Publications by authors named "Jeffrey A Bakal"

57 Publications

Symptômes associés au frottis SRAS-CoV-2-positif chez des enfants de l’Alberta.

CMAJ 2021 02;193(5):E177-E185

Alberta Strategy for Patient Oriented Research Support Unit Data Platform et Provincial Research Data Services (King, Whitten), Services de santé de l'Alberta, Calgary, Alb.; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (Bakal, McAlister) et Provincial Research Data Services (Bakal), Services de santé de l'Alberta, Edmonton, Alb.; Division de médecine interne générale (McAlister), Université de l'Alberta, Edmonton, Alb.

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http://dx.doi.org/10.1503/cmaj.202065-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954568PMC
February 2021

Which Adults Presenting for Severe Acute Respiratory Syndrome Coronavirus 2 Testing Are Most Likely to Produce a Positive Swab Result?: A Population-Based Cohort of 15,132 Adults From Alberta, Canada.

Chest 2020 Dec 4. Epub 2020 Dec 4.

Division of General Internal Medicine, University of Alberta and the Alberta Strategy for Patient-Oriented Research Support Unit Data Platform, Edmonton, AB, Canada.

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http://dx.doi.org/10.1016/j.chest.2020.11.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833780PMC
December 2020

Geographic Inequalities of Respiratory Health Services Utilization during Childhood in Edmonton and Calgary, Canada: A Tale of Two Cities.

Int J Environ Res Public Health 2020 12 2;17(23). Epub 2020 Dec 2.

Department of Obstetrics and Gynecology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2S2, Canada.

Young children are susceptible to respiratory diseases. Inequalities exist across socioeconomic groups for paediatric respiratory health services utilization in Alberta. However, the geographic distribution of those inequalities has not been fully explored. The aim of this study was to identify geographic inequalities in respiratory health services utilization in early childhood in Calgary and Edmonton, two major urban centres in Western Canada. We conducted a geographic analysis of data from a retrospective cohort of all singleton live births occurred between 2005 and 2010. We aggregated at area-level the total number of episodes of respiratory care (hospitalizations and emergency department visits) that occurred during the first five years of life for bronchiolitis, pneumonia, lower/upper respiratory tract infections, influenza, and asthma-wheezing. We used spatial filters to identify geographic inequalities in the prevalence of acute paediatric respiratory health services utilization in Calgary and Edmonton. The average health gap between areas with the highest and the lowest prevalence of respiratory health services utilization was 1.5-fold in Calgary and 1.4-fold in Edmonton. Geographic inequalities were not completely explained by the spatial distribution of socioeconomic status, suggesting that other unmeasured factors at the neighbourhood level may explain local variability in the use of acute respiratory health services in early childhood.
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http://dx.doi.org/10.3390/ijerph17238973DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7730300PMC
December 2020

Symptoms associated with a positive result for a swab for SARS-CoV-2 infection among children in Alberta.

CMAJ 2021 01 24;193(1):E1-E9. Epub 2020 Nov 24.

Alberta Strategy for Patient Oriented Research Support Unit Data Platform and Provincial Research Data Services (King, Whitten), Alberta Health Services, Calgary Alta.; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (Bakal, McAlister) and Provincial Research Data Services (Bakal), Alberta Health Services, Edmonton, Alta.; Division of General Internal Medicine (McAlister), University of Alberta, Edmonton, Alta.

Background: Research involving children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has primarily focused on those presenting to emergency departments. We aimed to determine the symptoms most commonly associated with a positive result for a SARS-CoV-2 swab among community-based children.

Methods: We conducted an observational study among children tested and followed for SARS-CoV-2 infection using nasal, nasopharyngeal, throat or other (e.g., nasopharyngeal aspirate or tracheal secretions, or unknown) swabs between Apr. 13 and Sept. 30, 2020, in Alberta. We calculated positive likelihood ratios (LRs) for self-reported symptoms and a positive SARS-CoV-2 swab result in the entire cohort and in 3 sensitivity analyses: all children with at least 1 symptom, all children tested because of contact tracing whether they were symptomatic or not and all children 5 years of age or older.

Results: We analyzed results for 2463 children who underwent testing for SARS-CoV-2 infection; 1987 children had a positive result and 476 had a negative result. Of children with a positive test result for SARS-CoV-2, 714 (35.9%) reported being asymptomatic. Although cough (24.5%) and rhinorrhea (19.3%) were 2 of the most common symptoms among children with SARS-CoV-2 infection, they were also common among those with negative test results and were not predictive of a positive test (positive LR 0.96, 95% confidence interval [CI] 0.81-1.14, and 0.87, 95% CI 0.72-1.06, respectively). Anosmia/ageusia (positive LR 7.33, 95% CI 3.03-17.76), nausea/vomiting (positive LR 5.51, 95% CI 1.74-17.43), headache (positive LR 2.49, 95% CI 1.74- 3.57) and fever (positive LR 1.68, 95% CI 1.34-2.11) were the symptoms most predictive of a positive result for a SARS-CoV-2 swab. The positive LR for the combination of anosmia/ageusia, nausea/vomiting and headache was 65.92 (95% CI 49.48-91.92).

Interpretation: About two-thirds of the children who tested positive for SARS-CoV-2 infection reported symptoms. The symptoms most strongly associated with a positive SARS-CoV-2 swab result were anosmia/ageusia, nausea/vomiting, headache and fever.
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http://dx.doi.org/10.1503/cmaj.202065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7774482PMC
January 2021

Developments in asthma incidence and prevalence in Alberta between 1995 and 2015.

Allergy Asthma Clin Immunol 2020 9;16:87. Epub 2020 Oct 9.

Division of Pulmonary Medicine, Department of Medicine, University of Alberta, 11350 83rd Ave, 3-134b Clinical Sciences Building, Edmonton, AB T6G 2G3 Canada.

Background: Asthma is a chronic respiratory disease characterized by reversible bronchoconstriction and airway inflammation. According to Statistics Canada in 2014, 8.1% of Canadians aged 12 and older reported having asthma diagnosed by a health care professional. Therefore, in 2014 there were an estimated 274,661 persons with asthma in Alberta. Most epidemiological studies estimate prevalence and incidence using survey-based data, which has limitations. The Ontario Asthma Surveillance Information System (OASIS) group has developed and validated an algorithm for epidemiologic asthma studies using provincial health databases. In Alberta, there are some studies using provincial databases, but most are restricted to emergency department visits and do not represent the entire asthma population. Using the validated asthma definition for epidemiologic studies, we performed an analysis of the Alberta Health administrative databases to investigate and report province-wide asthma prevalence, incidence and mortality in Alberta from 1995 to 2015.

Methods: Data from administrative databases, provided by Alberta Health, was analyzed to determine age and sex specific prevalence, incidence and mortality of the asthma population. The population cohort was all individuals residing in the province of Alberta, ages 0 to 99 from 1995-2015. Kendall's Tau coefficient test was used to ascertain whether the observed trends were statistically significant.

Results: Between 1995 and 2015, the age-standardized incidence of asthma decreased by more than 50% in both males and females. Prevalence, however, increased threefold over the 20 years (for both genders) from 3.9 to 12.3% (Tau = 1.00, p < 0.0001) in females and from 3.5 to 11.6% (Tau = 1.00, p < 0.0001) in males. Thus, in 2015 there were 496,927 people with asthma in Alberta. All-cause mortality in the asthma population decreased over time, in both females (Tau = - 0.71, p < 0.0001) and males (Tau = - 0.69, p = 0.0001). For the last several years, all-cause mortality was higher in those with asthma. There were ~ 7 deaths/1000 in the population with asthma versus ~ 5 deaths/1000 in those without asthma.

Conclusions: The incidence of asthma decreased in both females and males while prevalence continued to increase, although at a slower rate than previously. All-cause mortality in asthma patients was higher than in those without asthma, but both decreased over time.
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http://dx.doi.org/10.1186/s13223-020-00485-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547457PMC
October 2020

Gut microbiota modulation with long-chain corn bran arabinoxylan in adults with overweight and obesity is linked to an individualized temporal increase in fecal propionate.

Microbiome 2020 08 19;8(1):118. Epub 2020 Aug 19.

Department of Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, AB, T6G 2E1, Canada.

Background: Variability in the health effects of dietary fiber might arise from inter-individual differences in the gut microbiota's ability to ferment these substrates into beneficial metabolites. Our understanding of what drives this individuality is vastly incomplete and will require an ecological perspective as microbiomes function as complex inter-connected communities. Here, we performed a parallel two-arm, exploratory randomized controlled trial in 31 adults with overweight and class-I obesity to characterize the effects of long-chain, complex arabinoxylan (n = 15) at high supplementation doses (female: 25 g/day; male: 35 g/day) on gut microbiota composition and short-chain fatty acid production as compared to microcrystalline cellulose (n = 16, non-fermentable control), and integrated the findings using an ecological framework.

Results: Arabinoxylan resulted in a global shift in fecal bacterial community composition, reduced α-diversity, and the promotion of specific taxa, including operational taxonomic units related to Bifidobacterium longum, Blautia obeum, and Prevotella copri. Arabinoxylan further increased fecal propionate concentrations (p = 0.012, Friedman's test), an effect that showed two distinct groupings of temporal responses in participants. The two groups showed differences in compositional shifts of the microbiota (p ≤ 0.025, PERMANOVA), and multiple linear regression (MLR) analyses revealed that the propionate response was predictable through shifts and, to a lesser degree, baseline composition of the microbiota. Principal components (PCs) derived from community data were better predictors in MLR models as compared to single taxa, indicating that arabinoxylan fermentation is the result of multi-species interactions within microbiomes.

Conclusion: This study showed that long-chain arabinoxylan modulates both microbiota composition and the output of health-relevant SCFAs, providing information for a more targeted application of this fiber. Variation in propionate production was linked to both compositional shifts and baseline composition, with PCs derived from shifts of the global microbial community showing the strongest associations. These findings constitute a proof-of-concept for the merit of an ecological framework that considers features of the wider gut microbial community for the prediction of metabolic outcomes of dietary fiber fermentation. This provides a basis to personalize the use of dietary fiber in nutritional application and to stratify human populations by relevant gut microbiota features to account for the inconsistent health effects in human intervention studies.

Trial Registration: Clinicaltrials.gov, NCT02322112 , registered on July 3, 2015. Video Abstract.
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http://dx.doi.org/10.1186/s40168-020-00887-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7439537PMC
August 2020

Elevated Angiotensin 1-7/Angiotensin II Ratio Predicts Favorable Outcomes in Patients With Heart Failure.

Circ Heart Fail 2020 07 25;13(7):e006939. Epub 2020 Jun 25.

Division of Cardiology, Department of Medicine (K.W., R.B., G.Y.O.), University of Alberta, Edmonton, Canada.

Background: ACE2 (angiotensin-converting enzyme 2) and Ang 1-7 (angiotensin 1-7) are endogenous negative regulators of the renin-angiotensin system exerting cardioprotective effects in models of heart failure. Recombinant human ACE2 markedly increased plasma Ang 1-7 and lowered Ang II levels in phase II clinical trials. We hypothesize that the dynamic state of this renin-angiotensin system protective arm could influence long-term outcomes in patients with heart failure.

Methods: One hundred ten patients with heart failure were prospectively enrolled from our outpatient clinic and the emergency department. Comprehensive circulating and equilibrium levels of plasma angiotensin peptide profiles were assessed using novel liquid chromatography-mass spectrometry/mass spectroscopy techniques. Plasma aldosterone, B-type natriuretic peptide, active renin concentration, and clinical profiles were captured at baseline. During a median follow-up of 5.1 years (interquartile range, 4.7-5.7 years), composite clinical outcomes were assessed using all-cause in-patient hospitalizations and mortality.

Results: Circulating and equilibrium angiotensin peptide levels strongly correlated in our patient cohort. Adjusting for covariates, elevated equilibrium (hazard ratio, 0.38 [95% CI, 0.18-0.81] =0.012), and circulating (hazard ratio, 0.38 [95% CI, 0.18-0.80] =0.011) Ang 1-7/Ang II ratios were associated with improved survival. Lower hospitalization duration was also associated with elevated equilibrium (<0.001) and circulating (=0.023) Ang 1-7/Ang II ratios. Importantly, individual Ang 1-7 and Ang II peptide levels failed to predict all-cause mortality or hospitalization duration in our patient cohort.

Conclusions: We extensively profiled plasma angiotensin peptides in patients with heart failure and identified elevated Ang 1-7/Ang II ratio, as an independent and incremental predictor of beneficial outcomes, higher survival rate, and decreased hospitalization duration. These findings provide important clinical evidence supporting strategies aiming to promote the beneficial Ang 1-7/Mas axis concurrent with renin-angiotensin system blockade therapies inhibiting the detrimental Ang II/AT receptor axis.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.006939DOI Listing
July 2020

Early Integrated Palliative Care Bundle Impacts Location of Death in Interstitial Lung Disease: A Pilot Retrospective Study.

Am J Hosp Palliat Care 2021 Feb 20;38(2):104-113. Epub 2020 May 20.

Division of Pulmonary Medicine, Department of Medicine, 12357University of Alberta, Edmonton, Alberta, Canada.

Background: Interstitial lung diseases (ILDs) comprise a heterogeneous group of fibrotic, progressive pulmonary diseases characterized by poor end-of-life care and hospital deaths. In 2012, we launched our Multidisciplinary Collaborative (MDC) ILD clinic to deliver integrated palliative approach throughout disease trajectory to improve care. We sought to explore the effects of palliative care and other factors on location of death (LOD) of patients with ILD.

Methods: The MDC-ILD clinic implemented a palliative care bundle including advance care planning (ACP), opiates use, allied health home care engagement, and use of supplemental oxygen and early caregiver engagement in care. Data from patients with ILD who attended the clinic and died between 2012 and 2019 were used to generate scores representing the components and duration of palliative care (palliative care bundle score) and caregiver involvement (caregiver engagement score). We examined the impact of these scores on patients' LOD.

Results: A total of 92 MDC-ILD clinic patients were included, 57 (62%) had home or hospice deaths. Patients who died at home or hospice had higher palliative care bundle scores (10.0 ± 4.0 vs 7.8 ± 3.9, = .01) and caregiver engagement scores (1.7 ± 0.6 vs 1.3 ± 0.7, = .01) compared to those who died in hospital. Patients were 1.13 times more likely to die at home or hospice following a 1-point increase in palliative care bundle score (95% CI: 1.01-1.29, = .04) and 2.38 times more likely following a 1-point increase in caregiver engagement score (95% CI: 1.17-5.15, = .02).

Conclusions: Home and hospice deaths are feasible in ILD. Early initiation of palliative care bundle components such as ACP discussions, symptom self-management, caregiver engagement, and close collaboration with allied health home care supports can promote adherence to patient preference for home or hospice deaths.
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http://dx.doi.org/10.1177/1049909120924995DOI Listing
February 2021

Health Care Costs at the End of Life for Patients with Idiopathic Pulmonary Fibrosis. Evaluation of a Pilot Multidisciplinary Collaborative Interstitial Lung Disease Clinic.

Ann Am Thorac Soc 2020 06;17(6):706-713

Alberta Health Services, Edmonton, Alberta, Canada; and.

Even though idiopathic pulmonary fibrosis (IPF) is a disease with high morbidity and mortality and no cure, palliative care is rarely implemented, leading to high symptom burden and unmet care needs. In 2012, we implemented a multidisciplinary collaborative (MDC) care model linking clinic and community multidisciplinary teams to provide an early integrated palliative approach, focusing on early symptom management and advance care planning. To evaluate the differences in resource use and associated costs of end-of-life care between patients with IPF who received early integrated palliative care and patients with IPF who received conventional treatment. Using administrative health data, we identified all patients in the Province of Alberta, Canada, who presented to a hospital with an IPF diagnosis between January 1, 2012, and December 31, 2018, and died within this time frame. We compared three groups of patients: those who received MDC care (our clinic patients), specialist care (SC; respirologist), or non-specialist care (NSC; no contact with a respiratory clinic). The primary outcomes were healthcare resource use and costs in the year before death. Of 2,768 patients across the three study groups, in the last year of life, MDC patients were more than three times as likely as SC patients to have received antifibrotic therapies (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.2), almost twice as likely to have received pulmonary rehabilitation (OR, 1.9; 95% CI, 1.1-3.4), and 36% more likely to have received opiates (OR, 1.4; 95% CI, 0.8-2.3). The median total healthcare costs in the last 3 months of life were approximately C$7,700 lower for MDC patients than for those receiving SC, driven primarily by fewer hospitalizations and emergency department visits. MDC patients were also less likely to die in the hospital (44.9% MDC vs. 64.9% SC vs. 66.8% NSC;  < 0.001) and had the highest rates of no hospitalization in the last year of life. An integrated palliative approach in IPF is associated with improvements in the quality of end-of-life care and reduction in costs. Transformation of care models is required to deliver palliative care for patients with IPF. MDC teams within such models can address the high burden of unmet needs for symptom management, advance care planning, and community support in this complex population.
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http://dx.doi.org/10.1513/AnnalsATS.201909-707OCDOI Listing
June 2020

External Validation and Refinement of Emergency Heart Failure Mortality Risk Grade Risk Model in Patients With Heart Failure in the Emergency Department.

CJC Open 2019 May 12;1(3):123-130. Epub 2019 Apr 12.

Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.

Background: Emergency Heart Failure Mortality Risk Grade (EHMRG) assesses the risk of death within 7 days of emergency department (ED) presentation for patients with acute heart failure (AHF). We aimed to externally validate and refine the EHMRG model in patients who presented to the ED with AHF.

Methods: We performed a cohort study using administrative data for all ambulance-transported patients from Alberta (2012-2016) presenting to the ED with a primary diagnosis of AHF.

Results: Among 6708 patients with AHF, the 7-day mortality was 0.0%, 0.8%, 1.6%, 4.0%, 4.2%, and 12.0% across EHMRG risk categories (1-4, 5A and 5B). The EHMRG score had a c-index of 0.73 (95% confidence interval [CI], 0.71-0.76) for 7-day mortality and 0.71 (95% CI, 0.70-0.73) for 30-day mortality, but lower c-statistics for other outcomes (0.61-0.67). The inclusion of natriuretic peptides to the EHMRG model improved prediction (Net Reclassification Improvement, 0.268; 95% CI, 0.173-0.363; 0.01) for 7-day mortality, as did the addition of the Canadian Triage and Acuity Scale (Net Reclassification Improvement, 0.111; 95% CI, 0.005-0.218; 0.04).

Conclusion: The EHMRG model exhibited moderate discriminative ability in a large population-based cohort of patients with AHF in the ED. Revision of the EHMRG score through factor inclusion and exclusion could improve the model's performance.
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http://dx.doi.org/10.1016/j.cjco.2019.03.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063601PMC
May 2019

Identification of emergency department patients for referral to rapid-access addiction services.

CJEM 2020 03;22(2):170-177

University of Alberta Department of Emergency Medicine, Edmonton, AB, Canada.

Objectives: Substance-related emergency department (ED) visits are rapidly increasing. Despite this finding, many EDs do not have access to on-site addiction services. This study characterized substance-related ED presentations and assessed the ED health care team's perceived need for an on-site rapid-access addiction clinic for direct patient referral from the ED.

Methods: This prospectively enrolled cohort study was conducted at an urban tertiary care ED from June to August 2018. Adult ED patients with problematic or high-risk substance use were enrolled by ED staff using a one-page form. The electronic and paper records from the index ED visit were reviewed. The primary outcome evaluated whether the ED health care team would have referred the patient to an on-site rapid-access addiction clinic, if one were available.

Results: We received 557 enrolment forms and 458 were included in the analysis. Median age was 35 years, and 64% of included patients were male. Alcohol was the most commonly reported substance of problematic or high-risk use (60%). Previous ED visits within 7 days of the index visit were made by 28% of patients. The ED health care team indicated "Yes" for rapid-access addiction clinic referral from the ED for 66% of patients, with a mean of 4.3 patients referred per day during the study period.

Conclusions: At least four patients per day would have been referred to an on-site rapid-access addiction clinic from the ED, had one been available. This indicates a gap in care and collaborating with other sites that have successfully implemented this clinic model is an important next step.
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http://dx.doi.org/10.1017/cem.2019.453DOI Listing
March 2020

Precision Microbiome Modulation with Discrete Dietary Fiber Structures Directs Short-Chain Fatty Acid Production.

Cell Host Microbe 2020 Mar 30;27(3):389-404.e6. Epub 2020 Jan 30.

Department of Agricultural, Nutritional and Food Science, University of Alberta, Edmonton, AB T6G 2E1, Canada; Department of Biological Sciences, University of Alberta, Edmonton, AB T6G 2E1, Canada; APC Microbiome Ireland, School of Microbiology, Department of Medicine, and APC Microbiome Institute, University College Cork - National University of Ireland, Cork T12 YT20, Ireland. Electronic address:

Dietary fibers (DFs) impact the gut microbiome in ways often considered beneficial. However, it is unknown if precise and predictable manipulations of the gut microbiota, and especially its metabolic activity, can be achieved through DFs with discrete chemical structures. Using a dose-response trial with three type-IV resistant starches (RS4s) in healthy humans, we found that crystalline and phosphate cross-linked starch structures induce divergent and highly specific effects on microbiome composition that are linked to directed shifts in the output of either propionate or butyrate. The dominant RS4-induced effects were remarkably consistent within treatment groups, dose-dependent plateauing at 35 g/day, and can be explained by substrate-specific binding and utilization of the RS4s by bacterial taxa with different pathways for starch metabolism. Overall, these findings support the potential of using discrete DF structures to achieve targeted manipulations of the gut microbiome and its metabolic functions relevant to health.
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http://dx.doi.org/10.1016/j.chom.2020.01.006DOI Listing
March 2020

Cardiac Intervention Improves Heart Disease and Clinical Outcomes in Patients With Muscular Dystrophy in a Multidisciplinary Care Setting.

J Am Heart Assoc 2020 01 14;9(2):e014004. Epub 2020 Jan 14.

Division of Cardiology Faculty of Medicine and Dentistry University of Alberta Edmonton Canada.

Background Patients with muscular dystrophy (MD) represent a vulnerable patient population with no clearly defined care model in modern-day clinical practice to manage a high burden of heart disease and comorbidities. We demonstrate the effectiveness of cardiac interventions, namely the initiation and optimization of medical and device therapies, as part of a multidisciplinary care approach to improve clinical outcomes in patients with MD. Methods and Results We conducted a prospective cohort study at the Neuromuscular Multidisciplinary clinic following patients with dystrophinopathies, limb-girdle MD, type 1 myotonic dystrophy, and facioscapulohumeral MD. A negative control group classified as non-MD myopathies without heart disease, was also tracked. Our cohort of 185 patients (median age: 42 years; 79 [42.7%] women), included 145 patients with MD. Cardiomyopathy was present in 65.6% of the patients with dystrophinopathies (21 of 32) and 27.3% of the patients with limb-girdle MD (9 of 33). Conduction abnormalities were common in type 1 myotonic dystrophy (33.3% [20/60] patients). Cardiac intervention reversed systolic dysfunction, with left ventricular ejection fraction improving from 43% to 50.0% over a 3-year period. A sustained reduction in healthcare utilization was also observed. The number of outpatient clinic visits decreased from 3.0 to 1.5 visits per year, the duration of hospitalizations was reduced from 14.2 to 0.9 days per year, and the number of cardiac-related hospitalizations decreased from 0.4 to 0.1 hospitalizations per year associated with low mortality. Conclusions Our study demonstrates that cardiac intervention as part of a comprehensive multidisciplinary care approach to treating patients with MD leads to a sustained improvement in clinical outcomes.
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http://dx.doi.org/10.1161/JAHA.119.014004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7033817PMC
January 2020

Cardiac Intervention Improves Heart Disease and Clinical Outcomes in Patients With Muscular Dystrophy in a Multidisciplinary Care Setting.

J Am Heart Assoc 2020 01 14;9(2):e014004. Epub 2020 Jan 14.

Division of Cardiology Faculty of Medicine and Dentistry University of Alberta Edmonton Canada.

Background Patients with muscular dystrophy (MD) represent a vulnerable patient population with no clearly defined care model in modern-day clinical practice to manage a high burden of heart disease and comorbidities. We demonstrate the effectiveness of cardiac interventions, namely the initiation and optimization of medical and device therapies, as part of a multidisciplinary care approach to improve clinical outcomes in patients with MD. Methods and Results We conducted a prospective cohort study at the Neuromuscular Multidisciplinary clinic following patients with dystrophinopathies, limb-girdle MD, type 1 myotonic dystrophy, and facioscapulohumeral MD. A negative control group classified as non-MD myopathies without heart disease, was also tracked. Our cohort of 185 patients (median age: 42 years; 79 [42.7%] women), included 145 patients with MD. Cardiomyopathy was present in 65.6% of the patients with dystrophinopathies (21 of 32) and 27.3% of the patients with limb-girdle MD (9 of 33). Conduction abnormalities were common in type 1 myotonic dystrophy (33.3% [20/60] patients). Cardiac intervention reversed systolic dysfunction, with left ventricular ejection fraction improving from 43% to 50.0% over a 3-year period. A sustained reduction in healthcare utilization was also observed. The number of outpatient clinic visits decreased from 3.0 to 1.5 visits per year, the duration of hospitalizations was reduced from 14.2 to 0.9 days per year, and the number of cardiac-related hospitalizations decreased from 0.4 to 0.1 hospitalizations per year associated with low mortality. Conclusions Our study demonstrates that cardiac intervention as part of a comprehensive multidisciplinary care approach to treating patients with MD leads to a sustained improvement in clinical outcomes.
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http://dx.doi.org/10.1161/JAHA.119.014004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7033817PMC
January 2020

Prevalence and Postdischarge Outcomes Associated with Frailty in Medical Inpatients: Impact of Different Frailty Definitions.

J Hosp Med 2019 07 20;14(7):407-410. Epub 2019 Mar 20.

Alberta SPOR Support Unit Data Platform, University of Alberta, Edmonton, Alberta, Canada.

We compared prevalence estimates and prognostication if frailty were defined using the face-to-face Clinical Frailty Scale (CFS) or the administrative-data-derived Hospital Frailty Risk Score (HFRS). We evaluated 489 adults from a prospective cohort study of medical patients being discharged back to the community; 276 (56%) were deemed frail (214 [44%] on the HFRS and 161 [33%] on the CFS), but only 99 (20%) met both frailty definitions (kappa 0.24, 95% CI 0.16-0.33). Patients classified as frail on the CFS exhibited significantly higher 30-day readmission/death rates, 19% versus 10% for those not frail (aOR [adjusted odds ratio] 2.53, 95% CI 1.40-4.57) and 21% versus 6% for those aged >65 years (aOR 4.31, 95% CI 1.80-10.31). Patients with HFRS-defined frailty exhibited higher 30-day readmission/death rates that were not statistically significant (16% vs 11%, aOR 1.62 [95% CI 0.95-2.75] in all adults and 14% vs 11%, aOR 1.24 [95% CI 0.58-2.83] in those aged >65 years).
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http://dx.doi.org/10.12788/jhm.3174DOI Listing
July 2019

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions.

CMAJ 2018 03;190(10):E276-E284

Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta.

Background: Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care.

Methods: We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months.

Results: Adults receiving care within a primary care network ( = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care ( = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years.

Interpretation: Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.
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http://dx.doi.org/10.1503/cmaj.170385DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849446PMC
March 2018

Comparing three different measures of frailty in medical inpatients: Multicenter prospective cohort study examining 30-day risk of readmission or death.

J Hosp Med 2016 08 17;11(8):556-62. Epub 2016 May 17.

Division of General Internal Medicine, University of Alberta, Alberta, Edmonton, Alberta, Canada.

Background: Multiple tools are used to identify frailty.

Objective: To compare the global Clinical Frailty Scale (CFS) with more objective phenotypic tools (modified Fried score and the Timed Up and Go Test [TUGT]).

Design: Prospective cohort study.

Setting: General medical wards in Edmonton, Canada.

Participants: Adults being discharged back to the community.

Measurements: All frailty assessments were done within 24 hours of discharge. Patients were classified as frail if they scored ≥5 on the CFS and/or ≥3 on the modified Fried score, and/or had reduced mobility (>20 seconds on the TUGT). The main outcome was readmission or death within 30 days.

Results: Of 495 patients, 211 (43%) were frail according to at least 1 assessment, 46 (9%) met all 3 frailty definitions, and 17% died or were readmitted to the hospital within 30 days. Although patients classified as frail on the CFS exhibited significantly higher 30-day readmission/death rates (23% vs 14% for not frail, P = 0.005; 28% vs. 12% in the elderly, P < 0.001), even after adjusting for age and sex (adjusted odds ratio [aOR]: 2.02, 95% confidence interval [CI]: 1.19-3.41 for all adults; aOR: 3.20, 95% CI: 1.55-6.60 for the elderly), patients meeting either of the phenotypic definitions for frailty but not the CFS definition were not at higher risk of 30-day readmission/death (aOR: 0.87, 95% CI: 0.34-2.19 for all adults and aOR: 1.41, 95% CI: 0.72-2.78 for the elderly).

Conclusions: Frailty has a significant impact on postdischarge outcomes, and the CFS is the most useful of the frequently used frailty tools for predicting poor outcomes after discharge. Journal of Hospital Medicine 2016;11:556-562. © 2016 Society of Hospital Medicine.
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http://dx.doi.org/10.1002/jhm.2607DOI Listing
August 2016

Do stable non-ST-segment elevation acute coronary syndromes require admission to coronary care units?

Am Heart J 2016 05 23;175:184-92. Epub 2016 Jan 23.

Canadian Vigour Center, Edmonton, AB, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.

Background: Clinical practice guidelines recommend admitting patients with stable non-ST-segment elevation acute coronary syndrome (NSTE ACS) to telemetry units, yet up to two-thirds of patients are admitted to higher-acuity critical care units (CCUs). The outcomes of patients with stable NSTE ACS initially admitted to a CCU vs a cardiology ward with telemetry have not been described.

Methods: We used population-based data of 7,869 patients hospitalized with NSTE ACS admitted to hospitals in Alberta, Canada, between April 1, 2007, and March 31, 2013. We compared outcomes among patients initially admitted to a CCU (n=5,141) with those admitted to cardiology telemetry wards (n=2,728).

Results: Patients admitted to cardiology telemetry wards were older (median 69 vs 65years, P<.001) and more likely to be female (37.2% vs 32.1%, P<.001) and have a prior myocardial infarction (14.3% vs 11.5%, P<.001) compared with patients admitted to a CCU. Patients admitted directly to cardiology telemetry wards had similar hospital stays (6.2 vs 5.7days, P=.29) and fewer cardiac procedures (40.3% vs 48.5%, P<.001) compared with patients initially admitted to CCUs. There were no differences in the frequency of in-hospital mortality (1.3% vs 1.2%, adjusted odds ratio [aOR] 1.57, 95% CI 0.98-2.52), cardiac arrest (0.7% vs 0.9%, aOR 1.37, 95% CI 0.94-2.00), 30-day all-cause mortality (1.6% vs 1.5%, aOR 1.50, 95% CI 0.82-2.75), or 30-day all-cause postdischarge readmission (10.6% vs 10.8%, aOR 1.07, 95% CI 0.90-1.28) between cardiology telemetry ward and CCU patients. Results were similar across low-, intermediate-, and high-risk Duke Jeopardy Scores, and in patients with non-ST-segment myocardial infarction or unstable angina.

Conclusions: There were no differences in clinical outcomes observed between patients with NSTE ACS initially admitted to a ward or a CCU. These findings suggest that stable NSTE ACS may be managed appropriately on telemetry wards and presents an opportunity to reduce hospital costs and critical care capacity strain.
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http://dx.doi.org/10.1016/j.ahj.2015.11.020DOI Listing
May 2016

Factors Associated With Natriuretic Peptide Testing in Patients Presenting to Emergency Departments With Suspected Heart Failure.

Can J Cardiol 2016 08 7;32(8):986.e1-8. Epub 2015 Dec 7.

Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address:

Background: Testing for natriuretic peptides (NPs) such as brain natriuretic peptide (BNP) or N-terminal prohormone brain natriuretic peptide (NT-proBNP) in the emergency department (ED) assists in the evaluation of patients with acute heart failure (HF). The aim of this study was to investigate factors related to the use of NP testing in the ED in a large population-based sample in Canada.

Methods: This was a retrospective cohort study using linked administrative data from Alberta in 2012. Patients were included if they had testing for an NP in the ED; a comparator group with HF but without NP testing was also included.

Results: Of the 16,223 patients in the cohort, 5793 were patients with HF (n = 3148 tested and n = 2645 not tested for NPs) and 10,430 were patients without HF but who were tested for NPs. Patients without HF who were tested for NPs had respiratory disease (34%), non-HF cardiovascular diseases (13%), and other conditions (52%). Patients with HF who were tested had a higher rate of hospital admission from the ED (78.4% vs 62.2%; P < 0.001) and lower 7-day and 90-day repeated ED visit rates compared with those who were not tested. Among patients with HF, male sex, being an urban resident, being seen by an emergency medicine or cardiology specialist, and being seen in hospitals with medium ED visit volumes were associated with increased likelihood of testing for NPs.

Conclusions: Several factors, including the type of provider and ED clinical volume, influenced the use of NP testing in routine ED practice. Standardization of an NP testing strategy in clinical practice would be useful for health care systems.
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http://dx.doi.org/10.1016/j.cjca.2015.11.019DOI Listing
August 2016

Medication Discrepancies Associated With a Medication Reconciliation Program and Clinical Outcomes After Hospital Discharge.

Pharmacotherapy 2016 Apr;36(4):415-21

The Epidemiology Coordinating and Research (EPICORE) Centre, University of Alberta, Edmonton, Alberta, Canada.

Study Objective: To identify the frequency of unintended medication discrepancies 30 days postdischarge from medicine wards with interprofessional medication reconciliation processes and clinical import.

Methods: Prospective cohort study of adults discharged between October 2013 and November 2014 from two teaching hospitals in Edmonton, Canada. The Best Possible Medication Discharge Plan (BPMDP) was prepared for all patients. Patients were called 30 days postdischarge to determine the medication discrepancy rate from the BPMDP and whether this was intentional or unintentional; three clinicians used standardized criteria to determine if the discrepancy was inconsequential. Electronic health records and patient contact were used to ascertain death, hospital readmissions, and emergency department (ED) visits at 90 days.

Results: Of 433 patients (mean age 64 yrs, 52% female, median discharge prescriptions 6 [interquartile range 4-9]), 168 (38.8%) had at least one unintentional medication discrepancy at 30 days (325 total discrepancies; median one [interquartile range 1-2 discrepancies per patient]). Patients with unintentional medication discrepancies were older (65.9 vs 61.9 yrs, p=0.03) with more discharge medications (7 vs 6, p=0.03). Most unintentional discrepancies (91.1%) were judged inconsequential. The presence of an unintentional medication discrepancy was not associated with 90-day readmission or death (42/167 [25.1%] vs 64/263 [24.3%], adjusted odds ratio 0.96 [95% confidence interval 0.60-1.54]) or ED visits (69 [41.3%] vs 101 [38.4%], adjusted odds ratio 1.11 [95% confidence interval 0.74-1.67].

Conclusion: Despite the presence of an interprofessional medication reconciliation process, over one-third of patients had a medication discrepancy within 30 days of discharge, although most were inconsequential and there was no association between unintended medication discrepancies and risk of readmission, ED visit, or death 3 months after discharge.
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http://dx.doi.org/10.1002/phar.1734DOI Listing
April 2016

Does Reducing Inpatient Length of Stay Have Upstream Effects on the Emergency Room: Exploring the Impact of the General Internal Medicine Care Transformation Initiative.

Acad Emerg Med 2016 06 11;23(6):711-7. Epub 2016 May 11.

Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada.

Objective: The General Internal Medicine (GIM) Care Transformation Initiative implemented at one of four teaching hospitals in the same city resulted in improved efficiency of in-hospital care. Whether it had beneficial effects upstream in the emergency department (ED) is unclear.

Methods: Controlled before-after study of ED length of stay (LOS) and crowding metrics for the intervention site (n = 108,951 visits) compared to the three other teaching hospitals (controls, n = 300,930 visits). Our primary outcome was ED LOS for GIM patients but secondary outcomes included ED LOS for all adults and ED crowding metrics.

Results: The GIM Care Transformation was associated with an additional 2.8-hour reduction in median ED LOS (from 25.6 hours to 13.5 hours) over and above the 9.3-hour decline (from 30.6 hours to 21.3 hours) seen in the three control EDs for GIM patients who were hospitalized (p < 0.001). As less than one in 30 ED visits resulted in a GIM ward admission, the median ED LOS for all patients declined by 15 minutes (from 4.6 hours to 4.3 hours, p < 0.001) in the control hospitals and by 30 minutes (from 5.7 hours to 5.1 hours, p < 0.001) at the intervention hospital pre versus post (p = 0.04 for the 15-minute additional reduction, p < 0.001 for level change on interrupted time series). Other metrics of ED crowding improved by similar amounts at the intervention and control hospitals with no statistically significant differences.

Conclusion: Although the GIM Care Transformation Initiative was associated with substantial reductions in ED LOS for patients admitted to GIM wards at the intervention hospital, it resulted in only minor changes in overall ED LOS and no appreciable changes in ED crowding metrics.
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http://dx.doi.org/10.1111/acem.12935DOI Listing
June 2016

Physician experience and outcomes among patients admitted to general internal medicine teaching wards.

CMAJ 2015 Oct 17;187(14):1041-1048. Epub 2015 Aug 17.

Division of General Internal Medicine (McAlister, Kassam); Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Youngson, Bakal), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Bakal), Alberta Health Services, Calgary, Alta.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Calgary, Alta.

Background: Physician scores on examinations decline with time after graduation. However, whether this translates into declining quality of care is unknown. Our objective was to determine how physician experience is associated with negative outcomes for patients admitted to hospital.

Methods: We conducted a retrospective cohort study involving all patients admitted to general internal medicine wards over a 2-year period at all 7 teaching hospitals in Alberta, Canada. We used files from the Alberta College of Physicians and Surgeons to determine the number of years since medical school graduation for each patient's most responsible physician. Our primary outcome was the composite of in-hospital death, or readmission or death within 30 days postdischarge.

Results: We identified 10 046 patients who were cared for by 149 physicians. Patient characteristics were similar across physician experience strata, as were primary outcome rates (17.4% for patients whose care was managed by physicians in the highest quartile of experience, compared with 18.8% in those receiving care from the least experienced physicians; adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.72-1.06). Outcomes were similar between experience quartiles when further stratified by physician volume, most responsible diagnosis or complexity of the patient's condition. Although we found substantial variability in length of stay between individual physicians, there were no significant differences between physician experience quartiles (mean adjusted for patient covariates and accounting for intraphysician clustering: 7.90 [95% CI 7.39-8.42] d for most experienced quartile; 7.63 [95% CI 7.13-8.14] d for least experienced quartile).

Interpretation: For patients admitted to general internal medicine teaching wards, we saw no negative association between physician experience and outcomes commonly used as proxies for quality of inpatient care.
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http://dx.doi.org/10.1503/cmaj.150316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592295PMC
October 2015

External validation of the Hospital-patient One-year Mortality Risk (HOMR) model for predicting death within 1 year after hospital admission.

CMAJ 2015 Jul 8;187(10):725-733. Epub 2015 Jun 8.

Departments of Medicine and of Epidemiology and Community Medicine, University of Ottawa (van Walraven), Ottawa, Ont.; Ottawa Hospital Research Institute (van Walraven, Hawken), Ottawa, Ont.; Department of Medicine, University of Alberta, and Alberta Innovates - Health Solutions (McAlister), Edmonton, Alta.; Health Research Methods and Analytics, Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, and Alberta Strategy for Patient Oriented Research Support Unit (Bakal), Edmonton, Alta.; Division of General Internal Medicine, Bern University, Bern, Switzerland; Brigham & Women's Hospital and Harvard Medical School (Donzé), Boston, Mass.

Background: Predicting long-term survival after admission to hospital is helpful for clinical, administrative and research purposes. The Hospital-patient One-year Mortality Risk (HOMR) model was derived and internally validated to predict the risk of death within 1 year after admission. We conducted an external validation of the model in a large multicentre study.

Methods: We used administrative data for all nonpsychiatric admissions of adult patients to hospitals in the provinces of Ontario (2003-2010) and Alberta (2011-2012), and to the Brigham and Women's Hospital in Boston (2010-2012) to calculate each patient's HOMR score at admission. The HOMR score is based on a set of parameters that captures patient demographics, health burden and severity of acute illness. We determined patient status (alive or dead) 1 year after admission using population-based registries.

Results: The 3 validation cohorts (n = 2,862,996 in Ontario, 210 595 in Alberta and 66,683 in Boston) were distinct from each other and from the derivation cohort. The overall risk of death within 1 year after admission was 8.7% (95% confidence interval [CI] 8.7% to 8.8%). The HOMR score was strongly and significantly associated with risk of death in all populations and was highly discriminative, with a C statistic ranging from 0.89 (95% CI 0.87 to 0.91) to 0.92 (95% CI 0.91 to 0.92). Observed and expected outcome risks were similar (median absolute difference in percent dying in 1 yr 0.3%, interquartile range 0.05%-2.5%).

Interpretation: The HOMR score, calculated using routinely collected administrative data, accurately predicted the risk of death among adult patients within 1 year after admission to hospital for nonpsychiatric indications. Similar performance was seen when the score was used in geographically and temporally diverse populations. The HOMR model can be used for risk adjustment in analyses of health administrative data to predict long-term survival among hospital patients.
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http://dx.doi.org/10.1503/cmaj.150209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500693PMC
July 2015

Association between frailty and 30-day outcomes after discharge from hospital.

CMAJ 2015 Aug 25;187(11):799-804. Epub 2015 May 25.

Division of General Internal Medicine (Kahlon, Pederson, Majumdar, Belga, Lau, Padwal, McAlister); Patient Health Outcomes Research and Clinical Effectiveness Unit (Bakal, McAlister); Epidemiology Coordinating and Research (EPICORE) Centre (Fradette, Boyko, McAlister), University of Alberta; Department of Medicine (Johnston), Royal Alexandra Hospital, Edmonton, Alta.

Background: Readmissions after hospital discharge are common and costly, but prediction models are poor at identifying patients at high risk of readmission. We evaluated the impact of frailty on readmission or death within 30 days after discharge from general internal medicine wards.

Methods: We prospectively enrolled patients discharged from 7 medical wards at 2 teaching hospitals in Edmonton. Frailty was defined by means of the previously validated Clinical Frailty Scale. The primary outcome was the composite of readmission or death within 30 days after discharge.

Results: Of the 495 patients included in the study, 162 (33%) met the definition of frailty: 91 (18%) had mild, 60 (12%) had moderate, and 11 (2%) had severe frailty. Frail patients were older, had more comorbidities, lower quality of life, and higher LACE scores at discharge than those who were not frail. The composite of 30-day readmission or death was higher among frail than among nonfrail patients (39 [24.1%] v. 46 [13.8%]). Although frailty added additional prognostic information to predictive models that included age, sex and LACE score, only moderate to severe frailty (31.0% event rate) was an independent risk factor for readmission or death (adjusted odds ratio 2.19, 95% confidence interval 1.12-4.24).

Interpretation: Frailty was common and associated with a substantially increased risk of early readmission or death after discharge from medical wards. The Clinical Frailty Scale could be useful in identifying high-risk patients being discharged from general internal medicine wards.
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http://dx.doi.org/10.1503/cmaj.150100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4527901PMC
August 2015

Novel approaches to composite endpoints in clinical trials.

EuroIntervention 2015 May;11(1):122-4

Canadian VIGOUR Centre at the University of Alberta, Edmonton, Alberta, Canada.

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http://dx.doi.org/10.4244/EIJV11I1A22DOI Listing
May 2015

Assessing the use of international classification of diseases-10th revision codes from the emergency department for the identification of acute heart failure.

JACC Heart Fail 2015 May;3(5):386-391

Division of Cardiology, Department of Medicine, University of Alberta, Alberta, Canada; Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. Electronic address:

Objectives: The objective of this study was to compare administrative codes with chart review for patients with acute heart failure (AHF).

Background: Administrative databases are used in population health research; however, the validity of codes in the emergency department (ED) for AHF compared with chart review is uncertain.

Methods: A cohort of 952 patients with suspected AHF were prospectively recruited from 4 EDs in Edmonton, Alberta, Canada, from 2009 to 2012. Patients had their diagnoses adjudicated by expert physicians using a standardized scoring system and detailed chart review. ED and hospital discharge International Classification of Diseases-10th Revision (ICD-10) codes were captured in the main diagnosis or in any diagnostic field.

Results: The 897 patients had a median age of 77 years (interquartile range: 67 to 85 years), and 806 (90%) were admitted to the hospital. Overall, 809 patients (90.2%) had AHF by adjudication and 660 (73.6%) had ICD-10 code I50.x as a main diagnosis in the ED administrative data, respectively. The positive predictive value of an AHF main diagnosis in the ED administrative data was 93.3% (95% confidence interval [CI]: 92.0% to 94.7%), with sensitivity of 76.1% (95% CI: 75.0% to 77.2%) and specificity of 50.0% (95% CI: 39.8% to 60.1%). The positive predictive value for AHF in any diagnostic field of the ED administrative data was 92.0% (95% CI: 91.1% to 93.0%), with a sensitivity of 89.4% (95% CI: 88.5% to 90.4%) and specificity of 28.4% (95% CI: 20.1% to 37.9%).

Conclusions: An ICD-10 I50.x diagnosis in the ED is highly predictive of AHF compared with chart-level adjudication using a validated score. Thus, the use of these codes in ED administrative databases could identify AHF for clinical and epidemiological studies.
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http://dx.doi.org/10.1016/j.jchf.2014.11.010DOI Listing
May 2015

Correlation of cardiovascular magnetic resonance imaging findings and endomyocardial biopsy results in patients undergoing screening for heart transplant rejection.

J Heart Lung Transplant 2015 May 8;34(5):643-50. Epub 2015 Jan 8.

Division of Cardiology, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada. Electronic address:

Background: Endomyocardial biopsy (EMB) is the current gold standard to screen for heart transplant rejection but has important risks and limitations. Cardiovascular magnetic resonance imaging (CMRI) is increasingly used to characterize cardiac function and myocardial tissue. We evaluated the diagnostic accuracy of CMRI compared with EMB and clinically diagnosed heart transplant rejection.

Methods: Comprehensive CMRI scans were performed on adult heart transplant recipients within 24 hours of EMB (routine or clinically indicated), before initiation of any anti-rejection therapy, and blinded to EMB results. Multivariable analysis was used to create CMRI diagnostic criteria for comparison with a positive EMB (Grade ≥ 2R or antibody-mediated rejection) and clinical rejection (change in medical therapy to treat rejection).

Results: Sixty participants (75% male; mean age, 51 ± 14 years) were recruited, providing 73 comparisons between CMRI and EMB for the diagnosis of rejection. Multivariable logistic regression identified myocardial edema (T2 relaxation time) and right ventricular end-diastolic volume index as independent predictors of a positive EMB. Combining threshold right ventricular end-diastolic volume index and edema values predicted a positive EMB with very good accuracy: sensitivity, 93%; specificity, 78%; positive predictive value, 52%; and negative predictive valve, 98%. CMRI was more sensitive than EMB at predicting clinical rejection (sensitivity of 67% vs 58%).

Conclusions: CMRI has high sensitivity and high negative predictive value in predicting biopsy-positive heart transplant rejection and may be useful as a screening test before routine EMB. CMRI also has better sensitivity for clinically diagnosed heart transplant rejection and could be helpful in cases of negative rejection on the biopsy specimen.
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http://dx.doi.org/10.1016/j.healun.2014.12.020DOI Listing
May 2015

Variation in critical care unit admission rates and outcomes for patients with acute coronary syndromes or heart failure among high- and low-volume cardiac hospitals.

J Am Heart Assoc 2015 Feb 27;4(3):e001708. Epub 2015 Feb 27.

Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada (S.D., J.A.B., M.L., P.K., F.A.M.A., J.A.E.) Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada (P.K., J.A.E.).

Background: Little is known about cross-hospital differences in critical care units admission rates and related resource utilization and outcomes among patients hospitalized with acute coronary syndromes (ACS) or heart failure (HF).

Methods And Results: Using a population-based sample of 16,078 patients admitted to a critical care unit with a primary diagnosis of ACS (n=14,610) or HF (n=1467) between April 1, 2003 and March 31, 2013 in Alberta, Canada, we stratified hospitals into high (>250), medium (200 to 250), or low (<200) volume based on their annual volume of all ACS and HF hospitalization. The percentage of hospitalized patients admitted to critical care units varied across low, medium, and high-volume hospitals for both ACS and HF as follows: 77.9%, 81.3%, and 76.3% (P<0.001), and 18.0%, 16.3%, and 13.0% (P<0.001), respectively. Compared to low-volume units, critical care patients with ACS and HF admitted to high-volume hospitals had shorter mean critical care stays (56.6 versus 95.6 hours, P<0.001), more critical care procedures (1.9 versus 1.2 per patient, <0.001), and higher resource-intensive weighting (2.8 versus 1.5, P<0.001). No differences in in-hospital mortality (5.5% versus 6.2%, adjusted odds ratio 0.93; 95% CI, 0.61 to 1.41) were observed between high- and low-volume hospitals; however, 30-day cardiovascular readmissions (4.6% versus 6.8%, odds ratio 0.77; 95% CI, 0.60 to 0.99) and cardiovascular emergency-room visits (6.6% versus 9.5%, odds ratio 0.80; 95% CI, 0.69 to 0.94) were lower in high-volume compared to low-volume hospitals. Outcomes stratified by ACS or HF admission diagnosis were similar.

Conclusions: Cardiac patients hospitalized in low-volume hospitals were more frequently admitted to critical care units and had longer hospitals stays despite lower resource-intensive weighting. These findings may provide opportunities to standardize critical care utilization for ACS and HF patients across high- and low-volume hospitals.
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http://dx.doi.org/10.1161/JAHA.114.001708DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392446PMC
February 2015

Correlation between peak expiratory flow rate and NT-proBNP in patients with acute heart failure. An analysis from ASCEND-HF trial.

Int J Cardiol 2015 Mar 30;182:184-6. Epub 2014 Dec 30.

Mazankowski Alberta Heart Institute, University of Alberta and the Canadian VIGOUR Center, Edmonton, Alberta, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2014.12.138DOI Listing
March 2015

Heart failure re-admission: measuring the ever shortening gap between repeat heart failure hospitalizations.

PLoS One 2014 11;9(9):e106494. Epub 2014 Sep 11.

Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.

Many quality-of-care and risk prediction metrics rely on time to first rehospitalization even though heart failure (HF) patients may undergo several repeat hospitalizations. The aim of this study is to compare repeat hospitalization models. Using a population-based cohort of 40,667 patients, we examined both HF and all cause re-hospitalizations using up to five years of follow-up. Two models were examined: the gap-time model which estimates the adjusted time between hospitalizations and a multistate model which considered patients to be in one of four states; community-dwelling, in hospital for HF, in hospital for any reason, or dead. The transition probabilities and times were then modeled using patient characteristics and number of repeat hospitalizations. We found that during the five years of follow-up roughly half of the patients returned for a subsequent hospitalization for each repeat hospitalization. Additionally, we noted that the unadjusted time between hospitalizations was reduced ∼40% between each successive hospitalization. After adjustment each additional hospitalization was associated with a 28 day (95% CI: 22-35) reduction in time spent out of hospital. A similar pattern was seen when considering the four state model. A large proportion of patients had multiple repeat hospitalizations. Extending the gap between hospitalizations should be an important goal of treatment evaluation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106494PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4161342PMC
May 2015