A Qualitative Study of Nursing Home Staff Lived Experience With Advance Care Planning

OBJECTIVE

Advance care planning (ACP) within nursing homes (NHs) is an integral component of resident-centered care yet remains an ongoing area for improvement. This study explored health care providers' experiences when facilitating ACP discussions with residents and their families.

DESIGN

Interpretive description was used to explore meanings and generate knowledge that is applicable for clinical contexts.

SETTING AND PARTICIPANTS

A purposive sample of 27 staff members (2 directors of care, 3 assistant directors of care, 1 nurse practitioner, 11 registered nurses, 3 registered practical nurses, and 7 social workers) from 29 NHs located across 3 Canadian provinces that participated in cluster-randomized intervention study to improve ACP.

METHODS

Semistructured interviews were conducted between January and July 2020. Interpretive description methods were used for analysis.

RESULTS

Three themes were identified. "Navigating Relational Tensions During ACP with Families" captures the relational tensions that participants experienced while navigating ACP processes with residents and their families. The second theme, "Where's the Doctor?" highlights the general lack of physician involvement in ACP discussions and the subsequent pressures faced by participants when supporting residents and families. The last theme, "Crises Change the Best Laid Plans," illustrates the challenges participants face when trying to adhere to existing care plans during residents' medical crises.

CONCLUSION AND IMPLICATIONS

Participants' experiences indicate that current ACP processes in NHs do not meet the needs of residents, families, or care teams. Additional support from physicians and changes to structural processes are needed to support resident-centered end-of-life planning within this care context.

BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial

Background

Nursing home (NH) residents should have the opportunity to consider, discuss and document their healthcare wishes. However, such advance care planning (ACP) is frequently suboptimal.

Objective

Assess a comprehensive, person-centred ACP approach.

Design

Unblinded, cluster randomised trial.

Setting

Fourteen control and 15 intervention NHs in three Canadian provinces, 2018–2020.

Subjects

713 residents (442 control, 271 intervention) aged ≥65 years, with elevated mortality risk.

Methods

The intervention was a structured, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$\sim$\end{document}60-min discussion between a resident, substitute decision-maker (SDM) and nursing home staff to: (i) confirm SDMs’ identities and role; (ii) prepare SDMs for medical emergencies; (iii) explain residents’ clinical condition and prognosis; (iv) ascertain residents’ preferred philosophy to guide decision-making and (v) identify residents’ preferred options for specific medical emergencies. Control NHs continued their usual ACP processes. Co-primary outcomes were: (a) comprehensiveness of advance care planning, assessed using the Audit of Advance Care Planning, and (b) Comfort Assessment in Dying. Ten secondary outcomes were assessed. P-values were adjusted for all 12 outcomes using the false discovery rate method.

Results

The intervention resulted in 5.21-fold higher odds of respondents rating ACP comprehensiveness as being better (95% confidence interval [CI] 3.53, 7.61). Comfort in dying did not differ (difference = −0.61; 95% CI −2.2, 1.0). Among the secondary outcomes, antimicrobial use was significantly lower in intervention homes (rate ratio = 0.79, 95% CI 0.66, 0.94).

Conclusions

Superior comprehensiveness of the BABEL approach to ACP underscores the importance of allowing adequate time to address all important aspects of ACP and may reduce unwanted interventions towards the end of life.

Improving detection of work-related asthma: a review of gaps in awareness, reporting and knowledge translation

Background

Work-related asthma (WRA) accounts for up to 25% of all adults with asthma. Early diagnosis is key for optimal management as delays in diagnosis are associated with worse outcomes. However, WRA is significantly underreported and the median time to diagnosis is 4 years. The objective of this review is to identify the gaps in awareness and reporting of WRA and identify gaps in current knowledge translation strategies for chronic disease in general, and asthma specifically. This will identify reasons for delays in WRA diagnosis, as well inform suggestions to improve knowledge translation strategies for dissemination and implementation of WRA prevention and management guidelines.

Methods

Non-systematic literature reviews were conducted on PubMed with a focus on work-related asthma screening and diagnosis, and knowledge translation or translational medicine research in asthma and chronic disease. In total, 3571 titles and abstracts were reviewed with no restriction on date published. Of those, 207 were relevant and fully read. Another 37 articles were included and reviewed after citation reviews of articles from the initial search and from suggestions from editors. In total, 63 articles were included in the final review.

Results

Patients, employers, and healthcare professionals lack awareness and under-report WRA which contribute to the delayed diagnosis of WRA, primarily through lack of education, stigma associated with WRA, and lack of awareness and screening in primary care. Knowledge translation strategies for asthma research typically involve the creation of guidelines for diagnosis of the disease, asthma care plans and tools for education and management. While there are some prevention programs in place for certain industries, gaps in knowledge translation strategies including lack of screening tools currently available for WRA, poor education of employers and physicians in identifying WRA, and education of patients is often done post-diagnosis and focuses on management rather than prevention or screening.

Conclusion

Future knowledge translation strategies should focus on educating employees and employers well before potential exposure to agents associated with WRA and screening for WRA in primary care to enable health care providers to recognize and diagnose WRA.

Reliability and normative values of the Wheelchair Propulsion Test: A preliminary investigation

BACKGROUND

Normative data for the equivalent of gait speed via the Wheelchair Propulsion Test (WPT) do not exist for wheelchair users.

OBJECTIVE

The purposes of the current study were to: 1) determine the reliability of the WPT, 2) propose and compare normative values for the WPT for young adult males and females utilizing three different propulsion techniques, and 3) compare how different wheelchair types affect performance on the WPT.

METHODS

50 young adults (25 of each sex) performed the WPT using three different propulsion techniques in three different types of wheelchairs. Participants were asked to propel a wheelchair over 10 m at a comfortable speed. Time and number of pushes were recorded for three trials for each propulsion technique in each type of wheelchair.

RESULTS

All of the ICC(2,2) values were >0.83 for speed and number of pushes. Normative values for speed, number of pushes, push frequency and effectiveness categorized by propulsion technique, sex and wheelchair type were developed.

CONCLUSIONS

Preliminary normative values have been established for young adults performing the WPT. This study highlights the need to maintain consistency of the wheelchair type and propulsion technique between trials in order for the WPT to be reliable.

Examining mechanisms for gender differences in admission to intensive care units

OBJECTIVE

To evaluate whether the male predominance of older people admitted to intensive care units (ICUs) is due to gender differences in the presence of spouses, partners, or children; rates of gender-specific disease; or triage decisions made by health system personnel.

DATA SOURCES AND COLLECTION

Three population-based datasets, 2004-2012, of Canadians ≥65 years: provincial health care data from Manitoba (n = 250 190) and national data of nursing home residents (n = 133 982) and community-based homecare recipients (n = 210 090).

STUDY DESIGN

Retrospective observational study, using multivariable Cox proportional hazards and logistic regression.

PRINCIPAL FINDINGS

Males predominated in ICU admissions: from Manitoba (hazard ratio [HR] = 1.87, 95% CI = 1.80-1.95), nursing homes (HR = 1.47, 1.35-1.60), and homecare (odds ratio = 1.14, 1.11-1.17). Adjustment for spouses, partners, and children did not attenuate this effect. The HR for gender was lower by 13.5 percent, relative, after excluding ICU care for cardiac causes. Male predominance was not present during a second ICU admission among survivors of a first ICU-containing hospitalization (HR = 1.07, 0.96-1.20).

CONCLUSIONS

In three older cohorts, the male predominance of ICU admission was not explained by gender differences in the presence of a spouse, partner, or children, or cardiac disease rates. The third finding suggests that triage bias is unlikely to be responsible for the male predominance.

A functional macrophage migration inhibitory factor promoter polymorphism is associated with reduced diffusing capacity

Cigarette smoke exposure is the leading modifiable risk factor for chronic obstructive pulmonary disease (COPD); however, the clinical and pathologic consequences of chronic cigarette smoke exposure are variable among smokers. Macrophage migration inhibitory factor (MIF) is a pleiotropic cytokine implicated in the pathogenesis of COPD. Within the promoter of the MIF gene is a functional polymorphism that regulates MIF expression (-794 CATT_5-8 microsatellite repeat) ( rs5844572 ). The role of this polymorphim in mediating disease susceptibility to COPD-related traits remains unknown. We performed a cross-sectional analysis of DNA samples from 641 subjects to analyze MIF-794 CATT_5-8 ( rs5844572 ) polymorphism by standard methods. We generated multivariable logistic regression models to determine the risk of low expressing MIF alleles for airflow obstruction [defined by forced expiratory volume in 1 s (FEV₁)/forced vital capacity ratio <0.70] and an abnormal diffusion capacity [defined by a diffusion capacity for carbon monoxide (DL_CO) percent predicted <80%]. We then used generalized linear models to determine the association of MIF genotypes with FEV₁ percent predicted and DL_CO percent predicted. The MIF-794 CATT₅ allele was associated with an abnormal diffusion capacity in two cohorts [odds ratio (OR): 9.31, 95% confidence interval (CI): 1.97-4.06; and OR: 2.21, 95% CI: 1.03-4.75]. Similarly, the MIF-794 CATT₅ allele was associated with a reduced DL_CO percentage predicted in these two cohorts: 63.5 vs. 70.0 ( P = 0.0023) and 60.1 vs. 65.4 ( P = 0.059). This study suggests an association between a common genetic polymorphism of an endogenous innate immune gene, MIF, with reduced DL_CO, an important measurement of COPD severity.

Wheeze trajectories are modifiable through early-life intervention and predict asthma in adolescence

BACKGROUND

The objectives of this study were to identify developmental trajectories of wheezing using data-driven methodology, and to examine whether trajectory membership differentially impacts the effectiveness of primary preventive efforts that target modifiable asthma risk factors.

METHODS

Secondary analysis of the Canadian Asthma Primary Prevention Study (CAPPS), a multifaceted prenatal intervention among children at high risk of asthma, followed from birth to 15 years. Wheezing trajectories were identified by latent class growth analysis. Predictors, intervention effects, and asthma diagnoses were examined between and within trajectory groups.

RESULTS

Among 525 children, 3 wheeze trajectory groups were identified: Low-Progressive (365, 69%), Early-Transient (52, 10%), and Early-Persistent (108, 21%). The study intervention was associated with lower odds of Early-Transient and Early-Persistent wheezing (P < .01). Other predictors of wheeze trajectories included, maternal asthma, maternal education, city of residence, breastfeeding, household pets, infant sex and atopy at 12 months. The odds of an asthma diagnosis were three-fold to six-fold higher in the Early-Persistent vs Low-Progressive group at all follow-up assessments (P = .03), whereas Early-Transient wheezing (limited to the first year) was not associated with asthma. In the Early-Persistent group, the odds of wheezing were lower among intervention than control children (adjusted odds ratio: 0.67; 95% CI: 0.48; 0.93) at 7 years.

CONCLUSIONS

Using data-driven methodology, children can be classified into clinically meaningful wheeze trajectory groups that appear to be programmed by modifiable and non-modifiable factors, and are useful for predicting asthma risk. Early-life interventions can alter some wheeze trajectories (ie, Early-Persistent) in infancy and reduce wheezing prevalence in mid-childhood.

51 OPTIMIZATION OF VITRIFICATION PARAMETERS FOR RHESUS MACAQUE BLASTOCYSTS

The cryobiological characteristics of rhesus macaque embryos are not well defined, and only a few studies report limited success rates after recovery from slow-freezing cryopreservation. Vitrification is the method currently in use by many infertility clinics with 85 to 96% embryos surviving post-thaw. However, success of thawing rhesus macaque embryos after vitrification is not well documented. Therefore, multiple vitrification parameters were evaluated on rhesus expanded blastocysts by comparing culture medium, vitrification method, and embryo integrity. Embryos (n = 204) were produced by standard IVF and cultured in either Global (single-step; LifeGlobal Group, Guilford, CT, USA) or Quinns Advantage (sequential; SAGE, Trumbull, CT, USA) in a humidified tri-gas mixture (6% CO2, 5% O2, 89% N2) at 37°C until blastocyst expansion was observed after 7 to 9 days of culture. Embryos were then vitrified in straws using the Global Fast Freeze Vitrification protocol or in cryotops using the Kitazato method (VT 601-Top-Kitazato, Japan). Additional embryos were biopsied with an objective-mounted laser to remove ~10 to 20 trophectoderm cells before vitrification with Global Fast Freeze in straws. Embryos were thawed at 30°C and cultured at 37°C for an additional 48 h or until arrested. Morphology was graded as good (re-expanded), poor (shrunken cytoplasm), or lysed, following thaw, and success of good or hatched embryos was analysed by Fisher’s exact test with P < 0.05. Because our goal was to provide good quality embryos for embryo transfer, the ability to hatch was our standard for determining success. There was no significant difference in embryo quality between culture medium, vitrification method, or embryo integrity. Overall, 90% of the embryos were scored as morphologically good regardless of culture medium based on re-expansion post-thaw <24 h (55/61) but had a relatively low hatching rate of 25% (15/61), demonstrating that not all re-expanded embryos will go on to achieve the hatched state. Initial trials vitrifying with the Global protocol were associated with decreased recovery rates as many embryos were lost. Cryotops were able to increase our recovery rate to 100% (n = 22) but with only 5% surviving post-thaw (1/22). Decreasing the amount of media used to recover embryos from straws enabled a re-evaluation of the cryotop technique with an improved recovery of 92% (60/65). Biopsied embryos tended to have a higher hatch rate (48%; 10/21) compared with intact embryos frozen at the same stage (26%; 9/35). The trophectoderm biopsy likely allows for better permeation of the cryoprotectant before vitrification in embryos due to a collapsed blastocoel. Taken together, these data suggest that vitrification is a viable method of preserving embryos of genetic value and those that undergo manipulation, including trophectoderm.

Vitamin D, serum 25(OH)D, LL-37 and polymorphisms in a Canadian First Nation population with endemic tuberculosis

BACKGROUND

Canadian First Nation populations have experienced endemic and epidemic tuberculosis (TB) for decades. Vitamin D-mediated induction of the host defence peptide LL-37 is known to enhance control of pathogens such as Mycobacterium tuberculosis.

OBJECTIVE

Evaluate associations between serum levels of 25-hydroxy vitamin D (25(OH)D) and LL-37, in adult Dene First Nation participants (N = 34) and assess correlations with single nucleotide polymorphisms (SNPs) in the vitamin D receptor (VDR) and vitamin D binding protein (VDBP).

DESIGN

Venous blood was collected from all participants at baseline (winter and summer) and in conjunction with taking vitamin D supplements (1,000 IU/day) (winter and summer). Samples were analysed using ELISA for concentrations of vitamin D and LL-37, and SNPs in the VDR and VDBP regions were genotyped.

RESULTS

Circulating levels of 25(OH)D were not altered by vitamin D supplementation, but LL-37 levels were significantly decreased. VDBP and VDR SNPs did not correlate with serum concentrations of 25(OH)D, but LL-37 levels significantly decreased in individuals with VDBP D432E T/G and T/T, and with VDR SNP Bsm1 T/T genotypes.

CONCLUSIONS

Our findings suggest that vitamin D supplementation may not be beneficial as an intervention to boost innate immune resistance to M. tuberculosis in the Dene population.

Surge capacity: analysis of census fluctuations to estimate the number of intensive care unit beds needed

OBJECTIVE

To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed.

STUDY SETTING

Three geographic regions in the Canadian province of Manitoba.

STUDY DESIGN

Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007.

METHODS

We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals.

PRINCIPAL FINDINGS

Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25-58 percent; (2) 4-29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13-36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds.

CONCLUSIONS

Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate "surge capacity" can lead to demand that frequently and severely exceeds supply.

Genome-wide association study of the age of onset of childhood asthma

BACKGROUND

Childhood asthma is a complex disease with known heritability and phenotypic diversity. Although an earlier onset has been associated with more severe disease, there has been no genome-wide association study of the age of onset of asthma in children.

OBJECTIVE

We sought to identify genetic variants associated with earlier onset of childhood asthma.

METHODS

We conducted the first genome-wide association study of the age of onset of childhood asthma among participants in the Childhood Asthma Management Program (CAMP) and used 3 independent cohorts from North America, Costa Rica, and Sweden for replication.

RESULTS

Two single nucleotide polymorphisms (SNPs) were associated with earlier onset of asthma in the combined analysis of CAMP and the replication cohorts: rs9815663 (Fisher P= 2.31 × 10(-8)) and rs7927044 (P= 6.54 × 10(-9)). Of these 2 SNPs, rs9815663 was also significantly associated with earlier asthma onset in an analysis including only the replication cohorts. Ten SNPs in linkage disequilibrium with rs9815663 were also associated with earlier asthma onset (2.24 × 10(-7)

CONCLUSIONS

We have identified 2 SNPs associated with earlier onset of childhood asthma in 4 independent cohorts.

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Key Words

• asthma
• pediatrics
• age of onset
• asthma genetics
• c1orf100
• genome-wide association study
• pediatric asthma

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MESH Headings

• Adolescent
• Age of Onset
• Asthma/epidemiology
• Asthma/genetics
• Child
• Cohort Studies
• Costa Rica/epidemiology
• Female
• Genetic Predisposition to Disease
• Genome-Wide Association Study/methods
• Genotype
• Humans
• Linkage Disequilibrium
• Male
• North America/epidemiology
• Polymorphism, Single Nucleotide/genetics
• Sweden/epidemiology

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Grants

• R00 HL096840 NHLBI NIH HHS
• N01-HR-16051 NHLBI NIH HHS
• M01 RR002719 NCRR NIH HHS
• N01-HR-16044 NHLBI NIH HHS
• N01-HR-16048 NHLBI NIH HHS
• M01 RR000036 NCRR NIH HHS
• N01-HR-16045 NHLBI NIH HHS
• M01RR02719-14 NCRR NIH HHS
• M01 RR000051 NCRR NIH HHS
• HL66289 NHLBI NIH HHS
• R01 HL066289 NHLBI NIH HHS
• N01-HR-16047 NHLBI NIH HHS
• N01-HR-16046 NHLBI NIH HHS
• N02-HL-6-4278 NHLBI NIH HHS
• K01 HL004370 NHLBI NIH HHS
• N01-HR-16049 NHLBI NIH HHS
• RR00036 NCRR NIH HHS
• N01-HR-16052 NHLBI NIH HHS
• R37 HL066289 NHLBI NIH HHS
• N01-HR-16050 NHLBI NIH HHS
• Wellcome Trust
• WT084703MA Wellcome Trust
• N01HR16044 NHLBI NIH HHS
• M01RR00051 NCRR NIH HHS
• M01RR0099718-24 NCRR NIH HHS

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Affiliation(s)

Erick Forno Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Division of Pediatric Pulmonology, Dept. of Pediatrics, University of Miami, Miami, FL Harvard Medical School, Boston, MA
Jessica Lasky-Su Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Blanca Himes Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Judie Howrylak Channing Laboratory, Brigham and Women’s Hospital, Boston, MA
Clare Ramsey Dept. of Medicine, University of Manitoba, Winnipeg, Canada
John Brehm Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Division of Pulmonary/Critical Care Medicine, Dept. of Medicine, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Barbara Klanderman Channing Laboratory, Brigham and Women’s Hospital, Boston, MA
John Ziniti Channing Laboratory, Brigham and Women’s Hospital, Boston, MA
Erik Melén Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
Goran Pershagen Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
Magnus Wickman Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Sachs Children’s Hospital, Stockholm, Sweden
Fernando Martinez Department of Pediatrics, University of Arizona, Tucson, AZ
Dave Mauger Penn State Hershey College of Medicine, Hershey, PA
Christine Sorkness University of Wisconsin, Madison, WI
Kelan Tantisira Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Division of Pulmonary/Critical Care Medicine, Dept. of Medicine, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Benjamin A. Raby Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Division of Pulmonary/Critical Care Medicine, Dept. of Medicine, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Scott T. Weiss Channing Laboratory, Brigham and Women’s Hospital, Boston, MA Harvard Medical School, Boston, MA
Juan C. Celedón Division of Pediatric Pulmonary Medicine, Allergy and Immunology, Dept. of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA

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Critically ill patients with 2009 influenza A(H1N1) infection in Canada

CONTEXT

Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.

OBJECTIVE

To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.

DESIGN, SETTING, AND PATIENTS

A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009.

MAIN OUTCOME MEASURES

The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay.

RESULTS

Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of Pao(2) to fraction of inspired oxygen [Fio(2)] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29).

CONCLUSION

Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.

Expenditure on health care in obese women with and without sleep apnea

STUDY OBJECTIVES

To determine the effect of obesity and sleep apnea on health care expenditure in women over 10 years.

DESIGN

Retrospective observational study

SETTING

Tertiary university-based medical center

PATIENTS AND CONTROLS

Three groups of age-matched women: 223 obese women with OSAS (body mass index: 39.3 +/- 0.6 kg/m2), and from the general population, 223 obese controls (BMI 36.3 +/- 0.4) and 223 normal weight controls (BMI 23.9 +/- 0.4).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We examined health care utilization in the 3 matched groups for the 10 years leading up to the documentation of OSAS. The mean physician fees and the number of physician visits were significantly higher in obese controls than in normal weight controls during the observed period. Physician fees and physician visits progressively increased in the 10 years before diagnosis in the OSAS cases and were significantly higher than in the matched obese controls. Physician fees, in Canadian dollars, one year before diagnosis in the OSAS cases were higher than in obese controls: $547.49 +/- 34.79 vs $246.85 +/- 20.88 (P<0.0001). More was spent for OSAS cases on physician fees for circulatory, endocrine and metabolic diseases, and mental disorders than the obese controls. Physician visits one year before diagnosis in the OSAS cases were more frequent than in the obese controls: 13.2 +/- 0.73 visits vs 7.26 +/- 0.49 visits (P<0.0001).

CONCLUSIONS

Obese women are heavier users of health services than normal weight controls. Obese women with OSAS use significantly more health services than obese controls. Since OSAS imposes a greater financial burden, treatment of OSAS may reduce other comorbidities and lower overall medical costs.