Barriers to Successful Discharge After Cardiac Surgery: A Focus Group Study and Cross-Sectional Survey

At present, there is a lack of information on patient and caregiver values, and perceived priorities and barriers, to guide successful post-discharge recovery. This was a single center, multiple methods study that investigated patient, caregiver, and health care provider perceptions of the discharge process after cardiac surgery. Themes emerging from focus group discussions with patients and caregivers were used to develop surveys relating to values, barriers, and challenges relating to the discharge process. Thirty-two patients (n = 16) and caregivers (n = 16) participated in four separate focus groups. Four themes emerged from these discussions: (1) a lack of understanding about what the discharge process entails and when discharge is appropriate, (2) issues relating to the information provided to patients at the time of discharge, (3) participant experiences with the health care system, and (4) the experiences of caregivers. Seventy-eight patients, 34 caregivers, 53 nurses and/or other allied health professionals, and 8 surgeons completed the cross-sectional surveys. The most important component of the discharge process for patients and caregivers was "knowing what to do in an emergency." Health care providers less accurately identified what caregivers perceived as the most important aspects of the discharge process.Statements relating to informational barriers to discharge were the most discordant among patient and caregiver respondents. After discharge, patients and caregivers identified the need for longer-term follow up with the surgeon and more support in the community. Incorporation of patient and caregiver values to guide the post-cardiac surgery discharge process is essential to promote successful recovery.

Realist analysis of streaming interventions in emergency departments

Background

Several of the many emergency department (ED) interventions intended to address the complex problem of (over)crowding are based on the principle of streaming: directing different groups of patients to different processes of care. Although the theoretical basis of streaming is robust, evidence on the effectiveness of these interventions remains inconclusive.

Methods

This qualitative research, grounded in the population-capacity-process model, sought to determine how, why and under what conditions streaming interventions may be effective. Data came from a broader study exploring patient flow strategies across Western Canada through in-depth interviews with managers at all levels. We undertook realist analysis of interview data from the 98 participants who discussed relevant interventions (fast-track/minor treatment areas, rapid assessment zones, diverse short-stay units), focusing on their explanations of initiatives’ perceived outcomes.

Results

Essential features of streaming interventions included separation of designated populations (population), provision of dedicated space and resources (capacity) and rapid cycle time (process). These features supported key mechanisms of impact: patients wait only for services they need; patient variability is reduced; lag time between steps is eliminated; and provider attitude change promotes prompt discharge. Conversely, reported failures usually involved neglect of one of these dimensions during intervention design and/or implementation. Participants also identified important contextual barriers to success, notably lack of outflow sites and demand outstripping capacity. Nonetheless, failure was more commonly attributed to intervention flaws than to context factors.

Conclusions

While streaming interventions have the potential to reduce crowding, a theory-based intervention relies on its implementers’ adherence to the theory. Streaming interventions cannot be expected to yield the desired results if operationalised in a manner incongruent with the theory on which they are supposedly based.

Understanding the Particularities of an Unconditional Prenatal Cash Benefit for Low-Income Women: A Case Study Approach

We explored the particularities of the Healthy Baby Prenatal Benefit (HBPB), an unconditional cash transfer program for low-income pregnant women in Manitoba, Canada, which aims to connect recipients with prenatal care and community support programs, and help them access healthy foods during pregnancy. While previous studies have shown associations between HBPB and improved birth outcomes, here we focus on how the intervention contributed to positive outcomes. Using a case study design, we collected data from government and program documents and interviews with policy makers, academics, program staff, and recipients of HBPB. Key informants identified using evidence and aligning with government priorities as key facilitators to the implementation of HBPB. Program recipients described how HBPB helped them improve their nutrition, prepare for baby, and engage in self-care to moderate the effect of stressful life events. This study provides important contextualized evidence to support government decision making on healthy child development policies.

Primary care renewal strategies in Manitoba: Family physicians' perceptions

OBJECTIVE

To understand family physicians' perceptions of Manitoba's strategies for primary care renewal or reform (PCR).

DESIGN

Qualitative substudy of an explanatory case study.

SETTING

Rural and urban Manitoba.

PARTICIPANTS

A total of 60 family physicians (31 fee-for-service physicians, 26 alternate-funded physicians, and 3 physicians representing provincial physician organizations).

METHODS

Semistructured interviews and focus groups.

MAIN FINDINGS

Many physicians were hesitant to participate in PCR initiatives, perceiving clear risks but uncertain benefits to patients and providers. Additional barriers to participation included concerns about the adequacy and import of communication about PCR, the meaningfulness of opportunities for physician "voice," and the trustworthiness of decision makers. There was an appetite for tailored, clinic-level support in addressing concrete, physician-identified problems; however, the initiatives on offer were not widely viewed as providing such support.

CONCLUSION

Although some of the observed barriers might fade over time, concentrating PCR efforts on the everyday realities of family physician practice might be the best way to build a primary care system that works for patients and providers.

Teen clinics: missing the mark? Comparing pregnancy and sexually transmitted infections rates among enrolled and non-enrolled adolescents

Background

In Manitoba, Canada, school-based clinics providing sexual and reproductive health services for adolescents have been implemented to address high rates of sexually transmitted infections (STIs) and pregnancies.

Methods

The objectives of this population-based study were to compare pregnancy and STI rates between adolescents enrolled in schools with school-based clinics, those in schools without clinics, and those not enrolled in school. Data were from the PATHS Data Resource held in the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. Adolescents aged 14 to 19 between 2003 and 2009 were included in the study. Annualized rates of pregnancies and positive STI tests were estimated and Poisson regression models were used to test for differences in rates amongst the three groups.

Results

As a proportion, pregnancies among non-enrolled female adolescents accounted for 55 % of all pregnancies in this age group during the study period. Pregnancy rates were 2–3 times as high among non-enrolled female adolescents. Compared to adolescents enrolled in schools without school-based clinics, age-adjusted STI rates were 3.5 times (p < .001) higher in non-enrolled males and 2.3 times (p < .001) higher in non-enrolled females.

Conclusions

The highest rates for pregnancies and STIs were observed among non-enrolled adolescents. Although provision of reproductive and health services to in-school adolescents should remain a priority, program planning and design should consider optimal strategies to engage out of school youth.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0386-9) contains supplementary material, which is available to authorized users.

Every team needs a coach: Training for interprofessional clinical placements

Despite growing awareness of the benefits of interprofessional education and interprofessional collaboration (IPC), understanding how teams successfully transition to IPC is limited. Student exposure to interprofessional teams fosters the learners' integration and application of classroom-based interprofessional theory to practice. A further benefit might be reinforcing the value of IPC to members of the mentoring team and strengthening their IPC. The research question for this study was: Does training in IPC and clinical team facilitation and mentorship of pre-licensure learners during interprofessional clinical placements improve the mentoring teams' collaborative working relationships compared to control teams? Statistical analyses included repeated time analysis multivariate analysis of variance (MANOVA). Teams on four clinical units participated in the project. Impact on intervention teams pre- versus post-interprofessional clinical placement was modest with only the Cost of Team score of the Attitudes Towards Healthcare Team Scale improving relative to controls (p = 0.059) although reflective evaluations by intervention team members noted many perceived benefits of interprofessional clinical placements. The significantly higher group scores for control teams (geriatric and palliative care) on three of four subscales of the Assessment of Interprofessional Team Collaboration Scale underscore our need to better understand the unique features within geriatric and palliative care settings that foster superior IPC and to recognise that the transition to IPC likely requires a more diverse intervention than the interprofessional clinical placement experience implemented in this study. More recently, it is encouraging to see the development of innovative tools that use an evidence-based, multi-dimensional approach to support teams in their transition to IPC.

Does a pay-for-performance program for primary care physicians alleviate health inequity in childhood vaccination rates?

Introduction

Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates.

Methods

The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1–Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort.

Results

The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008, 0.021).

Conclusions

The P4P program had a limited impact on vaccination rates and did not address health inequity.

Geographical variation analysis of all-cause hospital readmission cases in Winnipeg, Canada

BACKGROUND

Hospital readmission is costly and potentially avoidable. The concept of virtual wards as a new model of care is intended to reduce hospital readmissions by providing short-term transitional care to high-risk and complex patients in the community. In order to provide information regarding the development of virtual wards in the Winnipeg Health Region, Canada, this study used spatial statistics to identify geographic variations of hospital readmissions in 25 neighborhood clusters.

METHODS

The data were obtained from the Population Health Research Data Repository housed at the Manitoba Centre for Health Policy. We used a Bayesian Disease Mapping approach which applied Markov chain Monte Carlo (MCMC) for cluster detection.

RESULTS

Between 2005/06 and 2008/09, 123,842 patients were hospitalized in all Winnipeg hospitals. Of these, 41,551 (33%) were readmitted to hospital in the year following discharge. Most of these readmitted patients (89.4%) had 1-2 readmissions, while 11.6% of readmitted patients had more than 2 readmissions after initial discharge. The smoothed age- and sex- adjusted relative risk rates of hospital readmission in 25 Winnipeg neighborhood clusters ranged between 0.73 and 1.27. We found that there were spatial cluster variations of hospital readmission across the Winnipeg Health Region. Seven neighborhood clusters are more likely to be significant potential clusters for hospital readmissions (p < .05), while six neighborhood clusters are less likely to be significant potential clusters.

CONCLUSIONS

This study provides the foundation and implementation guide for the Winnipeg Regional Health Authority virtual ward program. The findings will also help to improve long-term condition management in community settings and will help program planners to assure the efficient use of healthcare resources.

Protocol for the PREHAB study-Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial

INTRODUCTION

Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25-50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery.

METHODS AND ANALYSIS

This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40-60% of heart rate reserve. Data collection will occur at baseline, 1-2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days.

POTENTIAL IMPACT OF STUDY

The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery.

ETHICS AND DISSEMINATION

Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208).

TRIAL REGISTRATION NUMBER

The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815).

Development and validation of a predictive model for all-cause hospital readmissions in Winnipeg, Canada

Objective

A number of predictive models have been developed to identify patients at risk of hospital readmission. Most of these have focused on readmission within 30 days of discharge. We used population-based health administrative data to develop a predictive model for hospital readmission within 12 months of discharge in Winnipeg, Canada.

Methods

This was a retrospective cohort study with derivation and validation data sets. Multivariable logistic regression analyses were performed and factors significantly associated with readmission were selected to construct a risk scoring tool.

Results

Several variables were identified that predicted readmission (i.e. older age, male, at least one hospital admission in the previous two years, an emergent (index) hospital admission, Charlson comorbidity score >0 and length of stay). Discrimination power was acceptable (C statistic =0.701). At a median risk score threshold, the sensitivity, specificity, positive and negative predictive values were 45.5%, 79%, 68.8% and 58.6%.

Conclusions

This predictive model demonstrated that hospital readmission within 12 months of discharge can be reasonably well predicted based on administrative data. It will help health care providers target interventions to prevent unnecessary hospital readmissions.

Effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis

BACKGROUND

The majority of internet-based anxiety and depression intervention studies have targeted adults. An increasing number of studies of children, youth, and young adults have been conducted, but the evidence on effectiveness has not been synthesized. The objective of this research is to systematically review the most recent findings in this area and calculate overall (pooled) effect estimates of internet-based anxiety and/or depression interventions.

METHODS

We searched five literature databases (PubMed, EMBASE, CINAHL, PsychInfo, and Google Scholar) for studies published between January 1990 and December 2012. We included studies evaluating the effectiveness of internet-based interventions for children, youth, and young adults (age <25 years) with anxiety and/or depression and their parents. Two reviewers independently assessed the risk of bias regarding selection bias, allocation bias, confounding bias, blinding, data collection, and withdrawals/dropouts. We included studies rated as high or moderate quality according to the risk of bias assessment. We conducted meta-analyses using the random effects model. We calculated standardized mean difference and its 95% confidence interval (95% CI) for anxiety and depression symptom severity scores by comparing internet-based intervention vs. waitlist control and internet-based intervention vs. face-to-face intervention. We also calculated pooled remission rate ratio and 95% CI.

RESULTS

We included seven studies involving 569 participants aged between 7 and 25 years. Meta-analysis suggested that, compared to waitlist control, internet-based interventions were able to reduce anxiety symptom severity (standardized mean difference and 95% CI = -0.52 [-0.90, -0.14]) and increase remission rate (pooled remission rate ratio and 95% CI =3.63 [1.59, 8.27]). The effect in reducing depression symptom severity was not statistically significant (standardized mean difference and 95% CI = -0.16 [-0.44, 0.12]). We found no statistical difference in anxiety or depression symptoms between internet-based intervention and face-to-face intervention (or usual care).

CONCLUSIONS

The present analysis indicated that internet-based interventions were effective in reducing anxiety symptoms and increasing remission rate, but not effective in reducing depression symptom severity. Due to the small number of higher quality studies, more attention to this area of research is encouraged.

TRIAL REGISTRATION

PROSPERO registration: CRD42012002100.

Prescribing of psychotropic medications to the elderly population of a Canadian province: a retrospective study using administrative databases

Background. Psychotropic medications, in particular second-generation antipsychotics (SGAs) and benzodiazepines, have been associated with harm in elderly populations. Health agencies around the world have issued warnings about the risks of prescribing such medications to frail individuals affected by dementia and current guidelines recommend their use only in cases where the benefits clearly outweigh the risks. This study documents the use of psychotropic medications in the entire elderly population of a Canadian province in the context of current clinical guidelines for the treatment of behavioural disturbances.

Methods. Prevalent and incident utilization of antipsychotics, benzodiazepines and related medications (zopiclone and zaleplon) were determined in the population of Manitobans over age 65 in the time period 1997/98 to 2008/09 fiscal years. Comparisons between patients living in the community and those living in personal care (nursing) homes (PCH) were conducted. Influence of sociodemographic characteristics on prescribing was assessed by generalized estimating equations. Non-optimal use was defined as the prescribing of high dose of antipsychotic medications and the use of combination therapy of a benzodiazepine (or zopiclone/zaleplon) with an antipsychotic. A decrease in intensity of use over time and lower proportions of patients treated with antipsychotics at high dose or in combination with benzodiazepines (or zopiclone/zaleplon) was considered a trend toward better prescribing. Multiple regression analysis determined predictors of non-optimal use in the elderly population.

Results. A 20-fold greater prevalent utilization of SGAs was observed in PCH-dwelling elderly persons compared to those living in the community. In 2008/09, 27% of PCH-dwelling individuals received a prescription for an SGA. Patient characteristics, such as younger age, male gender, diagnoses of dementia (or use of an acetylcholinesterase inhibitor) or psychosis in the year prior the prescription, were predictors of non-optimal prescribing (e.g., high dose antipsychotics). During the period 2002/3 and 2007/8, amongst new users of SGAs, 10.2% received high doses. Those receiving high dose antipsychotics did not show high levels of polypharmacy.

Conclusions. Despite encouraging trends, the use of psychotropic medications remains high in elderly individuals, especially in residents of nursing homes. Clinicians caring for such patients need to carefully assess risks and benefits.

The contributions of First Nations ethnicity, income, and delays in surgery on mortality post-fracture: a population-based analysis

We examined the independent contributions of First Nations ethnicity and lower income to post-fracture mortality. A similar relative increase in mortality associated with fracture appears to translate into a larger absolute increase in post-fracture mortality for First Nations compared to non-First Nations peoples. Lower income also predicted increased mortality post-fracture.

INTRODUCTION

First Nations peoples have a greater risk of mortality than non-First Nations peoples. We examined the independent contributions of First Nations ethnicity and income to mortality post-fracture, and associations with time to surgery post-hip fracture.

METHODS

Non-traumatic fracture cases and fracture-free controls were identified from population-based administrative data repositories for Manitoba, Canada (aged≥50 years). Populations were retrospectively matched for sex, age (within 5 years), First Nations ethnicity, and number of comorbidities. Differences in mortality post-fracture of hip, wrist, or spine, 1996-2004 (population 1, n=63,081), and the hip, 1987-2002(Population 2, n=41,211) were examined using Cox proportional hazards regression to model time to death. For hip fracture, logistic regression analyses were used to model the probability of death within 30 days and 1 year.

RESULTS

Population 1: First Nations ethnicity was associated with an increased mortality risk of 30-53% for each fracture type. Lower income was associated with an increased mortality risk of 18-26%. Population 2: lower income predicted mortality overall (odds ratio (OR) 1.15, 95% confidence interval (CI) 1.07-1.23) and for hip fracture cases (OR 1.18, 95%CI 1.05-1.32), as did older age, male sex, diabetes, and >5 comorbidities (all p≤0.01). Higher mortality was associated with pertrochanteric fracture (OR 1.14, 95% CI 1.03-1.27), or surgery delay of 2-3 days (OR 1.34, 95% CI 1.18-1.52) or ≥4 days (OR 2.35, 95% CI 2.07-2.67).

CONCLUSION

A larger absolute increase in mortality post-fracture was observed for First Nations compared to non-First Nations peoples. Lower income and surgery delay>2 days predicted mortality post-fracture. These data have implications regarding prioritization of healthcare to ensure targeted, timely care for First Nations peoples and/or individuals with lower income.

Estimating the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis

SUMMARY

Based on a population age 50+, significant excess costs relative to matched controls exist for patients with incident fractures that are similar in relative magnitude to other chronic diseases such as stroke or heart disease. Prevalent fractures also have significant excess costs that are similar in relative magnitude to asthma/chronic obstructive pulmonary disease.

INTRODUCTION

Cost of illness studies for osteoporosis that only include incident fractures may ignore the long-term cost of prevalent fractures and primary preventive care. We estimated the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis relative to matched controls.

METHODS

Men and women age 50+ were selected from administrative records in the province of Manitoba, Canada for the fiscal year 2007-2008. Three types of cases were identified: (1) patients with incident fractures in the current year (2007-2008), (2) patients with prevalent fractures in previous years (1995-2007), and (3) nonfracture osteoporosis patients identified by specific pharmacotherapy or low bone mineral density. Excess resource utilization and costs were estimated by subtracting control means from case means.

RESULTS

Seventy-three percent of provincial population age 50+ (52 % of all men and 91 % of all women) were included (121,937 cases, 162,171 controls). There were 3,776 cases with incident fracture (1,273 men and 2,503 women), 43,406 cases with prevalent fractures (15,784 men and 27,622 women) and 74,755 nonfracture osteoporosis cases (7,705 men and 67,050 women). All incident fractures had significant excess costs. Incident hip fractures had the highest excess cost: men $44,963 (95 % CI: $38,498-51,428) and women $45,715 (95 % CI: $36,998-54,433). Prevalent fractures (other than miscellaneous or wrist fractures) also had significant excess costs. No significant excess costs existed for nonfracture osteoporosis.

CONCLUSION

Significant excess costs exist for patients with incident fractures and with prevalent hip, vertebral, humerus, multiple, and traumatic fractures. Ignoring prevalent fractures underestimate the true cost of osteoporosis.

Institutionalization following incident non-traumatic fractures in community-dwelling men and women

Institutionalization after hip fracture occurs in at least 30% of patients in the year following hospital discharge. We demonstrate that the risk of transfer to a long-term care facility, after adjustment for age and burden of co-morbidity, is also increased following fractures at other osteoporotic sites in men and women. For most fractures, men are at greater risk than women.

INTRODUCTION

High institutionalization rates have been documented following non-traumatic hip fractures; however, there is lack of knowledge regarding the frequency of transfer to long-term care institutions of patients who sustain such fractures at other anatomical sites.

METHODS

Using the comprehensive health care databases of the province of Manitoba, Canada, we performed a retrospective matched cohort study of community-dwelling men and women aged 50 years and older who sustained an incident non-traumatic fracture between April 1, 1986, and March 31, 2006. Using Cox proportional hazards regression analysis, we estimated the sex-specific relative risk of transfers to long-term care institutions in the year following fracture at osteoporotic sites.

RESULTS

We identified a total of 70,264 individuals with incident fractures (70.0% in women) among whom 3,996 new admissions to long-term care institutions were documented in the year following the index fracture. New admissions increased over time (p < 0.0001 for temporal trends). The age- and co-morbidity-adjusted hazard ratio (HR) of institutionalization following a hip fracture was 4.89 (95% confidence interval [CI], 4.19 to 5.69) in men, and this risk was consistently at least twice that of controls for all other fracture sites (all p < 0.0001). In women, the relative risks were highest subsequent to a hip (HR, 2.79; 95% CI, 2.56 to 3.04) or vertebral fracture (HR, 2.18; 95% CI, 1.82 to 2.62).

CONCLUSIONS

Non-traumatic fractures at any site have serious consequences, including institutionalization. Men are at greater risk of transfer to long-term care following fracture than women.

Learning from the census: the Socio-economic Factor Index (SEFI) and health outcomes in Manitoba

OBJECTIVES

Using data from the Canadian census, researchers at the Manitoba Centre for Health Policy sought to create an area-based socio-economic measure (ABSM). The degree of association between the ABSM and health was evaluated.

METHODS

Values on several census variables (including income, education, employment and family structure) were captured at the enumeration-area or dissemination-area level and submitted to a principal components factor analysis to create three ABSMs: an updated version of the Socio-economic Factor Index (SEFI-2) and modified versions of Pampalon's material deprivation and social deprivation indices. Factor scores from these analyses were then compared with several population health measures: Premature Mortality Rate (PMR), Potential Years of Life Lost (PYLL), life expectancy, and self-rated health.

RESULTS

SEFI-2 scores were strongly related not only to the other ABSMs but also to every measure of health status. The strongest correlations between an ABSM and health measure were for SEFI-2 and PYLL(r=0.85), and SEFI-2 and PMR (r=0.80). The weakest correlations were found with the social deprivation ABSM measure and the self-rated health measure.

CONCLUSIONS

ABSMs based on measures from the Canadian census are a valuable resource to population health researchers. Importantly, depending on the research question and reason for the inclusion of an ABSM, these composite measures may perform better than a simple measure of income alone. The ability to adjust for socio-economic status when assessing population health status or population health interventions contributes to the validity of conclusions drawn when conducting this type of research, and ABSMs may be able to substitute for area health status where it may not be easily determined.

Osteoporosis-related fracture case definitions for population-based administrative data

Background

Population-based administrative data have been used to study osteoporosis-related fracture risk factors and outcomes, but there has been limited research about the validity of these data for ascertaining fracture cases. The objectives of this study were to: (a) compare fracture incidence estimates from administrative data with estimates from population-based clinically-validated data, and (b) test for differences in incidence estimates from multiple administrative data case definitions.

Methods

Thirty-five case definitions for incident fractures of the hip, wrist, humerus, and clinical vertebrae were constructed using diagnosis codes in hospital data and diagnosis and service codes in physician billing data from Manitoba, Canada. Clinically-validated fractures were identified from the Canadian Multicentre Osteoporosis Study (CaMos). Generalized linear models were used to test for differences in incidence estimates.

Results

For hip fracture, sex-specific differences were observed in the magnitude of under- and over-ascertainment of administrative data case definitions when compared with CaMos data. The length of the fracture-free period to ascertain incident cases had a variable effect on over-ascertainment across fracture sites, as did the use of imaging, fixation, or repair service codes. Case definitions based on hospital data resulted in under-ascertainment of incident clinical vertebral fractures. There were no significant differences in trend estimates for wrist, humerus, and clinical vertebral case definitions.

Conclusions

The validity of administrative data for estimating fracture incidence depends on the site and features of the case definition.

A population-based analysis of the post-fracture care gap 1996-2008: the situation is not improving

The post-fracture care gap has not narrowed in recent years. Following an initial improvement, rates of medication initiation have actually declined.

INTRODUCTION

The current study characterizes temporal changes in post-fracture bone mineral density (BMD) testing or osteoporosis treatment initiation from 1996/1997 to 2007/2008.

METHODS

A population-based administrative data repository for Manitoba, Canada was accessed to identify non-traumatic fractures in individuals aged 50 years and older. Outcomes included BMD testing or dispensation of an osteoporosis medication in the 12 months following the fracture.

RESULTS

Thirty thousand nine hundred and twenty (30,920) fracture events met the inclusion criteria; 15,670 affected major osteoporotic fracture sites. Based on either BMD testing or treatment initiation, intervention rates reached a maximum of only 15.5% in 2003/2004, compared with 6.3% in 1996/1997, and 13.2% in 2007/2008 (p-for-trend < 0.001). Post-fracture BMD testing increased from 0.7% in 1996/1997 to 8.9% 2007/2008 (p-for-trend < 0.001). Osteoporosis medication use increased from 6.1% in 1996/1997 to 12.3% in 2001/2002 and then progressively declined to 5.9% by 2007/2008 (p-for-trend = 0.025). Similar trends were observed when only major osteoporotic fractures were included. The initiation of BMD testing or medication varied according to age, gender, geographic region, and income.

CONCLUSION

Despite increased attention to gaps in osteoporosis management post-fracture in the last 10 years, the situation has not improved: in 2007/20008, fewer than 20% of untreated individuals with a low-trauma fracture received intervention. Novel strategies are required to disseminate and implement best practices at the point of care to reduce the risk of recurrent fractures.

The post-fracture care gap among Canadian First Nations peoples: a retrospective cohort study

Despite targeted attempts to reduce post-fracture care gaps, we hypothesized that a larger care gap would be experienced by First Nations compared to non-First Nations people. First Nations peoples were eight times less likely to receive post-fracture care compared to non-First Nations peoples, representing a clinically significant ethnic difference in post-fracture care.

INTRODUCTION

First Nations peoples are the largest group of aboriginal (indigenous or native) peoples in Canada. Canadian First Nations peoples have a greater risk of fracture compared to non-First Nations peoples. We hypothesized that ethnicity might be associated with a larger gap in post-fracture care.

METHODS

Non-traumatic major osteoporotic fractures for First Nations and non-First Nations peoples aged ≥ 50 years were identified from a population-based data repository for Manitoba, Canada between April 1996 and March 2002. Logistic regression analysis was used to examine the probability of receiving a BMD test, a diagnosis of osteoporosis, or beginning an osteoporosis-related drug in the 6 months post-fracture.

RESULTS

A total of 11,234 major osteoporotic fractures were identified; 502 occurred in First Nations peoples. After adjustment for confounding covariates, First Nations peoples were less likely to receive a BMD test [odds ratio (OR) 0.1, 95% confidence interval (CI), 0.0-0.5], osteoporosis-related drug treatment (OR, 0.5; 95% CI, 0.3-0.7), or a diagnosis of osteoporosis (OR, 0.5; 95% CI, 0.3-0.7) following a fracture compared to non-First Nations peoples. Females were more likely to have a BMD test (OR, 5.0; 95% CI, 2.6-9.3), to be diagnosed with osteoporosis (OR, 1.7; 95% CI, 1.5-2.0), and to begin drug treatment (OR, 4.1; 95% CI, 2.7-6.4) compared to males.

CONCLUSIONS

An ethnicity difference in post-fracture care was observed. Further work is needed to elucidate underlying mechanisms for this difference and to determine whether failure to initiate treatment originates with the medical practitioner, the patient, or a combination of both. It is imperative that all residents of Manitoba receive efficacious and equal care post-fracture, regardless of ethnicity.

Mortality rates after incident non-traumatic fractures in older men and women

Non-traumatic fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Furthermore, in certain age subgroups of women and men, this rate remained elevated beyond 5 years for fractures of the hip, vertebrae, humerus, and other sites.

INTRODUCTION

Increased mortality rates have been documented following non-traumatic hip, vertebral, and shoulder fractures. However, data are lacking as to the duration of excess mortality and whether there is increased mortality following fractures at other sites. We determined mortality up to 15 years following incident fractures at typical osteoporotic sites.

METHODS

Using healthcare databases for the Province of Manitoba, Canada, we identified individuals 50 years and older with an incident non-traumatic fracture between 1986 and 2007. Each fracture case was matched to three fracture-free controls. Generalized linear models were used to test for trends in mortality and to estimate the relative risk for cases after adjusting for co-morbidity and living arrangements.

RESULTS

During the study period, we identified 21,067 incident fractures in men followed by 10,724 (50.1%) deaths and 49,197 incident fractures in women followed by 22,018 deaths (44.8%). Seventy-six percent of the fractures were at sites other than the hip and vertebrae. After adjustment for age, number of co-morbidities, and level of dependence in living arrangements, the risk of death in cases, relative to controls, was increased in both sexes for hip, vertebral, humerus, wrist (in men only), and other fracture sites. Post-fracture mortality was higher in men than women. Relative mortality was the highest in the younger age groups across the spectrum of fracture sites.

CONCLUSIONS

Fractures at typical osteoporotic sites are associated with increased mortality across all age groups, particularly in men. Better understanding of factors associated with increased post-fracture mortality should inform the development of management strategies.

Stereotyping as a barrier to collaboration: Does interprofessional education make a difference?

This research was part of a Health Canada funded initiative developed to provide evidence about the effectiveness of interprofessional education (IPE) interventions to promote collaborative patient-centred care. Health professional students' ratings of health professions and the effect of IPE on those ratings were examined. Participants were divided into three groups (N=51); control, education, and practice site immersion. Utilizing the Student Stereotypes Rating Questionnaire (SSRQ) which consists of a five point Likert-type scale each group rated health professionals on nine characteristics: academic ability, interpersonal skills, professional competence, leadership, practical skills, independence, confidence, decision-making, and being a team player (Hean, Macleod-Clark, Adams, and Humphris, 2006). Data were collected at four time points; prior to an IPE classroom intervention, following an IPE classroom intervention, following the IPE immersion experience, and four months post IPE immersion experience. Overall, perceptions of other health professions were more positive following the 2.5day interprofessional education session and immersion experience. Student ratings of the seven professions among the nine characteristics will be presented, highlighting similarities and differences across professional groups. Findings support the incorporation of IPE curricula that address the role and functions of other health care professions to facilitate the development collaborative patient-centred care health care teams.

Tamoxifen Use and Osteoporotic Fracture Risk: A Population-Based Analysis

Purpose

Although tamoxifen has been shown to increase bone mineral density in clinical trials, it is less clear whether this significantly affects fracture rates. Even fewer data are available on skeletal outcomes when tamoxifen is used outside of the context of a clinical trial. A population-based case-control study was undertaken to determine whether tamoxifen use is associated with osteoporotic fractures in routine clinical practice.

Patients and Methods

Population-based administrative data for the Province of Manitoba, Canada, were examined for tamoxifen use and nontraumatic fracture codes in women 50 years of age or older. Women with osteoporotic fractures (vertebral, wrist or hip; n = 11,096) from 1996 to 2004 were each compared with three controls without fracture, matched for age, ethnicity, and comorbidity (n = 33,209). Tamoxifen use was classified as never, past use, or current use.

Results

Lower osteoporotic fracture rates were associated with current tamoxifen use (univariate odds ratio [OR] = 0.68; 95% CI, 0.55 to 0.84). After controlling for demographic and medical diagnoses known to affect fracture risk, current use was associated with a significantly reduced overall osteoporotic fracture risk (adjusted OR = 0.68; 95% CI, 0.55 to 0.88) and of hip fractures (adjusted OR = 0.47; 95% CI, 0.28 to 0.77). Neither recent nor remote past tamoxifen use was associated with reduced osteoporotic fracture risk. Breast cancer was not independently associated with osteoporotic fractures (adjusted OR = 0.95; 95% CI, 0.81 to 1.12).

Conclusion

In a population-based case-control study, current tamoxifen use was associated with a substantial reduction in osteoporotic fractures.

Using multiple data features improved the validity of osteoporosis case ascertainment from administrative databases

OBJECTIVES

The aim was to construct and validate algorithms for osteoporosis case ascertainment from administrative databases and to estimate the population prevalence of osteoporosis for these algorithms.

STUDY DESIGN AND SETTING

Artificial neural networks, classification trees, and logistic regression were applied to hospital, physician, and pharmacy data from Manitoba, Canada. Discriminative performance and calibration (i.e., error) were compared for algorithms defined from different sets of diagnosis, prescription drug, comorbidity, and demographic variables. Algorithms were validated against a regional bone mineral density testing program.

RESULTS

Discriminative performance and calibration were poorer and sensitivity was generally lower for algorithms based on diagnosis codes alone than for algorithms based on an expanded set of data features that included osteoporosis prescriptions and age. Validation measures were similar for neural networks and classification trees, but prevalence estimates were lower for the former model.

CONCLUSION

Multiple features of administrative data generally resulted in improved sensitivity of osteoporosis case-detection algorithm without loss of specificity. However, prevalence estimates using an expanded set of features were still slightly lower than estimates from a population-based study with primary data collection. The classification methods developed in this study can be extended to other chronic diseases for which there may be multiple markers in administrative data.

Population-based data sources for chronic disease surveillance

This study estimated agreement between population-based administrative and survey data for ascertaining cases of arthritis, asthma, diabetes, heart disease, hypertension and stroke. Chronic disease case definitions that varied by data source, number of years and number of diagnosis or prescription drug codes were constructed from Manitoba's administrative data. These data were linked to the Canadian Community Health Survey. Agreement between the two data sources, estimated by the kappa coefficient, was calculated for each case definition, and differences were tested. Socio-demographic and comorbidity variables associated with agreement were tested using weighted logistic regression. Agreement was strongest for diabetes and hypertension and lowest for arthritis. The case definition elements that contributed to the highest agreement between the two population-based data sources varied across the chronic diseases. Low agreement between administrative and survey data is likely to occur for conditions that are difficult to diagnose, but will be mediated by individual socio-demographic and health status characteristics. Construction of a chronic disease case definition from administrative data should be accompanied by a justification for the choice of each of its elements.

Biphasic fracture risk in diabetes: a population-based study

Diabetes is associated with increased fracture rates but the effect size, time course and modifying factors are poorly understood. This study was undertaken to assess the effect of diabetes on fracture rates and possible interactions with age, duration of diabetes and comorbidity. A retrospective, population-based matched cohort study (1984-2004) was performed using the Population Health Information System (POPULIS) for the Province of Manitoba, Canada. The study cohort consisted of 82,094 diabetic adults and 236,682 non-diabetic matched controls. Diabetes was subclassified as long term, short term, and newly diagnosed. Number of ambulatory diagnostic groups (ADGs) was an index of comorbidity. Poisson regression was used to study counts of combined hip, wrist and spine (osteoporotic) fractures (5691 with diabetes and 16,457 without diabetes) and hip fractures (1901 with diabetes and 5224 without diabetes). Independent effects of longer duration of diabetes (p-for-trend<0.0001) and number of ADGs (p-for-trend<0.0001) were observed on fracture rates. Newly diagnosed diabetes showed a reduction in osteoporotic fractures (rate ratio [RR] 0.91 [95% CI, 0.86-0.95]) and hip fractures (RR 0.83 [0.75-0.92]). Long-term diabetes showed an increase in osteoporotic fractures (RR 1.15 [CI, 1.09-1.22]) and hip fractures (RR 1.40 [1.28-1.53]). We conclude that long-term diabetes is associated with increased fracture risk, whereas newly diagnosed diabetes shows a reduction in fractures. It is hypothesized that the opposing effects of overweight/obesity and diabetes-related complications contribute to the observed biphasic fracture risk, though causality cannot be proven from this observational study.

The prevalence of and the clinical and demographic characteristics associated with high-intensity proton pump inhibitor use

INTRODUCTION

High-intensity proton pump inhibitor (PPI) use is often recommended by physicians, though there is little proven benefit over standard PPI dosing in many clinical situations. We therefore sought to calculate the prevalence and predictors of high-intensity PPI use.

METHODS

We used a Canadian provincial administrative database to capture all PPI prescriptions between 1996 and 2004. A person was defined as a high-intensity user if he used PPIs at more than 1.5 times the standard PPI dose for greater than 45 of 90 days before the index date. The prevalence of high-intensity use was calculated at four index dates annually. Stepwise logistic regression was performed to determine clinical and demographic factors associated with high-intensity PPI use.

RESULTS

The prevalence of high-intensity PPI use increased from 9.7% in 1997 to 14.2% in 2004. Polypharmacy, concomitant use of antispasmodic/promotility agents, and recent endoscopy were most strongly predictive of high-intensity PPI use. Severity of gastroesophageal reflux disease (GERD) (as assessed by the number of GERD-related physician visits) was relatively weakly predictive of high-intensity PPI use.

CONCLUSIONS

High-intensity PPI use is becoming more prevalent over time, and its use is strongly associated with factors suggestive of a high degree of comorbidity and treatment failure. Further research into factors that drive high-intensity PPI prescription and use are required.

Pharmaceutical use among older adults: using administrative data to examine medication-related issues

Medication use is recognized as the least expensive, most cost-effective health care intervention. In older adults this is especially important, as they are the largest consumer of prescription medications. We describe the use of a linked data set including pharmaceutical, medical, and hospital claims to examine pharmaceutical use in the population of older adults and then give several examples of its application. Indicators to describe the population's overall use of medication and the appropriate use of specific medication have been developed. Indicators of appropriate use are characterized using the dispensation of benzodiazepines to older adults.We have found that a significant proportion of new users of benzodiazepines are still prescribed a long-acting version (over 10%), signifying potential inappropriate use. The data are also able to describe some significant outcomes from the use of pharmaceuticals such a death, fracture, and population-based clinical measures where available.

Validity of a prescription claims database to estimate medication adherence in older persons

BACKGROUND

Prescription claims data have been used to estimate refill medication adherence through calculations of cumulative medication acquisition (CMA) and cumulative medication gap (CMG) values. Few studies have assessed the validity of these calculated rates.

OBJECTIVES

We sought to assess the validity of CMA and CMG calculated from the Manitoba prescription claims database (DPIN) against pill count medication adherence, targeting overall medications and angiotensin converting enzyme inhibitors (ACEIs).

METHODS

Using a survey of a convenience sample of subjects recruited through community pharmacies, subjects who were eligible for study (ie, 65 years or older, noninstitutionalized, taking 2 or more "discrete" prescribed medications, including an ACEI, and willing to provide informed consent) were studied. Pill counts were conducted on all prescribed medicines during 3 home interviews over the course of 4 months. Ten months of DPIN data also were collected on each subject.

RESULTS

The concordance between CMA and pill count for overall medications was 411/522 (79%) and for ACEIs was 89/101 (88%) with no systematic differences (McNemar's P = 0.68 and P = 0.097, respectively). CMG and pill count showed even better concordance of 438/514 (85%) for overall medications and 96/101 (95%) for ACEIs, although systematic differences were noted for overall medications (McNemar's P = 0.0012) but not for ACEIs (McNemar's P = 0.500). Spearman's rank correlations were weak for all comparisons.

CONCLUSIONS

The high concordance between prescription claims database and pill counts suggested that the rate with which patients refill their medications usually is consistent with the rate they consume them. DPIN is not accurate for nondiscrete dosage forms or medications prescribed for "as-required" use.

The interaction of ethnicity and chronic disease as risk factors for osteoporotic fractures: a comparison in Canadian Aboriginals and non-Aboriginals

INTRODUCTION

Efforts to develop global methods for absolute fracture risk prediction are currently limited by uncertainty over the validity of these models in non-White populations. Aboriginal Canadians have higher fractures rates than non-Aboriginals. This analysis examined the interaction of ethnicity with diabetes mellitus, disease comorbidity and substance abuse as possible explanatory variables.

METHODS

A retrospective, population-based matched cohort study of fracture rates was performed using Manitoba administrative health data (1984-2003). The study cohort consisted of 27,952 registered Aboriginal adults (aged 20 years or older) and 83,856 non-Aboriginal controls (matched three to one for year of birth and gender). Diabetes mellitus, number of ambulatory disease groups (ADGs), substance abuse and incident fractures were based upon validated definitions. Poisson regression analyses of fracture rates modelled the explanatory variables as main effects and two-way interactions with ethnicity.

RESULTS

Osteoporotic fracture rates were approximately twofold higher in the Aboriginal cohort (p<0.0001). Diabetes, greater number of ADGs and substance abuse were all more common in the Aboriginal cohort (all p<0.0001). These factors were associated with increased fracture rates (all p<0.0001) and significantly higher population attributable risk percent in the Aboriginal cohort (all p<0.0001). However, no significant interactions between the risk factors and ethnicity were observed (p>0.1 for all interaction effects).

CONCLUSION

Greater prevalence of diabetes, comorbidity and substance abuse contributes to higher rates of fracture. The relative risk of fracture for these factors is similar for both Aboriginal and non-Aboriginals despite large differences in absolute fracture risk and risk factor prevalence.

Demographic risk factors for fracture in First Nations people

BACKGROUND

Recently, First Nations people were shown to be at high fracture risk compared with the general population. However, factors contributing to this risk have not been examined. This analysis focusses on geographic area of residence, income level, and diabetes mellitus as possible explanatory variables since they have been implicated in the fracture rates observed in other populations.

METHODS

A retrospective, population-based matched cohort study of fracture rates was performed using the Manitoba administrative health data (1987-1999). The First Nations cohort included all Registered First Nations adults (20 years or older) as indicated in either federal and/or provincial files (n = 32,692). Controls (up to three for each First Nations subject) were matched by year of birth, sex and geographic area of residence. After exclusion of unmatched subjects, analysis was based upon 31,557 First Nations subjects and 79,720 controls.

RESULTS

Overall and site-specific fracture rates were significantly higher in the First Nations cohort. Income quintile, geographic area of residence, and diabetes were fracture determinants but the excess fracture risk of First Nations ethnicity persisted even after adjustment for these factors.

CONCLUSION

First Nations people are at high risk for fracture but the causal factors contributing to this are unclear. Further research is needed to evaluate the importance of other potential explanatory variables.

Potential impact of oral contraceptive choice on myocardial infarction mortality and deep vein thrombosis

OBJECTIVES

To summarise the epidemiological evidence on the relationship between second- (OC2) and third-generation (OC3) oral contraceptives (OC) and the mortality associated with deep vein thrombosis (DVT) and myocardial infarction (MI), and to extrapolate and balance the evidence for these risks to the population of French OC users.

METHODS

All studies published on the risk of MI during OC2 and OC3 use were analysed. For DVT the Committee for Proprietary Medicinal Products public assessment report published in 2001 and more recent studies published on this topic were used. The estimates of odds ratios (OR) for risk of death from DVT or MI were extracted from the published manuscripts. ORs were used to calculate the aetiological fraction of risk for death from DVT and MI in the population; the relative impact of OC3 compared to OC2 use was expressed as an excess risk of death overall and by age group for French women.

RESULTS

Compared with OC2, the use of OC3 would prevent a maximum of 24 deaths from MI per year and induce a maximum of 16 deaths. Conversely, OC3 would induce 282-940 excess cases of DVT per year, resulting in 28-94 pulmonary embolisms and 3-19 deaths in the 4.7 million French OC users.

CONCLUSION

Balancing the evidence, it is difficult to conclude that the overall cardiovascular risk is significantly lower for either of the two OC schemes.

Demographic risk factors for fracture in First Nations people

BACKGROUND

Recently, First Nations people were shown to be at high fracture risk compared with the general population. However, factors contributing to this risk have not been examined. This analysis focusses on geographic area of residence, income level, and diabetes mellitus as possible explanatory variables since they have been implicated in the fracture rates observed in other populations.

METHODS

A retrospective, population-based matched cohort study of fracture rates was performed using the Manitoba administrative health data (1987-1999). The First Nations cohort included all Registered First Nations adults (20 years or older) as indicated in either federal and/or provincial files (n = 32,692). Controls (up to three for each First Nations subject) were matched by year of birth, sex and geographic area of residence. After exclusion of unmatched subjects, analysis was based upon 31,557 First Nations subjects and 79,720 controls.

RESULTS

Overall and site-specific fracture rates were significantly higher in the First Nations cohort. Income quintile, geographic area of residence, and diabetes were fracture determinants but the excess fracture risk of First Nations ethnicity persisted even after adjustment for these factors.

CONCLUSION

First Nations people are at high risk for fracture but the causal factors contributing to this are unclear. Further research is needed to evaluate the importance of other potential explanatory variables.

Comparison of anti-infective drug use in elderly persons in Manitoba, Nova Scotia, and Saskatchewan, Canada: relationship to drug insurance reimbursement policies

BACKGROUND

Antimicrobial drug resistance continues to be a concern. Inappropriate use of antimicrobial agents is a well-documented contributory factor in the development of resistance. Canadian publicly funded drug insurance (pharmacare) programs have various approaches to reimbursement for antimicrobial drugs and promoting the appropriate prescribing of these agents.

OBJECTIVE

The objective of this study was to examine changes in antimicrobial use over a 3-year period in relation to the reimbursement policies of the public drug insurance programs for elderly persons in Manitoba, Nova Scotia, and Saskatchewan.

METHODS

The pharmacare databases of the 3 provincial drug insurance programs were accessed for fiscal years 1995/96, 1996/97, and 1997/98. Antimicrobial drug use was reported as mean age- and sex-standardized defined daily doses (DDDs) dispensed per 1000 beneficiaries per year. Provincial antimicrobial drug use was compared and related to provincial reimbursement policies.

RESULTS

The rates and types of antimicrobial drugs dispensed to elderly beneficiaries of the Manitoba, Nova Scotia, and Saskatchewan pharmacare programs varied. Between fiscal years 1995/96 and 1997/98, DDDs of antimicrobials per 1000 beneficiaries per year decreased by 11.5% in Saskatchewan and increased by 1.2% in Manitoba and 6.2% in Nova Scotia. Rates of use of broadspectrum agents such as amoxicillin/clavulanate, azithromycin, clarithromycin, and fluoroquinolones were lower in the provinces that had reimbursement guidelines. Even when reimbursement policies were similar, as for fluoroquinolones in Manitoba and Saskatchewan, rates of use varied markedly, possibly as a result of the method of implementing the reimbursement guidelines. Use of fluoroquinolones, macrolides, penicillins, beta-lactamase-resistant penicillins, and tetracyclines was lower and use of sulfonamides and trimethoprim was greater in Saskatchewan than in Nova Scotia and Manitoba.

CONCLUSIONS

The reimbursement guidelines of provincial drug insurance programs are among the factors affecting the use of antimicrobial agents. Both the type of reimbursement policy and the policy implementation mechanism affected the rate of utilization. Further research is needed to link drug-use information with data such as antimicrobial resistance patterns, diagnoses, physician visits, and hospitalizations.

Fracture risk among First Nations people: a retrospective matched cohort study

BACKGROUND

Canadian First Nations people have unique cultural, socioeconomic and health-related factors that may affect fracture rates. We sought to determine the overall and site-specific fracture rates of First Nations people compared with non-First Nations people.

METHODS

We studied fracture rates among First Nations people aged 20 years and older (n = 32 692) using the Manitoba administrative health database (1987-1999). We used federal and provincial sources to identify ethnicity, and we randomly matched each First Nations person with 3 people of the same sex and year of birth who did not meet this definition of First Nations ethnicity (n = 98 076). We used a provincial database of hospital separations and physician billing claims to calculate standardized incidence ratios (SIRs) and 95% confidence intervals (CIs) for each fracture type based on a 5-year age strata.

RESULTS

First Nations people had significantly higher rates of any fracture (age- and sex-adjusted SIR 2.23, 95% CI 2.18-2.29). Hip fractures (SIR 1.88, 95% CI 1.61-2.14), wrist fractures (SIR 3.01, 95% CI 2.63-3.42) and spine fractures (SIR 1.93, 95% CI 1.79-2.20) occurred predominantly in older people and women. In contrast, craniofacial fractures (SIR 5.07, 95% CI 4.74-5.42) were predominant in men and younger adults.

INTERPRETATION

First Nations people are a previously unidentified group at high risk for fracture.

Encouraging physician appropriate prescribing of non-steroidal anti-inflammatory therapies: protocol of a randomized controlled trial [ISRCTN43532635]

Background

Traditional non-steroidal anti-inflammatory drugs (NSAIDs) are a widely used class of therapy in the treatment of chronic pain and inflammation. The drugs are effective and can be relatively inexpensive thanks to available generic versions. Unfortunately the traditional NSAIDs are associated with gastrointestinal complications in a small proportion of patients, requiring costly co-therapy with gastro-protective agents. Recently, a new class of non-steroidal anti-inflammatory agents known as coxibs has become available, fashioned to be safer than the traditional NSAIDs but priced considerably higher than the traditional generics. To help physicians choose appropriately and cost-effectively from the expanded number of anti-inflammatory therapies, scientific bodies have issued clinical practice guidelines and third party payers have published restricted reimbursement policies. The objective of this study is to determine whether an educational intervention can prompt physicians to adjust their prescribing in accordance with these expert recommendations.

Methods

This is an ongoing, randomized controlled trial. All primary care physicians in Manitoba, Canada have been randomly assigned to a control group or an intervention study group. The educational intervention being evaluated consists of an audit and feedback mechanism combined with optional participation in a Continuing Medical Education interactive workshop. The primary outcome of the study is the change, from pre-to post-intervention, in physicians' appropriate prescribing of non-steroidal anti-inflammatory therapies for patients requiring chronic treatment. Three classes of non-steroidal anti-inflammatory therapies have been identified: coxib therapy, traditional NSAID monotherapy, and traditional NSAID therapy combined with gastro-protective agents. Appropriate prescribing is defined based on international clinical practice guidelines and the provincial drug reimbursement policy in Manitoba.

Does the use of 5-aminosalicylates in inflammatory bowel disease prevent the development of colorectal cancer?

OBJECTIVES

There is increased interest in determining whether 5-aminosalicylate (5-ASA) use can prevent the development of colorectal cancer (CRC) among patients with inflammatory bowel disease (IBD). The aim of this study was to determine whether use of 5-ASA was associated with a reduced risk of CRC in these patients.

METHODS

We extracted from our population-based University of Manitoba Inflammatory Bowel Disease Epidemiology Database the number of patients with a new diagnosis of CRC between the years 1997 and 2000. From within our Inflammatory Bowel Disease Epidemiology Database we extracted a control group of IBD patients who did not develop CRC matched to the case group who did develop CRC by age, sex, diagnosis, year of diagnosis, and geographic area of residence. We linked cases and controls with Manitoba Health's Drug Program Information Network to study 5-ASA use within 2 yr before CRC diagnosis. The Drug Program Information Network database is a population-based database that was established in 1995 and that records all prescription drugs.

RESULTS

There were 25 cases of IBD identified as having CRC. These were matched with 348 cases of IBD who did not develop CRC. CRC cases were more likely to be exposed to 5-ASA (odds ratio = 1.46; 95% CI = 0.58-3.73) but this result was not statistically significant. The mean total days of use was 400.9 days +/- 185.9 among CRC cases versus 420.2 days +/- 241.7 among non-CRC cases (p = 0.92). The prescribed daily dose was 2295 mg/day +/- 1041 mg among CRC cases and 1811 mg +/- 520 mg among controls (p = 0.21).

CONCLUSIONS

These data do not support 5-ASA as protective in preventing CRC.

The association between corticosteroid use and development of fractures among IBD patients in a population-based database

OBJECTIVES

Because the rate of fracture among patients with inflammatory bowel disease (IBD) is only slightly higher than that in the general population, it is important to define high-risk groups worthy of diagnostic evaluation or prophylactic interventions. Corticosteroid use has been considered in other diseases to be a risk for fracture, although not all studies in IBD are concordant on this point. We aimed to determine whether patients with IBD drawn from a population-based database who sustain fractures are more likely to have been using corticosteroids than a matched group of IBD patients who did not fracture.

METHODS

We extracted from our population-based University of Manitoba Inflammatory Bowel Disease Epidemiology Database the number of patients with a new diagnosis of fracture between the years 1997-2000. From within our Inflammatory Bowel Disease Epidemiology Database, we extracted a control group of IBD patients who did not develop fractures matched to the case group who did by age, gender, diagnosis, year of diagnosis, and geographic area of residence. We linked our cohorts with Manitoba Health's Drug Program Information Network to study corticosteroid use within 2 yr before fracture diagnosis. The Drug Program Information Network is a population-based database, established in 1995, which records all prescription drugs.

RESULTS

Fractures were identified in 13 patients with Crohn's disease and in 28 patients with ulcerative colitis. The control group included 103 Crohn's disease and 173 ulcerative colitis patients who did not fracture. In Crohn's disease, for the group who fractured compared with the controls who did not fracture, corticosteroid use before fracture was evident in seven (54%) compared with 21 (22%) who did not fracture (chi(2) = 4.45, df = 1, p = 0.035). In ulcerative colitis, for the group who fractured compared with the controls who did not fracture, corticosteroid use before fracture was evident in five (18%) compared with 37 (21%) who did not fracture (chi(2) = 0.031, df = 1, p = 0.861). Fracture cases were more likely to be exposed to oral corticosteroids (OR = 1.75; 95% CI = 0.82-3.75), but this result is not significant. Regarding corticosteroid dosing among the 12 patients with IBD who fractured and used corticosteroids, the mean total days supply was 314 days +/- 236 days compared with 258 days +/- 278 days in those who did not fracture (p = 0.16). The prescribed daily dose among corticosteroid users was comparable for those who fractured versus those who did not fracture (18 mg/day vs 21 mg/day, p = 0.90).

CONCLUSIONS

Patients who require corticosteroids in Crohn's disease should be considered at risk for fracture. Further research is required to delineate after how much corticosteroid use are subjects at risk and/or after what duration of active disease.

Contribution of clinical risk factors to bone density-based absolute fracture risk assessment in postmenopausal women

Hip fractures are independently associated with advancing age, specific clinical risk factors (CRFs), and low bone mineral density (BMD). The use of BMD T-scores for quantifying fracture risk ignores the contribution of age and CRFs. We previously developed a mathematical model of absolute hip fracture risk that incorporates patient age, BMD, and the results of eleven specific CRFs. The purpose of this study was to compare the contribution of an approach to fracture risk stratification using the full model (age, CRFs and BMD) with that of a unidimensional BMD-only model. We selected 213 consecutive postmenopausal females (mean age 65.3, range 50-87.9) with CRF data referred for BMD assessment of fracture risk. Absolute hip fracture risk (over the next 5 years and remaining lifetime) was estimated using both the full and BMD-only models. The mean ratio of absolute hip fracture risks (BMD-only/full model) derived for each patient was 0.8 (95% CI, 0.16-4.0) for hip fracture in the next 5 years and 1.1 (CI, 0.1-7.6) for remaining lifetime. The wide confidence intervals indicate a large contribution of age and CRFs to fracture risk stratification. Categorization of women as "high risk" was frequently discordant for the two models. One-half of the women designated "high risk" under the full model were classified as "low risk" based upon BMD alone. In conclusion, we have shown that a multidimensional approach to hip fracture risk stratification is feasible, and greatly modifies risk stratification based on BMD alone.

Establishing a regional bone density program: lessons from the Manitoba experience

In 1997, the province of Manitoba, Canada developed a regional bone density program to address concerns related to access, waiting times, and quality assurance. We report our experience with this model of bone density service delivery, which is unique in North America, and confront the challenge of balancing accessibility, clear guidelines, and fiscal responsibility.

Bone mineral density testing in healthy postmenopausal women. The role of clinical risk factor assessment in determining fracture risk

The ease of measurement and the quantitative nature of bone mineral densitometry (BMD) is clinically appealing. Despite BMD's proven capability to stratify fracture risk, data indicate that clinical risk factors provide complementary information on fracture susceptibility that is independent of BMD. Methods to quantify fracture risk using both clinical and BMD variables would have great appeal for clinical decision-making. We describe a procedure for quantifying hip fracture risk (5-yr and remaining lifetime) based on (1) the individual's age alone (base model, assuming average clinical risk factors and bone density), (2) incorporation of multiple patient-specific clinical risk factor data in the base model, and (3) incorporation of both patient-specific clinical risk factor data and BMD results.