Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study

AIM

We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system.

METHODS AND RESULTS

In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived.

CONCLUSION

Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.

Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System

BACKGROUND

Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use.

METHODS

Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply.

RESULTS

Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year.

CONCLUSIONS

In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Association of Neighborhood-Level Material Deprivation With Atrial Fibrillation Care in a Single-Payer Health Care System: A Population-Based Cohort Study

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, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply.

RESULTS

Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13-1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07-1.27]), heart failure (HR, 1.14 [95% CI, 1.11-1.18]), or bleeding (HR, 1.16 [95% CI, 1.07-1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89-0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96-0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95-0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82-0.86]), cardioversion (HR, 0.80 [95% CI, 0.76-0.84]), and ablation (HR, 0.45 [95% CI, 0.30-0.67]).

CONCLUSIONS

Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Prone positioning of patients with moderate hypoxaemia due to covid-19: multicentre pragmatic randomised trial (COVID-PRONE)

OBJECTIVES

To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients admitted to hospital with covid-19.

DESIGN

Multicentre pragmatic randomised clinical trial.

SETTING

15 hospitals in Canada and the United States from May 2020 until May 2021.

PARTICIPANTS

Eligible patients had a laboratory confirmed or a clinically highly suspected diagnosis of covid-19, needed supplemental oxygen (up to 50% fraction of inspired oxygen), and were able to independently lie prone with verbal instruction. Of the 570 patients who were assessed for eligibility, 257 were randomised and 248 were included in the analysis.

INTERVENTION

Patients were randomised 1:1 to prone positioning (that is, instructing a patient to lie on their stomach while they are in bed) or standard of care (that is, no instruction to adopt prone position).

MAIN OUTCOME MEASURES

The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as needing at least 60% fraction of inspired oxygen for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to fraction of inspired oxygen.

RESULTS

The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomisation was 1 day, the median age of patients was 56 (interquartile range 45-65) years, 89 (36%) patients were female, and 222 (90%) were receiving oxygen via nasal prongs at the time of randomisation. The median time spent prone in the first 72 hours was 6 (1.5-12.8) hours in total for the prone arm compared with 0 (0-2) hours in the control arm. The risk of the primary outcome was similar between the prone group (18 (14%) events) and the standard care group (17 (14%) events) (odds ratio 0.92, 95% confidence interval 0.44 to 1.92). The change in the ratio of oxygen saturation to fraction of inspired oxygen after 72 hours was similar for patients randomised to prone positioning and standard of care.

CONCLUSION

Among non-critically ill patients with hypoxaemia who were admitted to hospital with covid-19, a multifaceted intervention to increase prone positioning did not improve outcomes. However, wide confidence intervals preclude definitively ruling out benefit or harm. Adherence to prone positioning was poor, despite multiple efforts to increase it. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.

STUDY REGISTRATION

ClinicalTrials.gov NCT04383613.

Cost-effectiveness of genome-wide sequencing for unexplained developmental disabilities and multiple congenital anomalies

PURPOSE

Genetic testing is routine practice for individuals with unexplained developmental disabilities and multiple congenital anomalies. However, current testing pathways can be costly and time consuming, and the diagnostic yield low. Genome-wide sequencing, including exome sequencing (ES) and genome sequencing (GS), can improve diagnosis, but at a higher cost. This study aimed to assess the cost-effectiveness of genome-wide sequencing in Ontario, Canada.

METHODS

A cost-effectiveness analysis was conducted using a discrete event simulation from a public payer perspective. Six strategies involving ES or GS were compared. Outcomes reported were direct medical costs, number of molecular diagnoses, number of positive findings, and number of active treatment changes.

RESULTS

If ES was used as a second-tier test (after the current first-tier, chromosomal microarray, fails to provide a diagnosis), it would be less costly and more effective than standard testing (CAN$6357 [95% CI: 6179-6520] vs. CAN$8783 per patient [95% CI: 2309-31,123]). If ES was used after standard testing, it would cost an additional CAN$15,228 to identify the genetic diagnosis for one additional patient compared with standard testing. The results remained robust when parameters and assumptions were varied.

CONCLUSION

ES would likely be cost-saving if used earlier in the diagnostic pathway.

Pushing the envelope: Advancing Canadian healthcare payment models through evaluation

When health systems aim to improve, two key considerations tend to be front and centre: cost and quality. On the cost side, health spending in Canada continues to rise. On the quality side, improvement is needed across the country. As the primary funder of healthcare, governments' historical role has focused on managing costs through their powers to set budgets, decide who gets paid, and how. Increasingly, governments are recognizing that the ways in which they choose to pay providers and organizations can also have an impact on the quality of care provided. Using Ontario as an example, we present a Canadian vision for modernizing how healthcare is organized and reimbursed and for using evidence and evaluation as the backbone for iterating new models. Realizing this vision will move Canada closer to international leadership in delivering high-quality, affordable care.

What "Value" Should We Pay For? A Path Toward Value-Based Payment in Canadian Healthcare Systems

There is broad consensus that achieving a "value-based" healthcare system requires a shift toward "value-based payment," but less agreement on what this entails beyond moving away from fee-for-service reimbursement. Opinions diverge on the ideal end-state payment model, and the evidence base remains equivocal. We propose a framework for Canadian payers interested in pursuing value-based payment reforms that draws lessons from two widely recognized examples of paying for value in healthcare: the US Center for Medicare & Medicaid Innovation and Canada's own experience using health technology assessment to inform payment policy.

Care setting and 30-day hospital readmissions among older adults: a population-based cohort study

BACKGROUND

Despite the fact that many older adults receive home or long-term care services, the effect of these care settings on hospital readmission is often overlooked. Efforts to reduce hospital readmissions, including capacity planning and targeting of interventions, require clear data on the frequency of and risk factors for readmission among different populations of older adults.

METHODS

We identified all adults older than 65 years discharged from an unplanned medical hospital stay in Ontario between April 2008 and December 2015. We defined 2 preadmission care settings (community, long-term care) and 3 discharge care settings (community, home care, long-term care) and used multinomial regression to estimate associations with 30-day readmission (and death as a competing risk).

RESULTS

We identified 701 527 individuals (mean age 78.4 yr), of whom 414 302 (59.1%) started in and returned to the community. Overall, 88 305 in dividuals (12.6%) were re admitted within 30 days, but this proportion varied by care setting combination. Relative to individuals returning to the community, those discharged to the community with home care (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.39-1.46) and those returning to long-term care (adjusted OR 1.35, 95% CI 1.27-1.43) had a greater risk of readmission, whereas those newly admitted to long-term care had a lower risk of readmission (adjusted OR 0.68, 95% CI 0.63-0.72).

INTERPRETATION

In Ontario, about 40% of older people were discharged from hospital to either home care or long-term care. These discharge settings, as well as whether an individual was admitted to hospital from long-term care, have important implications for understanding 30-day readmission rates. System planning and efforts to reduce readmission among older adults should take into account care settings at both admission and discharge.

Cost-Effectiveness of Magnetic Resonance-Guided Focused Ultrasound for Essential Tremor

BACKGROUND

Radiofrequency thalamotomy and deep brain stimulation are current treatments for moderate to severe medication-refractory essential tremor. However, they are invasive and thus carry risks. Magnetic resonance-guided focused ultrasound is a new, less invasive surgical option. The objective of the present study was to determine the cost-effectiveness of magnetic resonance-guided focused ultrasound compared with standard treatments in Canada.

METHODS

We conducted a cost-utility analysis using a Markov cohort model. We compared magnetic resonance-guided focused ultrasound with no surgery in people ineligible for invasive neurosurgery and with radiofrequency thalamotomy and deep brain stimulation in people eligible for invasive neurosurgery. In the reference case analysis, we used a 5-year time horizon and a public payer perspective and discounted costs and benefits at 1.5% per year.

RESULTS

Compared with no surgery in people ineligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound cost $21,438 more but yielded 0.47 additional quality-adjusted life years, producing an incremental cost-effectiveness ratio of $45,817 per quality-adjusted life year gained. In people eligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound was slightly less effective but much less expensive compared with the current standard of care, deep brain stimulation. The results were sensitive to assumptions regarding the time horizon, cost of magnetic resonance-guided focused ultrasound, and probability of recurrence.

CONCLUSIONS

In people ineligible for invasive neurosurgery, the incremental cost-effectiveness ratio of magnetic resonance-guided focused ultrasound versus no surgery is comparable to many other tests and treatments that are widely adopted in high-income countries. In people eligible for invasive neurosurgery, magnetic resonance-guided focused ultrasound is also a reasonable option. © 2018 International Parkinson and Movement Disorder Society.

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series

BACKGROUND

Opioids have narrow therapeutic windows, and errors in ordering or administration can be fatal. The purpose of this study was to describe deaths involving hydromorphone and morphine, which have similar-sounding names, but different potencies.

METHODS

In this case series, we describe deaths of patients admitted to hospital or residents of long-term care facilities that involved hydromorphone and morphine. We searched for deaths referred to the Patient Safety Review Committee of the Office of the Chief Coroner for Ontario between 2007 and 2012, and subsequently reviewed by 2014. We reviewed each case to identify intervention points where errors could have been prevented.

RESULTS

We identified 8 cases involving decedents aged 19 to 91 years. The cases involved errors in prescribing, order processing and transcription, dispensing, administration and monitoring. For 7 of the 8 cases, there were multiple (2 or more) possible intervention points. Six cases may have been prevented by additional patient monitoring, and 5 cases involved dispensing errors.

INTERPRETATION

Opioid toxicity deaths in patients living in institutions can be prevented at multiple points in the prescribing and dispensing processes. Interventions aimed at preventing errors in hydromorphone and morphine prescribing, administration and patient monitoring should be implemented and rigorously evaluated.

Robot-assisted hysterectomy for endometrial and cervical cancers: a systematic review

Total and radical hysterectomies are the most common treatment strategies for early-stage endometrial and cervical cancers, respectively. Surgical modalities include open surgery, laparoscopy, and more recently, minimally invasive robot-assisted surgery. We searched several electronic databases for randomized controlled trials and observational studies with a comparison group, published between 2009 and 2014. Our outcomes of interest included both perioperative and morbidity outcomes. We included 35 observational studies in this review. We did not find any randomized controlled trials. The quality of evidence for all reported outcomes was very low. For women with endometrial cancer, we found that there was a reduction in estimated blood loss between the robot-assisted surgery compared to both laparoscopy and open surgery. There was a reduction in length of hospital stay between robot-assisted surgery and open surgery but not laparoscopy. There was no difference in total lymph node removal between the three modalities. There was no difference in the rate of overall complications between the robot-assisted technique and laparoscopy. For women with cervical cancer, there were no differences in estimated blood loss or removal of lymph nodes between robot-assisted and laparoscopic procedure. Compared to laparotomy, robot-assisted hysterectomy for cervical cancer showed an overall reduction in estimated blood loss. Although robot-assisted hysterectomy is clinically effective for the treatment of both endometrial and cervical cancers, methodologically rigorous studies are lacking to draw definitive conclusions.

Mechanical Thrombectomy in Acute Ischemic Stroke: A Systematic Review

Although intravenous thrombolysis increases the probability of a good functional outcome in carefully selected patients with acute ischemic stroke, a substantial proportion of patients who receive thrombolysis do not have a good outcome. Several recent trials of mechanical thrombectomy appear to indicate that this treatment may be superior to thrombolysis. We therefore conducted a systematic review and meta-analysis to evaluate the clinical effectiveness and safety of new-generation mechanical thrombectomy devices with intravenous thrombolysis (if eligible) compared with intravenous thrombolysis (if eligible) in patients with acute ischemic stroke caused by a proximal intracranial occlusion. We systematically searched seven databases for randomized controlled trials published between January 2005 and March 2015 comparing stent retrievers or thromboaspiration devices with best medical therapy (with or without intravenous thrombolysis) in adults with acute ischemic stroke. We assessed risk of bias and overall quality of the included trials. We combined the data using a fixed or random effects meta-analysis, where appropriate. We identified 1579 studies; of these, we evaluated 122 full-text papers and included five randomized control trials (n=1287). Compared with patients treated medically, patients who received mechanical thrombectomy were more likely to be functionally independent as measured by a modified Rankin score of 0-2 (odds ratio, 2.39; 95% confidence interval, 1.88-3.04; I2=0%). This finding was robust to subgroup analysis. Mortality and symptomatic intracerebral hemorrhage were not significantly different between the two groups. Mechanical thrombectomy significantly improves functional independence in appropriately selected patients with acute ischemic stroke.

Increase in Utilization of Afterhours Medical Imaging: A Study of Three Canadian Academic Centers

Objectives

The objectives of our study were to assess trends in afterhours medical imaging utilization for emergency department (ED) and inpatient (IP) patient populations from 2006-2013, including analysis by modality and specialty and with adjustment for patient volume.

Methods

For this retrospective study, we reviewed the number of CT, MRI, and ultrasound studies performed for the ED and IP patients during the afterhours time period (5pm - 8am on weekdays and 24 hours on weekends and statutory holidays) from 2006-2013 at three different Canadian academic hospitals. We used the Jonckheere-Terpstra (JT) test to determine statistical significance of imaging and patient volume trends. A regression model was used to examine whether there was an increasing trend over time in the volume of imaging tests per 1000 patients.

Results

For all three sites from 2006-2013 during the afterhours time period: There was a statistically significant increasing trend in total medical imaging volume, which also held true when the volumes were assessed by modality and by specialty. There was a statistically significant increasing trend in ED and IP patient volume. When medical imaging volumes were adjusted for patient volumes, there was a statistically significant increasing trend in imaging being performed per patient.

Conclusion

Afterhours medical imaging volumes demonstrated a statistically significant increasing trend at all three sites from 2006-2013 when assessed by total volume, modality, and specialty. During the same time period and at all three sites, the ED and IP patient volumes also demonstrated a statistically significant increasing trend with more medical imaging, however, being performed per patient.

Impact of legislation and a prescription monitoring program on the prevalence of potentially inappropriate prescriptions for monitored drugs in Ontario: a time series analysis

BACKGROUND

The increased use of opioid analgesics, sedative hypnotics and stimulants, coupled with the associated risks of overdose have raised concerns around the inappropriate prescribing of these monitored drugs. We assessed the impact of new legislation, the Narcotics Safety and Awareness Act, and a centralized Narcotics Monitoring System (implemented November 2011 and May 2012, respectively), on the dispensing of prescriptions suggestive of misuse.

METHODS

We conducted a time series analysis of publicly funded prescriptions for opioids, benzodiazepines and stimulants dispensed monthly in Ontario from January 2007 to May 2013, based on information in the Ontario Public Drug Benefit Database. In the primary analysis, a prescription was deemed potentially inappropriate if it was dispensed within 7 days of an earlier prescription and was for at least 30 tablets of a drug in the same class as the earlier prescription, but originated from a different physician and a different pharmacy.

RESULTS

After enactment of the new legislation, the prevalence of potentially inappropriate opioid prescriptions decreased by 12.5% in 6 months (from 1.6% in October 2011 to 1.4% in April 2012; p = 0.01). No further significant change was observed after the introduction of the narcotic monitoring system (p = 0.8). By May 2013, the prevalence had dropped to 1.0%. Inappropriate benzodiazepine prescribing was significantly influenced by both the legislation (p < 0.001) and the monitoring system (p = 0.05), which together reduced potentially inappropriate prescribing by 50.0% between October 2011 and May 2013 (from 0.4% to 0.2%). The prevalence of potentially inappropriate prescribing of stimulants was significantly influenced by the introduction of the monitoring system in May 2012, falling from 0.7% in April 2012 to 0.3% in May 2013 (p = 0.02).

INTERPRETATION

For a select group of drugs prone to misuse and diversion, legislation and a prescription monitoring program reduced the prevalence of prescriptions suggestive of misuse. This suggests that regulatory interventions can promote appropriate prescribing which could potentially be applied to other jurisdictions and drugs of concern.

The perspectives of patients, family members and healthcare professionals on readmissions: preventable or inevitable?

An understanding of what complex medical patients with chronic conditions, family members and healthcare professionals perceive to be the key reasons for the readmission is important to preventing their occurrence. In this context, we undertook a study to understand the perceptions of patients, family members and healthcare professionals regarding the reasons for, and preventability of, readmissions. An exploratory case design with semi-structured interviews was conducted with 49 participants, including patients, family members, nurses, case managers, physicians, discharge planners from a general internal medicine unit at a large and academic hospital. Data were analyzed using a directed content analysis approach that involved three investigators. Two contrasting themes emerged from the analysis of interview data set. The first theme was readmissions as preventable occurrences. Our analyses elucidated contributing factors to readmissions during the patients' hospital stay and after the patients were discharged. The second theme was readmissions as inevitable, occurring due to the progression of disease. Our study findings indicate that some readmissions are perceived to be inevitable due to the burden of disease while others are perceived to be preventable and associated with factors both in hospital and post-discharge. Continued interprofessional efforts are required to identify patients at risk for readmission and to organize and deliver care to improve health outcomes after hospitalization.

Integrated client care for frail older adults in the community: preliminary report on a system-wide approach

The Toronto Central Community Care Access Centre is leading a collaborative local health integration network systemic change initiative to implement and evaluate a practical model of integrated care for older adults with complex needs. The approach is embedded in the community where older adults and their families live and is designed to first and foremost improve the quality of care while ultimately bending the cost curve. The model is leveraging and aligning existing system resources by bringing together sectors from across the health system to create ways of working that build capacity in the system to be more responsive to this population. Outcomes to date will be discussed and next steps described. The secondary goal was to understand the key elements of this integration that can be scaled locally and across the province.

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions

BACKGROUND

Urgent, unplanned hospital readmissions are increasingly being used to gauge the quality of care. We reviewed urgent readmissions to determine which were potentially avoidable and compared rates of all-cause and avoidable readmissions.

METHODS

In a multicentre, prospective cohort study, we reviewed all urgent readmissions that occurred within six months among patients discharged to the community from 11 teaching and community hospitals between October 2002 and July 2006. Summaries of the readmissions were reviewed by at least four practising physicians using standardized methods to judge whether the readmission was an adverse event (poor clinical outcome due to medical care) and whether the adverse event could have been avoided. We used a latent class model to determine whether the probability that each readmission was truly avoidable exceeded 50%.

RESULTS

Of the 4812 patients included in the study, 649 (13.5%, 95% confidence interval [CI] 12.5%-14.5%) had an urgent readmission within six months after discharge. We considered 104 of them (16.0% of those readmitted, 95% CI 13.3%-19.1%; 2.2% of those discharged, 95% CI 1.8%-2.6%) to have had a potentially avoidable readmission. The proportion of patients who had an urgent readmission varied significantly by hospital (range 7.5%-22.5%; χ(2) = 92.9, p < 0.001); the proportion of readmissions deemed avoidable did not show significant variation by hospital (range 1.2%-3.7%; χ(2) = 12.5, p < 0.25). We found no association between the proportion of patients who had an urgent readmission and the proportion of patients who had an avoidable readmission (Pearson correlation 0.294; p = 0.38). In addition, we found no association between hospital rankings by proportion of patients readmitted and rankings by proportion of patients with an avoidable readmission (Spearman correlation coefficient 0.28, p = 0.41).

INTERPRETATION

Urgent readmissions deemed potentially avoidable were relatively uncommon, comprising less than 20% of all urgent readmissions following hospital discharge. Hospital-specific proportions of patients who were readmitted were not related to proportions with a potentially avoidable readmission.

Private health insurance: an international overview and considerations for Canada

Since the passage of the Canada Health Act in 1984 and its prohibition of extra-billing, there has been an extremely limited role for private health insurance in Canada as a mechanism to pay for medically necessary physician or hospital services. In the aftermath of the landmark Supreme Court decision Chaoulli v. Québec, this may change.

Sex differences in inappropriate prescribing among elderly veterans

BACKGROUND

Previous studies have suggested that older women may be more likely than older men to receive potentially inappropriate prescriptions. A better understanding of sex differences in inappropriate prescribing can help inform the development of effective interventions.

OBJECTIVE

This study was conducted to assess sex differences in rates of inappropriate prescribing before and after accounting for potentially appropriate indications and to examine sex differences in predictors of inappropriate drug use.

METHODS

This was a retrospective cohort study of administrative data from the national Veterans Health Administration (VA). Participants were veterans aged >or=65 years who had >or=1 patient visit at VA outpatient facilities in fiscal year 1999 (FY99) and 2000 (FY00). The main outcome measure was the diagnosis-adjusted prevalence of 33 potentially inappropriate medications as judged by the Beers criteria in FY00: overall, by individual drug, and in 3 categories grouped by potential indication ("always avoid," "rarely appropriate," and "some indications").

RESULTS

The study population included 965,756 patients (946,641 men and 19,115 women). Women were more likely than men to receive inappropriate medications overall and in all 3 categories, even after accounting for diagnoses that may have justified the prescription. Women were more likely to receive 16 of the 33 medications (analgesics, psychotropic drugs, and anticholinergic agents), and men were more likely to receive 3 of the 33. After controlling for sociodemographic characteristics, number of medications, and care characteristics, women remained more likely to receive inappropriate drugs. Receipt of geriatric care was equally protective for men and women, although only a small proportion received this care. Psychiatric comorbidity was associated with inappropriate prescribing for men but not for women.

CONCLUSIONS

Analgesic, psychotropic, and anticholinergic medications that should be avoided contributed to higher rates of inappropriate drug use among older women than among older men. Targeted efforts to avoid these medications in older women may help reduce overall rates of inappropriate prescribing. Sex-stratified reporting of quality indicators that assess inappropriate prescribing among community-dwelling elders would help monitor the effectiveness of improvement efforts.