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1.  Classification of Canadian immigrants into visible minority groups using country of birth and mother tongue 
Open Medicine  2013;7(4):e85-e93.
The Permanent Resident Database of Citizenship and Immigration Canada (CIC) contains sociodemographic information on immigrants but lacks ethnic group classifications. To enhance its usability for ethnicityrelated research, we categorized immigrants in the CIC database into one of Canada's official visible minority groups or a white category using their country of birth and mother tongue.
Using public data sources, we classified each of 267 country names and 245 mother tongues in the CIC data into 1 of 10 visible minority groups (South Asian, Chinese, black, Latin American, Filipino, West Asian, Arab, Southeast Asian, Korean, and Japanese) or a white group. We then used country of birth alone (method A) or country of birth plus mother tongue (method B) to classify 2.5 million people in the CIC database who immigrated to Ontario between 1985 and 2010 and who had a valid encrypted health card number. We validated the ethnic categorizations using linked selfreported ethnicity data for 6499 people who responded to the Canadian Community Health Survey (CCHS).
Among immigrants listed in the CIC database, the 4 most frequent visible minority groups as classified by method B were South Asian (n = 582 812), Chinese (n = 400 771), black (n = 254 189), and Latin American (n = 179 118). Methods A and B agreed in 94% of the categorizations (kappa coefficient 0.94, 95% confidence interval [CI] 0.93–0.94). Both methods A and B agreed with self-reported CCHS ethnicity in 86% of all categorizations (for both comparisons, kappa coefficient 0.83, 95% CI 0.82–0.84). Both methods A and B had high sensitivity and specificity for most visible minority groups when validated using self-reported ethnicity from the CCHS (e.g., with method B, sensitivity and specificity were, respectively, 0.85 and 0.97 for South Asians, 0.93 and 0.99 for Chinese, and 0.90 and 0.97 for blacks).
The use of country of birth and mother tongue is a validated and practical method for classifying immigrants to Canada into ethnic categories.
PMCID: PMC4161499  PMID: 25237404
2.  Temporal Trends in the Utilization of Echocardiography in Ontario, 2001-2009 
JACC. Cardiovascular imaging  2013;6(4):515-522.
The purpose of this study was to examine utilization and growth in echocardiography among the general population of Ontario between 2001 and 2009. The age- and sex-adjusted rates of echocardiography grew from 39.1 per 1,000 persons in 2001 to 59.9 per 1,000 persons in 2009, for an annual rate of increase of 5.5%. Repeat echocardiograms increased at a rate of 10.6% per year and accounted for 25.3% of all procedures in 2009 as compared to 18.5% in 2002. While significant increases in echocardiography utilization were observed, opportunities may exist to improve the clinical utility of the echocardiograms performed in Ontario.
PMCID: PMC3915739  PMID: 23579013
echocardiography; resource utilization; cardiovascular imaging
3.  Trends in the incidence and outcomes of heart failure in Ontario, Canada: 1997 to 2007 
Heart failure is a leading cause of admission to hospital, but whether the incidence of heart failure is increasing or decreasing is uncertain. We examined temporal trends in the incidence and outcomes of heart failure in Ontario, Canada.
Using population-based administrative databases of hospital discharge abstracts and physician health insurance claims, we identified 419 551 incident cases of heart failure in Ontario between Apr. 1, 1997, and Mar. 31, 2008. All patients were classified as either inpatients or outpatients based on the patient’s location at the time of the initial diagnosis. We tracked subsequent outcomes through linked administrative databases.
The age- and sex-standardized incidence of heart failure decreased 32.7% from 454.7 per 100 000 people in 1997 to 306.1 per 100 000 people in 2007 (p < 0.001). A comparable decrease in incidence occurred in both inpatient and outpatient settings. The greatest relative decrease occurred in patients aged 85 and over. Over the study period, 1-year risk-adjusted mortality decreased from 17.7% in 1997 to 16.2% in 2007 (p = 0.02) for outpatients, with a nonsignificant decrease from 35.7% in 1997 to 33.8% in 2007 (p = 0.1) for inpatients.
The incidence of heart failure decreased substantially during the study period. Nevertheless, the prognosis for patients with heart failure remains poor and is associated with high mortality.
PMCID: PMC3470643  PMID: 22908143
4.  Deriving Ethnic-Specific BMI Cutoff Points for Assessing Diabetes Risk 
Diabetes Care  2011;34(8):1741-1748.
The definition of obesity (BMI ≥30 kg/m2), a key risk factor of diabetes, is widely used in white populations; however, its appropriateness in nonwhite populations has been questioned. We compared the incidence rates of diabetes across white, South Asian, Chinese, and black populations and identified equivalent ethnic-specific BMI cutoff values for assessing diabetes risk.
We conducted a multiethnic cohort study of 59,824 nondiabetic adults aged ≥30 years living in Ontario, Canada. Subjects were identified from Statistics Canada’s population health surveys and followed for up to 12.8 years for diabetes incidence using record linkages to multiple health administrative databases.
The median duration of follow-up was 6 years. After adjusting for age, sex, sociodemographic characteristics, and BMI, the risk of diabetes was significantly higher among South Asian (hazard ratio 3.40, P < 0.001), black (1.99, P < 0.001), and Chinese (1.87, P = 0.002) subjects than among white subjects. The median age at diagnosis was lowest among South Asian (aged 49 years) subjects, followed by Chinese (aged 55 years), black (aged 57 years), and white (aged 58 years) subjects. For the equivalent incidence rate of diabetes at a BMI of 30 kg/m2 in white subjects, the BMI cutoff value was 24 kg/m2 in South Asian, 25 kg/m2 in Chinese, and 26 kg/m2 in black subjects.
South Asian, Chinese, and black subjects developed diabetes at a higher rate, at an earlier age, and at lower ranges of BMI than their white counterparts. Our findings highlight the need for designing ethnically tailored prevention strategies and for lowering current targets for ideal body weight for nonwhite populations.
PMCID: PMC3142051  PMID: 21680722
5.  Determinants of variations in coronary revascularization practices 
The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario.
In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low–medium [2.0–2.7], medium–high [2.8–3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization.
The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%–99.0%) and those with left main artery disease usually underwent CABG (80.8%–94.2%), regardless of the hospital’s procedure ratio. Variation in the management of patients with non-emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization “culture” at the treating hospital.
The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non-emergent multivessel disease.
PMCID: PMC3273505  PMID: 22158396
6.  Comparison of cardiovascular risk profiles among ethnic groups using population health surveys between 1996 and 2007 
Although people of South Asian, Chinese and black ethnic backgrounds represent about 60% of the world’s population, most knowledge of cardiovascular risk is derived from studies conducted in white populations. We conducted a large, population-based comparison of cardiovascular risk among people of white, South Asian, Chinese and black ethnicity living in Ontario, Canada.
We examined the age- and sex-standardized prevalence of eight cardiovascular risk factors, heart disease and stroke among 154 653 white people, 3364 South Asian people, 3038 Chinese people and 2742 black people. For this study, we pooled respondent data from five cross-sectional health surveys conducted between 1996 and 2007: the National Population Health Survey of 1996 and the Canadian Community Health Survey, versions 1.1, 2.1, 3.1 and 4.1.
The four ethnic groups varied considerably in the prevalence of the four major cardiovascular risk factors that we examined: for smoking, South Asian 8.6%, Chinese 8.7%, black 11.4% and white 24.8%; for obesity, Chinese 2.5%, South Asian 8.1%, black 14.1% and white 14.8%; for diabetes mellitus, white 4.2%, Chinese 4.3%, South Asian 8.1% and black 8.5%; and for hypertension, white 13.7%, Chinese 15.1%, South Asian 17.0% and black 19.8%. The prevalence of heart disease ranged from a low of 3.2% in the Chinese population to a high of 5.2% in the South Asian population, and the prevalence of stroke ranged from a low of 0.6% in the Chinese population to a high of 1.7% in the South Asian population. Although the black population had the least favourable cardiovascular risk factor profile overall, this group had a relatively low prevalence of heart disease (3.4%).
Ethnic groups living in Ontario had striking differences in cardiovascular risk profiles. Awareness of these differences may help in identifying priorities for the development of cardiovascular disease prevention programs for specific ethnic groups.
PMCID: PMC2871219  PMID: 20403888
7.  Access to primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in Canada: a geographic analysis 
Open Medicine  2010;4(1):e13-e21.
Primary percutaneous coronary intervention (PCI) is preferred over fibrinolysis for the treatment of ST-segment elevation myocardial infarction (STEMI). In the United States, nearly 80% of people aged 18 years and older have access to a PCI facility within 60 minutes. We conducted this study to evaluate the areas in Canada and the proportion of the population aged 40 years and older with access to a PCI facility within 60, 90 and 120 minutes.
We used geographic information systems to estimate travel times by ground transport to PCI facilities across Canada. Time to dispatch, time to patient and time at the scene were considered in the overall access times. Using 2006 Canadian census data, we extracted the number of adults aged 40 years and older who lived in areas with access to a PCI facility within 60, 90 and 120 minutes. We also examined the effect on these estimates of the hypothetical addition of new PCI facilities in underserved areas.
Only a small proportion of the country’s geographic area was within 60 minutes of a PCI facility. Despite this, 63.9% of Canadians aged 40 and older had such access. This proportion varied widely across provinces, from a low of 15.8% in New Brunswick to a high of 72.6% in Ontario. The hypothetical addition of a single facility to each of 4 selected provinces could increase the proportion by 3.2% to 4.3%, depending on the province. About 470 000 adults would gain access in such a scenario of new facilities.
We found that nearly two-thirds of Canada’s population aged 40 years and older had timely access to PCI facilities. The proportion varied widely across the country. Such information can inform the development of regionalized STEMI care models.
PMCID: PMC3116676  PMID: 21686287
8.  Using methods from the data mining and machine learning literature for disease classification and prediction: A case study examining classification of heart failure sub-types 
Journal of clinical epidemiology  2013;66(4):398-407.
Physicians classify patients into those with or without a specific disease. Furthermore, there is often interest in classifying patients according to disease etiology or subtype. Classification trees are frequently used to classify patients according to the presence or absence of a disease. However, classification trees can suffer from limited accuracy. In the data-mining and machine learning literature, alternate classification schemes have been developed. These include bootstrap aggregation (bagging), boosting, random forests, and support vector machines.
Study design and Setting
We compared the performance of these classification methods with those of conventional classification trees to classify patients with heart failure according to the following sub-types: heart failure with preserved ejection fraction (HFPEF) vs. heart failure with reduced ejection fraction (HFREF). We also compared the ability of these methods to predict the probability of the presence of HFPEF with that of conventional logistic regression.
We found that modern, flexible tree-based methods from the data mining literature offer substantial improvement in prediction and classification of heart failure sub-type compared to conventional classification and regression trees. However, conventional logistic regression had superior performance for predicting the probability of the presence of HFPEF compared to the methods proposed in the data mining literature.
The use of tree-based methods offers superior performance over conventional classification and regression trees for predicting and classifying heart failure subtypes in a population-based sample of patients from Ontario. However, these methods do not offer substantial improvements over logistic regression for predicting the presence of HFPEF.
PMCID: PMC4322906  PMID: 23384592
Boosting; classification trees; Bagging; random forests; classification; regression trees; support vector machines; regression methods; statistical methods; prediction; heart failure
9.  National trends in rates of death and hospital admissions related to acute myocardial infarction, heart failure and stroke, 1994–2004 
Rates of death from cardiovascular and cerebrovascular diseases have been steadily declining over the past few decades. Whether such declines are occurring to a similar degree for common disorders such as acute myocardial infarction, heart failure and stroke is uncertain. We examined recent national trends in mortality and rates of hospital admission for these 3 conditions.
We analyzed mortality data from Statistic Canada’s Canadian Mortality Database and data on hospital admissions from the Canadian Institute for Health Information’s Hospital Morbidity Database for the period 1994–2004. We determined age- and sex-standardized rates of death and hospital admissions per 100 000 population aged 20 years and over as well as in-hospital case-fatality rates.
The overall age- and sex-standardized rate of death from cardiovascular disease in Canada declined 30.0%, from 360.6 per 100 000 in 1994 to 252.5 per 100 000 in 2004. During the same period, the rate fell 38.1% for acute myocardial infarction, 23.5% for heart failure and 28.2% for stroke, with improvements observed across most age and sex groups. The age- and sex-standardized rate of hospital admissions decreased 27.6% for stroke and 27.2% for heart failure. The rate for acute myocardial infarction fell only 9.2%. In contrast, the relative decline in the inhospital case-fatality rate was greatest for acute myocardial infarction (33.1%; p < 0.001). Much smaller relative improvements in case-fatality rates were noted for heart failure (8.1%) and stroke (8.9%).
The rates of death and hospital admissions for acute myocardial infarction, heart failure and stroke in Canada changed at different rates over the 10-year study period. Awareness of these trends may guide future efforts for health promotion and health care planning and help to determine priorities for research and treatment.
PMCID: PMC2696549  PMID: 19546444
11.  Cardiovascular Disease Population Risk Tool (CVDPoRT): predictive algorithm for assessing CVD risk in the community setting. A study protocol 
BMJ Open  2014;4(10):e006701.
Recent publications have called for substantial improvements in the design, conduct, analysis and reporting of prediction models. Publication of study protocols, with prespecification of key aspects of the analysis plan, can help to improve transparency, increase quality and protect against increased type I error. Valid population-based risk algorithms are essential for population health planning and policy decision-making. The purpose of this study is to develop, evaluate and apply cardiovascular disease (CVD) risk algorithms for the population setting.
Methods and analysis
The Ontario sample of the Canadian Community Health Survey (2001, 2003, 2005; 77 251 respondents) will be used to assess risk factors focusing on health behaviours (physical activity, diet, smoking and alcohol use). Incident CVD outcomes will be assessed through linkage to administrative healthcare databases (619 886 person-years of follow-up until 31 December 2011). Sociodemographic factors (age, sex, immigrant status, education) and mediating factors such as presence of diabetes and hypertension will be included as predictors. Algorithms will be developed using competing risks survival analysis. The analysis plan adheres to published recommendations for the development of valid prediction models to limit the risk of overfitting and improve the quality of predictions. Key considerations are fully prespecifying the predictor variables; appropriate handling of missing data; use of flexible functions for continuous predictors; and avoiding data-driven variable selection procedures. The 2007 and 2009 surveys (approximately 50 000 respondents) will be used for validation. Calibration will be assessed overall and in predefined subgroups of importance to clinicians and policymakers.
Ethics and dissemination
This study has been approved by the Ottawa Health Science Network Research Ethics Board. The findings will be disseminated through professional and scientific conferences, and in peer-reviewed journals. The algorithm will be accessible electronically for population and individual uses.
Trial registration number NCT02267447.
PMCID: PMC4208046  PMID: 25341454
13.  Predictors of early and late stroke following cardiac surgery 
Much is known about the short-term risks of stroke following cardiac surgery. We examined the rate and predictors of long-term stroke in a cohort of patients who underwent cardiac surgery.
We obtained linked data for patients who underwent cardiac surgery in the province of Ontario between 1996 and 2006. We analyzed the incidence of stroke and death up to 2 years postoperatively.
Of 108 711 patients, 1.8% (95% confidence interval [CI] 1.7%–1.9%) had a stroke perioperatively, and 3.6% (95% CI 3.5%–3.7%) had a stroke within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 year; adjusted hazard ratio [HR] for all stroke 1.9, 95% CI 1.8–2.0), a history of stroke or transient ischemic attack (adjusted HR 2.1, 95% CI 1.9–2.3), peripheral vascular disease (adjusted HR 1.6, 95% CI 1.5–1.7), combined coronary bypass grafting and valve surgery (adjusted HR 1.7, 95% CI 1.5–1.8) and valve surgery alone (adjusted HR 1.4, 95% CI 1.2–1.5). Preoperative need for dialysis (adjusted odds ratio [OR] 2.1, 95% CI 1.6–2.8) and new-onset postoperative atrial fibrillation (adjusted OR 1.5, 95% CI 1.3–1.6) were predictors of only early stroke. A CHADS2 score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1 (19.9% v. 9.3% among patients with a history of atrial fibrillation, 16.8% v. 7.8% among those with new-onset postoperative atrial fibrillation and 14.8% v. 5.8% among those without this condition).
Patients who had cardiac surgery were at highest risk of stroke in the early postoperative period and had continued risk over the ensuing 2 years, with similar risk factors over these periods. New-onset postoperative atrial fibrillation was a predictor of only early stroke. The CHADS2 score predicted stroke risk among patients with and without atrial fibrillation.
PMCID: PMC4150704  PMID: 25047983
14.  Cardiovascular Complications and Mortality After Diabetes Diagnosis for South Asian and Chinese Patients 
Diabetes Care  2013;36(9):2670-2676.
Many non-European ethnic groups have an increased risk for diabetes; however, the published literature demonstrates considerable uncertainty about the rates of diabetes complications among minority populations. The objective of this study was to determine the risks of cardiovascular complications and of mortality after diabetes diagnosis for South Asian and Chinese patients, compared with European patients.
A population-based cohort study identified all 491,243 adults with newly diagnosed diabetes in Ontario, Canada, between April 2002 and March 2009. Subjects were followed until March 2011 for the first occurrence of any cardiovascular complication of diabetes (coronary artery disease, stroke, or lower-extremity amputation) and for all-cause mortality. Median follow-up was 4.7 years.
The crude incidence of cardiovascular complications after diabetes diagnosis was 17.9 per 1,000 patient-years among European patients, 12.0 among South Asian patients, and 7.7 among Chinese patients. After adjusting for baseline characteristics, the cause-specific hazard ratios (HRs) for cardiovascular complications relative to European patients were 0.95 (95% CI 0.90–1.00; P = 0.056) and 0.50 (0.46–0.53; P < 0.001) for South Asian and Chinese patients, respectively. Mortality was lower for both minority groups (adjusted HR for South Asian patients 0.56 [95% CI 0.52–0.60]; P < 0.001; for Chinese patients 0.58 [0.55–0.62]; P < 0.001).
Chinese patients were at substantially lower risk than European patients for cardiovascular complications after diabetes diagnosis, whereas South Asian patients were at comparable risk. Mortality after diabetes diagnosis was markedly lower for both minority populations.
PMCID: PMC3747942  PMID: 23637350
15.  Projections of preventable risks for cardiovascular disease in Canada to 2021: a microsimulation modelling approach 
CMAJ Open  2014;2(2):E94-E101.
Reductions in preventable risks associated with cardiovascular disease have contributed to a steady decrease in its incidence over the past 50 years in most developed countries. However, it is unclear whether this trend will continue. Our objective was to examine future risk by projecting trends in preventable risk factors in Canada to 2021.
We created a population-based microsimulation model using national data on births, deaths and migration; socioeconomic data; cardiovascular disease risk factors; and algorithms for changes in these risk factors (based on sociodemographic characteristics and previous cardiovascular disease risk). An initial population of 22.5 million people, representing the Canadian adult population in 2001, had 13 characteristics including the risk factors used in clinical risk prediction. There were 6.1 million potential exposure profiles for each person each year. Outcome measures included annual prevalence of risk factors (smoking, obesity, diabetes, hypertension and lipid levels) and of co-occurring risks.
From 2003 to 2009, the projected risks of cardiovascular disease based on the microsimulation model closely approximated those based on national surveys. Except for obesity and diabetes, all risk factors were projected to decrease through to 2021. The largest projected decreases were for the prevalence of smoking (from 25.7% in 2001 to 17.7% in 2021) and uncontrolled hypertension (from 16.1% to 10.8%). Between 2015 and 2017, obesity was projected to surpass smoking as the most prevalent risk factor.
Risks of cardiovascular disease are projected to decrease modestly in Canada, leading to a likely continuing decline in its incidence.
PMCID: PMC4089435  PMID: 25077135
16.  The CANHEART health index: a tool for monitoring the cardiovascular health of the Canadian population 
To comprehensively examine the cardiovascular health of Canadians, we developed the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) health index. We analyzed trends in health behaviours and factors to monitor the cardiovascular health of the Canadian population.
We used data from the Canadian Community Health Survey (2003–2011 [excluding 2005]; response rates 70%–81%) to examine trends in the prevalence of 6 cardiovascular health factors and behaviours (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension) among Canadian adults aged 20 or older. We defined ideal criteria for each of the 6 health metrics. The number of ideal metrics was summed to create the CANHEART health index; values range from 0 (worst) to 6 (best or ideal). A separate CANHEART index was developed for youth age 12–19 years; this index included 4 health factors and behaviours (smoking, physical activity, fruit and vegetable consumption and overweight/obesity). We determined the prevalence of ideal cardiovascular health and the mean CANHEART health index score, stratified by age, sex and province.
During the study period, physical activity and fruit and vegetable consumption increased and smoking decreased among Canadian adults. The prevalence of overweight/obesity, hypertension and diabetes increased. In 2009–2010, 9.4% of Canadian adults were in ideal cardiovascular health, 53.3% were in intermediate health (4–5 healthy factors or behaviours), and 37.3% were in poor cardiovascular health (0–3 healthy factors or behaviours). Twice as many women as men were in ideal cardiovascular health (12.8% vs. 6.1%). Among youth, the prevalence of smoking decreased and the prevalence of overweight/obesity increased. In 2009–2010, 16.6% of Canadian youth were in ideal cardiovascular health, 33.7% were in intermediate health (3 healthy factors or behaviours), and 49.7% were in poor cardiovascular health (0–2 healthy factors or behaviours).
Fewer than 1 in 10 Canadian adults and 1 in 5 Canadian youth were in ideal cardiovascular health from 2003 to 2011. Intensive health promotion activities are needed to meet the Heart and Stroke Foundation of Canada’s goal of improving the cardiovascular health of Canadians by 10% by 2020 as measured by the CANHEART health index.
PMCID: PMC3928209  PMID: 24366893
17.  A comparison of Chinese and non-Chinese Canadian patients hospitalized with heart failure 
Canadians of Chinese descent, represent one of the fastest growing visible minority groups in Canada, (as well as the second largest), but relatively little is known about the clinical features of heart failure (HF) in Chinese-Canadian versus non-Chinese Canadian patients.
We conducted a population-based analysis of urban patients hospitalized in Ontario, Canada for the first time with a most responsible diagnosis of HF between April 1, 1995 and March 31, 2008. Among the 99,278 patients, 1,339 (1.3%) were classified as Chinese using a previously validated list of Chinese surnames. Through linkage to other administrative databases, we compared the clinical characteristics, pharmacological management, and outcomes of Chinese versus non-Chinese HF patients.
Ischemic heart disease was identified as the possible etiology of HF in a greater proportion of non-Chinese patients (47.7% vs. 35.3%; p < 0.001) whereas hypertension (26.1% vs. 16.1%; p < 0.001) and valvular heart disease (11.6% vs. 7.2%; p < 0.001) were relatively more common in Chinese patients. Chinese patients were prescribed angiotensin-converting enzyme (ACE) inhibitors less frequently (57.5% vs. 66.4%, p < 0.001) and angiotensin receptor blockers (ARBs) more frequently (17.4% vs. 8.9%, p < 0.001) compared to non-Chinese patients. They were also less likely to be adherent to ACE inhibitors over a 1-year follow up period. However, the 1-year case-fatality rates were comparable between the Chinese (31.7%) and non-Chinese (30.2%) subjects (p = 0.24).
There are important differences in the causes and medical management of HF in Chinese and non-Chinese patients residing in Canada. Despite these differences, the long-term outcomes of HF patients were similar.
PMCID: PMC4029301  PMID: 24325765
Heart failure; Hypertension; Valvular heart disease
18.  The Average Lifespan of Patients Discharged from Hospital with Heart Failure 
Journal of General Internal Medicine  2012;27(9):1171-1179.
There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk.
To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden.
Population-based retrospective cohort study.
Ontario, Canada.
7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000.
Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata.
The average life-span of the cohort was 5.5 years (STD +/− 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year.
Data regarding changes in patient clinical status over time were unavailable.
The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.
PMCID: PMC3515002  PMID: 22549300
life-expectancy; heart failure; risk; survival; comorbidity
19.  Effect of a provincial system of stroke care delivery on stroke care and outcomes 
Systems of stroke care delivery have been promoted as a means of improving the quality of stroke care, but little is known about their effectiveness. We assessed the effect of the Ontario Stroke System, a province-wide strategy of regionalized stroke care delivery, on stroke care and outcomes in Ontario, Canada.
We used population-based provincial administrative databases to identify all emergency department visits and hospital admissions for acute stroke and transient ischemic attack from Jan. 1, 2001, to Dec. 31, 2010. Using piecewise regression analyses, we assessed the effect of the full implementation of the Ontario Stroke System in 2005 on the proportion of patients who received care at stroke centres, and on rates of discharge to long-term care facilities and 30-day mortality after stroke.
We included 243 287 visits by patients with acute stroke or transient ischemic attack. The full implementation of the Ontario Stroke System in 2005 was associated with an increase in rates of care at stroke centres (before implementation: 40.0%; after implementation: 46.5%), decreased rates of discharge to long-term care facilities (before implementation: 16.9%; after implementation: 14.8%) and decreased 30-day mortality for hemorrhagic (before implementation: 38.3%; after implementation: 34.4%) and ischemic stroke (before implementation: 16.3%; after implementation: 15.7%). The system’s implementation was also associated with marked increases in the proportion of patients who received neuroimaging, thrombolytic therapy, care in a stroke unit and antithrombotic therapy.
The implementation of an organized system of stroke care delivery was associated with improved processes of care and outcomes after stroke.
PMCID: PMC3708028  PMID: 23713072
20.  Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community 
European Heart Journal  2012;33(14):1734-1741.
Heart failure (HF) is a major public health burden worldwide. Of patients presenting with HF, 30–55% have a preserved ejection fraction (HFPEF) rather than a reduced ejection fraction (HFREF). Our objective was to examine discriminating clinical features in new-onset HFPEF vs. HFREF.
Methods and results
Of 712 participants in the Framingham Heart Study (FHS) hospitalized for new-onset HF between 1981 and 2008 (median age 81 years, 53% female), 46% had HFPEF (EF >45%) and 54% had HFREF (EF ≤45%). In multivariable logistic regression, coronary heart disease (CHD), higher heart rate, higher potassium, left bundle branch block, and ischaemic electrocardiographic changes increased the odds of HFREF; female sex and atrial fibrillation increased the odds of HFPEF. In aggregate, these clinical features predicted HF subtype with good discrimination (c-statistic 0.78). Predictors were examined in the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. Of 4436 HF patients (median age 75 years, 47% female), 32% had HFPEF and 68% had HFREF. Distinguishing clinical features were consistent between FHS and EFFECT, with comparable discrimination in EFFECT (c-statistic 0.75). In exploratory analyses examining the traits of the intermediate EF group (EF 35–55%), CHD predisposed to a decrease in EF, whereas other clinical traits showed an overlapping spectrum between HFPEF and HFREF.
Multiple clinical characteristics at the time of initial HF presentation differed in participants with HFPEF vs. HFREF. While CHD was clearly associated with a lower EF, overlapping characteristics were observed in the middle of the left ventricular EF range spectrum.
PMCID: PMC3530391  PMID: 22507977
Heart failure; Epidemiology; Risk factors; Ejection fraction
21.  Socioeconomic Status, Functional Recovery, and Long-Term Mortality among Patients Surviving Acute Myocardial Infarction 
PLoS ONE  2013;8(6):e65130.
To examine the relationship between socio-economic status (SES), functional recovery and long-term mortality following acute myocardial infarction (AMI).
The extent to which SES mortality disparities are explained by differences in functional recovery following AMI is unclear.
We prospectively examined 1368 patients who survived at least one-year following an index AMI between 1999 and 2003 in Ontario, Canada. Each patient was linked to administrative data and followed over 9.6 years to track mortality. All patients underwent medical chart abstraction and telephone interviews following AMI to identify individual-level SES, clinical factors, processes of care (i.e., use of, and adherence, to evidence-based medications, physician visits, invasive cardiac procedures, referrals to cardiac rehabilitation), as well as changes in psychosocial stressors, quality of life, and self-reported functional capacity.
As compared with their lower SES counterparts, higher SES patients experienced greater functional recovery (1.80 ml/kg/min average increase in peak V02, P<0.001) after adjusting for all baseline clinical factors. Post-AMI functional recovery was the strongest modifiable predictor of long-term mortality (Adjusted HR for each ml/kg/min increase in functional capacity: 0.91; 95% CI: 0.87–0.94, P<0.001) irrespective of SES (P = 0.51 for interaction between SES, functional recovery, and mortality). SES-mortality associations were attenuated by 27% after adjustments for functional recovery, rendering the residual SES-mortality association no longer statistically significant (Adjusted HR: 0.84; 95% CI:0.70–1.00, P = 0.05). The effects of functional recovery on SES-mortality associations were not explained by access inequities to physician specialists or cardiac rehabilitation.
Functional recovery may play an important role in explaining SES-mortality gradients following AMI.
PMCID: PMC3670842  PMID: 23755180
22.  Neighborhood income and stroke care and outcomes 
Neurology  2012;79(12):1200-1207.
To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas.
We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors.
There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29).
In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors.
PMCID: PMC3440450  PMID: 22895592
23.  Economic analysis of Heart and Stroke Foundation of Ontario’s Hypertension Management Initiative 
Hypertension is suboptimally treated in primary care settings. We evaluated the cost-effectiveness of the Heart and Stroke Foundation of Ontario’s Hypertension Management Initiative (HMI), an interdisciplinary, evidence-informed chronic disease management model for primary care that focuses on improving blood pressure management and control by primary care providers and patients according to clinical best practice guidelines.
The perspective of our analysis was that of the Ontario Ministry of Health and Long-Term Care with a lifetime horizon and 5% annual discount rate. Using data from a prospective cohort study from the HMI, we created two matched groups: pre-HMI (standard care), and post-HMI (n = 1720). For each patient, we estimated the 10-year risk of cardiovascular disease (CVD) using the Framingham risk equation and life expectancy from life tables. Long-term health care costs incurred with physician visits, acute and chronic care hospitalizations, emergency department visits, same-day surgeries, and medication use were determined through linkage to administrative databases, using a bottom-up approach.
The HMI intervention was associated with significant reductions in systolic blood pressure (126 mmHg vs 134 mmHg with standard care; P-value < 0.001). These improvements were associated with a reduction in the 10-year risk of CVD (9.5% risk vs 10.7% in standard care; P-value < 0.001) and a statistically significant improvement in discounted life expectancy (9.536 years vs 9.516 in standard care; P-value < 0.001). The HMI cohort had a discounted mean lifetime cost of $22,884 CAD vs $22,786 CAD for standard care, with an incremental cost-effectiveness ratio of $4939 CAD per life-year gained.
We found that the HMI is a cost-effective means of providing evidence-informed, chronic disease management in primary care to patients with hypertension.
PMCID: PMC3501398  PMID: 23180969
hypertension; economic evaluation; cardiovascular disease
24.  Regression trees for predicting mortality in patients with cardiovascular disease: What improvement is achieved by using ensemble-based methods? 
In biomedical research, the logistic regression model is the most commonly used method for predicting the probability of a binary outcome. While many clinical researchers have expressed an enthusiasm for regression trees, this method may have limited accuracy for predicting health outcomes. We aimed to evaluate the improvement that is achieved by using ensemble-based methods, including bootstrap aggregation (bagging) of regression trees, random forests, and boosted regression trees. We analyzed 30-day mortality in two large cohorts of patients hospitalized with either acute myocardial infarction (N = 16,230) or congestive heart failure (N = 15,848) in two distinct eras (1999–2001 and 2004–2005). We found that both the in-sample and out-of-sample prediction of ensemble methods offered substantial improvement in predicting cardiovascular mortality compared to conventional regression trees. However, conventional logistic regression models that incorporated restricted cubic smoothing splines had even better performance. We conclude that ensemble methods from the data mining and machine learning literature increase the predictive performance of regression trees, but may not lead to clear advantages over conventional logistic regression models for predicting short-term mortality in population-based samples of subjects with cardiovascular disease.
PMCID: PMC3470596  PMID: 22777999 CAMSID: cams2404
Acute myocardial infarction; Bagging; Boosting; Data mining; Heart failure
25.  Obesity, lifestyle risk-factors, and health service outcomes among healthy middle-aged adults in Canada 
The extent to which uncomplicated obesity among an otherwise healthy middle-aged population is associated with higher longitudinal health-care expenditures remains unclear.
To examine the incremental long-term health service expenditures and outcomes associated with uncomplicated obesity, 9398 participants of the 1994–1996 National Population Health Survey were linked to administrative data and followed longitudinally forward for 11.5 years to track health service utilization costs and death. Patients with pre-existing heart disease, those who were 65 years of age and older, and those with self-reported body mass indexes of <18.5 kg/m2 at inception were excluded. Propensity-matching was used to compare obesity (+/− other baseline risk-factors and lifestyle behaviours) with normal-weight healthy controls. Cost-analyses were conducted from the perspective of Ontario’s publicly-funded health care system.
Obesity as an isolated risk-factor was not associated with significantly higher health-care costs as compared with normal weight matched controls (Canadian $8,294.67 vs. Canadian $7,323.59, P = 0.27). However, obesity in combination with other lifestyle factors was associated with significantly higher cumulative expenditures as compared with normal-weight healthy matched controls (CAD$14,186.81 for those with obesity + 3 additional risk-factors vs. CAD$7,029.87 for those with normal BMI and no other risk-factors, P < 0.001). The likelihood that obese individuals developed future diabetes and hypertension also rose markedly when other lifestyle factors, such as smoking, physical inactivity and/or psychosocial distress were present at baseline.
The incremental health-care costs associated with obesity was modest in isolation, but increased significantly when combined with other lifestyle risk-factors. Such findings have relevance to the selection, prioritization, and cost-effective targeting of therapeutic lifestyle interventions.
PMCID: PMC3439326  PMID: 22863333
Obesity; Risk-factors; Health service utilization; Health care expenditures; Cohort study; Outcomes

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