Rural-Urban Disparities in the Management and Outcomes of Atrial Fibrillation in Emergency Departments in Canada.

A POPULATION-BASED COHORT STUDY OF A CLINICAL DECISION INSTRUMENT FOR 30-DAY DEATH FOLLOWING AN EMERGENCY DEPARTMENT VISIT FOR ATRIAL FIBRILLATION: THE ATRIAL FIBRILLATION IN THE EMERGENCY ROOM (AFTER) STUDY

Continuity of care has been shown to be poor following in-hospital discharge, and there are substantially fewer resources to facilitate follow-up care arrangements after discharge from an emergency department. Our objective was to assess the frequency, timeliness and predictors for obtaining follow-up care following discharge from an emergency department in Ontario with a new diagnosis of atrial fibrillation. We conducted a retrospective cohort study involving all patients discharged from the 157 nonpediatric emergency departments in Ontario, who received a new diagnosis of atrial fibrillation between 2007 and 2012. We determined the frequency of follow-up care with a family physician, cardiologist or internist within 7 (timely) and 30 days of the emergency department visit, and assessed the association of emergency and family physician characteristics, including primary care model type, with obtaining timely follow-up care. Among 14 907 patients discharged from Ontario emergency departments with a new, primary diagnosis of atrial fibrillation, half (n = 7473) had timely follow-up care. At 30 days, 2678 patients (18.0%) still had not obtained follow-up care. Among emergency and family physician factors, lack of a family physician had the largest independent association with acquiring timely follow-up care (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.50-0.69). Using patients with a family physician belonging to a primarily fee-for-service remuneration model as the comparison group, patients with a family physician belonging to a capitation-based Family Health Network, as part of a Family Health Team, were less likely to receive timely follow-up care (OR 0.73, 95% CI 0.62-0.86), as were those whose family physician belonged to the same model type that was not part of a Family Health Team (OR 0.77, 95% CI 0.60-0.97). Only half of the patients who were discharged from an emergency department in Ontario with a new diagnosis of atrial fibrillation were seen within 7 days of discharge. The most influential factor was having a family physician; patients with a family physician being remunerated via primarily fee-for-service methods were more likely to be seen within 7 days than those who were reimbursed through a primarily capitation model. Systems-wide solutions are needed to ensure timely follow-up care is available for all patients with chronic diseases.

BackgroundUnderstanding the epidemiology of ophthalmic presentations to emergency departments can help guide resource allocation, medical education programs, and optimize the patient experience. The purpose of this investigation was to summarize and assess the urgency of ophthalmic presentations in emergency departments (EDs) in Ontario, Canada over a 5-year period.MethodsThis was a multicentered retrospective review of all patient presentations to EDs in Ontario between January 1st, 2012, to December 31st, 2017. Presentations were included if patients had an ophthalmic related ICD-10 code as their primary problem prompting ED presentation.ResultsA total of 774,057 patients patient presentations were included across the pediatric (149,679 patients) and adult (624,378 patients) cohorts. The mean (SD) age at presentation was 47.4 (17.9) years, and 6.54 (5.20) in the adult and pediatric cohorts respectively. Of the total presentations, 256,776 (33.1%) were due to a trauma related presentation. Problems pertaining to Cornea and External disease were the most common reason for presentation (51.0% of cases). Of all presentations, 34.1% were classified as either ‘emergent’ or ‘likely emergent’; the remaining presentations were either ‘non-emergent’ (39.5%) or the urgency ‘could not be determined’ (26.4%). The three most frequent presentations were due to conjunctivitis (121,175 cases or 15.7%), ocular foreign bodies (104,322 cases or 13.5%), and corneal / conjunctival abrasions (94,554 cases of 12.2%).ConclusionsThis investigation summarizes all ophthalmic presentations to EDs in Ontario, Canada over a 5-year period. The results of this investigation can help guide ophthalmic related knowledge translation. Additionally, these results highlight that in Canadian EDs, a significant proportion of ophthalmic presentations are nonurgent; systems level efforts to improve access for eye-related complaints to healthcare professionals outside of the ED can help facilitate improved resource allocation. As we emerge from the COVID-19 pandemic, optimising the structure of patient care access is crucial to help alleviate the pressure from overburdened EDs while effectively meeting patient healthcare needs.

Atrial fibrillation (AF) with rapid ventricular rate (RVR) is a common diagnosis in the Emergency Department (ED) requiring evaluation and treatment. We present the characteristics and outcomes of patients presenting with primary or secondary AF in a tertiary hospital ED. This retrospective cohort study included consecutive patients ≥21 years old, with a primary or secondary diagnosis of AF with RVR in the ED over a 1-year period from 1 January 2016 to 31 December 2016. Primary AF is defined as AF with no precipitating cause and secondary AF as AF secondary to a precipitating cause. A total of 464 patients presented to the ED from 1 January to 31 December 2016 with primary and secondary diagnosis of AF with RVR; 44.8% had primary diagnosis of AF whereas 55.2% had secondary AF. Overall admission rate from ED was high at 91.8% (primary 84.6% vs secondary 97.7%). Patients with primary AF were younger (68 vs 74 years, P <0.001), had lower rates of cardiovascular risk factors, and shorter length of stay (median 4 vs 5 days). Within 30 days of discharge, they had lower ED reattendance (16.3% vs 25.8%, P <0.001) and lower readmission (16.3% vs 25.8%, P <0.001). There was no mortality in the primary AF group (0% vs 9.8%, P <0.001). Currently, majority of patients with AF with RVR are admitted from the ED. Other study suggests patients with uncomplicated primary AF have lower adverse outcomes and some could potentially be treated as outpatients.

Currently, 11% of patients seen in the emergency department for atrial fibrillation die within 1 year of the visit. Our objective was to examine the association of rapid (within 3 days), early (7 days), and basic (30 days) outpatient physician follow-up with short- and long-term outcomes in patients with atrial fibrillation discharged from an emergency department. This retrospective cohort study included all adult patients discharged from one of the 163 emergency departments in Ontario, Canada with a primary diagnosis of atrial fibrillation, 2007 to 2014. We used a landmark analysis with propensity score matching, and logistic regression, to assess all-cause mortality and cardiovascular hospitalizations at 1 year and 90 days, 30-day return emergency visits, and 1-year oral anticoagulation prescription fills. In the 10 657 patients with rapid follow-up care who were propensity score matched to a patient with follow-up between days 4 and 7, the hazard of a return emergency visit was reduced by 11% (HR, 0.89 [95% CI, 0.80-0.98]). It was not associated with mortality or hospitalization. In the 17 234 patients with early follow-up who were matched to a patient with care between days 8 and 30, the rate of 1-year mortality was 11% lower (HR, 0.89 [95% CI, 0.81-0.97]) and 1-year hospitalization was 6% lower (HR, 0.94 [95% CI, 0.89-1.00]). Relative to no 30-day care, basic follow-up care was associated with an increased hazard of 90-day hospitalization (HR, 1.32 [95% CI, 1.12-1.56]) but was no longer associated with mortality. In patients with early follow-up, the odds of filling an oral anticoagulation prescription a year later were 64% higher than those without it (OR, 1.64 [95% CI, 1.54-1.78]). Compared with follow-up care between days 8 and 30, follow-up within a week after discharge from an emergency department with atrial fibrillation was associated with a reduction in the rate of death and hospitalization within 1 year, an association that was not present with 30-day follow-up.

A Clinical Decision Instrument for 30-Day Death After an Emergency Department Visit for Atrial Fibrillation: The Atrial Fibrillation in the Emergency Room (AFTER) Study

A clinical decision instrument to predict 30-day death and cardiovascular hospitalizations after an emergency department visit for atrial fibrillation: The Atrial Fibrillation in the Emergency Room, Part 2 (AFTER2) study

Several factors have been linked to the variation in the quality of care for patients with atrial fibrillation (AF). Whether hospitalization primarily for AF (primary diagnosis of AF) as opposed to another primary diagnosis but having concomitant AF (secondary diagnosis of AF) impacts quality of care for AF is not known. Accordingly, we sought to evaluate the differences in quality of care of Medicare patients admitted with primary diagnosis versus secondary diagnosis of AF. We studied a random sample of Medicare fee-for-service discharges from Michigan's acute care hospitals over a 1-year period with a primary or secondary diagnosis of AF (ICD-9-CM 427.31). Main outcome measure. Warfarin use at the time of discharge. Of 5993 patients in the study, 772 had a primary diagnosis of AF and 5221 had a secondary diagnosis of AF. Patients with a secondary diagnosis of AF were older, more likely to be male, and less likely to be hypertensive. Patients with a secondary diagnosis of AF 'ideal' for anticoagulation (n = 1648) were less likely to receive warfarin compared with 'ideal' patients with primary diagnosis of AF (n = 363) (52.6% versus. 59.8%, P < 0.001). Adherence to test indicators was lower in patients with secondary diagnosis of AF. Secondary diagnosis of AF rather than AF as a primary diagnosis appears to account for most Medicare patients with AF admitted to hospitals. Whereas quality of care is lower in patients with secondary diagnosis of AF, opportunity for quality improvement exists for both groups of patients with AF.

Regional disparities in the care and outcomes of atrial fibrillation patients in a universal health care system: a population-based cohort study

While prior studies have shown regional disparities in patients with myocardial infarction and heart failure within a universal health care, there are limited data on the association between different regions within a universal health care system and outcomes after an atrial fibrillation (AF) diagnosis. In this context, we aimed to assess variations in processes of care and outcomes among patients with the diagnosis of AF presenting to the emergency department (ED). We conducted a population-based retrospective cohort study of all adult patients (≥ 18years) with their first presentation to the ED with AF between April 1, 2012, and March 31, 2022 in Ontario, Canada. We divided the analyses into five major Ontario Health Regions (North, East, Central, Toronto, and West). North was used as the reference group. The primary outcome was all-cause mortality or admission. Secondary outcomes included all-cause mortality, all-cause admission, and all-cause ED visit. We examined outcomes up to 1year from index AF diagnosis. Cox proportional hazards regression analysis was used to study the association of different regions and outcomes. Among 104,383 patients with the diagnosis of AF in the ED (mean age 69.4years, 47.1% female), there were significant differences between Ontario Health Regions in physician follow-up (less access to primary care in North or a cardiologist in West) and procedures performed (less cardioversions or ablations performed in North). There was a significantly lower rate of the primary outcome of all-cause mortality or admission in Ontario Health Regions compared to the North (East HR 0.87 (0.83, 0.90), Central HR 0.87 (0.83, 0.91), Toronto HR 0.88 (0.84, 0.92), and West HR 0.87 (0.84, 0.91)). Similar findings were noted with lower all-cause admission and all-cause ED visit in Ontario Health Regions compared to the North, but all-cause mortality did not differ between regions. Despite universal health care and prescription medication coverage, regional variations exist in the management of AF patients. Patients in Northern Ontario were less likely to visit a primary care physician and had worse outcomes driven by higher admission rate after AF diagnosis.

Aims While myocardial ischaemia plays a major role in the pathogenesis of heart failure (HF), the indications for coronary angiography during acute HF are not established. We determined the association of early coronary angiography during acute HF hospitalization with 2-year mortality, cardiovascular death, HF readmissions, and coronary revascularization.Methods and results In a two-stage sampling process, we identified acute HF patients who presented to 70 emergency departments in Ontario (April 2010 to March 2013) and determined whether they underwent early coronary angiography within 14 days after presentation using administrative databases. After clinical record review, we defined a cohort with acute ischaemic HF as patients with at least one factor suggesting underlying ischaemic heart disease, including previous myocardial infarction, troponin elevation, or angina on presentation. We oversampled patients undergoing angiography. We used inverse-probability-of-treatment weighting (IPTW) to adjust for baseline differences. Of 7239 patients with acute HF, 2994 met inclusion criteria [median age 75 (interquartile range 65–83) years; 40.9% women]. Early angiography was performed in 1567 patients (52.3%) and was associated with lower all-cause mortality [hazard ratio (HR) 0.74, 95% confidence interval (CI) 0.61–0.90, P = 0.002], cardiovascular death (HR 0.72, 95% CI 0.56–0.93, P = 0.012), and HF readmissions (HR 0.84, 95% CI 0.71–0.99, P = 0.042) after IPTW. Those undergoing early angiography experienced higher rates of percutaneous coronary intervention (HR 2.58, 95% CI 1.73–3.86, P < 0.001) and coronary artery bypass grafting (HR 2.94, 95% CI 1.75–4.93, P < 0.001) within 2 years.Conclusions Early coronary angiography was associated with lower all-cause mortality, cardiovascular death, HF readmissions, and higher rates of coronary revascularization in acute HF patients with possible ischaemia.

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation

ObjectivesAtrial fibrillation (AF) is common in the emergency department (ED), however, patients with AF sometimes visit ED because of other primary reason. There are no data on the characteristics and...

Background and Aims Glucagon-like-peptide-1 receptor agonists (GLP1RA) have emerged as a therapy that promotes weight loss and confers cardiorenal protection. While recent trials have suggested benefit on heart failure hospitalizations; their effects on all-cause emergency department (ED) visits and hospitalizations have not been well characterized. In this population-based study we examined the effect of initiating a GLP1RA versus a dipeptidyl peptidase 4 inhibitor (DPP4i) on ED visits and all-cause hospitalization in patients across the spectrum of chronic kidney disease (CKD). Method This retrospective cohort study was conducted in Ontario, Canada, using administrative databases housed at ICES. We included a cohort of patients aged ≥18 years with eGFR &amp;lt;90 ml/min/1.73 m2 who received a first prescription of a GLP1RA or DPP4i through the Ontario Drug Benefit between September 30, 2019 to December 31, 2021. Follow-up extended until June 30, 2022. We used inverse probability of treatment weighting (IPTW) based on a propensity score conditioned on 72 covariates to address confounding. We evaluated the effect of GLP1RA initiation on all cause ED visits and hospitalization using time-to-recurrent-event approaches with the Prentice-Williams-Peterson (PWP) gap time model which assumes an event-specific hazard for each ED encounter or hospitalization. In an additional analysis, we evaluated recurrent ED visits and/or hospitalizations using the Andersen-Gill extension of the Cox proportional hazards model and robust sandwich estimators to obtain the 95% confidence intervals. Results The study cohort included 24,576 patients who were new users of a GLP1RA, and 23,600 who were new users of a DPP-4i eGFR &amp;lt;90 ml/min/1.73 m2. Baseline characteristics were balanced between groups (mean age of 69 years, 50% female, 92% with type 2 diabetes mellitus, 3.5% had heart failure, and 41% had CKD stages 3–5). Semaglutide represented 98.4% of GLP1RA prescriptions. Across the cohort, 9.6% had more than one hospitalization while 25.8% had more than one emergency department encounter. Using the PWP gap time model, new use of GLP1RA was associated with a lower risk of all-cause ED encounters or hospitalizations: HR 0.90 (95% CI, 0.87 to 0.94; P &amp;lt; 0.0001). This finding was consistent when we used the calendar time model (HR 0.90; 95% CI, 0.87 to 0.94) or the Andersen-Gill extension of the Cox proportional hazards model (HR 0.87; 95% CI, 0.82 to 0.92) (Table 1). Conclusion In this large population-based study, GLP1RA initiation was associated with a reduction in all-cause ED visits and/or hospitalizations when compared to DPP-4 inhibitor initiation. This finding has potentially substantial implications on health care delivery and resource utilization.