Association between sodium-glucose cotransporter-2 inhibitors and arrhythmic outcomes in patients with diabetes and pre-existing atrial fibrillation

AIMS

Prior studies suggest that sodium-glucose cotransporter-2 inhibitors (SGLT2is) may decrease the incidence of atrial fibrillation (AF). However, it is unknown whether SGLT2i can attenuate the disease course of AF among patients with pre-existing AF and Type II diabetes mellitus (DM). In this study, our objective was to examine the association between SGLT2i prescription and arrhythmic outcomes among patients with DM and pre-existing AF.

METHODS AND RESULTS

We conducted a population-based cohort study of adults with DM and AF between 2014 and 2019. Using a prevalent new-user design, individuals prescribed SGLT2i were matched 1:1 to those prescribed dipeptidyl peptidase-4 inhibitors (DPP4is) based on time-conditional propensity scores. The primary endpoint was a composite of AF-related healthcare utilization (i.e. hospitalization, emergency department visits, electrical cardioversion, or catheter ablation). Secondary outcome measures included all-cause mortality, heart failure (HF) hospitalization, and ischaemic stroke or transient ischaemic attack (TIA). Cox proportional hazard models were used to examine the association of SGLT2i with the study endpoint. Among 2242 patients with DM and AF followed for an average of 3.0 years, the primary endpoint occurred in 8.7% (n = 97) of patients in the SGLT2i group vs. 10.0% (n = 112) of patients in the DPP4i group [adjusted hazard ratio 0.73 (95% confidence interval 0.55-0.96; P = 0.03)]. Sodium-glucose cotransporter-2 inhibitors were associated with significant reductions in all-cause mortality and HF hospitalization, but there was no difference in the risk of ischaemic stroke/TIA.

CONCLUSION

Among patients with DM and pre-existing AF, SGLT2is are associated with decreased AF-related health resource utilization and improved arrhythmic outcomes compared with DPP4is.

Sodium-glucose co-transporter-2 inhibitors are associated with kidney benefits at all degrees of albuminuria: A retrospective cohort study of adults with diabetes

AIM

To estimate the real-world effectiveness of sodium-glucose co-transporter-2 inhibitors (SGLT2is) versus dipeptidyl peptidase-4 inhibitors (DPP4is) at reducing loss of kidney function and adverse kidney events in adults with varying levels of albuminuria.

MATERIALS AND METHODS

In this retrospective cohort study using administrative data, we matched new SGLT2i users 1:2 to DPP4i users on diabetes therapy, chronic kidney disease (CKD) stage, albuminuria and time-conditional propensity score. Albuminuria was defined by spot urine albumin or equivalent as mild, moderate or severe. Linear regression was used to model the estimated glomerular filtration rate (eGFR), and Poisson regression for a composite kidney outcome (> 40% loss of eGFR, kidney replacement therapy or death from kidney causes) and all-cause mortality.

RESULTS

SGLT2i users (n = 19 238, median age 57.9 years, female 40.9%) had mostly nil/mild albuminuria (70.7%). SGLT2is were associated with a 1.36 (95% CI 0.98-1.74) mL/min/1.73m2 (P < .001) acute (≤ 60 days) decline in eGFR, relative to DPP4is. Thereafter, SGLT2is were associated with 1.04 (95% CI 0.93-1.15) mL/min/1.73m2 (P < .001) less annual eGFR loss. SGLT2i users had fewer adverse kidney outcomes (incidence rate ratio [IRR] 0.58 [0.47-0.71]; P < .001), but not all-cause mortality (IRR 0.82 [0.66-1.01]; P = .06). Outcomes were similar considering only those with nil/mild albuminuria.

CONCLUSIONS

SGLT2is may prevent eGFR decline and reduce the risk of adverse kidney events in adults with diabetes and nil or non-severe albuminuria.

Association of cesarean section delivery with childhood behavior: a systematic review protocol

OBJECTIVE

This review will evaluate the association between cesarean section delivery and child behavior problems.

INTRODUCTION

Cesarean section (C-section) deliveries account for over 30% of deliveries in Canada and 21% of all births globally. Mode of delivery via C-section has been associated with altered maternal mental health in the postpartum period, and postpartum depression is linked to an increased risk of internalizing and externalizing behaviors in children. Given the high rates of C-section deliveries worldwide, it is important to determine how mode of delivery impacts child behavior.

INCLUSION CRITERIA

The review will examine child behavior outcomes among preschool and school-aged children as determined by medical diagnosis or a standardized assessment tool. Multiple gestation pregnancies and pre-term delivery will be excluded.

METHODS

A search will be conducted using APA PsycINFO (Ovid), MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), and Scopus. This review will evaluate peer-reviewed primary observational research studies specifically looking at C-section delivery. Two reviewers will independently screen titles, abstracts, and full-text studies to determine alignment with the inclusion and exclusion criteria. Data will be recorded using the standardized JBI data extraction tool and will be presented using figures, tables, and a summary. Where feasible, we will conduct a meta-analysis and subgroup analysis of suitable populations. Critical appraisal of studies will be performed for included studies. The certainty of the evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

REVIEW REGISTRATION

PROSPERO CRD42022371294.

Sociodemographic Characteristics and Mental and Physical Health Diagnoses of Yazidi Refugees Who Survived the Daesh Genocide and Resettled in Canada

Importance

The health status of Yazidi refugees, a group of ethnoreligious minority individuals from northern Iraq who resettled in Canada between 2017 and 2018 after experiencing genocide, displacement, and enslavement by the Islamic State (Daesh), is unknown but important to guide health care and future resettlement planning for Yazidi refugees and other genocide victims. In addition, resettled Yazidi refugees requested documentation of the health impacts of the Daesh genocide.

Objective

To characterize sociodemographic characteristics, mental and physical health conditions, and family separations among Yazidi refugees who resettled in Canada.

Design, Setting, and Participants

This retrospective clinician- and community-engaged cross-sectional study included 242 Yazidi refugees seen at a Canadian refugee clinic between February 24, 2017, and August 24, 2018. Sociodemographic and clinical diagnoses were extracted through review of electronic medical records. Two reviewers independently categorized patients' diagnoses by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and ICD-10-CM chapter groups. Diagnosis frequencies were calculated and stratified by age group and sex. Five expert refugee clinicians used a modified Delphi approach to identify diagnoses likely to be associated with Daesh exposure, then corroborated these findings with Yazidi leader coinvestigators. A total of 12 patients without identified diagnoses during the study period were excluded from the analysis of health conditions. Data were analyzed from September 1, 2019, to November 30, 2022.

Main Outcomes and Measures

Sociodemographic characteristics; exposure to Daesh captivity, torture, or violence (hereinafter, Daesh exposure); mental and physical health diagnoses; and family separations.

Results

Among 242 Yazidi refugees, the median (IQR) age was 19.5 (10.0-30.0) years, and 141 (58.3%) were female. A total of 124 refugees (51.2%) had direct Daesh exposure, and 60 of 63 families (95.2%) experienced family separations after resettlement. Among 230 refugees included in the health conditions analysis, the most common clinical diagnoses were abdominal and pelvic pain (47 patients [20.4%]), iron deficiency (43 patients [18.7%]), anemia (36 patients [15.7%]), and posttraumatic stress disorder (33 patients [14.3%]). Frequently identified ICD-10-CM chapters were symptoms and signs (113 patients [49.1%]), nutritional diseases (86 patients [37.4%]), mental and behavioral disorders (77 patients [33.5%]), and infectious and parasitic diseases (72 patients [31.3%]). Clinicians identified mental health conditions (74 patients [32.2%]), suspected somatoform disorders (111 patients [48.3%]), and sexual and physical violence (26 patients [11.3%]) as likely to be associated with Daesh exposure.

Conclusions and Relevance

In this cross-sectional study, Yazidi refugees who resettled in Canada after surviving the Daesh genocide experienced substantial trauma, complex mental and physical health conditions, and nearly universal family separations. These findings highlight the need for comprehensive health care, community engagement, and family reunification and may inform care for other refugees and genocide victims.

Strategies Addressing Barriers to the Implementation of a Pediatric Hand Fracture Care Pathway

We recently highlighted shortcomings in the care of pediatric hand fractures in our local context. The Calgary Kids’ Hand Rule (CKHR) was developed to predict hand fractures that require referral to a hand surgeon. The aims of this study were to identify barriers to a new care pathway for pediatric hand fractures, based on the CKHR and to generate tailored strategies to support its implementation.

Prognostic value of echocardiography-derived right ventricular dysfunction in haemodynamically stable pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

We sought to determine the prognostic value of transthoracic echocardiography (TTE)-derived right ventricular dysfunction (RVD) in haemodynamically stable and intermediate-risk patients with acute pulmonary embolism (PE), evaluate continuous RVD parameters, and assess the literature quality.

METHODS

We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials for studies assessing TTE-derived RVD in haemodynamically stable PE that reported in-hospital adverse events within 30 days. We determined pooled odds ratios (ORs) using a random-effects model, created funnel plots, evaluated the Newcastle-Ottawa scale and performed Grading of Recommendations, Assessment, Development and Evaluation.

RESULTS

Based on 55 studies (17 090 patients, 37.8% RVD), RVD was associated with combined adverse events (AEs) (OR 3.29, 95% confidence interval (CI) 2.59-4.18), mortality (OR 2.00, CI 1.66-2.40) and PE-related mortality (OR 4.01, CI 2.79-5.78). In intermediate-risk patients, RVD was associated with AEs (OR 1.99, CI 1.17-3.37) and PE-related mortality (OR 6.16, CI 1.33-28.40), but not mortality (OR 1.63, CI 0.76-3.48). Continuous RVD parameters provide a greater spectrum of risk compared to categorical RVD. We identified publication bias, poor methodological quality in 34/55 studies and overall low certainty of evidence.

CONCLUSIONS

RVD is frequent in PE and associated with adverse outcomes. However, data quality and publication bias are limitations of existing evidence.

Association of Albuminuria and Regression of Chronic Kidney Disease in Adults With Newly Diagnosed Moderate to Severe Chronic Kidney Disease

IMPORTANCE

People with chronic kidney disease (CKD) are risk-stratified for adverse events based on estimated glomerular filtration rate (eGFR) and albuminuria level. CKD has often a favorable course (CKD regression) regardless of eGFR. Determining whether lower albuminuria is associated with CKD regression may have implications on CKD management.

OBJECTIVE

To assess the 5-year probability of CKD regression across albuminuria categories accounting for the competing risks of CKD progression and death in people with newly diagnosed CKD and the association between albuminuria level and CKD regression.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used administrative and laboratory data from Alberta, Canada, for adults with incident moderate to severe CKD (defined as sustained eGFR of 15-44 mL/min/1.73 m2 for >90 days), between April 1, 2008, and March 31, 2017, and albuminuria measures before cohort entry. Data analysis occurred in January to June 2022.

EXPOSURE

Albuminuria categories were defined by albumin to creatinine ratios (ACRs): A1 (ACR, <3 mg/mmol), A2 (ACR, 3-29 mg/mmol), A3<60 (ACR, 30-59 mg/mmol), and A3≥60 (ACR, ≥60 mg/mmol).

MAIN OUTCOMES AND MEASURES

The main outcome was time to the earliest of CKD regression or progression (sustained change in CKD stage for >3 months and ≥25% increase or decrease in eGFR from baseline or kidney failure, respectively), death, or censoring (outmigration or study end date: March 31, 2019). Cumulative incidence functions were used to estimate absolute risks, and cause-specific Cox models were used to assess the association between albuminuria and CKD regression, accounting for age, sex, eGFR, comorbidities, and health services use indicators.

RESULTS

Of 58 004 people with moderate to severe CKD (mean [SD] age, 77 [12] years; 31 725 [55%] women), 35 360 had A1 albuminuria (61%), 15 597 had A2 albuminuria (27%), 1527 had A3<60 albuminuria (3%), and 5520 had A3≥60 albuminuria (10%). Five-year probability of regression was highest with A1 (22.6%), followed by A2 (16.5%), and A3<60 (11.6%) and lowest with A3≥60 (5.3%). Using A1 albuminuria as the reference group, the hazard of regression was highest for A2 (hazard ratio [HR], 0.75; 95% CI, 0.72-0.79), then A3<60 (HR, 0.47; 95% CI, 0.40-0.54), and lowest for A3≥60 (HR, 0.27; 95% CI, 0.24-0.30).

CONCLUSIONS AND RELEVANCE

In this cohort study of people with moderate to severe CKD, albuminuria levels were inversely associated with CKD regression. These findings extend the key prognostic role of albuminuria, offering novel opportunities to discuss both favorable and adverse outcomes in people with CKD and inform CKD management.

Health State Utility Values in People With Stroke: A Systematic Review and Meta-Analysis

Background Health state utility values are commonly used to provide summary measures of health-related quality of life in studies of stroke. Contemporaneous summaries are needed as a benchmark to contextualize future observational studies and inform the effectiveness of interventions aimed at improving post-stroke quality of life. Methods and Results We conducted a systematic search of the literature using Medline, EMBASE, and Web of Science from January 1995 until October 2020 using search terms for stroke, health-related quality of life, and indirect health utility metrics. We calculated pooled estimates of health utility values for EQ-5D-3L, EQ-5D-5L, AQoL, HUI2, HUI3, 15D, and SF-6D using random effects models. For the EQ-5D-3L we conducted stratified meta-analyses and meta-regression by key subgroups. We screened 14 251 abstracts and 111 studies met our inclusion criteria (sample size range 11 to 12 447). EQ-5D-3L was reported in 78% of studies (study n=87; patient n=56 976). The pooled estimate for EQ-5D-3L at ≥3 months following stroke was 0.65 (95% CI, 0.63-0.67), which was ≈20% below population norms. There was high heterogeneity (I2>90%) between studies, and estimates differed by study size, case definition of stroke, and country of study. Women, older individuals, those with hemorrhagic stroke, and patients prior to discharge had lower pooled EQ-5D-3L estimates. Conclusions Pooled estimates of health utility for stroke survivors were substantially below population averages. We provide reference values for health utility in stroke to support future clinical and economic studies and identify subgroups with lower healthy utility. Registration URL: https://www.crd.york.ac.uk/prospero/. Unique Identifier: CRD42020215942.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study

PURPOSE

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs.

METHODS

We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression.

RESULTS

Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin.

CONCLUSIONS

Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Linkage of Emergency Medical Services and Hospital Data: A Necessary Precursor to Improve Understanding of Outcomes of Prehospital Care

Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias.Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records.Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found.Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias.

Machine learning for identification of frailty in Canadian primary care practices

Introduction

Frailty is a medical syndrome, commonly affecting people aged 65 years and over and is characterized by a greater risk of adverse outcomes following illness or injury. Electronic medical records contain a large amount of longitudinal data that can be used for primary care research. Machine learning can fully utilize this wide breadth of data for the detection of diseases and syndromes. The creation of a frailty case definition using machine learning may facilitate early intervention, inform advanced screening tests, and allow for surveillance.

Objectives

The objective of this study was to develop a validated case definition of frailty for the primary care context, using machine learning.

Methods

Physicians participating in the Canadian Primary Care Sentinel Surveillance Network across Canada were asked to retrospectively identify the level of frailty present in a sample of their own patients (total n = 5,466), collected from 2015–2019. Frailty levels were dichotomized using a cut-off of 5. Extracted features included previously prescribed medications, billing codes, and other routinely collected primary care data. We used eight supervised machine learning algorithms, with performance assessed using a hold-out test set. A balanced training dataset was also created by oversampling. Sensitivity analyses considered two alternative dichotomization cut-offs. Model performance was evaluated using area under the receiver-operating characteristic curve, F1, accuracy, sensitivity, specificity, negative predictive value and positive predictive value.

Results

The prevalence of frailty within our sample was 18.4%. Of the eight models developed to identify frail patients, an XGBoost model achieved the highest sensitivity (78.14%) and specificity (74.41%). The balanced training dataset did not improve classification performance. Sensitivity analyses did not show improved performance for cut-offs other than 5.

Conclusion

Supervised machine learning was able to create well performing classification models for frailty. Future research is needed to assess frailty inter-rater reliability, and link multiple data sources for frailty identification.

Association between neighborhood built environment and health-related fitness: a systematic review protocol

OBJECTIVE

The objective of this review is to summarize the current literature on the association between the neighborhood built environment and components of health-related fitness. The findings may be useful for policy-makers and health professionals to inform the development of health-supportive neighborhood built environments.

INTRODUCTION

There is accumulating evidence linking neighborhood built environments to health, including physical activity and chronic health conditions, yet little is known about the potential links between the built environment and health-related fitness. Although physical activity and health-related fitness are intimately linked, health-related fitness is thought to be a more proximate and stronger correlate of health. Understanding how the built environment influences health-related fitness will allow better health-promoting urban design and population-level interventions.

INCLUSION CRITERIA

Published and unpublished evidence will be included if it has a quantitative component and the sample includes adults aged 18 years or older, with no physical disabilities or health issues that may affect health-related fitness. The exposure of interest will be objectively measured and self-reported neighborhood built characteristics. The outcome of interest will be objectively measured and self-reported components of health-related fitness (ie, morphological, muscular, motor, and cardiorespiratory fitness).

METHODS

We will follow the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases used in the search will include MEDLINE, Embase, CINAHL, Web of Science, SPORTDiscus, Environment Complete, and Transport Research International Documentation with no date or language restrictions. Two independent reviewers will screen titles and abstracts, and assess full-text studies against the inclusion criteria. Study quality will be assessed by two independent reviewers using the critical appraisal tools from JBI. A narrative approach will be used to synthesize the study findings; if data permit, a meta-analysis will be completed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020179807.

1185The association between neighbourhood built environment and health-related fitness: A systematic review

Background

Few studies have investigated potential links between the built environment and health-related fitness, even though there is some evidence linking neighbourhood built environments to physical activity behaviors and chronic health conditions.

Methods

Following PRISMA guidelines eight databases were searched from inception to August 2020 using a combination of built environment and health-related fitness terms. Inclusion criteria was limited to quantitative studies that sampled of adults aged 18 years or older with no physical disabilities or health issues that may impact health-related fitness.

Results

Of the 26,219 citations identified within our comprehensive search, 25 studies met eligibility and underwent data extraction and quality assessment. Objectively measured built environment characteristics (e.g., improved sidewalks, higher street connectivity, older neighbourhoods, higher residential density, and higher land use mix) were associated with increased flexibility, cardiorespiratory fitness, grip strength, and body composition. Moreover, perceptions of neighbourhood features such as higher neighbourhood walkability, greater park access and quality, and lower neighbourhood crime, were associated with increased perceived cardiorespiratory fitness, muscular strength, flexibility, and overall fitness. However, many of these findings were from cross-sectional studies where adjustment for key confounders varied. Results also varied by sex in the small number of studies that provided sex-specific stratifications.

Conclusions

This project may help elucidate the pathway between the built environment and health-related fitness.

Key messages

Neighbourhood built environment features are associated with aspects of health-related fitness.

86Segmenting persistently high-cost individuals into actionable groups

Background

Despite growing evidence describing high cost patients, decision-makers struggle to implement effective strategies to improve care and curb spending in this population. Using a multi-phased approach, we aimed to classify high cost patients into homogeneous subgroups amenable to targeted interventions.

Methods

We linked population-level administrative health data in Alberta, Canada from 2012-2017. We defined “persistently high-cost” as those in the top 1% of cumulative inpatient, outpatient and medication cost in at least two consecutive years. We used latent class analysis to separate this persistent high-cost population into potentially actionable subgroups.

Results

Of the 3,795,067 adults residing in Alberta, 21,361 were ‘persistently high-cost’. Latent class models identified 10 high-cost subgroups: individuals with CKD (19.3% of persistent high-cost individuals), those undergoing joint surgery/replacement and rehabilitation (18.6%), individuals with IBD (11.6%), patients receiving biologics for autoimmune conditions (11.3%), patients receiving high cost drugs for other conditions (11.1%), community-dwelling individuals with multimorbid chronic conditions (9.0%), individuals with schizophrenia (6.8%), individuals with other mental health issues (6.2%), rural individuals with COPD (3.4%), and frail elderly in institutional settings (2.7%).

Conclusions

Latent class analysis was able to identify 10 persistently high-cost groups based on meaningful differences in health care spending, demographics, and clinical diagnoses.

Key messages

This taxonomy will inform the identification of interventions shown to improve care and reduce cost for each subgroup in addition to consultation with key stakeholders to identify and reflect on key barriers and facilitators to implementing identified interventions within the local context.

Prevalence of polypharmacy and associated adverse health outcomes in adult patients with chronic kidney disease: protocol for a systematic review and meta-analysis

BACKGROUND

Polypharmacy, often defined as the concomitant use of ≥ 5 medications, has been identified as a significant global public health threat. Aging and multimorbidity are key drivers of polypharmacy and have been linked to a broad range of adverse health outcomes and mortality. Patients with chronic kidney disease (CKD) are particularly at high risk of polypharmacy and use of potentially inappropriate medications given the numerous risk factors and complications associated with CKD. The aim of this systematic review will be to assess the prevalence of polypharmacy among adult patients with CKD, and the potential association between polypharmacy and adverse health outcomes within this population.

METHODS/DESIGN

We will search empirical databases such as MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and PsycINFO and grey literature from inception onwards (with no language restrictions) for observational studies (e.g., cross-sectional or cohort studies) reporting the prevalence of polypharmacy in adult patients with CKD (all stages including dialysis). Two reviewers will independently screen all citations, full-text articles, and extract data. Potential conflicts will be resolved through discussion. The study methodological quality will be appraised using an appropriate tool. The primary outcome will be the prevalence of polypharmacy. Secondary outcomes will include any adverse health outcomes (e.g., worsening kidney function) in association with polypharmacy. If appropriate, we will conduct random effects meta-analysis of observational data to summarize the pooled prevalence of polypharmacy and the associations between polypharmacy and adverse outcomes. Statistical heterogeneity will be estimated using Cochran's Q and I2 index. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., sex, kidney replacement therapy, multimorbidity).

DISCUSSION

Given that polypharmacy is a major and a growing public health issue, our findings will highlight the prevalence of polypharmacy, hazards associated with it, and medication thresholds associated with adverse outcomes in patients with CKD. Our study will also draw attention to the prognostic importance of improving medication practices as a key priority area to help minimize the use of inappropriate medications in patients with CKD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: [ CRD42020206514 ].

Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study

Background:

Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable.

Objective:

To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category.

Design:

Retrospective cohort study using population-based data.

Setting:

Alberta, Canada.

Patients:

All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository.

Measurements:

CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm.

Methods:

Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category.

Results:

Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively).

Limitations:

Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable.

Conclusions:

Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings.

Trial registration:

Not applicable—observational study design

Effect of oral anticoagulant use on surgical delay and mortality in hip fracture

AIMS

Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality).

RESULTS

A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA.

CONCLUSION

Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222-233.

Validation of Risk Prediction Models to Inform Clinical Decisions After Acute Kidney Injury

Rationale & Objective

There is limited evidence to guide follow-up after acute kidney injury (AKI). Knowledge gaps include which patients to prioritize, at what time point, and for mitigation of which outcomes. In this study, we sought to compare the net benefit of risk model–based clinical decisions following AKI.

Study Design

External validation of 2 risk models of AKI outcomes: the Grampian -Aberdeen (United Kingdom) AKI readmissions model and the Alberta (Canada) kidney disease risk model of chronic kidney disease (CKD) glomerular (G) filtration rate categories 4 and 5 (CKD G4 and G5). Process mining to delineate existing care pathways.

Setting & Participants

Validation was based on data from adult hospital survivors of AKI from Grampian, 2011-2013.

Predictors

KDIGO-based measures of AKI severity and comorbidities specified in the original models.

Outcomes

Death or readmission within 90 days for all hospital survivors. Progression to new CKD G4-G5 for patients surviving at least 90 days after AKI.

Analytical Approach

Decision curve analysis to assess the “net benefit” of use of risk models to guide clinical care compared to alternative approaches (eg, prioritizing all AKI, severe AKI, or only those without kidney recovery).

Results

26,575 of 105,461 hospital survivors in Grampian (mean age, 60.9 ± 19.8 [SD] years) were included for validation of the death or readmission model, and 9,382 patients (mean age, 60.9 ± 19.8 years) for the CKD G4-G5 model. Both models discriminated well (area under the curve [AUC], 0.77 and 0.86, respectively). Decision curve analysis showed greater net benefit for follow up of all AKI than only severe AKI in most cases. Both original and refitted models provided net benefit superior to any other decision strategy. In process mining of all hospital discharges, 41% of readmissions and deaths occurred among people recovering after AKI. 1,464 of 3,776 people (39%) readmitted after AKI had received no intervening monitoring.

Limitations

Both original models overstated risks, indicating a need for regular updating.

Conclusions

Follow up after AKI has potential net benefit for preempting readmissions, death, and subsequent CKD progression. Decisions could be improved by using risk models and by focusing on AKI across a full spectrum of severity. The current lack of monitoring among many with poor outcomes indicates possible opportunities for implementation of decision support.

Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: A systematic review and meta-analysis

BACKGROUND

Hip fracture patients on oral anticoagulants (OACs) experience increased time-to-surgery and higher mortality compared to non-anticoagulated patients. However, it is unclear whether pre-injury OAC status and its associated operative delay are associated with worsening of peri-operative hemostasis or an increased risk of postoperative thromboembolism.

METHODS

We performed a systematic review to identify studies that directly compared hemostatic and thromboembolic outcomes among hip fracture patients on an OAC prior to admission with those not on anticoagulants. Random effects meta-analyses were used to pool all outcomes of interest (estimated blood loss, transfusion requirements, and postoperative thromboembolism).

RESULTS

Twenty-one studies involving 21 417 patients were included. Estimated blood loss was higher among patients presenting with OACs compared to those not anticoagulated (mean difference 31.0 mL, 95% confidence interval [CI] 6.2-55.7). Anticoagulated patients also had a 1.3-fold higher risk of receiving red blood cell transfusions (odds ratio [OR] 1.34, 95% CI 1.20-1.51); however, rates of postoperative thromboembolism were similar regardless of anticoagulation status (OR 0.96, 95% CI 0.40-2.79 for venous thromboembolism; OR 0.58, 95% CI 0.25-1.36 for arterial thromboembolism). No subgroup effect was found based on anticoagulant type or degree of surgical delay.

CONCLUSION

Hip fracture patients on OACs experience increased surgical blood loss and higher risk of red blood cell transfusions. However, the degree of surgical delay did not mitigate this risk, and there was no difference in postoperative thromboembolism. The impact of appropriate, timely OAC reversal on blood conservation and expedited surgery in anticoagulated hip fracture patients warrants urgent evaluation.

Internalizing Symptoms in Pediatric Migraine: A Systematic Review Protocol

OBJECTIVES

The primary objective of the proposed systematic review is to determine if there is an association between internalizing disorders and symptoms (ie, subclinical symptoms) and migraine in children and adolescents.

METHODS

We will perform a peer-reviewed Peer Review of Electronic Search Strategies search of MEDLINE, Embase, PsycINFO, and CINAHL from inception to December 2019. The authors will also review all reference lists of included studies for relevant citations. Observational studies on the association of pediatric migraine with internalizing disorders and symptoms will be included in this review. Case-control, cohort, and cross-sectional studies that include participants aged 18 years and under will be eligible for inclusion. The primary outcome for this systematic review will be migraine and the exposures of interest will include internalizing disorders (eg, major depressive disorder, dysthymia, generalized anxiety disorder, and post-traumatic stress disorder) and internalizing symptoms (depression symptoms, anxiety symptoms, obsessive compulsive symptoms, and post-traumatic stress symptoms). Two investigators will independently carry out an initial screen of abstracts, followed by a second screen of full-text manuscripts. Data extraction will be completed by 2 independent investigators. Study quality will be assessed using the Newcastle-Ottawa criteria for case-control and cohort studies and using a modified version of the Newcastle-Ottawa criteria for cross-sectional studies. A narrative synthesis of the data will be provided and, if possible, data will be quantitatively summarized using appropriate meta-analytic methods. Throughout the manuscript, the Preferred Reporting Items for Systematic Review and Meta-Analysis reporting standards will be followed.

RESULTS

The goal of this systematic review will be to provide a narrative, and if possible, quantitative summary on the association between pediatric migraine and internalizing disorders and symptoms.

CONCLUSIONS

The methods applied in this systematic review protocol can be used to inform the design of future systematic reviews of observational studies in headache medicine. The results of this systematic review will be used to inform the clinical community on the association between pediatric migraine and internalizing disorders and symptoms and may also be used to inform the design of future research studies in this area.

Impact of payment model on the behaviour of specialist physicians: A systematic review

Physician payment models are perceived to be an important strategy for improving health, access, quality, and the value of health care. Evidence is predominantly from primary care, and little is known regarding whether specialists respond similarly. We conducted a systematic review to synthesize evidence on the impact of specialist physician payment models across the domains of health care quality; clinical outcomes; utilization, access, and costs; and patient and physician satisfaction. We searched Medline, Embase, and six other databases from their inception through October 2018. Eligible articles addressed specialist physicians, payment models, outcomes of interest, and used an experimental or quasi-experimental design. Of 11,648 studies reviewed for eligibility, 11 articles reporting on seven payment reforms were included. Fee-for-service (FFS) was associated with increased desired utilization and fewer adverse outcomes (in the case of hemodialysis patients) and better access to care (in the case of emergency department services). Replacing FFS with capitation and salary models led to fewer elective surgical procedures (cataracts and tubal ligations) and, with an episode-based model, appeared to increase the use of less costly resources. Four of the seven reforms met their goals but many had unintended consequences. Payment model appears to affect utilization of specialty care, although the association with other outcomes is unclear due to mixed results or lack of evidence. Studies of salary and salary-based reforms point to specialists responding to some incentives differently than theory would predict. Additional research is warranted to improve the evidence driving specialist payment policy.

Characterizing patients with high use of the primary and tertiary care systems: A retrospective cohort study

OBJECTIVES

To utilize complementary data from primary care and administrative health and social services to describe the clinical, social and demographic characteristics of high users of health care services.

METHODS

We conducted a retrospective cohort study using data from the Manitoba Primary Care Research Network (MaPCReN) and the Manitoba Centre for Health Policy Research Data Repository in Canada. We assessed data from 193,760 patients with at least one visit to a primary care provider between 2011 and 2016. We defined HU within the following areas: primary care, hospital discharges, length of stay and emergency department visits. Descriptive statistics and logistic regression was used to identify key demographic, social, and medical complexities associated with HU.

RESULTS

Between 2011 and 2016, 30.8 % of patients had HU during at least one year within at least one area. Among patients with HU, 5 % had persistent HU (HU for ≥2 years) and 359 (0.6 %) had HU across all four definitions. Medical complexity was associated with HU for patients with hospital discharges, ED visits and primary care visits, whereas socially complex patients were more likely to have a longer LOS, and visit the ED.

CONCLUSIONS

There were unique characteristics in the various HU cohorts including medical, social, and demographic features that can inform strategies aimed at improving health system efficiency in managing patients with HU.

Preferences for a self-management e-health tool for patients with chronic kidney disease: results of a patient-oriented consensus workshop

BACKGROUND

Electronic health (e-health) tools may support patients' self-management of chronic kidney disease. We aimed to identify preferences of patients with chronic kidney disease, caregivers and health care providers regarding content and features for an e-health tool to support chronic kidney disease self-management.

METHODS

A patient-oriented research approach was taken, with 6 patient partners (5 patients and 1 caregiver) involved in study design, data collection and review of results. Patients, caregivers and clinicians from across Canada participated in a 1-day consensus workshop in June 2018. Using personas (fictional characters) and a cumulative voting technique, they identified preferences for content for 8 predetermined topics (understanding chronic kidney disease, diet, finances, medication, symptoms, travel, mental and physical health, work/school) and features for an e-health tool.

RESULTS

There were 24 participants, including 11 patients and 6 caregivers, from across Canada. The following content suggestions were ranked the highest: basic information about kidneys, chronic kidney disease and disease progression; reliable information on diet requirements for chronic kidney disease and comorbidities, renal-friendly foods; affordability of medication, equipment, food, financial resources and planning; common medications, adverse effects, indications, cost and coverage; symptom types and management; travel limitations, insurance, access to health care, travel checklists; screening and supports to address mental health, cultural sensitivity, adjusting to new normal; and support to help integrate at work/school, restrictions. Preferred features included visuals, the ability to enter and track health information and interact with health care providers, "on-the-go" access, links to resources and access to personal health information.

INTERPRETATION

A consensus workshop developed around personas was successful for identifying detailed subject matter for 8 predetermined topic areas, as well as preferred features to consider in the codevelopment of a chronic kidney disease self-management e-health tool. The use of personas could be applied to other applications in patient-oriented research exploring patient preferences and needs in order to improve care and relevant outcomes.

Predictors of mortality and length of stay in patients with hospital-acquired Clostridioides difficile infection: a population-based study in Alberta, Canada

In a population-based, five-year retrospective cohort study of 5304 adult patients with hospital-acquired Clostridioides difficile infection across Alberta (N=101 hospitals), 30-day all-cause and attributable mortality were 12.2% and 4.5%, respectively. Patients >75 years of age had the highest odds of attributable mortality (odds ratio (OR) 9.34, 95% confidence interval (CI) 2.92-29.83) and largest difference in mean length of stay (11.7 days, 95% CI 8.2-15.2). A novel finding was that elevated white blood cell count at admission was associated with reduced attributable mortality (OR 0.67, 95% CI 0.50-0.90) which deserves further study. Advancing age was incrementally and significantly associated with all outcomes.

Self-management interventions for adults with chronic kidney disease: a scoping review

OBJECTIVE

To systematically identify and describe self-management interventions for adult patients with chronic kidney disease (CKD).

SETTING

Community-based.

PARTICIPANTS

Adults with CKD stages 1-5 (not requiring kidney replacement therapy).

INTERVENTIONS

Self-management strategies for adults with CKD.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using a scoping review, electronic databases and grey literature were searched in October 2016 to identify self-management interventions for adults with CKD stages 1-5 (not requiring kidney replacement therapy). Randomised controlled trials (RCTs), non-RCTs, qualitative and mixed method studies were included and study selection and data extraction were independently performed by two reviewers. Outcomes included behaviours, cognitions, physiological measures, symptoms, health status and healthcare.

RESULTS

Fifty studies (19 RCTs, 7 quasi-experimental, 5 observational, 13 pre-post intervention, 1 mixed method and 5 qualitative) reporting 45 interventions were included. The most common intervention topic was diet/nutrition and interventions were regularly delivered face to face. Interventions were administered by a variety of providers, with nursing professionals the most common health professional group. Cognitions (ie, changes in general CKD knowledge, perceived self-management and motivation) were the most frequently reported outcome domain that showed improvement. Less than 1% of the interventions were co-developed with patients and 20% were based on a theory or framework.

CONCLUSIONS

There was a wide range of self-management interventions with considerable variability in outcomes for adults with CKD. Major gaps in the literature include lack of patient engagement in the design of the interventions, with the majority of interventions not applying a behavioural change theory to inform their development. This work highlights the need to involve patients to co-developed and evaluate a self-management intervention based on sound theories and clinical evidence.

Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends

INTRODUCTION

Severe maternal morbidity and mortality have increased in the USA in recent years. This trend has not been consistent across all racial groups. The reasons behind this, and the relation between preexisting conditions, pregnancy-associated disease and severe maternal morbidity/mortality, have not been fully explored.

MATERIAL AND METHODS

Annual data on delivery hospitalizations between 1993 and 2012 were obtained from the Nationwide Inpatient Sample (NIS), representing a 20% sample of hospital discharges from across the USA. Chi-square tests for trend were used to examine temporal patterns in the proportion of pregnancies affected by comorbidities as defined by the Obstetric Comorbidity Score and were stratified by maternal race. Logistic regression was used to determine the impact of temporal increases in comorbidity on severe maternal morbidity/mortality.

RESULTS

In 1993, 34.3% of pregnancies had a comorbidity score of ≥1; this significantly increased to 44.1% by 2012 (p < 0.001). Baseline differences were observed between all races (Whites 33.7%, Blacks 34.5%, Hispanics 28.0%, Asian/Pacific Islanders 28.1%). Although significant increases were observed for all races, the relative rate of change was lowest for Whites (26.1% increase) and highest for Asian/Pacific Islanders (49.1% increase). The odds of severe maternal morbidity/mortality have steadily increased over time; however, adjustment for Obstetric Comorbidity Score significantly attenuates this correlation.

CONCLUSION

The rate of both preexisting comorbidities and pregnancy-associated disease is increasing in pregnant women in the USA and varies substantially by race. These trends provide valuable insight into the increasing complexity of pregnancy in the USA and explain a proportion of the observed increase in severe maternal morbidity/mortality.

Comparison of Methods to Define High Use of Inpatient Services Using Population-Based Data

BACKGROUND

A variety of methods have been proposed to define "high users" of inpatient services, which may have implications for targeting subgroups for intervention.

OBJECTIVE

To compare 3 common definitions of high inpatient service use and their influence on patient capture, outcomes, and inpatient burden.

DESIGN, SETTING, PATIENTS

We defined "high use" based on the upper 5th percentile of the population by 3 definitions: (1) number of inpatient episodes (≥3 hospitalizations/year), (2) cumulative length of stay (≥56 days in hospital/year), and (3) cumulative cost based on hospitalization resource intensity weights (≥ $63,597 Canadian dollars/year). Clinical characteristics, health outcomes, and overall health burden were compared across definitions and stratified by age.

RESULTS

Of that population, 10.3% of individuals were common to all definitions. High users based on number of inpatient episodes were more likely to be admitted for acute conditions, with most high users based on length of stay admitted for mental health-related conditions, while those based on costs were more likely to have hospitalizations resulting in death (9.3%). High-episode individuals accounted for 16.6% of all inpatient episodes, high-length of stay individuals for 46.4% of all hospital days, and high-cost individuals for 38.9% of total cost.

CONCLUSIONS

Three definitions of high users of inpatient services captured significantly different groups of patients. This has implications for targeting subgroups for intervention and highlights important considerations for selecting the most suitable definition for a given objective.

A systematic review of the cost and cost-effectiveness of electronic discharge communications

BACKGROUND

The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered.

OBJECTIVE

To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider.

METHODS

We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis.

RESULTS

One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes.

DISCUSSION

Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care.

The prevalence of potentially preventable deaths in an acute care hospital: A retrospective cohort

Studies estimate that 6% to 27% of deaths in hospitals might be prevented with higher quality care. These estimates may be inaccurate because they fail to account for the uncertainty associated with classifying preventability. The purpose of this study was to measure the prevalence of preventable deaths, accounting for the uncertainty in preventability ratings.We created standardized structured case abstracts for all deaths at a multisite academic teaching hospital over a 3-month period. Each case abstract was evaluated independently by 4 reviewers who rated death preventability on a 100-point scale ranging from 0 ("Definitely not preventable") to 100 ("Definitely preventable"). Ratings were categorized into a 4-level ordinal scale and latent class analysis was used to measure the prevalence of each preventability class and estimate the probability that deaths in each class were preventable.There were 480 deaths (3.4% of all admissions) during the study period. The latent class model (LCM) found that 91.6% (95% CI: 88.4-94.8%) of deaths were "nonpreventable" and 8.4% (5.2-11.6%) were "possibly preventable." "Possibly preventable" deaths could be identified with 90% certainty, but due to error in reviewer ratings, a "possibly preventable" death had a 50% probability of being receiving a rating of less than 25/100 by any single reviewer. Only 5 of 31 deaths classified as a "possibly preventable" (1.0% of all deaths) were judged to likely be alive in 3 months with perfect care.After accounting for uncertainty associated with rating the preventability of hospital deaths, we found that 8.4% of deaths were deemed possibly preventable. There was only moderate probability that these deaths were truly preventable.

Prevalence of symptoms at the end of life in an acute care hospital: a retrospective cohort study

BACKGROUND

There is currently debate over the benefits and harms of physician-assisted death. One of the factors influencing this debate is concern about symptoms in the days before death. The objective of this study was to describe the frequency of symptoms before death and determine patient characteristics associated with these symptoms.

METHODS

We reviewed the medical record of every patient who died at a multisite academic teaching hospital over a 3-month period. We determined the number of episodes of pain, dyspnea, agitation and nausea during the final 48 hours of life and assessed the patient and encounter characteristics associated with 2 or more episodes of symptoms.

RESULTS

A total of 480 patients died during the study period. Of these patients, 29.2% (140/480) had 2 or more symptoms in the final 48 hours of life. Higher Elixhauser comorbidity scores (relative risk [RR] 1.35, 95% confidence interval [CI] 1.23-1.49), having a family doctor (RR 2.33, 95% CI 1.02-5.38), being admitted to the medical oncology service (RR 1.51, 95% CI 1.11-2.05) and having a documented order for no resuscitation written early during the stay in hospital (RR 1.38, 95% CI 1.01-1.89) were independently associated with symptoms. Admission to intensive care was associated with fewer symptoms (RR 0.39, CI 95% 0.19-0.80).

INTERPRETATION

Symptoms are common in the final 48 hours of life, particularly in patients with multimorbidity who want limitations on the aggressiveness of their care. An integrated palliative approach is needed for select at-risk patients.

The association between individual counselling and health behaviour change: the See Kidney Disease (SeeKD) targeted screening programme for chronic kidney disease

BACKGROUND

Health behaviour change is an important component of management for patients with chronic kidney disease (CKD); however, the optimal method to promote health behaviour change for self-management of CKD is unknown. The See Kidney Disease (SeeKD) targeted screening programme screened Canadians at risk for CKD and promoted health behaviour change through individual counselling and goal setting.

OBJECTIVES

The objectives of this study are to determine the effectiveness of individual counselling sessions for eliciting behaviour change and to describe participant characteristics associated with behaviour change.

DESIGN

This is a cross-sectional, descriptive study.

SETTING

The study setting is the National SeeKD targeted screening programme.

PATIENTS

The participants are all 'at risk' patients who were screened for CKD and returned a follow-up health behaviour survey (n = 1129).

MEASUREMENTS

Health behaviour change was defined as a self-reported change in lifestyle, including dietary changes or medication adherence.

METHODS

An individual counselling session was provided to participants by allied healthcare professionals to promote health behaviour change. A survey was mailed to all participants at risk of CKD within 2-4 weeks following the screening event to determine if behaviour changes had been initiated. Descriptive statistics were used to describe respondent characteristics and self-reported behaviour change following screening events. Results were stratified by estimated glomerular filtration rate (eGFR) (< 60 and ≥ 60 mL/min/1.73 m(2)). Log binomial regression analysis was used to determine the predictors of behaviour change.

RESULTS

Of the 1129 respondents, the majority (89.8 %) reported making a health behaviour change after the screening event. Respondents who were overweight (body mass index [BMI] 25-29.9 kg/m(2)) or obese (BMI ≥ 30.0 kg/m(2)) were more likely to report a behaviour change (prevalence rate ratio (PRR) 0.66, 95 % confidence interval (CI) 0.44-0.99 and PRR 0.49, 95 % CI 0.30-0.80, respectively). Further, participants with a prior intent to change their behaviour were more likely to make a behaviour change (PRR 0.58, 95 % CI 0.35-0.96). Results did not vary by eGFR category.

LIMITATIONS

We are unable to determine the effectiveness of the behaviour change intervention given the lack of a control group. Potential response bias and social desirability bias must also be considered when interpreting the study findings.

CONCLUSIONS

Individual counselling and goal setting provided at screening events may stimulate behaviour change amongst individuals at risk for CKD. However, further research is required to determine if this behaviour change is sustained and the impact on CKD progression and outcomes.

Out-of-pocket spending on drugs and pharmaceutical products and cost-related prescription non-adherence among Canadians with chronic disease

BACKGROUND

Approximately one-third of Canadians' prescription medication costs are paid directly out-of-pocket. This study attempts to determine if out-of-pocket spending greater than 5% of household income on drugs and pharmaceutical products is associated with cost-related prescription non-adherence among people with cardiovascular-related chronic conditions.

DATA AND METHODS

The data are from the survey on Barriers to Care for People with Chronic Health Conditions. Three categories of out-of-pocket spending on drugs and pharmaceutical products as a percentage of household income were identified: 0%, more than 0% to less than 5%, and 5% or more. Log-binomial regression was used to investigate associations between category of out-of-pocket spending and cost-related non-adherence.

RESULTS

In 2012, about 80% of people aged 40 or older who lived in British Columbia, Alberta, Saskatchewan or Manitoba and had cardiovascular-related chronic conditions reported out-of-pocket spending on drugs and pharmaceutical products; 4.8% reported out-of-pocket spending of at least 5% of their household income. These individuals were significantly older, more often lived in households with incomes less than $30,000, and more often reported multiple morbidities than did people whose out-of-pocket spending on drugs and pharmaceutical products was less than 5% of household income. When the results were adjusted for age and sex, people whose spending amounted to 5% or more of household income were almost three times as likely (prevalence rate ratio = 2.6) to report cost-related prescription non-adherence than were those spending less than 5%.

INTERPRETATION

Spending at least 5% of household income on drugs and pharmaceutical products was significantly associated with cost-related prescription non-adherence. Additional data are required to determine if even lower levels of spending put individuals at risk of cost related non-adherence.

Methods for identifying 30 chronic conditions: application to administrative data

BACKGROUND

Multimorbidity is common and associated with poor clinical outcomes and high health care costs. Administrative data are a promising tool for studying the epidemiology of multimorbidity. Our goal was to derive and apply a new scheme for using administrative data to identify the presence of chronic conditions and multimorbidity.

METHODS

We identified validated algorithms that use ICD-9 CM/ICD-10 data to ascertain the presence or absence of 40 morbidities. Algorithms with both positive predictive value and sensitivity ≥70% were graded as "high validity"; those with positive predictive value ≥70% and sensitivity <70% were graded as "moderate validity". To show proof of concept, we applied identified algorithms with high to moderate validity to inpatient and outpatient claims and utilization data from 574,409 people residing in Edmonton, Canada during the 2008/2009 fiscal year.

RESULTS

Of the 40 morbidities, we identified 30 that could be identified with high to moderate validity. Approximately one quarter of participants had identified multimorbidity (2 or more conditions), one quarter had a single identified morbidity and the remaining participants were not identified as having any of the 30 morbidities.

CONCLUSIONS

We identified a panel of 30 chronic conditions that can be identified from administrative data using validated algorithms, facilitating the study and surveillance of multimorbidity. We encourage other groups to use this scheme, to facilitate comparisons between settings and jurisdictions.

The efficacy of motivational interviewing for disordered gambling: systematic review and meta-analysis

Motivational interviewing is a client-centered therapeutic intervention that aims to resolve ambivalence toward change. We conducted a systematic review and meta-analysis on the efficacy of motivational interviewing, compared to non-motivational interviewing controls, in the treatment of disordered gambling. Electronic databases were searched for randomized controlled trials that evaluated change in gambling behavior using motivational interviewing in adult disordered gamblers. The primary outcomes were the weighted mean difference (WMD) for change in average days gambled per month and average dollars lost per month. The search strategy yielded 447 articles, of which 20 met criteria for full text review. Overall, 8 studies (N=730) fulfilled the inclusion criteria for systematic review and 5 (N=477) were included in the meta-analysis. Motivational interviewing was associated with significant reduction in gambling frequency up to a year after treatment delivery. For gambling expenditure, motivational interviewing yielded significant reductions in dollars spent gambling compared to non-motivational controls at post-treatment only (1-3 months). Overall, the results of this review suggest that motivational interviewing is an efficacious style of therapy for disordered gambling in the short term. Whether treatment effects are maintained over time remains unclear.

Hypertension and obstructive sleep apnea in Caucasian children

AIM

To evaluate the prevalence of hypertension and/or left ventricular hypertrophy (LVH) in children with a diagnosis of obstructive sleep apnea (OSA).

METHODS

A cross-sectional case series of consecutive, otherwise healthy children aged > 4 years, with polysomnography-proven OSA [apnea hypopnea index (AHI) > 1.5/h] is described. Echocardiography was performed on all subjects and left ventricular mass was calculated. Study subjects underwent additional investigation with 24-h ambulatory blood pressure (BP) monitoring.

RESULTS

Thirty children (21 males) were studied. Mean age was 8.9 years. Mean body mass index was 19.87 kg/cm(2). Mean AHI was 14.3/h. 10/30 (33%) of the study population met criteria for pre-hypertension (n = 3) or masked hypertension (n = 7) based on standard ambulatory monitoring criteria. All 10 children had systolic hypertension throughout the night with 5 of these also having elevated daytime systolic readings. There was a relationship between AHI and BP showing an increase of 1.162 percentile units in mean diastolic night BP (age, gender and height specific) per unit increase in AHI (P = 0.018). There were no subjects with LVH and/or right ventricular hypertrophy.

CONCLUSION

In our population of otherwise healthy Caucasian children, there was a high prevalence of hypertension that would not have been identified using standard office/clinic protocols.