Best practices for developing cardiovascular quality indicators.

The Canadian Heart Health Strategy and Action Plan recommended that the Canadian Cardiovascular Society (CCS) lead the development of pan-Canadian data definitions and quality indicators (QIs) for evaluating cardiovascular care in Canada. In response to this recommendation, the CCS developed and adopted a standardized QI development methodology. This report provides a brief overview of the CCS "Best Practices" for developing pan-Canadian cardiovascular QIs. A more detailed description is available in Supplemental Material. The CCS Best Practices QI development methodology consists of 3 phases: phase I, plan and organize the QI development initiative; phase II, develop and select QIs; and phase III, operationalize the QIs. Phase I includes identifying the cardiovascular focus or content area, determining the objective and/or purpose of the initiative, the target users of, and the target population for, the QIs, and selection of a QI working group. Phase II involves formulating the QIs including generating a preliminary set of QIs and draft definitions, followed by an indicator rating and ranking process based on the CCS QI rating criteria. Phase III involves finalizing technical specifications and pilot testing the QIs. It also describes the CCS QI approval process and addresses knowledge translation. Adoption of a standardized methodology for QI development will improve the quality, completeness, acceptability, and usability of pan-Canadian cardiovascular QIs developed by the CCS. Public release of the QI definitions and related performance data might help improve patient care quality and outcomes.

Quality of diabetes and hyperlipidemia screening before a first myocardial infarction.

BACKGROUND: There has been significant attention to the quality of care for acute myocardial infarction (MI). However, little is known about the quality of preventive care before a patient's first MI. METHODS: We conducted a retrospective, cohort analysis of 5688 patients admitted with their first MI to 96 acute care hospitals in Ontario, Canada, from April 2004 to March 2005 using the Enhanced Feedback For Effective Cardiac Treatment clinical study database. We calculated rates of screening for diabetes and hyperlipidemia according to guidelines using linkages to the Ontario Health Insurance Plan database. Screening rates were stratified by age, sex, socioeconomic status, and number of primary care visits in the past 5 years. RESULTS: Among the 5688 eligible patients, 27.1% did not receive serum cholesterol screening in the 5 years preceding their MI and 27.5% of patients did not receive a fasting blood glucose or glucose tolerance test in the 3 years before their MI. Women were more likely to be screened than men. Screening rates generally increased with age and were similar across socioeconomic categories. There was a positive association between the number of primary care visits and the likelihood of being screened. CONCLUSIONS: A significant number of patients admitted with their first MI were not screened for important modifiable risk factors. Opportunities for the prevention of coronary disease are being missed. More emphasis is needed on identifying risk factors before the development of acute coronary disease.

Trends in the incidence and outcomes of heart failure in Ontario, Canada: 1997 to 2007.

BACKGROUND: Heart failure is a leading cause of admission to hospital, but whether the incidence of heart failure is increasing or decreasing is uncertain. We examined temporal trends in the incidence and outcomes of heart failure in Ontario, Canada. METHODS: Using population-based administrative databases of hospital discharge abstracts and physician health insurance claims, we identified 419 551 incident cases of heart failure in Ontario between Apr. 1, 1997, and Mar. 31, 2008. All patients were classified as either inpatients or outpatients based on the patient's location at the time of the initial diagnosis. We tracked subsequent outcomes through linked administrative databases. RESULTS: The age- and sex-standardized incidence of heart failure decreased 32.7% from 454.7 per 100 000 people in 1997 to 306.1 per 100 000 people in 2007 (p < 0.001). A comparable decrease in incidence occurred in both inpatient and outpatient settings. The greatest relative decrease occurred in patients aged 85 and over. Over the study period, 1-year risk-adjusted mortality decreased from 17.7% in 1997 to 16.2% in 2007 (p = 0.02) for outpatients, with a nonsignificant decrease from 35.7% in 1997 to 33.8% in 2007 (p = 0.1) for inpatients. INTERPRETATION: The incidence of heart failure decreased substantially during the study period. Nevertheless, the prognosis for patients with heart failure remains poor and is associated with high mortality.

Comparison of processes of care and clinical outcomes for patients newly hospitalized for heart failure attended by different physician specialists.

BACKGROUND: Previous studies suggest that patients with heart failure (HF) treated by cardiologists have improved outcomes compared with patients treated by other physicians. It remains unclear whether these findings reflect differences in patient characteristics, processes of care, practice setting, or a combination of these factors. METHODS: We examined physician specialty-related differences in processes of care and clinical outcomes for 7,634 patients newly hospitalized for HF in Ontario, Canada, who were included in the EFFECT study between April 2004 and March 2005. Patients were categorized according to whether they received cardiologist, generalist (e.g., internist or family doctor), or generalist care with cardiology consultation. RESULTS: Multivariable hierarchical modeling demonstrated that patients treated by generalists alone had higher risk of 30-day (odds ratio [OR] 1.50, 95% CI 1.18-1.91) and 1-year mortality (OR 1.29, 95% CI 1.10-1.50), as well as the 1-year composite outcome of death and readmission, compared with patients treated by cardiologists. These differences were significantly attenuated if patients who had "do not resuscitate" orders were excluded. Patients who had a cardiologist involved in their care were more likely to undergo diagnostic procedures, such as echocardiography, and had higher rates of certain evidence-based pharmacologic therapy such as ß-blockers. CONCLUSION: Physician specialty-related differences in HF outcomes appear to reflect a combination of both case-mix differences and differences in the use of certain heart failure processes of care. These findings suggest that it may be possible to improve HF outcomes in patients receiving care from generalist physicians.

An international environmental scan of quality indicators for cardiovascular care.

Quality indicators (QIs) are increasingly being used to measure and improve the quality of cardiac care. We conducted an international environmental scan to identify and critically appraise published QI development initiatives addressing cardiovascular disease (CVD). A review of the peer-reviewed and grey English-language literature was conducted to identify published CVD QI development initiatives. The quality of identified studies was assessed using a modified version of the Appraisal of Guidelines for Research and Evaluation (AGREE) II QI tool-an instrument originally developed for the assessment of the quality of clinical practice guidelines. An initial literature search identified 2314 potentially relevant abstracts of peer-reviewed articles. After a review of the abstracts, 120 full text articles were retrieved and reviewed. Of these, 20 articles and 1 peer-reviewed monograph were selected for critical appraisal (n = 21). Most of the initiatives were conducted in North America (76%) and were published after 2005 (62%). The majority (5 of 6) of the AGREE II QI domain scores were skewed toward higher values, including the median score for the 'overall quality' rating (83.3%). Of the CVD categories addressed within the 21 initiatives, heart failure was the most common (n = 10 QI indicator sets), followed by acute coronary syndromes (n = 8). Considerable variation was observed in the methods utilized and the degree of scientific rigour applied in the published international CVD QI development initiatives. Adoption of standardized methods could help improve the quality of QI development initiatives.

CIHI survey: Hospital costs for preterm and small-for-gestational age babies in Canada.

In 2006-2007, more than 54,000 (or one in seven) babies across Canada were born preterm or small for their gestational age (SGA). These babies are often at higher risk for morbidity and mortality than are full-term babies with normal birth weight, and account for a disproportionately high percentage of healthcare costs among newborns. This article highlights key findings from a recent report by the Canadian Institute for Health Information, Too Early, Too Small: A Profile of Small Babies across Canada, and provides information on the hospital costs among low birth weight, preterm and SGA babies. Birth weight and gestational age were found to be important determinants of hospital costs - as birth weight and gestational age decreased, average in-hospital costs increased. Furthermore, multiple-birth babies had higher hospital costs than did singleton babies. As in other areas of the health system, information relating to costs and spending can inform neonatal and obstetrical health planning and decision-making.

Physician diagnostic and reporting practices for gastrointestinal illnesses in three health regions of British Columbia.

OBJECTIVES: To estimate seasonal proportions of patient visits due to acute gastrointestinal illness (GI), assess factors influencing physicians' stool sample requests, their understanding of laboratory testing protocols and adherence to provincial stool request guidelines in three British Columbia (BC) health regions. METHODS: During a one-year period, eligible physicians were mailed four self-administered questionnaires used to estimate proportions of patients diagnosed with GI, related stool sample requests in the preceding month, and to assess factors prompting stool sample requests. RESULTS: The response rate overall for the initial comprehensive questionnaire was 18.6%; 7.4% responded to all four questionnaires. An estimated 2.5% of patient visits had a GI diagnosis; of these, 24.8% were asked to submit stool samples. Significant (p < 0.05) regional and seasonal variations were found in rates of GI and stool sample requests. Top-ranked factors prompting stool sample requests were: bloody diarrhoea, recent overseas travel, immunocompromised status, and duration of illness > 7 days; "non-patient" factors included: laboratory availability, time to receive laboratory results, and cost. Physicians' perceptions of which organisms were tested for in a 'routine' stool culture varied. INTERPRETATION: BC physicians appear to adhere to existing standardized guidelines for sample requests. This may result in systematic under-representation of certain diseases in reportable communicable disease statistics.