Impact of patient characteristics on the Canadian Patient Experiences Survey-Inpatient Care: survey analysis from an academic tertiary care centre

OBJECTIVE

To determine the role of patient demographics, care domains and self-perceived health status in the analysis and interpretation of results from the Canadian Patient Experience Survey-Inpatient Care.

DESIGN

Cross-sectional survey.

SETTING

Single large Canadian two campus tertiary care academic centre.

PARTICIPANTS

Random sampling of hospital patients postdischarge.

INTERVENTION AND MAIN OUTCOME MEASURES

Logistic regression models were developed to analyse topbox scoring on four questions of global care (rate experience, recommend hospital, rate hospital, overall helped). Means of each composite domain were correlated to the four overall scores at the patient level to determine Spearman's rank correlation coefficients which were plotted against the overall (hospital) domain score for the key driver analysis.

RESULTS

Topbox scoring was decreased with worse degrees of perceived physical and mental health in all four global questions (p<0.05). Female gender and higher levels of education were associated with worse scoring on rate experience, recommend hospital and rate hospital (p<0.001). Whereas there was a significant difference between hospital departments in unadjusted measures, these differences were no longer evident after adjustment with patient covariates. Key driver analysis identified person-centred care, care transition and the domain related to emergency admission as areas of highest potential for improvement.

CONCLUSIONS

Global measures of overall care are influenced by patient-perceived physical and mental health. Caution should be exercised in using patient-satisfaction surveys to compare performance between different healthcare provision entities, as apparent differences could be explained by variation in patient mix rather than variation in performance.

Time is of the essence: an observational time-motion study of internal medicine residents while they are on duty

BACKGROUND

The effects of changes to resident physician duty hours need to be measureable. This time-motion study was done to record internal medicine residents' workflow while on duty and to determine the feasibility of capturing detailed data using a mobile electronic tool.

METHODS

Junior and senior residents were shadowed by a single observer during six-hour blocks of time, covering all seven days. Activities were recorded in real-time. Eighty-nine activities grouped into nine categories were determined a priori.

RESULTS

A total of 17,714 events were recorded, encompassing 516 hours of observation. Time was apportioned in the following categories: Direct Patient Care (22%), Communication (19%), Personal tasks (15%), Documentation (14%), Education (13%), Indirect care (11%), Transit (6%), Administration (0.6%), and Non-physician tasks (0.4%). Nineteen percent of the education time was spent in self-directed learning activities. Only 9% of the total on duty time was spent in the presence of patients. Sixty-five percent of communication time was devoted to information transfer. A total of 968 interruptions were recorded which took on average 93.5 seconds each to service.

CONCLUSION

Detailed recording of residents' workflow is feasible and can now lead to the measurement of the effects of future changes to residency training. Education activities accounted for 13% of on-duty time.

A Novel Neuroscience Intermediate-Level Care Unit Model: Retrospective Analysis of Impact on Patient Flow and Safety

BACKGROUND AND PURPOSE

Neurointensive care units have been shown to improve patient outcomes across a variety of neurological and neurosurgical conditions. However, the efficacy of less resource-intensive intermediate-level care units to deliver similar care has not been well studied. The purpose of this study is to evaluate the impact of neurocritical specialist comanagement on patient flow and safety in a neuroscience intermediate-level care unit.

METHODS

Our intervention consisted of the addition of a physician with critical care experience as well as training in neurology, anesthesiology, or intensive care to a neuroscience intermediate-level care unit to comanage patients alongside neurology and neurosurgery staff during weekday daytime hours. A retrospective analysis was performed on prospectively collected data pertaining to all patients admitted to the unit over a 3-year period, 1 year before our intervention and 2 years after. Patient statistics including wait times to admission, length of stay (LOS), and mortality were reviewed.

RESULTS

Following the intervention, there were significant reductions in wait times to unit admission from both the emergency department and postanesthetic care unit, as well as reductions in the average LOS. No significant safety concerns were identified.

CONCLUSION

This study has demonstrated that the optimization of a neuroscience intermediate-level care unit involving comanagement of patients by a neurocritical specialist can reduce wait times to admission and lengths of stay, with preserved safety outcomes.

Variations in Resource Intensity and Cost Among High Users of the Emergency Department

OBJECTIVES

High users of emergency department (ED) services are often identified by number of visits per year, with little exploration of the distribution/pattern of visits over time. The purpose of this study was to examine patient- and encounter-level factors and costs related to periods of short-term resource intensity among high users of the ED within a tertiary care teaching facility.

METHODS

We identified all adults with at least three visits to the Ottawa Hospital ED within a 1-year period from April 1, 2012, to March 31, 2013. Within this high-user cohort, we then measured intensity of use by calculating average daily visit rates to identify individuals with a cluster of ED visits. Those with at least three ED visits/7 days at any point during follow-up were considered patients with clustered ED use (i.e., a period of short-term resource intensity). Detailed clinical and administrative data were used to compare patient- and encounter-level characteristics and cost profiles between the clustered and nonclustered groups. Analyses were repeated using varying cut points to define high users (at least five and at least eight visits per year).

RESULTS

Of the 16,153 patients identified as high ED users during the study period, 13.5% had their visits clustered within a short period of time. These clustered users were more likely to be homeless, to require psychiatric services, and to leave without being seen by a physician and less likely to be admitted to the hospital. Approximately one in three (31.2%) high ED users with clustered visits returned for the same medical problem (namely pain-related disorders, shortness of breath, and cellulitis) within a 1-week period. Similar trends were observed when the high-user cohort was restricted to those with at least five and at least eight ED visits/year. Finally, patients with short-term intensity periods had lower direct and indirect costs per encounter than those without.

CONCLUSIONS

Using a novel methodology that accounts for both number and intensity of ED encounters over time, we were able to identify specific subpopulations of high ED users. Further work is required to determine if this methodology has utility for targeting care pathways within this heterogeneous and high-risk patient group.

Clinical characteristics and preventable acute care spending among a high cost inpatient population

BACKGROUND

A small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.

METHODS

We identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.

RESULTS

During the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).

CONCLUSIONS

Within a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.

Time-motion studies of internal medicine residents' duty hours: a systematic review and meta-analysis

BACKGROUND

Since the mid-1980s, medical residents' long duty hours have been under scrutiny as a factor affecting patient safety and the work environment for the residents. After several mandated changes in duty hours, it is important to understand how residents spend their time before proposing and implementing future changes. Time-motion methodology may provide reliable information on what residents do while on duty.

PURPOSE

The purpose of this study is to review all available literature pertaining to time-motion studies of internal medicine residents while on a medicine service and to understand how much of their time is apportioned to various categories of tasks, and also to determine the effects of the Accreditation Council for Graduate Medical Education (ACGME)-mandated duty hour changes on resident workflow in North America.

METHODS

Electronic bibliographic databases were searched for articles in English between 1941 and April 2013 reporting time-motion studies of internal medicine residents rotating through a general medicine service.

RESULTS

Eight articles were included. Residents spent 41.8% of time in patient care activities, 18.1% communicating, 13.8% in educational activities, 19.7% in personal/other, and 6.6% in transit. North American data showed the following changes after the implementation of the ACGME 2003 duty hours standard: patient care activities from 41.8% to 40.8%, communication activities from 19.0% to 22.3%, educational activities from 17.7% to 11.6%, and personal/other activities from 21.5% to 17.1%.

CONCLUSION

There was a paucity of time-motion data. There was great variability in the operational definitions of task categories reported in the studies. Implementation of the ACGME duty hour standards did not have a significant effect on the percentage of time spent in particular tasks. There are conflicting reports on how duty hour changes have affected patient safety. A low proportion of time spent in educational activities deserves further study and may point to a review of the educational models used.

Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records

INTRODUCTION

To determine if using a combination of hospital administrative data and ambulatory care physician billings can accurately identify patients with congestive heart failure (CHF), we tested 9 algorithms for identifying individuals with CHF from administrative data.

METHODS

The validation cohort against which the 9 algorithms were tested combined data from a random sample of adult patients from EMRALD, an electronic medical record database of primary care physicians in Ontario, Canada, and data collected in 2004/05 from a random sample of primary care patients for a study of hypertension. Algorithms were evaluated on sensitivity, specificity, positive predictive value, area under the curve on the ROC graph and the combination of likelihood ratio positive and negative.

RESULTS

We found that that one hospital record or one physician billing followed by a second record from either source within one year had the best result, with a sensitivity of 84.8% and a specificity of 97.0%.

CONCLUSION

Population prevalence of CHF can be accurately measured using combined administrative data from hospitalization and ambulatory care.

Indications for and results of outpatient computed tomography and magnetic resonance imaging in Ontario

OBJECTIVE

Population rates of computed tomography (CT) and magnetic resonance imaging (MRI) continue to increase markedly. However, little is known about the indications for and results of these imaging tests.

METHODS

A cross-sectional chart-abstraction study was used to determine the indications for and results of outpatient CT and MRI scans performed on or after January 1, 2005, at randomly selected Ontario hospitals.

RESULTS

We studied 11,824 CT and 11,867 MRI scans. Cancer-related indications accounted for over 50% of CT scans of the abdomen-pelvis and chest. Headache was the most frequent indication for CT of the brain. More than one-half of MRI scans of the extremities were for knee pain or suspected meniscal tear. Back pain and radiculopathy were the most frequent indications for MRI of the spine. There was considerable variation between institutions in ordering patterns, with as much as a 70-fold difference between hospitals in the frequency of scans ordered for a specific indication. Less than 2% of CT scans of the brain for headache found abnormalities that could explain the headache, while over 90% of MRI scans of the spine for back pain were abnormal, although the clinical importance of the abnormalities was unclear.

CONCLUSIONS

These data are a starting point for a discussion about appropriateness. Further information will be obtained by examining individual indications more closely, and linking these data to administrative databases to evaluate the impact of these imaging tests on clinical practice.

Colorectal cancer screening with nurse-performed flexible sigmoidoscopy: results from a Canadian community-based program

BACKGROUND

Despite highest-quality evidence that early detection of colorectal cancer (CRC) can lead to reduced mortality, no organized CRC screening programs exist in Canada.

OBJECTIVE

To report the safety, the feasibility, and the detection rate for the first Canadian community-based nurse-performed flexible sigmoidoscopy (FS) screening program for CRC, established in 1999.

DESIGN

Cross-sectional analysis of data collected from a prospective study of FS done by nurses from March 1999 to November 2002. Estimate of differences between men and women in FS findings, with relative risks. Logistic regression used to calculate odds ratios for advanced neoplasia.

SETTING

Endoscopy suite of a community hospital.

PATIENTS

Asymptomatic men and women > or =50 years, with no previous history of CRC.

INTERVENTION

FS done by a nurses, and colonoscopy for persons with abnormalities done by an experienced gastroenterologist.

MAIN OUTCOME MEASUREMENTS

Mean depth of insertion of endoscope; duration of FS procedure; number and location of polyps found during FS; number, location, and type of polyps found during colonoscopy.

RESULTS

A total of 1818 individuals (mean age, 62 years) underwent nurse-performed FS (mean duration, 7.3 minutes; mean depth of insertion of the endoscope, 53.5 cm), without complications. Results of the FS were abnormal for 240 (13.2%) of the 1818 participants; 231 (12.7%) underwent colonoscopy. Distal neoplasms (adenomas or cancer) were detected in 8.7% (158/1818). After adjustment for age and family history of CRC, the risk of advanced neoplasm in the distal colon for men was about twice that for women (odds ratio 1.95, 95% confidence interval 1.21-3.14). Cancer was detected in 5 of the 1818 participants screened (0.28%), and high-grade dysplasia was detected in an additional 5 (0.28%). One of the cancers and all the lesions with high-grade dysplasia were treated endoscopically.

CONCLUSIONS

Our community-based nurse-performed FS screening program was feasible and safe. The referral rate for colonoscopy was 13%, and the cancer detection rate was 2.8 per 1000 persons screened.

Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis

BACKGROUND & AIMS

The rate of new or missed colorectal cancer (CRC) after colonoscopy and their risk factors in usual practice are unknown. Our objective was to evaluate the rate and risk factors in a population-based study.

METHODS

We analyzed data from the Canadian Institute for Health Information, the Ontario Health Insurance Program, and Ontario Cancer Registry for all patients (> or =20 years of age) with a new diagnosis of right-sided, transverse, splenic flexure/descending, rectal or sigmoid CRC in Ontario from April 1, 1997 to March 31, 2002, who had a colonoscopy within the 3 years before their diagnosis. Patients with new or missed cancers were those whose most recent colonoscopy was 6 to 36 months before diagnosis. We examined characteristics that might be risk factors for new or missed CRC.

RESULTS

We identified a diagnosis of CRC in 3288 (right sided), 777 (transverse), 710 (splenic flexure/descending), and 7712 (rectal or sigmoid) patients. The rates of new or missed cancers were 5.9%, 5.5%, 2.1%, and 2.3%, respectively. Independent risk factors for these cancers in men and women were older age; diverticular disease; right-sided or transverse CRC; colonoscopy by an internist or family physician; and colonoscopy in an office.

CONCLUSIONS

Because having an office colonoscopy and certain patient, procedure, and physician characteristics are independent risk factors for new or missed CRC, physicians must inform patients of the small risk (2% to 6%) of these cancers after colonoscopy. The influence of type of physician and setting on the accuracy of colonoscopy, potentially modifiable risk factors, warrants further study.

A rural CT scanner: evaluating the effect on local health care

OBJECTIVE

The first small rural hospital in Ontario to propose a computed tomography (CT) scanner was in Walkerton, a town 160 km north of London. The Ontario Ministry of Health approved the proposal as a pilot project to evaluate the effect on local health care of a rural scanner. This evaluation study had 3 parts: a survey of physicians, a survey of patients, and an analysis of population CT scanning rates.

METHOD

The physicians in the area served by the scanner were asked about its impact on their care of their patients in a mailed questionnaire and in semistructured interviews. Scanner outpatients were given a questionnaire in which they rated the importance of its advantages. The analysis of scanning rates--the ratio of number of scans to estimated population--compared rates in the area with other Ontario rates before and after the scanner was introduced.

RESULTS

The physicians reported that local CT allowed them to diagnose and treat patients sooner, closer to home, and with greater confidence. On average, 75% of the patients ranked faster and closer access as very important. Scanning rates in the area rose, although they did not match urban rates.

CONCLUSIONS

The study confirms that the rural scanner changed the area's health care in significant ways and that it helped to narrow the gap between rural and urban service levels. We recommend that CT be expanded to other rural regions.

Hospital volume and mortality for mechanical ventilation of medical and surgical patients: A population-based analysis using administrative data*

OBJECTIVE

In an effort to improve efficiency and quality of care, regionalization of adult critical care services, similar to trauma and neonatal intensive care, has been suggested. However, there is little research to understand if hospitals with higher patient volumes have better outcomes. Our objective is to determine whether hospital volume is associated with improved survival for medical or surgical patients receiving mechanical ventilation.

DESIGN

Population-based retrospective cohort study.

SETTING

Province of Ontario, Canada.

PATIENTS

A total of 13,846 medical and 6,373 surgical patients receiving mechanical ventilation for greater than two consecutive days between 1998 and 2000.

INTERVENTIONS

None.

MEASUREMENTS

Odds ratio for death within 30 days of initiation of mechanical ventilation was calculated in relation to hospital volume of ventilation. Estimates were adjusted for patient demographics, diagnoses, and urgency status; hospital region and rural location; and accounted for clustering within hospitals.

MAIN RESULTS

There was no effect of volume on mortality for surgical patients. After adjustment for clustering, among medical patients, the lowest-volume category (<100 episodes/yr) had a nonsignificant increase in mortality, with an odds ratio (95% confidence interval) of 1.13 (0.87-1.47) compared with the highest-volume category (> or =700 episodes/yr). A post hoc analysis revealed that within the lowest-volume category, the proportion of patients transferred to larger hospitals was 81% for hospitals with <20 episodes/yr and only 32% for hospitals with 20-99 episodes/yr, with odds ratios (95% confidence interval) for mortality of 0.74 (0.49-1.12) and 1.18 (0.90-1.54), respectively, compared with the highest-volume category.

CONCLUSIONS

For surgical patients requiring mechanical ventilation for >2 days, hospital volume had no effect on mortality. For medical patients, higher mortality may occur in a subgroup of low-volume hospitals that do not routinely transfer their patients to larger-volume facilities. This finding needs further investigation in a larger-sized study.

Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: a population-based study

PURPOSE

This study was designed to determine whether changes in length of stay and 30-day readmission, reoperation, and excision rates for the ileal pouch-anal anastomosis occurred over time and with changes in surgical technique and hospital volume.

METHODS

Using three population-based administrative databases, data on all ileal pouch-anal anastomoses performed in the province of Ontario between January 1992 and June 1998 were obtained. The effect of age, gender, stage of the procedure, year of surgery, and hospital volume were examined for their effect on length of stay and readmission, reoperation, and excision rates.

RESULTS

There were 1,285 ileal pouch-anal anastomoses performed in 58 hospitals. There was a significant decrease in length of stay and reoperation and excision rates but a concommitant increase in readmission rate during the study period. Patients younger than aged 40 years had a significantly lower length of stay and excision rate. Patients who had a two-stage procedure had a shorter length of stay, readmission, and reoperative rate compared with those having a three-stage procedure. Hospital volume was a significant predictor of need for reoperation and excision with both low-volume and medium-volume hospitals having significantly higher rates than high-volume hospitals.

CONCLUSIONS

Outcome after ileal pouch-anal anastomosis has improved. It is significantly better in patients younger than aged 40 years, having a two-stage procedure, and where surgery is performed at high-volume hospitals. It is likely that both modifications in surgical technique and surgical experience have led to improvements in clinical outcome after ileal pouch-anal anastomosis.

Temporal trends in new diagnoses of colorectal cancer with obstruction, perforation, or emergency admission in Ontario: 1993-2001

OBJECTIVES

Previous studies have shown that patients newly diagnosed with colorectal cancer requiring emergency admission to hospital or presenting with obstruction or perforation (defined here as OPE) have advanced disease. None of these studies, however, has evaluated temporal trends in these adverse outcomes, which may reflect screening failures. We evaluated temporal trends in the proportion of Ontario patients with a new diagnosis of colorectal cancer and OPE.

METHODS

Data were obtained from four sources: the Ontario Cancer Registry (OCR); the Canadian Institute for Health Information (CIHI) database, which contains diagnostic information on all patients discharged from hospitals; the Ontario Health Insurance Plan (OHIP) database, which records all physician claims in Ontario; and the Registered Persons Database, which contains demographic information on all Ontario residents covered under OHIP. We calculated the proportion of patients (>/=20 yr) with a new diagnosis of colorectal cancer recorded in CIHI who presented with OPE between 1993 and 2001. These patients were assigned to one of three cohort years: 1993-1995, 1996-1998, or 1999-2001. Those who received chemotherapy, radiotherapy, or palliative care before their first admission to hospital were excluded. We repeated the analysis using the number of OPE patients identified from CIHI in the numerator, and the number of patients (>/=20 yr) with a new diagnosis of colorectal cancer recorded in the OCR in the denominator. Adjusted risk of OPE was calculated using a logistic regression model.

RESULTS

Between 1993 and 2001, 59,670 patients with a new diagnosis of colorectal cancer were recorded in the CIHI database and 54,103 in the OCR. The proportion of these patients with OPE recorded in the CIHI decreased significantly over time: 23.8% (95% CI = 23.2-24.4%) during 1993-1995, 19.4% (95% CI = 18.8-20.0%) during 1996-1998, and 18.1% (95% CI 17.6-18.6%) during 1999-2001 (a 24% relative decrease over time). The relative decrease calculated from OCR data was similar. The adjusted relative decrease in the proportion of patients with OPE during 1993-2001 was 31%.

CONCLUSIONS

Much greater emphasis on screening is needed since approximately 20% of patients with a new diagnosis of colorectal cancer in 1999-2001 presented with OPE.

The growing volume of diabetes-related dialysis: a population based study

BACKGROUND

End-stage renal failure requiring dialysis is one of the most serious complications of diabetes mellitus, and diabetes is the most common cause of end-stage renal failure. The aim of this large, observational study is to describe the population-based incidence and prevalence rates and outcomes of diabetic individuals in Ontario, Canada who require dialysis therapy.

METHODS

Two cohorts of patients, those with diabetes and those without, were created between April 1, 1994 and March 31, 2000 (total of approximately 8.4 million) and followed until March 31, 2001 using several large, linked administrative databases at the Institute for Clinical Evaluative Sciences. The incidence, prevalence and mortality on dialysis for each cohort were determined. A multivariate Cox proportional hazards analysis, adjusting for age, sex and co-morbidity, was used to determine the independent impact of diabetes on patient survival.

RESULTS

The average annual incidence rate of dialysis was 12 times greater in persons with diabetes (130 per 100,000) vs without diabetes (11 per 100,000). By 1999-2000, diabetic patients comprised 51% of the incident dialysis population. The average annual prevalence rate was 10 times greater in the diabetic cohort. Patients with diabetes had more co-morbidities at the start of dialysis and poorer 3 year survival (55 vs 68%; P < 0.0001).

CONCLUSIONS

The incident and prevalent rates of dialysis for patients with diabetes mellitus are many times the rates of those without diabetes. Patients with diabetes mellitus often start dialysis with significant co-morbidities, which may contribute to the relatively high rate of mortality on dialysis.

Antihypertensive therapy and incidence of type 2 diabetes in an elderly cohort

OBJECTIVE

The aim of this study was to determine whether the incidence of type 2 diabetes differed among elderly users of four major antihypertensive drug classes.

RESEARCH DESIGN AND METHODS

This was a retrospective, observational cohort study of previously untreated elderly patients (aged > or = 66 years) identified as new users of an antihypertensive drug class between April 1995 and March 2000. Using a Cox proportional hazards model, the primary analysis compared diabetes incidence in users of ACE inhibitors, beta-blockers, and calcium channel blockers (CCBs), with thiazide diuretics allowed as second-line therapy. In the secondary analysis, thiazide diuretics were added as a fourth study group.

RESULTS

In the multivariable-adjusted primary analysis (n = 76,176), neither ACE inhibitor use (hazard ratio 0.96 [95% CI 0.84-1.1]) nor beta-blocker use (0.86 [0.74-1.0]) was associated with a statistically significant difference in type 2 diabetes incidence compared with the CCB control group. In the secondary analysis (n = 100,653), compared with CCB users, type 2 diabetes incidence was not significantly different between users of ACE inhibitors (0.97 [0.83-1.1]), beta-blockers (0.84 [0.7-1.0]), or thiazide diuretics (1.0 [0.89-1.2]).

CONCLUSIONS

Type 2 diabetes incidence did not significantly differ among users of the major antihypertensive drug classes in this elderly, population-based administrative cohort. These results do not support the theory that different antihypertensive drug classes are relatively more or less likely to cause diabetes.

Late Creation of Vascular Access for Hemodialysis and Increased Risk of Sepsis

The creation of fistulas or grafts before starting dialysis is recommended, but whether it reduces major adverse events is largely unknown. The objective of this study was to determine if early access creation was associated with a reduced risk of hospitalization from sepsis and mortality. Fistulas or grafts created at least 4 mo before starting hemodialysis were defined as Early creations (n = 1240), and accesses created between 4 mo and 1 mo before starting hemodialysis were defined as Just Prior creations (n = 997). Accesses created within 1 mo of starting dialysis or after were defined as Late creations (reference group, n = 3687). Hemodialysis catheter use was defined as insertion, removal, or manipulation of a catheter before the occurrence of sepsis. Eighty percent of accesses were fistulas. Early access creation was associated with a relative risk (RR) of sepsis of 0.57 (95% CI, 0.41 to 0.79) compared with Late access creation. Catheter use increased the risk of sepsis by 1.41 (95% CI, 1.14 to 1.81). The risk of sepsis with Early creation decreased to 0.48 (95% CI, 0.35 to 0.65) if catheter use was not adjusted. Early access creation was associated with lower mortality (RR 0.76; 95% CI 0.58 to 1.00), but this association became nonsignificant if catheter use and sepsis were adjusted. Catheter use and sepsis independently increased mortality. This study demonstrates that fistula creation at least 4 mo before starting chronic hemodialysis is associated the lowest risk of sepsis and death, primarily by reducing the use of hemodialysis catheters.

The striking effect of the Heart Outcomes Prevention Evaluation (HOPE) on ramipril prescribing in Ontario

BACKGROUND

The Heart Outcomes Prevention Evaluation (HOPE), a Canadian-led, multicentre, randomized controlled trial, demonstrated the effectiveness of the ACE inhibitor ramipril in the secondary prevention of cardiovascular disease in patients who were at high risk for cardiovascular events but did not have left ventricular dysfunction or heart failure. We studied whether HOPE affected the prescribing of ACE inhibitors generally, and ramipril specifically, in Ontario, where the trial was coordinated.

METHODS

We used linked administrative databases to examine prescribing patterns for ACE inhibitors in the 1.29 million to 1.54 million elderly (aged 66 and over) residents of Ontario during the study period and specifically those with diabetes or congestive heart failure. For all new prescriptions for these drugs filled between Jan. 1, 1993, and Mar. 31, 2001, we conducted time-series analyses to measure any association with the release of the HOPE results.

RESULTS

The monthly number of new prescriptions for ramipril from the time it was introduced in 1995 until HOPE's early termination, in April 1999, peaked at 58 per 100,000 elderly Ontario residents. The rate increased to 92/100,000 in May, coincident with newspaper coverage of the trial's early termination, then fell back to 63/100,000 in August. After HOPE's results were formally released, starting Aug. 31, the rate increased significantly; it peaked at 304/100,000 in May 2000 (p < 0.01). The market share of ramipril among ACE inhibitors also increased significantly (p < 0.01), both overall and among patients with diabetes or congestive heart failure.

INTERPRETATION

HOPE led to a striking and unprecedented increase, over 400%, in ramipril prescribing to elderly Ontario residents, including those not eligible for the trial. Many physicians are now prescribing ramipril for patients with diabetes or congestive heart failure.

Management and outcome differences in supraglottic cancer between Ontario, Canada, and the Surveillance, Epidemiology, and End Results areas of the United States

PURPOSE

We compared the management and outcome of supraglottic cancer in Ontario, Canada, with that in the Surveillance, Epidemiology, and End Results (SEER) Program areas in the United States.

METHODS

Electronic, clinical, and hospital data were linked to cancer registry data and supplemented by chart review where necessary. Stage-stratified analyses compared initial treatment and survival in the SEER areas (n = 1,643) with a random sample from Ontario (n = 265). We also compared laryngectomy rates at 3 years in those patients 65 years and older at diagnosis.

RESULTS

Radical surgery was more commonly used in SEER, with absolute differences increasing with increasing stage: I/II, 17%; III, 36%; and IV, 45%. The 5-year survival rates were 74% in Ontario and 56% in SEER for stage I/II disease (P =.01), 55.7% in Ontario and 46.8% in SEER for stage III disease (P =.40), and 28.5% in Ontario and 29.1% in SEER for stage IV disease (P =.28). Cancer-specific survival results mirrored the overall survival results with the exception of stage IV disease, for which 34.6% of Ontario patients survived their cancer compared with 38.1% in SEER (P =.10). This stage IV difference was more pronounced when we further controlled for possible cause of death errors by restricting the comparison to patients with a single primary cancer (P =.01). Three-year actuarial laryngectomy rates differed. In stage I/II, these rates were 3% in Ontario compared with 35% in SEER (P < 10(-3)). In stage III disease, the rates were 30% and 54%, respectively (P =.03), and in stage IV disease they were 33% and 64% (P =.002).

CONCLUSION

There are large differences in the management of supraglottic cancer between the SEER areas of the United States and Ontario. Long-term larynx retention was higher in Ontario, where radiotherapy is widely regarded as the treatment of choice and surgery is reserved for salvage. In stages I to III, survival was similar in the two regions despite the differences in treatment policy. In stage IV, there may be a small survival advantage in the U.S. SEER areas related to the higher use of primary surgery.

A comparison of published head and neck stage groupings in carcinomas of the tonsillar region

BACKGROUND

The combination of T, N, and M classifications into stage groupings was designed to facilitate a number of activities including: the estimation of prognosis and the comparison of therapeutic interventions among similar groups of cases. The authors tested the UICC/AJCC 5th edition stage grouping and seven other TNM-based groupings proposed for head and neck cancer to determine their ability to meet these expectations in a specific site: carcinoma of the tonsillar region.

METHODS

The authors defined four criteria to assess each stage grouping scheme: 1) The subgroups defined by T and N comprising a given group within a grouping scheme have similar survival rates (hazard consistency); 2) The survival rates differ across the groups (hazard discrimination); 3) The prediction of cure is high (outcome prediction); and 4) The distribution of patients among the groups is balanced. The authors identified or derived a measure for each criterion and the findings were summarized using a scoring system. The range of scores was from 0 (best) to 7 (worst). Data were from a retrospective chart review on 642 cases of carcinoma of the tonsillar region treated with radiotherapy for cure at the Princess Margaret Hospital from 1970-1991. None of the patients had distant metastases.

RESULTS

The scheme proposed by Synderman and Wagner, which was published in Otolaryngology Head and Neck Surgery in 1995 (vol.112, pages 691-4), scored best at 1.2. The UICC/AJCC scheme scored worst at 6.1. The hazard consistency ranged from a 3.1% average survival difference to 6.7% across the 8 schemes. The hazard discrimination measure varied by 28% from the best to worst scheme. Prediction varied by up to almost twofold across the schemes assessed. The distribution of patients varied from expected by between 0.13% and 0.57%.

CONCLUSION

UICC/AJCC stage groupings were defined without empirical investigation. When tested, this scheme did not perform as well as any of seven empirically-derived schemes the authors evaluated. The results of the current study suggest that the usefulness of the TNM system can be enhanced by optimizing the design of stage groupings through empirical investigation.

Chiropractic manipulation and stroke: a population-based case-control study

BACKGROUND AND PURPOSE

Several reports have linked chiropractic manipulation of the neck to dissection or occlusion of the vertebral artery. However, previous studies linking such strokes to neck manipulation consist primarily of uncontrolled case series. We designed a population-based nested case-control study to test the association.

METHODS

Hospitalization records were used to identify vertebrobasilar accidents (VBAs) in Ontario, Canada, during 1993-1998. Each of 582 cases was age and sex matched to 4 controls from the Ontario population with no history of stroke at the event date. Public health insurance billing records were used to document use of chiropractic services before the event date.

RESULTS

Results for those aged <45 years showed VBA cases to be 5 times more likely than controls to have visited a chiropractor within 1 week of the VBA (95% CI from bootstrapping, 1.32 to 43.87). Additionally, in the younger age group, cases were 5 times as likely to have had >/=3 visits with a cervical diagnosis in the month before the case's VBA date (95% CI from bootstrapping, 1.34 to 18.57). No significant associations were found for those aged >/=45 years.

CONCLUSIONS

While our analysis is consistent with a positive association in young adults, potential sources of bias are also discussed. The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment. Because of the popularity of spinal manipulation, high-quality research on both its risks and benefits is recommended.

Trends in hormonal management of prostate cancer: a population-based study in Ontario

OBJECTIVE

To provide a population-based description of current practice in the use of hormonal management of prostate cancer. DESIGN,SETTING & PARTICIPANTS: All men in Ontario, Canada, age 65 and older, with confirmed prostate cancer starting maintained hormonal therapy, from July 1992 through December 1998 (11,435 patients). Data sources included the provincial drug benefit plan, hospital services data, and Ontario Cancer Registry.

OUTCOME MEASURES

Rates and trends in the use of: surgical or medical castration; total androgen blockade (TAB); and monotherapies based on steroidal or nonsteroidal antiandrogens.

RESULTS

In 5.5 years, use of 'standard' therapy based on surgical or medical castration alone dropped from 36% to 26% of patients, while the use of TAB doubled from 22% to 41%. Approximately 15% of patients received nonsteroidal antiandrogens without evidence of therapy aimed at central androgen blockade. Marked regional differences were observed and not explained by patient age or practitioner specialty.

CONCLUSIONS

New hormonal therapies for prostate cancer have implications in terms of disease control, patient survival, side effects, and costs. Rapid growth in prescribing of antiandrogens may represent an unnecessary expense for public or private payers, and observed regional differences likely reflect lack of consensus on the relative merit of TAB. Patients and practitioners must have current information on the advantages and disadvantages of different therapeutic options, and quality-of life, particularly with respect to emerging drug therapies.

Glottic cancer in Ontario, Canada and the SEER areas of the United States. Do different management philosophies produce different outcome profiles?

We compared the management and outcome of glottic cancer in Ontario, Canada to that in the Surveillance, Epidemiology and End Results (SEER) Program areas in the United States to determine whether the greater use of primary radiotherapy with surgery reserved for salvage in Ontario was associated with similar survival and better larynx retention rates than the U.S. approach where primary surgery is used more often. Electronic, clinical and hospital data were linked to cancer registry data and supplemented by chart review where necessary. Initial treatment and survival in patients diagnosed in the SEER areas from 1988 through 1994 were compared to patients from Ontario diagnosed from 1982 through 1995. Actuarial laryngectomy rates were compared for patients over 65 at diagnosis in the two regions. Analyses were conducted over all cases and stratified by disease stage. In localized disease (T1 or T2), conservative treatment was the most common initial treatment in both regions, although total laryngectomy was used more often in SEER than Ontario (6.2% vs. 0.2%, respectively, P <.001). In advanced disease (T3 or T4), total laryngectomy was more commonly used as initial treatment in SEER (62.9% vs. 21.0% in Ontario, P < or =.001). Over all cases, the relative survival rate was 80% in Ontario at 5 years compared to 78% in SEER (P =.33). In localized disease, the relative survival rates were 4 to 5% higher in Ontario from the second year on, while in advanced disease 2 to 3% higher rates in SEER did not approach statistical significance. Actuarial laryngectomy rates at 3 years differed between the two regions, with a 4% higher rate in SEER (P =.01). In localized disease, 12.6% of Ontario patients had a laryngectomy by 3 years postdiagnosis compared to 17.9% in SEER (P =.05). In advanced disease, the rates were 63.3% and 79.2%, respectively (P =.07). There are large differences in the management of glottic cancer between the SEER areas of the U.S. and Ontario and no evidence that a policy emphasizing radiotherapy with surgery reserved for salvage is associated with worse survival. Ultimate laryngectomy rates are lower in Ontario for localized disease and may be lower for advanced disease. Conservation treatment should be used for localized disease while the treatment decision in advanced disease may be especially sensitive to patient values for voice retention versus initial cure.

A Canadian comparison of data sources for coronary artery bypass surgery outcome "report cards"

BACKGROUND

Prior comparisons of administrative versus clinical data for creating coronary artery bypass graft (CABG) surgery outcome "report cards" are all from the United States and yield inconsistent conclusions regarding the validity of administrative data report cards. In this study, we compared 2 CABG surgery outcome report cards for Ontario, Canada: one derived from clinical data from the Cardiac Care Network of Ontario and one derived from administrative data from the Canadian Institute for Health Information.

METHODS

Data from 4 fiscal years, 1992-93 through 1995-96, were used. The Canadian Institute for Health Information report card was derived from administrative data only. The Cardiac Care Network report card drew on prospectively collected clinical information that included variables such as left ventricular ejection fraction but also required linkages to the Canadian Institute for Health Information data for ascertainment of selected comorbidities and in-hospital mortality rates. Logistic regression models were used to calculate risk-adjusted death rates for each of the 9 hospitals performing CABG surgery in Ontario.

RESULTS

The risk-adjusted death rates were quite similar between data sources for 7 of the 9 hospitals. For 2 hospitals, rather large absolute differences in adjusted death rates of 0.58% and 0.64% were seen between report cards. There was a strong correlation between data sources for risk-adjusted hospital death rates (intraclass correlation coefficient = 0.927, P <.001) and for rankings of adjusted hospital death rates (Spearman correlation coefficient = 0.828, P =.02).

CONCLUSION

These results from Ontario, Canada, reveal general similarities between administrative and clinical data report cards for CABG surgery. However, clinical data are likely needed if individual hospitals are to be publicly scrutinized in outcome report cards.

Management and outcome of glottic cancer: a population-based comparison between Ontario, Canada and the SEER areas of the United States. Surveillance, Epidemiology and End Results

OBJECTIVE

We compared treatment practice and outcome in glottic cancer in Ontario, Canada to that in the Surveillance, Epidemiology and End Results (SEER) program areas in the United States to determine whether the Ontario emphasis on the use of delayed combined therapy was associated with similar survival and better laryngectomy-free survival than the U.S. approach, which emphasizes greater use of surgery.

METHODS

Electronic, clinical, and hospital data were linked to cancer registry data. The study groups compared on survival comprised all patients diagnosed from 1982 to the end of 1991 in Ontario (2324 patients) and in the SEER areas (5715 patients). Comparisons on initial treatment, laryngectomy rates, and laryngectomy-free survival were limited to subsets of these study populations due to data availability. Initial treatment data were provided by the SEER registries in the U.S. and by the cancer clinic and hospitalization data in Ontario. Information about laryngectomies performed subsequent to initial treatment was available from Medicare hospitalization data in the U.S. and from Canadian Institute for Health Information hospitalization data in Ontario.

RESULTS

Although radiotherapy was the most common initial treatment in both areas, it was used more often in Ontario (84.4% versus 63.2% in the U.S. [p < 0.001]). Relative survival was not statistically different with a relative risk comparing SEER to Ontario of 1.09, 95% confidence interval (CI) (0.93, 1.29). Laryngectomy rates were similar with a relative risk of 1.01, 95% CI (0.67, 1.52), and it follows from the survival and laryngectomy rate comparisons that the laryngectomy-free survival was not statistically different (p = .95).

CONCLUSIONS

There are large differences in the management of glottic cancer between the U.S. and Ontario and no corresponding differences in survival or laryngectomy-free survival. This work highlights a need for more clinical investigation into the relative merits of differing management policies in glottic cancer.