommandent que l'on ne propose pas de traitements de chimiothérapie aux patients présentant une espérance de survie de quelques semaines à quelques mois. Nous avons examiné, chez un groupe de patients atteints du cancer en Ontario, au Canada, les éléments associés au faible statut des malades selon les paramètres de l'Έchelle de performance pour soins palliatifs afin d'identifier les facteurs qui ont déterminé l'amorce de la chimiothérapie. Méthode: Cette étude rétrospective comprenait les patients chez qui lors du test d'évaluation de performance on avait noté au moins un élément négatif, soit un score de performance de 50 ou moins. En utilisant plusieurs banques de données administratives interreliées, nous avons étudié cette cohorte de patients devant être traités par chimiothérapie au cours de la période de 30 jours suivant leur évaluation. Résultats: Nous avons exclu les patients pour lesquels le traitement de chimiothérapie orale ou intraveineuse était déjà en cours ou récemment terminé ou ceux dont le statut s'était amélioré selon l'Έchelle de performance. De la partie restante de la cohorte, 9,3 pourcent (264/2 842) ont reçu le traitement par voie intraveineuse à l'intérieur des 30 jours suivant l'indice de l'Έchelle de performance. Conclusion: Un petit nombre de patients ayant un faible statut ont commencé la traitement de chimiothérapie au cours du mois suivant l'évaluation.
