Peter Faris

Background: The influence of fee‐for‐service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. Methods and Results: This retrospective, population‐based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed‐effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67–0.68) imaging tests per consultation. After adjustment, patients seeing fee‐for‐service physicians had 2.07 (95% CI, 1.68–2.54) and fee‐for‐service physicians with ability to interpret had 2.87 (95% CI, 2.16–3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site‐level variation 40% and physician‐level variation 29%. Conclusions: We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.

Background: Self-management education and support (SMES) interventions have modest effects on intermediate outcomes for those at risk of cardiovascular disease, but few studies have measured or demonstrated an effect on clinical end points. Advertising for commercial products is known to influence behavior, but advertising principles are not typically incorporated into SMES design. Methods: This randomized trial studied the effect of a novel tailored SMES program designed by an advertising firm among a population of older adults with low income at high cardiovascular risk in Alberta, Canada. The intervention included health promotion messaging from a fictitious “peer” and facilitated relay of clinical information to patients’ primary care provider and pharmacist. The primary outcome was the composite of death, myocardial infarction, stroke, coronary revascularization, and hospitalizations for cardiovascular-related ambulatory care–sensitive conditions. Rates of the primary outcome and its components were compared using negative binomial regression. Secondary outcomes included quality of life (EQ-5D [EuroQoL 5-dimension] index score), medication adherence, and overall health care costs. Results: We randomized 4761 individuals, with a mean age of 74.4 years, of whom 46.8% were female. There was no evidence of statistical interaction ( P =0.99) or of a synergistic effect between the 2 interventions in the factorial trial with respect to the primary outcome, which allowed us to evaluate the effect of each intervention separately. Over a median follow-up time of 36 months, the rate of the primary outcome was lower in the group that received SMES compared with the control group (incidence rate ratio, 0.78 [95% CI, 0.61 to 1.00]; P =0.047). No significant between-group changes in quality of life over time were observed (mean difference, 0.0001 [95% CI, −0.018 to 0.018]; P =0.99). The proportion of participants who were adherent to medications was not different between the 2 groups ( P =0.199 for statins and P =0.754 for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers). Overall adjusted health care costs did not differ between those receiving SMES and the control group ($2015 [95% CI, −$1953 to $5985]; P =0.320). Conclusions: For older adults with low income, a tailored SMES program using advertising principles reduced the rate of clinical outcomes compared with usual care. The mechanisms of improvement are unclear and further studies are required. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02579655.

Background: One in eight people with heart disease has poor medication adherence that, in part, is related to copayment costs. This study tested whether eliminating copayments for high-value medications among low-income older adults at high cardiovascular risk would improve clinical outcomes. Methods: This randomized 2×2 factorial trial studied 2 distinct interventions in Alberta, Canada: eliminating copayments for high-value preventive medications and a self-management education and support program (reported separately). The findings for the first intervention, which waived the usual 30% copayment on 15 medication classes commonly used to reduce cardiovascular events, compared with usual copayment, is reported here. The primary outcome was the composite of death, myocardial infarction, stroke, coronary revascularization, and cardiovascular-related hospitalizations over a 3-year follow-up. Rates of the primary outcome and its components were compared using negative binomial regression. Secondary outcomes included quality of life (Euroqol 5-dimension index score), medication adherence, and overall health care costs. Results: A total of 4761 individuals were randomized and followed for a median of 36 months. There was no evidence of statistical interaction ( P =0.99) or of a synergistic effect between the 2 interventions in the factorial trial with respect to the primary outcome, which allowed us to evaluate the effect of each intervention separately. The rate of the primary outcome was not reduced by copayment elimination, (521 versus 533 events, incidence rate ratio 0.84 [95% CI, 0.66–1.07], P =0.162). The incidence rate ratio for nonfatal myocardial infarction, nonfatal stroke, and cardiovascular death (0.97 [95% CI, 0.67–1.39]), death (0.94 [95% CI, 0.80 to 1.11]), and cardiovascular-related hospitalizations (0.78 [95% CI, 0.57 to 1.06]) did not differ between groups. No significant between-group changes in quality of life over time were observed (mean difference, 0.012 [95% CI, –0.006 to 0.030], P =0.19). The proportion of participants who were adherent to statins was 0.72 versus 0.69 for the copayment elimination versus usual copayment groups, respectively (mean difference, 0.03 [95% CI, 0.006–0.06], P =0.016). Overall adjusted health care costs did not differ ($3575 [95% CI, –605 to 7168], P =0.098). Conclusions: In low-income adults at high cardiovascular risk, eliminating copayments (average, $35/mo) did not improve clinical outcomes or reduce health care costs, despite a modest improvement in adherence to medications. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02579655.

Background: Prior to the pandemic, every day approximately 28 long term care (LTC) residents were transferred to an emergency department (ED) in Alberta. This was placing increasing strain on healthcare resources and potentially negatively impacting the health and wellness of residents (e.g., exposure to iatrogenic harms). Many residents’ conditions could be managed within LTC if appropriate supports were provided. Poor communication between LTC and EDs can also lead to long ED lengths of stay, unnecessary resource utilization, sub-optimal health outcomes, and exposure to iatrogenic harms for LTC residents. Two INTERACT® tools (tools for early identification of acute medical issues) and a new care and referral pathway were implemented to help identify and address changes in health status among LTC residents sooner, improve communication between LTC and ED providers, and reduce unnecessary ED transfers. Methods: Between October 2019 and April 2022, 40 LTC homes and 4 EDs within the Calgary zone implemented the standardized LTC-to-ED care and referral pathway supported by a centralized telephone advice and transfer system for healthcare providers, community paramedics, and two INTERACT® tools (Stop and Watch for healthcare aides; Change in Condition Cards for nursing). Using a randomized stepped-wedge design, the pathway was implemented within 9 cohorts of (4-5) LTC facilities every 3 months, supported by an implementation coach. Three-hour train the trainer implementation sessions were conducted in-person or online with over 325 health practitioners in the enrolled LTC homes using strategies adapted to consider local context and barriers, as well as considering pandemic-related challenges. Evaluation Methods: Evaluation of the intervention involved both qualitative and quantitative methods. The primary study outcome is change in transfers from LTC to ED; secondary (quantitative) outcomes include hospital admissions, utilization of the centralized telephone advice and transfer system, and community paramedic visits. Analysis of these quantitative outcomes utilized negative binomial regression to estimate the incident rate with 95% confidence intervals (per 1000 residents), while adjusting for the different cohorts. The quantitative evaluation also included an economic analysis to determine potential cost savings. Interviews with healthcare providers were conducted to provide context to their experience with the intervention and ways it can be improved. These interviews will be interpreted with the involvement of members of our project resident and family advisory council. Results: Quantitative results demonstrate a reduction in the LTC-to-ED transfer rate [1.70 (95%CI 1.61-1.79) post-intervention) vs 1.91 (95%CI 1.84-2.00) pre-intervention], along with reduction in hospital admission rates [0.94 (95%CI 0.88-1.00) vs 1.08 (95%CI 1.03-1.14)]. There was an increase in utilization of the centralized telephone advice and transfer system [0.18 (95%CI 0.16-0.22) vs. 0.13 (95%CI 0.11-0.16)], but no increase in the number of community paramedic visits [2.05 (95%CI 1.94-2.16) vs 2.50 (95%CI 2.39-2.61)]. Cost and qualitative outcome data is pending. Advice and Lessons Learned: LTC staff education and use of early warning tools for identifying a change in resident health status (INTERACT® tools) and/or utilization of a centralized telephone advice and transfer system may have played a role in reducing ED transfers. We did not observe the expected relationship between community paramedic visits and reduced LTC-to-ED transfers, possibly as a result of the pandemic-related facility outbreak restrictions. Teams should tailor implementation sessions and materials to site specific needs and contexts to help address their unique barriers and facilitators. Partnerships with key stakeholders across the care continuum are essential to ensure adequate support and effective uptake and sustainability of the mutli-faceted change intervention.

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of “damage control”; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095).

Objective: To examine the association between rheumatologist access, early treatment, and ongoing care of older-onset rheumatoid arthritis (RA) and healthcare utilization and costs following diagnosis.Methods: We analyzed data from a population-based inception cohort of individuals aged > 65 years with RA in Ontario, Canada, diagnosed between 2002 and 2014 with follow-up to 2019. We assessed 4 performance measures in the first 4 years following diagnosis, including access to rheumatology care, yearly follow-up, timely treatment, and ongoing treatment with a disease-modifying antirheumatic drug. We examined annual healthcare utilization, mean direct healthcare costs, and whether the performance measures were associated with costs in year 5.Results: A total of 13,293 individuals met inclusion criteria. The mean age was 73.7 (SD 5.7) years and 68% were female. Total mean direct healthcare cost per individual increased annually and was CAD $13,929 in year 5. All 4 performance measures were met for 35% of individuals. In multivariable analyses, costs for not meeting access to rheumatology care and timely treatment performance measures were 20% (95% CI 8-32) and 6% (95% CI 1-12) higher, respectively, than where those measures were met. The main driver of cost savings among individuals meeting all 4 performance measures were from lower complex continuing care, home care, and long-term care costs, as well as fewer hospitalizations and emergency visits.Conclusion: Access to rheumatologists for RA diagnosis, timely treatment, and ongoing care are associated with lower total healthcare costs at 5 years. Investments in improving access to care may be associated with long-term health system savings.

Objective: To determine whether there were improvements in rheumatology care for rheumatoid arthritis (RA) between 2002 and 2019 in Ontario, Canada, and to evaluate the impact of rheumatologist regional supply on access. Methods: We conducted a population-based retrospective study of all individuals diagnosed with RA between January 1, 2002 and December 31, 2019. Performance measures evaluated were: (i) percentage of RA patients seen by a rheumatologist within one year of diagnosis; and (ii) percentage of individuals with RA aged 66 years and older (whose prescription drugs are publicly funded) dispensed a disease modifying anti-rheumatic drug (DMARD) within 30 days after initial rheumatologist visit. Logistic regression was used to assess whether performance improved over time and whether the improvements differed by rheumatology supply, dichotomized as < 1 rheumatologist per 75,000 adults versus ≥1 per 75,000. Results: Among 112,494 incident RA patients, 84% saw a rheumatologist within one year: The percentage increased over time (adjusted odds ratio (OR) 2019 vs. 2002 = 1.43, p < 0.0001) and was consistently higher in regions with higher rheumatologist supply (OR = 1.73, 95% CI 1.67–1.80). Among seniors who were seen by a rheumatologist within 1 year of their diagnosis the likelihood of timely DMARD treatment was lower among individuals residing in regions with higher rheumatologist supply (OR = 0.90 95% CI 0.83–0.97). These trends persisted after adjusting for other covariates. Conclusion: While access to rheumatologists and treatment improved over time, shortcomings remain, particularly for DMARD use. Patients residing in regions with higher rheumatology supply were more likely to access care but less likely to receive timely treatment.

Objective: To examine the association between lifetime lactation and risk and duration of frequent vasomotor symptoms (VMS).Design: Prospective cohort.Setting: USA, 1995–2008.Sample: 2356 parous midlife women in the Study of Women's Health Across the Nation.Methods: Lifetime lactation was defined as the duration of breastfeeding across all births in months. We used generalised estimating equations to analyse risk of frequent VMS and Cox regression to analyse duration of frequent VMS in years.Main outcome measures: Frequent VMS (hot flashes and night sweats) were measured annually for 10 years, defined as occurring ≥6 days in the past 2 weeks.Results: Overall, 57.1% of women reported hot flashes and 43.0% reported night sweats during follow‐up. Lifetime lactation was inversely associated with hot flashes plateauing at 12 months of breastfeeding (6 months: adjusted odds ratio [AOR] 0.85, 95% confidence interval (CI) 0.75–0.96; 12 months: AOR 0.78, 95% CI 0.65–0.93) and was inversely associated with night sweats in a downward linear fashion (6 months: AOR 0.93, 95% CI 0.81–1.08; 18 months: AOR 0.82, 95% CI 0.67–1.02; 30 months: AOR 0.73, 95% CI 0.56–0.97). Lifetime lactation was associated with shorter duration of hot flashes and night sweats in a quadratic (bell‐shaped) fashion. The association was strongest at 12–18 months of breastfeeding and significant for hot flashes (6 months: adjusted hazard ratio [AHR] 1.35, 95% CI 1.11–1.65; 18 months: AHR 1.54, 95% CI 1.16–2.03; 30 months: AHR 1.18, 95% CI 0.83–1.68).Conclusions: Longer lifetime lactation is associated with decreased risk and duration of frequent VMS.

Objective: The study objective was to assess adherence to system‐level performance measures measuring retention in rheumatology care and disease modifying anti‐rheumatic drug (DMARD) treatment in rheumatoid arthritis (RA).Methods: We used a validated health administrative data case definition to identify individuals with RA in Ontario, Canada, between 2002 and 2014 who had at least 5 years of potential follow‐up prior to 2019. During the first 5 years following diagnosis, we assessed whether patients were seen by a rheumatologist yearly and the proportion dispensed a DMARD yearly (in those aged ≥66 for whom medication data were available). Multivariable logistic regression analyses were used to estimate the odds of remaining under rheumatologist care.Results: The cohort included 50,883 patients with RA (26.1% aged 66 years and older). Over half (57.7%) saw a rheumatologist yearly in all 5 years of follow‐up. Sharp declines in the percentage of patients with an annual visit were observed in each subsequent year after diagnosis, although a linear trend to improved retention in rheumatology care was seen over the study period (P < 0.0001). For individuals aged 66 years or older (n = 13,293), 82.1% under rheumatologist care during all 5 years after diagnosis were dispensed a DMARD annually compared with 31.0% of those not retained under rheumatology care. Older age, male sex, lower socioeconomic status, higher comorbidity score, and having an older rheumatologist decreased the odds of remaining under rheumatology care.Conclusion: System‐level improvement initiatives should focus on maintaining ongoing access to rheumatology specialty care. Further investigation into causes of loss to rheumatology follow‐up is needed.