Moira Kapral

Moira Kapral
University of Toronto | U of T · Faculty of Medicine

About

366
Publications
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Publications

Publications (366)
Article
Full-text available
Background There is a paucity of the literature on the relationship between frailty and excess mortality due to the COVID-19 pandemic. Methods The entire community-dwelling adult population of Ontario, Canada, as of January 1st, 2018, was identified using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort. Residents of lo...
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Background : To evaluate the association between proportion of life spent in a host nation and stroke incidence and outcomes among Canadian immigrants. Methods : We conducted a retrospective cohort study of 1.2 million adult Canadian immigrants (mean age 40 [±14.6] years, 50.5% women) who were followed between 2003 and 2018 using linked administra...
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Background: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. Methods: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019,...
Article
Although medication adherence is commonly measured in electronic datasets using the proportion of days covered (PDC), no standardized approach is used to calculate and report this measure. We conducted a scoping review to understand the approaches taken to calculate and report the PDC for cardiovascular medicines to develop improved guidance for re...
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Background: The Passive Surveillance Stroke Severity (PaSSV) Indicator was derived to estimate stroke severity from variables in administrative datasets but has not been externally validated. Methods: We used linked administrative datasets to identify patients with first hospitalization for acute stroke between 2007-2018 in Alberta, Canada. We u...
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Introduction: Studies suggest associations between proton pump inhibitors (PPIs) and dementia risk; however, many neither considered histamine-2 receptor antagonists (H2RAs) nor baseline cognitive status. Methods: Participants (National Alzheimer's Coordinating Center Database; 2005-2021) using a PPI or H2RA were compared. Covariate-adjusted Cox...
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Introduction: Schizophrenia is associated with stroke incidence and case-fatality but the causes of this are not well-understood. We evaluated the association between comorbid schizophrenia and the quality of secondary prevention care after ischemic stroke. Methods: We used linked health administrative data to identify adults discharged alive from...
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Background: Cancer is an important yet understudied risk factor for ischemic stroke. We sought to examine the relationship between previous stroke and risk for future stroke in individuals newly diagnosed with cancer. Methods: Using a provincial administrative database, we conducted a population-based matched cohort study of adults in Ontario, Cana...
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Introduction: Telemedicine is increasingly used, but its effectiveness for stroke prevention after minor stroke or TIA is not known. We compared the care and outcomes in patients discharged from an emergency department (ED) with TIA or stroke before and after the implementation of telemedicine stroke prevention clinics in Ontario, Canada. We hypoth...
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Background and Purpose The use of intravenous thrombolysis is associated with improved clinical outcomes. Whether thrombolysis is associated with reduced incidence of poststroke dementia remains uncertain. We sought to estimate if the use of thrombolysis following first-ever ischemic stroke was associated with a reduced rate of incident dementia us...
Article
Studies suggest associations between proton pump inhibitors (PPI) and higher dementia risk compared with no use; however, several studies did not consider histamine‐2 receptor antagonists (H2RAs), the other common acid suppressant for similar indications. Comparisons between them are clinically relevant, both in older people with and without cognit...
Article
Background We evaluated whether immigration status modified the association between sex and the quality of primary cardiovascular disease prevention in Ontario, Canada. Methods and Results We used a population‐based administrative database‐derived cohort of community‐dwelling adults (aged ≥40 years) without prior cardiovascular disease residing in...
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Objectives To evaluate the association between immigration status and all-cause mortality in different disease cohorts, and the impact of loss to follow-up on the observed associations. Design Population-based retrospective cohort study using linked administrative health data in Ontario, Canada. Setting We followed adults with a first-ever diagno...
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Background It is not known if initial reductions in hospitalization for stroke and myocardial infarction early during the coronavirus disease–2019 pandemic were followed by subsequent increases. We describe the rates of emergency department visits for stroke and myocardial infarction through the pandemic phases. Methods We used linked administrati...
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Background Neurovascular imaging for patients with high-risk transient ischemic attack (TIA) or minor stroke in the emergency department (ED) with computed tomography angiography (CTA) of the head and neck is the guideline-recommended standard of care, but it is underutilized in routine practice. We conducted a quality initiative to improve adheren...
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Background Temporal trends in life‐sustaining care after acute stroke are not well characterized. We sought to determine contemporary trends by age and sex in the use of life‐sustaining care after acute ischemic stroke and intracerebral hemorrhage in a large, population‐based cohort. Methods and Results We used linked administrative data to identi...
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Propensity score-based analysis is increasingly being used in observational studies to estimate the effects of treatments, interventions, and exposures. We introduce the concept of the propensity score and how it can be used in observational research. We describe four different ways of using the propensity score: matching on the propensity score, i...
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Background: While individuals living in long-term care (LTC) homes have experienced adverse outcomes of SARS-CoV-2 infection, few studies that have examined a broad range of predictors of 30-day mortality in this population. Methods: We studied residents living in LTC homes in Ontario, Canada, who underwent PCR testing for SARS-CoV-2 infection f...
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Objective To determine the association between material deprivation and direct healthcare costs and clinical outcomes following stroke in the context of a publicly funded universal healthcare system. Methods In this population-based cohort study of patients with ischemic and hemorrhagic stroke admitted to hospital between 2008 and 2017 in Ontario,...
Article
Objective To evaluate the association between immigration status and stroke incidence. Methods We conducted a retrospective cohort study of 8 million adults (15% immigrants) residing in Ontario, Canada on January 1, 2003, with no history of prior stroke or transient ischemic attack (TIA). Subjects were followed until March 31, 2018 to identify inc...
Article
Background: The Nationwide Inpatient Sample Subarachnoid Hemorrhage (SAH) Severity Score (NIS-SSS) was developed as a measure of SAH severity for use in administrative databases. The NIS-SSS consists of International Classification of Diseases Ninth Revision (ICD-9) diagnostic and procedure codes derived from the SAH inpatient course and has been...
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Background Hometime, the total number of days a person is living in the community (not in a healthcare institution) in a defined period of time after a hospitalization, is a patient-centred outcome metric increasingly used in healthcare research. Hometime exhibits several properties which make its statistical analysis difficult: it has a highly non...
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Background The economic burden of stroke on the healthcare system has been previously described, but sex differences in healthcare costs have not been well characterized. We described the direct person-level healthcare cost in men and women as well as the various health settings in which costs were incurred following stroke. Methods In this popula...
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Background Schizophrenia is associated with an increased risk of death following stroke; however, the magnitude and underlying reasons for this are not well understood. Objective To determine the association between schizophrenia and stroke case fatality, adjusting for baseline characteristics, stroke severity and processes of care. Design Retros...
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Background To compare hazard ratios obtained by using time on study (conventional) vs. biological age as the time-scale in survival analyses for a known age-dependent association between an exposure and outcome. Methods We conducted a retrospective cohort study of 9 million people in Ontario, Canada who were followed from 2003 to 2018 to identify...
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Background Ninety-day hometime, the number of days a patient is living in the community in the first 90 after stroke, exhibits a non-normal bucket-shaped distribution, with lower and upper constraints making its analysis difficult. In this proof-of-concept study we evaluated the performance of random forests regression in the analysis of hometime....
Article
Background Diagnostic neurovascular imaging data are important in stroke research, but obtaining these data typically requires laborious manual chart reviews. Objective We aimed to determine the accuracy of a natural language processing (NLP) approach to extract information on the presence and location of vascular occlusions as well as other strok...
Article
Background We assessed secular trends in the burden of ischaemic heart disease (IHD), stroke, and dementia in the Organization for Economic Co-operation and Development (OECD) countries.Methods Using the Global Burden of Disease (GBD) Study 2017, we compared sex-specific and age-standardized rates of disability-adjusted life years (DALY); mortality...
Article
Objective To determine contemporary trends in case fatality, discharge destination, and admission to long-term care after acute ischemic stroke and intracerebral hemorrhage (ICH) using a large, population-based cohort. Methods We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever isch...
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Introduction: Reductions in hospital visits for stroke during the COVID19 pandemic have been reported, but few have studied this question on a population-basis and less is understood about the temporal trends after economic and social reopening. We aimed to describe the rate of emergency department visits for acute stroke before and after the decla...
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Sex differences exist in the epidemiology, care, and outcomes of stroke. This article highlights recent advances in our understanding of sex and gender differences in the benefits of endovascular therapy, outcomes after stroke and transient neurological events, and the potential to prevent stroke in women with a history of hypertensive disorders of...
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Background and purpose: We evaluated the influence of age on the association between sex and the incidence of stroke or transient ischemic attack (TIA) using a population-based cohort from Ontario, Canada. Methods: We followed a cohort of adults (≥18 years) without prior stroke from January 1, 2003 (cohort start date) to March 31, 2018, to ident...
Article
This longitudinal study was designed to evaluate the association between acute prestroke stress and the severity stroke and its outcomes including mortality, recurrence, disability and functional dependency. Patients with first‐ever stroke (FES) were recruited from the Mashhad Stroke Incidence Study. Patients were asked about any acute severe prest...
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Objective To assess the association between immigration status and ethnicity and the outcomes of mortality and vascular event recurrence following ischemic stroke in Ontario, Canada. Methods We conducted a retrospective cohort study using linked administrative and clinical registry-based data from 2002 to 2018 and compared hazards of all-cause mor...
Article
There is increased recognition that diabetes can elevate Alzheimer’s disease (AD) risk and exacerbate memory decline. However, few studies have compared memory decline among patients with diabetes using different oral hypoglycemic drug classes. Participants using any hypoglycemic medications from 2005 to 2019 were identified from the National Alzhe...
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Background Provider profiling involves comparing the performance of hospitals on indicators of quality of care. Typically, provider profiling examines the performance of hospitals on each quality indicator in isolation. Consequently, one cannot formally examine whether hospitals that have poor performance on one indicator also have poor performance...
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Objective Few data are available on the associations between the level of pre-stroke physical activity and long-term outcomes in patients with stroke. This study is designed to assess the associations between pre-stroke physical activity and age of first-ever stroke occurrence and long-term outcomes.Methods Six hundred twenty-four cases with first-...
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Background Contemporary data on temporal trends in acute stroke incidence, specific to stroke type and age, are lacking. We sought to evaluate temporal trends in incidence of ischemic stroke and intracerebral hemorrhage over 15 years in a large population. Methods We used linked administrative data to identify all emergency department visits and h...
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Background and Purpose Many patients with ischemic stroke present with multiple comorbidities that threaten survival and recovery. This study sought to determine the risks of adverse long-term stroke outcomes associated with multimorbid diabetes mellitus and depression. Methods Retrospective analysis of prospectively collected data on consecutive...
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Background The incidence of ischemic stroke has increased among adults aged 18 to 64 years, yet little is known about relationships between specific risk factors and outcomes. This study investigates in‐hospital and long‐term outcomes in patients with stroke aged <65 years with preexisting diabetes mellitus. Methods and Results Consecutive patient...
Preprint
BACKGROUND Diagnostic neurovascular imaging data are important in stroke research, but obtaining these data typically requires laborious manual chart reviews. OBJECTIVE We aimed to determine the accuracy of a natural language processing (NLP) approach to extract information on the presence and location of vascular occlusions as well as other strok...
Article
Background: Loneliness is common in older adults, and it is associated with unhealthy behaviours, including substance use. We evaluated the association between loneliness and self-reported use of opioids and benzodiazepines in older adults. Methods: We used data from the Canadian Community Health Survey's 'Healthy Aging' sub-survey and included...
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Background and Purpose The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some count...
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Background and Purpose— We aimed to create a novel prognostic risk score to estimate outcomes after direct enteral tube placement in acute stroke. Methods— We used the Ontario Stroke Registry and linked databases to obtain clinical information on all patients with direct enteral tube insertion after ischemic stroke or intracerebral hemorrhage from...
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Background and Purpose— Immigrants to high-income countries have a lower incidence of stroke compared with long-term residents; however, little is known about the care and outcomes of stroke in immigrants. Methods— We used linked clinical and administrative data to conduct a retrospective cohort study of adults seen in the emergency department or...
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Background Adjusting for stroke severity is crucial for stroke outcomes research. However, this information is not available in administrative healthcare data. We aimed to derive an indicator of baseline stroke severity using these data. Methods and Results We identified patients with stroke enrolled in a population-based registry in Ontario, Cana...
Article
Background: Comorbid diabetes and depression are highly prevalent in atrial fibrillation (AF) and increase the risk of stroke. Women with AF show higher mortality rates and have worse functional outcomes post-stroke. However, the sex-specific effects of comorbid diabetes and depression on mortality and other adverse outcomes in stroke patients with...
Article
Background Women are more likely to be admitted to nursing home after stroke than men. Differences in patient characteristics and outcomes by sex after institutionalization are less understood. We examined sex differences in the characteristics and care needs of patients admitted to nursing home following stroke and their subsequent survival. Meth...
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Background: Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. Methods: We used the O...
Article
Background: First Nations people have high rates of diabetes mellitus, which is a risk factor for stroke. We studied the rates of hospital admission, processes of care and outcomes of stroke and transient ischemic attack (TIA) in First Nations people in Ontario. Methods: Using linked administrative databases, we identified annual cohorts of peop...
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Full-text available
Objective Home-time is an emerging patient-centred stroke outcome metric, but it is not well described in the population. We aimed to determine the association between 90-day home-time and global disability after stroke. We hypothesised that longer home-time would be associated with less disability. Design Hospital-based cohort study of patients w...
Article
Background: Stroke survivors have higher unmet health care needs than the general population. However, it is unclear whether such needs have changed over time, and whether these have been affected by the introduction of integrated systems of stroke care. Methods: We used data from the Canadian Community Health Surveys between 2000 and 2014. We d...
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Background and aim Atrial fibrillation is associated with increased risk of ischemic stroke and its global prevalence is increasing. We aimed to describe the contemporary temporal trends in hospital admissions, case fatality rate, as well as sex differences in atrial fibrillation-related stroke in Canada. Methods We conducted a retrospective cohor...
Article
Background and Purpose— Intravenous thrombolysis with r-tPA (recombinant tissue-type plasminogen activator) is associated with improved early functional outcome after stroke, but its long-term effects are less understood. We aimed to determine the association between r-tPA and 1-year outcomes after stroke. Methods— We used the Ontario Stroke Regis...
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Background: Integrated stroke systems have been associated with reduced disability in stroke survivors, but their impact on employability and productivity (hours worked/week and hourly wages) of stroke survivors is unclear. Methods: We used Canadian Community Health Surveys (2000-2014) to conduct a quasi-experimental study with the aim of determ...
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Background: Direct enteral feeding tube (DET) placement for dysphagia after stroke is associated with poor outcomes. However, the relationship between timing of DET placement and poststroke mortality and disability is unknown. We sought to determine the risk of mortality and severe disability in patients who receive DET at different times after st...
Article
Importance The risk for low-trauma fracture is increased by more than 30% after ischemic stroke, but existing fracture risk scores do not account for history of stroke as a high-risk condition. Objective To derive a risk score to predict the probability of fracture within 1 year after ischemic stroke and validate it in a separate cohort. Design,...
Article
Background and Purpose— Stroke is a risk factor for subsequent osteoporosis and fractures. We sought to understand current rates and predictors of screening and treatment for bone loss after stroke. Methods— Using the Ontario Stroke Registry from July 1, 2003 to March 31, 2013, we identified patients ≥65 years who were seen in the emergency depart...
Article
Background: Little is known about the association between socioeconomic status and long-term stroke outcomes, particularly in low- and middle-income countries. Methods: Patients were recruited from the Mashhad Stroke Incidence Study in Iran. We identified different socioeconomic variables including the level of education, occupation, household s...
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Background: Increasing data demonstrate a gender gap in career progression in neurology including underrepresentation of women in high impact neurology journal authorship and American Academy of Neurology recognition awards. We examined gender differences in leadership roles at the International Stroke Conference (ISC) from 2014-2018. Methods: As a...
Article
Introduction: Thrombolysis with tissue plasminogen activator (tPA) is associated with better functional outcomes after acute ischemic stroke, but its effect on survival is uncertain. We studied the association between tPA and long-term mortality in a large population-based cohort, and compared the causes of death in those who did and did not receiv...
Article
Objective: The 90-day home-time (90HT) indicator is a patient-centered outcome metric that is correlated with global disability after ischemic stroke (IS), but has not been well-characterized after intracerebral hemorrhage (ICH). 90HT is defined as the total number of days a patient is living outside of a healthcare institution in the first 90 days...
Article
Background Rural residence is associated with stroke incidence and mortality, but little is known about potential rural/urban differences in ambulatory stroke care. Methods and Results We used the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort, created from linked administrative databases from the province of Ontario, Can...
Article
Rationale: Stroke etiology and risk factors vary by age, sex, setting (hospital or community-based) and by region. Identifying these differences would improve our understanding of stroke etiology, diagnosis, and treatment. Aim: The Age, Sex and Setting in the Etiology of Stroke Study (ASSESS) is a multicenter cohort study to assess differences i...
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Background Approximately 8% to 21% of strokes affect adults aged <45 years. Although early stroke recurrence conveys the largest risk, long‐term risks for young survivors with no early complications are unclear. Methods and Results Longitudinal matched case‐control study (2003–2013). Consecutive patients with ischemic stroke or transient ischemic...
Article
Background: Reported incidence rates of pediatric stroke and transient ischemic attack (TIA) range widely. Treatment gaps are poorly characterized. We sought to evaluate in -Ontario, the incidence and characteristics of pediatric stroke and TIA including care gaps and the predictive value of International Classification of Diseases (ICD) codes. M...
Article
Background and Purpose— We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events. Methods— We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) bet...
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Among those aged 80 years and older in Ontario, Canada, stroke and dementia incidence declined concomitantly from 2002-03 to 2013-14. This study aimed to report the concurrent temporal trends of stroke and dementia prevalence in Ontario among the same age demographic. The prevalence of both stroke and dementia increased from 2003-04 to 2012-13 in b...
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Early identification of dysphagia by screening is recommended best practice for patients admitted to hospital with acute stroke. Screening can reduce the risk of pneumonia and promote stroke recovery, yet some institutions do not utilize a formal screening protocol. This study assessed the accuracy of informal dysphagia detection prior to implement...
Article
Objective To determine predictors of direct enteral tube (DET) placement after acute stroke. Methods We used the Ontario Stroke Registry to identify patients who received direct enteral tubes (gastrostomy or jejunostomy) during hospital stay after acute ischemic stroke or intracerebral hemorrhage from July 1, 2003 to March 31, 2013. We used multiv...
Article
Background: Accurate information about disability rate after stroke remains largely unclear in many countries. Population-based studies are necessary to estimate the rate and determinants of disability after stroke. Methods: Patients were recruited from the Mashhad Stroke Incidence Study and followed for five years after their index event. Disab...
Article
Background: The relationship between timing of direct enteral feeding tube (DET; gastrostomy/jejunostomy) placement and outcomes after stroke is unknown. Methods: We used the Ontario Stroke Registry and linked administrative databases to identify patients with acute stroke between 2003-2013 who received DET during hospital admission. We used multip...