Uptake of the Heart Failure Management Incentive Billing Code by Family Physicians in Ontario,Canada: A Retrospective Cohort Study

In 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) implemented an incentive payment, Q050A billing code, to family physicians for provision of comprehensive guideline-based care for patients with heart failure in the community. Our objective was to report on the uptake of this program from fiscal years 2008-2014. We determined the numbers of claims billed per year and the proportion of eligible patients with congestive heart failure (CHF) for whom a physician billed. The code was billed by 10.4% of all family physicians in 2008-2009, which increased to 15.1% in 2014-2015. The code was claimed for 4.1% of all identified patients with CHF in 2008-2009 and 5.9% of patients with CHF in 2014-2015. Given these findings, it is estimated that MOHLTC paid an additional CAD$10,118,514 to family physicians managing patients with CHF. This is the first study to examine the uptake of a CHF-specific incentive program, which will help to inform health policy makers in implementing such programs in Ontario.     

Hepatitis C Virus Infection Outcomes Among Immigrants to Canada: A Retrospective Cohort Analysis

Introduction and aimHCV-infected immigrants contribute to the total prevalence in Canada and other developed nations. Little is known about engagement in care, access to service, and treatment outcomes in recipients of Direct Acting Antiviral (DAA) HCV therapies among immigrants living with HCV.Material and methodsHCV patients assessed at The Ottawa Hospital Viral Hepatitis Clinic between 2000-2016 were identified. Immigration history, race, socioeconomic status, HCV work-up, treatment and outcome data were evaluated. HCV fibrosis assessment, treatment and sustained virologic response (SVR) were compared using logistic regression.Results2,335 HCV-infected patients were analyzed with 91% (2114) having data on immigration (23% immigrants). A median 16 years (Quartiles: 5, 29) passed from immigration to referral. Access to diagnostic procedures (Fibroscan/liver biopsy) was greater among immigrants compared to Canadian-born (78% vs. 68%, p = 0.001) and immigrants had an odds ratio of 1.72 (95% CI: 1.18-2.51) of receiving a FibroScan compared to Canadians after adjustment for demographic characteristics, HCV risk factors, and socioeconomic status. No differences in SVR were found between immigrants for IFN recipients. Among DAA recipients, rates of SVR were > 94% among all patients, 93% in Canadian-born and 98% among immigrants (p = 0.14).ConclusionNearly 80% of immigrants in this setting had access to fibrosis assessment which was higher than Canadian-born patients. Under half of both groups had initiated HCV therapy. Delays in accessing HCV care represent a missed opportunity to engage, treat and cure HCV patients. HCV screening and health care engagement at the time of immigration would optimize HCV care and therapeutic outcomes.     

Assessing Timely Presentation to Care Among People Diagnosed with HIV During Hospital Admission: A Population-Based Study in Ontario,Canada

Timely presentation to care for people newly diagnosed with HIV is critical to optimize health outcomes and reduce onward HIV transmission. Studies describing presentation to care following diagnosis during a hospital admission are lacking. We sought to assess the timeliness of presentation to care and to identify factors associated with delayed presentation. We conducted a population-level study using health administrative databases. Participants were all individuals older than 16 and newly diagnosed with HIV during hospital admission in Ontario, Canada, between April 1, 2007 and March 31, 2015. We used modified Poisson regression models to derive relative risk ratios for the association between sociodemographic and clinical variables and the presentation to out-patient HIV care by 90 days following hospital discharge. Among 372 patients who received a primary HIV diagnosis in hospital, 83.6% presented to care by 90 days. Following multivariable analysis, we did not find associations between patient sociodemographic or clinical characteristics and presentation to care by 90 days. In a secondary analysis of 483 patients diagnosed during hospitalization but for whom HIV was not recorded as the principal reason for admission, 73.1% presented to care by 90 days. Following multivariable adjustment, we found immigrants from countries with generalized HIV epidemics (RR 1.265, 95% CI 1.133–1.413) were more likely to present to care, whereas timely presentation was less likely for people with a mental health diagnosis (RR 0.817, 95% CI 0.742–0.898) and women (RR 0.748, 95% CI 0.559–1.001). Future work should evaluate mechanisms to facilitate presentation to care among these populations.     

Socioeconomic Status Indicators and Incidence of Heart Failure Among Men and Women With Coronary Heart Disease

BackgroundLow socioeconomic status (SES) is associated with increased coronary heart disease (CHD) risk. Little is known about the relationship between SES and heart failure (HF) incidence among CHD patients.Methods and ResultsThe association among education, occupation, and HF risk was studied in 2,951 CHD patients, free of HF at baseline, participating in a clinical trial, correcting for the competing risk of death. Over 8 years of close follow-up, 511 patients developed HF. These patients were older, and had higher frequency of metabolic risk factors and advanced CHD than HF-free counterparts. Age-adjusted HF incidence rate/1,000 person-years increased from 20.4 to 30.0 among patients with academic and elementary education, respectively. The rate for “blue collar” occupation was 25.1 compared with 18.5 among “academic”/“white collar” occupations combined. Adjusting for sex, obesity, diabetes, metabolic syndrome, peripheral vascular disease, hypertension, and myocardial infarction number, the HF hazard ratios [HRs] were 0.85 (95% confidence interval [CI] 0.70–1.03) and 0.76 (95% CI 0.58–0.99) for high-school and academic education versus elementary education, respectively. HR for “blue collar” compared with “academic”/“white collar” occupations was 1.30 (95% CI 0.97–1.74).ConclusionsSES indicators (mainly education) are associated with HF incidence among CHD patients. The association is only marginally explained by possible confounders or known mediators such as hypertension and myocardial infarction.     

Investigating Pain in Heart Failure Patients: The Pain Assessment,Incidence, and Nature in Heart Failure (PAIN-HF) Study

BackgroundPatients with advanced heart failure (HF) have high rates of pain and other symptoms that diminish quality of life. We know little about the characteristics and correlates of pain in patients with advanced HF.Methods and ResultsWe identified pain prevalence, location, character, severity, frequency, and correlates in 347 outpatients with advanced HF enrolled from hospices and clinics. We evaluated the correlation of pain with HF-related quality of life, mortality, symptoms and health problems, and current treatments for pain. Pain at any site was reported by 293 patients (84.4%), and 138 (39.5%) reported pain at more than one site. The most common site of pain was the legs below the knees (32.3% of subjects). Pain interfered with activity for 70% of patients. Pain was “severe” or “very severe” for 28.6% of subjects with chest pain, and for 38.9% of those with other sites of pain. The only medication reported to provide pain relief was opioids, prescribed for 34.1% of subjects (P = .001). The strongest predictors of pain were degenerative joint disease (DJD) (odds ratio [OR] 14.95, 95% confidence interval [CI] 3.9–56.0; P < .001), other arthritis (OR 2.8, 95% CI 1.20–6.62; P = .017), shortness of breath (OR 3.27, 95% CI 1.47–7.28; P = .004), and angina pectoris (OR 3.38, 95% CI 1.30–8.81; P = .013).ConclusionsPain occurred at multiple sites in patients with advanced HF. Pain correlated with DJD or other arthritis, shortness of breath, and angina. Only opioid analgesics provided relief of pain. Future research should evaluate the etiology of and interventions to manage pain in patients with HF.     

Frequency and Predictors of Falls Among Adults With Heart Failure: A Prospective Study

ObjectiveAdults with heart failure (HF) may be at high risk for falling due to age, comorbidities and frailty; however, few studies have examined falls in HF. The purpose of this study was to quantify the frequency and predictors of falls over 1 year among adults with HF.MethodsWe conducted a prospective study of adults with New York Heart Association (NYHA) functional class I–IV HF. After baseline assessment of physical frailty and clinical characteristics, participants self-reported falls every 3 months during 1 year. Comparative statistics were used to identify baseline differences between those who fell vs those who did not. A stepwise negative binomial regression model was used to identify predictors of fall rate over 1 year.ResultsThe sample (n = 111) was 63.4 ± 15.7 years old, 48% were women, 28% had HF with preserved ejection fraction, and 41% were frail. Over 1 year, 43 (39%) of participants reported at least 1 fall and 28 (25%) of participants reported 2+ falls. Among those who fell, 29 (67%) reported injurious falls. Those who fell had significantly higher body mass indexes and were more likely to have NYHA class III/IV, type 2 diabetes and HF with preserved ejection fraction and to meet slowness and physical exhaustion criteria than those who did not fall. The fall rate was elevated among those with type 2 diabetes and those meeting the slowness and physical exhaustion criteria for physical frailty.ConclusionsNearly 40% of adults with HF experienced a fall within 1 year. Screening for comorbidities, slowness and exhaustion may help to identify those at risk for a fall.     

Incidence and Epidemiology of Heart Failure

Epidemiologic data from the Framingham Study provide insights into the population burden of heart failure (CHF), its prognosis and modifiable risk factors that promote it. In the general population CHF is chiefly the end stage of hypertensive, coronary and valvular cardiovascular disease. It is a major and growing problem in most affluent countries because of aging populations of increased size, and the prolongation of the lives of cardiac patients by modern therapy. Once clinically manifest, CHF, despite recent innovations in therapy, carries an unacceptably high mortality rate. In the Framingham Study, median survival is only 1.7[emsp4 ]y for men and 3.2[emsp4 ]y for women, with only 25% of men and 38% of women surviving 5[emsp4 ]y. This is a mortality rate 4–8 times that of the general population of the same age. This poor outlook is observed for all etiologies of CHF and sudden death is a prominent feature of the mortality. Based on population attributable risks, hypertension has the greatest impact, accounting for 39% of CHF events in men and 59% in women. Despite its much lower prevalence in the population (3–10%) myocardial infarction also has a high attributable risk in men (34%) and women (13%). Valvular heart disease only accounted for 7–8% of CHF. Hypertension increased the age and risk factor adjusted hazard of CHF 2-fold in men and 3-fold in women, with a greater impact of the systolic than diastolic blood pressure. Diabetes increased CHF risk 2–8 fold with risk ratios twice as large in women as men. About 19% of CHF cases have diabetes. It accounted for 6–12% of the CHF in the Framingham Study cohort. Dyslipidemia characterized by a high total/HDL cholesterol ratio, but not the total cholesterol alone was a risk factor for CHF. An enlarged heart on X-Ray, ECG-LVH, a reduced vital capacity and rapid heart rate usually signified deteriorating cardiac function. CHF risk associated with ECG-LVH was independent of X-Ray cardiomegaly but risk was further augmented when both coexist. Echocardiographic left ventricular hypertrophy signifies a high risk of CHF proportional to the degree of increase in left ventricular mass without a critical value that delineates compensatory from pathological hypertrophy. Risk of CHF in persons predisposed by hypertension, diabetes or cardiac conditions varies over a 10-fold range depending on the aforementioned modifiable risk factors and indicators of deteriorating left ventricular function. Using multivariate risk formulations it is possible to identify 20% of the population from which 70% of the CHF will evolve. Those in the upper quintile of multivariate risk are good candidates for echocardiographic testing to delineate those needing aggressive preventive measures to delay the onset of CHF. Therapy of CHF must begin with treatment of presymptomatic left ventricular dysfunction to reverse the dysfunctional maladaptive changes.Framingham Heart Study. Framingham Study research is supported by NIH/NHLBI Contract N01-HC-38038 and the Visiting Scientist Program which is supported by     

Search for Chronic Beryllium Disease Among Sarcoidosis Patients in Ontario,Canada

Chronic beryllium disease (CBD) is clinically similar to other granulomatous diseases such as sarcoidosis. It is often misdiagnosed if a thorough occupational history is not taken. When appropriate, a beryllium lymphocyte proliferation tests (BeLPT) need to be performed. We aimed to search for CBD among currently diagnosed pulmonary sarcoidosis patients and to identify the occupations and exposures in Ontario leading to CBD. Questionnaire items included work history and details of possible exposure to beryllium. Participants who provided a history of previous work with metals underwent BeLPTs and an ELISPOT on the basis of having a higher pretest probability of CBD. Among 121 sarcoid patients enrolled, 87 (72%) reported no known previous metal dust or fume exposure, while 34 (28%) had metal exposure, including 17 (14%) with beryllium exposure at work or home. However, none of these 34 who underwent testing had positive test results. Self-reported exposure to beryllium or metals was relatively common in these patients with clinical sarcoidosis, but CBD was not confirmed using blood assays in this population.     

我国心力衰竭患者疾病认知程度的现况调查

目的:了解我国心力衰竭患者的疾病认知程度,并评估与其相关的人口学及临床因素,为实施相应的临床干预提供依据。方法:对我国2012~2014年不同地区、不同级别医院(24家)的970例心力衰竭患者进行问卷调查,内容包括心力衰竭知晓、生活方式、药物依从性、就医便利性、经济负担、健康宣教。生活方式改善包括低盐饮食、适量运动和监测体重。采用Pearson卡方分析探究可能影响心力衰竭认知程度的人口学及临床因素。结果:我国心力衰竭患者中心力衰竭知晓率、药物依从率及健康教育接受率分别为74.8%、83.0%和40.8%。全面改善生活方式的患者仅占5.6%。不同的医院级别、患者受教育程度、NYHA心功能分级、婚姻状况影响患者的心力衰竭知晓率(P均<0.01)。农村患者的疾病知晓率、药物依从率及健康教育接受率明显低于城镇患者(P均<0.01)。二、三级医院患者的药物依从率和健康教育接受率显著高于一级医院(P均<0.01)。结论:我国心力衰竭患者总体疾病认知程度较差,表现为知晓率、药物依从率、健康教育接受率低下,自我保健意识匮乏。各级医护人员应履行疾病告知义务,加强健康宣教力度,以期改善药物依从性,督促生活方式改良。     

Drinking Culture of Elderly Korean Immigrants in Canada: A Focus Group Study

The purpose of this study was to explore the drinking culture of elderly Korean immigrants in Canada. Using a focus group approach, qualitative data were collected from 19 elderly Korean immigrants (14 men; 5 women) residing in Canada. Data were analyzed using the techniques of grounded theory. The findings indicated that elderly Korean immigrants did not dramatically change their understanding of drinking or their ways of drinking. Instead, they modified their drinking behavior in accordance with the social and legal environment of their new country. In particular, Canadian alcohol policies, including the higher cost of alcohol, lower accessibility, and strict law enforcement, discouraged excessive drinking. Policy implications and recommendations for future research are presented.     

Psychological and Sociocultural Adaptation: Acculturation,Depressive Symptoms,and Life Satisfaction Among Older Iranian Immigrants in Canada

Informed by Ward’s (1996) theory of psychological and sociocultural adaptation, this study identified links between acculturation and the mental health of older Iranian immigrants living in Canada (N = 103). According to Ward and colleagues, both psychological and sociocultural adaptation change at different rates and extend into later life. For this study, participants 50+ years of age and born in Iran completed questionnaires measuring life satisfaction, depressive symptoms, acculturation, and demographic and sociocultural variables (e.g., pre- and post-immigration occupational status). We collected study data anonymously in Persian to obtain responses from long-term residents of Canada as well as more recent immigrants who may not read or write English. We examined both life satisfaction and (the absence of) depressive symptoms as distinct forms of psychological adaptation; these emerged as independent predictors of acculturation. Contrary to theory, acculturation appears to predict life satisfaction, not vice versa; moreover, there seems to be no direct link between depressive symptoms and acculturation. Our findings suggest that integration within Canadian society is associated with higher life satisfaction. In contrast, sociocultural factors are indirectly associated with life satisfaction (except age) and acculturation (except ethnic diversity of social interactions). Involuntary migrants reported higher levels of depression, whereas loss of occupational status is associated with reduced life satisfaction. Implications for future research and health policy are discussed.     

Sex-Specific Trends in Incidence and Mortality for Urban and Rural Ambulatory Patients with Heart Failure in Eastern Ontario from 1994 to 2013

Background

Differences in outcomes have previously been reported between urban and rural settings across a multitude of chronic diseases. Whether these discrepancies have changed over time, and how sex may influence these findings is unknown for patients with ambulatory heart failure (HF). We examined the temporal incidence and mortality trends by geography in these patients.

Yoga in Heart Failure Patients: A Pilot Study

BackgroundComplementary therapies such as yoga practice have become commonplace, yet the safety, physical, and psychological effects on patients with heart failure (HF) are unknown. The purpose of this study was to determine whether an 8-week yoga program was safe and would positively influence physical and psychological function in HF patients.Methods and ResultsStable HF patients were recruited (n = 15) and completed (n = 12) 8 weeks of yoga classes. Data collected were: safety (cardiac and orthopedic adverse events); physical function (strength, balance, endurance, flexibility); and psychological function (quality of life [QOL], depression scores, mindfulness) before and after 8 weeks of yoga classes.ResultsMean age was 52.4 ± 11.6 with three-fourths (n = 9) being male and Caucasian. No participant had any adverse events. Endurance (P < .02) and strength (upper P = .04 and lower body P = .01) significantly improved. Balance improved by 13.6 seconds (26.9 ± 19.7 to 40.0 ± 18.5; P = .05). Symptom stability, a subscale of QOL, improved significantly (P = .02). Although no subject was depressed, overall mood was improved. Subjects subjectively reported improvements in overall well-being.ConclusionsYoga practice was safe, with participants experiencing improved physical function and symptom stability. Larger studies are warranted to provide more nonpharmacological options for improved outcomes in patients with HF.     

Associations of Angiopoietins With Heart Failure Incidence and Severity

BackgroundAngiopoietin-1 and 2 (Ang1, Ang2) are important mediators of angiogenesis. Angiopoietin levels are perturbed in cardiovascular disease, but it is unclear whether angiopoietin signaling is causative, an adaptive response, or merely epiphenomenon of disease activity.Methods and ResultsIn a cohort free of cardiovascular disease at baseline (Multi-Ethnic Study of Atherosclerosis [MESA]), relationships between angiopoietins, cardiac morphology, and subsequent incidence of heart failure or cardiovascular death were evaluated. In cohorts with pulmonary arterial hypertension or left heart disease, associations between angiopoietins, invasive hemodynamics, and adverse clinical outcomes were evaluated. In MESA, Ang2 was associated with a higher incidence of heart failure or cardiovascular death (hazard ratio 1.21 per standard deviation, P < .001). Ang2 was associated with increased right atrial pressure (pulmonary arterial hypertension cohort) and increased wedge pressure and right atrial pressure (left heart disease cohort). Elevated Ang2 was associated with mortality in the pulmonary arterial hypertension cohort.ConclusionsAng2 was associated with incident heart failure or death among adults without cardiovascular disease at baseline and with disease severity in individuals with existing heart failure. Our finding that Ang2 is increased before disease onset and that elevations reflect disease severity, suggests Ang2 may contribute to heart failure pathogenesis.     

Diminished Renal Function and the Incidence of Heart Failure

Heart failure is one of the most common, costly, disabling and deadly diseases. During the last decade, several different indices reflecting renal function such as creatinine-based glomerular filtration rate, circulating levels of cystatin C and low-grade albuminuria have been demonstrated to be independent risk factors for heart failure. This review summarizes our current knowledge of the relationship between diminished renal function and the incidence of heart failure in the community, and also in individuals with increased risk of heart failure such as patients with overt cardiovascular disease, hypertension or diabetes. This review will also put forward important areas of future research in this field.