Many of these countries have a nationwide surveillance or a nationally coordinated system to manage patients with out-of-hospital emergencies. In these contexts, it is possible that quality improvement initiatives could be designed and translated more effectively, leading to improved survival for OHCA patients. It remains unclear whether findings from these studies are applicable in North America, where emergency medical services are organized by smaller jurisdictions and patients are managed by hundreds of destination hospitals. 2 In Ontario, for example, the population of 13.8 million is served by 53 individual land-based emergency medical service providers, with ≈280 destination hospitals providing postarrest care. 8 Population-level surveillance studies are critical to inform policy and evaluate current systems of care.Background-Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and poses a significant burden to the healthcare system, but few studies have evaluated whether OHCA incidence and survival have changed over time. Methods and Results-A population-based cohort study was conducted, including 34 291 OHCA patients >20 years of age who were transported alive to the emergency department of an acute-care hospital from April 1, 2002, to March 31, 2012 Patients with life-threatening trauma and those who died before hospital arrival were excluded. The overall age-and sex-standardized incidence of OHCA patients who were transported alive was 36 cases per 100 000 persons and did not significantly change over the study period. Cardiac risk factor prevalence increased significantly, whereas the rate of most cardiovascular conditions decreased significantly. The 30-day survival improved from 9.4% in 2002 to 13.6% in 2011; 1-year survival improved from 7.7% to 11.8% (P<0.001). Patients hospitalized in 2011 were significantly more likely to survive 30 days (adjusted odds ratio, 1.47 [95% CI, 1.22-1.77]) and 1 year (adjusted odds ratio, 1.55 [95% CI, 1.27-1.91]) compared with 2002. A significant interaction between temporal trends in survival improvement and age group was observed in which the improvement in survival was largest in the youngest age groups. Conclusions-OHCA patients who were transported alive are increasingly likely to have cardiovascular risk factors but less likely to have previous cardiovascular conditions. The overall incidence of OHCA patients transported to hospital alive did not change over the past decade. Short-and longer-term survival after OHCA has substantially improved, with younger patients experiencing the greatest improvement. Accordingly, the main objective of this study was to evaluate recent trends in the patient characteristics, incidence, and the survival of patients after OHCA. Methods Data SourcesOur analytic data sets were created by linking together multiple large administrative databases in Ontario using unique encrypted patient identification numbers to protect patient confidentiality. The Canadian Institute of Health Information Discharge Abstract...

The purpose of this study was to describe (1) the aggressiveness of care in a population of patients who die of lung cancer and (2) differences in care between a sample of lung cancer patients who died in an acute care hospital (DH) and a sample of lung cancer patients who were admitted to hospital during the last six months of life but were discharged and died elsewhere (DO). All lung cancer deaths in 2002 were identified in the provincial registry. Cases were linked to administrative sources of health care data to describe the population as a whole and the aggressiveness of the care that they received. Primary data were collected from a province-wide sample of patients' hospital charts focusing on reasons for admission, care in hospital, advanced planning, pain, and disposition. In total, 5,855 patients who died of lung cancer in 2002 were eligible for inclusion in the cohort. Rates of in-hospital death, emergency room visits, intensive care unit admissions, and chemotherapy use near the end of life were 59.5%, 32.2%, 5.5%, and 4.6%, respectively. The records of 491 patients were abstracted for this study. The DH and DO groups were similar with respect to age, gender, neighborhood income level, and extent of metastatic disease. The most common chief complaints were shortness of breath, pain, inability to cope at home, and altered level of consciousness. Compared to patients in the DO group, those in the DH group presented with pain more often (19% vs. 10%, P<0.005) and were more likely to be admitted with progressive chest malignancy (30% vs. 21%, P<0.05). Regardless of reason for admission, pain was commonly documented as a problem during admission: 73.5% in the DH group and 62.4% in the DO group (P<0.05). Lung cancer patients are heavy users of acute care beds and the emergency room at the end of life. Those who do or do not die in hospital are similar in many respects but our results suggest those dying in hospital have more problems with pain and burden from local chest malignancy.

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Background Rapid growth in transcatheter aortic valve replacement ( TAVR ) demand has translated to inadequate access, reflected by prolonged wait times. Increasing wait times are associated with important adverse outcomes while on the wait‐list; however, it is unknown if prolonged wait times influence postprocedural outcomes. Our objective was to determine the association between TAVR wait times and postprocedural outcomes. Methods and Results In this population‐based study in Ontario, Canada, we identified all TAVR procedures between April 1, 2010, and March 31, 2016. Wait time was defined as the number of days between initial referral and the procedure. Primary outcomes of interest were 30‐day all‐cause mortality and all‐cause readmission. Multivariable regression models incorporated wait time as a nonlinear variable, using cubic splines. The study cohort included 2170 TAVR procedures, of which 1741 cases were elective and 429 were urgent. There was a significant, nonlinear relationship between TAVR wait time and post‐ TAVR 30‐day mortality, as well as 30‐day readmission. We observed an increased hazard associated with shorter wait times that diminished as wait times increased. This statistically significant nonlinear relationship was seen in the unadjusted model as well as after adjusting for clinical variables. However, after adjusting for case urgency status, there was no relationship between wait times and postprocedural outcomes. In sensitivity analyses restricted to either only elective or only urgent cases, there was no relationship between wait times and postprocedural outcomes. Conclusions Wait time has a complex relationship with postprocedural outcomes that is mediated entirely by urgency status. This suggests that further research should elucidate factors that predict hospitalization requiring urgent TAVR while on the wait list.

BackgroundWomen hospitalized with a non‐ST segment elevation acute coronary syndrome (ACS) have worse clinical outcomes compared with men. An early invasive strategy with prompt coronary revascularization may mitigate sex differences in outcomes. However, few contemporary studies have evaluated whether clinical outcomes differ between women and men presenting with ACS treated with an early invasive strategy.Methods and ResultsA population‐based cohort of hospitalized ACS patients who received prompt cardiac catheterization from 2008 to 2011 in Ontario, Canada and followed for up to 2 years was studied. Clinical outcomes were compared between men and women, stratified by the use of coronary revascularization. Inverse probability weighting using the propensity score accounted for measured differences in baseline characteristics between men and women. Among the 23 473 ACS patients who received cardiac catheterization during an index hospitalization, 66.1% of men and 51.8% of women received coronary revascularization during the same hospitalization. In the propensity‐weighted cohort of patients who received coronary revascularization, the 1‐year rate of death or recurrent ACS was 10.6% for men (referent) compared with 13.1% for women (hazard ratio 1.24; 95% CI 1.16–1.33). In contrast, outcomes for patients who did not receive coronary revascularization did not differ significantly between women and men at 1 year (17.8% versus 16.9%; hazard ratio 1.06; 95% CI 0.99–1.14) or at longer follow‐up.ConclusionsAn increased risk of adverse clinical outcomes was observed for women with ACS undergoing an early invasive strategy and coronary revascularization compared with men.

Key Points Question What are the clinical and economic outcomes in patients who required permanent pacemaker implantation after transcatheter aortic valve replacement ? Findings In this population-based cohort study of 1263 patients who underwent transcatheter aortic valve replacement, implantation of a new permanent pacemaker was associated with significantly greater all-cause mortality, all-cause readmission, and all-cause emergency department visits. However, this did not translate to a statistically significant difference in cumulative postdischarge health care costs. Meaning The need for permanent pacemaker implantation after transcatheter aortic valve replacement is a complication associated with worse survival as well as increased risk of hospitalization.

Strikingly higher rates of papillary thyroid cancer in women compared with men suggest that hormonal factors may be involved in the development of this cancer. A number of independent studies have investigated the association between hormonal factors and papillary thyroid cancer risk in women but yielded conflicting and inconclusive findings. We performed a meta-analysis of all currently published studies to provide better estimates for the risk of papillary thyroid cancer related to menstrual, reproductive, and other hormonal factors in women. Six cohort studies and three case-control ones were included into our study after a comprehensive literature search. The pooled relative risk (RR) with 95 % confidence interval (95 % CI) implicated that late age at menopause was associated with an increased risk of papillary thyroid cancer (RR = 1.39, 95 % CI 1.03-1.89, P = 0.032). No significant association was demonstrated between papillary thyroid cancer risk and other hormone-related factors, including oral contraceptive, hormone replacement therapy, age at menarche, parity, age at first birth, menopausal status, and breast feeding. Subgroup analysis by study design confirmed those associations. Sensitivity analysis did not materially alter the pooled results. The meta-analysis firstly suggests that late age at menopause is a risk factor for papillary thyroid cancer.