Screening behaviours, demographics, and stage at diagnosis in the publicly funded Ontario Breast Screening Program

PURPOSE

The Ontario Breast Screening Program (OBSP) offers free screening mammograms every 2 years, to women aged 50-74. Study objectives were to determine demographic characteristics associated with the adherence to OBSP and if women screened in the OBSP have a lower stage at diagnosis than non-screened eligible women.

METHODS

We used the Ontario cancer registry (OCR) to identify 48,927 women, aged 51-74 years, diagnosed with breast cancer between 2010 and 2017. These women were assigned as having undergone adherent screening (N = 26,108), non-adherent screening (N = 6546) or not-screened (N = 16,273) in the OBSP. We used multinomial logistic regression to investigate the demographic characteristics associated with screening behaviour, as well as the association between screening status and stage at diagnosis.

RESULTS

Among women with breast cancer, those living in rural areas (versus the largest urban areas) had a lower odds of not being screened (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.68, 0.78). Women in low-income (versus high-income) communities were more likely not to be screened (OR 1.42, 95% CI 1.33, 1.51). When stratified, the association between income and screening status only held in urban areas. Non-screened women were more likely to be diagnosed with stage II (OR 1.91, 95% CI 1.82, 2.01), III (OR 2.96, 95% CI 2.76, 3.17), or IV (OR 8.96, 95% CI 7.94, 10.12) disease compared to stage I and were less likely to be diagnosed with ductal carcinoma in situ (DCIS) (OR 0.91, 95% CI 0.84-0.98).

CONCLUSIONS

This study suggests that targeting OBSP recruitment efforts to lower income urban communities could increase screening rates. OBSP adherent women were more likely to be diagnosed with earlier stage disease, supporting the value of this initiative and those like it.

Anti-Müllerian hormone-mediated preantral follicle atresia is a key determinant of antral follicle count in mice

STUDY QUESTION

Does anti-Müllerian hormone (AMH) induce preantral follicle atresia in mice?

SUMMARY ANSWER

The present findings suggest that AMH-mediated follicle atresia only occurs in early follicles before they become sensitive to FSH.

WHAT IS KNOWN ALREADY

Most prior studies have investigated the ability of AMH to inhibit primordial follicle activation. Our previous study showed that AMH-overexpressing mice had fewer preantral follicles than expected after accounting for primordial follicle inhibition but the reason for this was not determined.

STUDY DESIGN, SIZE, DURATION

Cross-sectional-control versus transgenic/knockout mouse studies were carried out.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Studies were conducted on female wild-type (Amh+/+), AMH-knockout (Amh-/-) and AMH overexpressing (Thy1.2-AMHTg/0) mice on a C57Bl/6J background (age: 42-120 days). The follicle counts were conducted for primordial, transitioning, primary, secondary and antral follicles in Amh-/- and Amh+/+ mice. After confirming that follicle development speeds were identical (proliferating cell nuclear antigen immunohistochemistry), the ratio of follicles surviving beyond each stage of folliculogenesis was determined in both genotypes. Evidence for increased rates of preantral follicle atresia was assessed by active caspase-3 immunohistochemistry in wild-type and Thy1.2-AMHTg/0 mice.

MAIN RESULTS AND THE ROLE OF CHANCE

Amh -/- mice at 100-120 days of age had lower primordial follicle counts but higher primordial follicle activation rates compared to Amh+/+ mice. These counteracting effects led to equivalent numbers of primordial follicles transitioning to the primary stage in Amh+/+ and Amh-/- mice. Despite this, Amh+/+ mice had fewer primary, secondary, small antral and medium antral follicles than Amh-/- mice indicating differing rates of developing follicle atresia between genotypes. Cleaved caspase-3 immunohistochemistry in Thy1.2-AMHTg/0 ovaries revealed high rates of granulosa cell and oocyte apoptosis in late primary/early secondary follicles of Thy1.2-AMHTg/0 mice.

LARGE SCALE DATA

N/A.

LIMITATIONS, REASONS FOR CAUTION

The findings were shown only in one species and additional research will be required to determine generalizability to other species.

WIDER IMPLICATIONS OF THE FINDINGS

This study is consistent with prior studies showing that Amh-/- mice have increased primordial follicle activation but these new findings demonstrate that AMH-mediated preantral follicle atresia is a predominant cause of the increased small antral follicle counts in Amh-/- mice. This suggests that the role of AMH is not to conserve the ovarian reserve to prolong fertility, but instead to prevent the antral follicle pool from becoming too large. While this study may demonstrate a new function for AMH, the biological purpose of this function requires further investigation, particularly in mono-ovulatory species.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the Health Research Council of New Zealand and the University of Otago. No competing interests to declare.

Impact of the COVID-19 Pandemic on Diabetes Care for Adults With Type 2 Diabetes in Ontario, Canada

OBJECTIVES

The COVID-19 pandemic and related public health prevention measures have led to a disruption of the delivery of routine care and may have had an impact on the quality of diabetes care. Our aim in this study was to evaluate the extent to which structure, process and outcome quality measures in diabetes care changed in the first 6 months of the pandemic compared with previous periods.

METHODS

A before-and-after observational study of all community-living Ontario residents >20 years of age and living with diabetes. The patients were divided into 3 cohorts: a pandemic cohort, alive March to September 2020 (n=1,393,404); reference cohort 1, alive March to September 2019 (n=1,415,490); and reference cohort 2, alive September 2019 to February 2020 (n=1,444,000). Outcome measures were in-person/virtual visits to general practitioners and specialists, eye examinations, glycated hemoglobin (A1C) and low-density lipoprotein (LDL) testing, filled prescriptions, and admissions to emergency departments (EDs) and hospitals for acute and chronic diabetes complications.

RESULTS

The probability of an in-person visit to a GP decreasing by 47% (95% confidence interval [CI], 47% to 47%) in the pandemic period compared with both previous periods. The probability of having an eye exam was lower by 43% (95% CI, 44% to 43%), an A1C test by 28% (95% CI, 29% to 28%) and an LDL test by 31% (95% CI, 31% to 31%) in the pandemic period compared with the same 6-month period the year before. There were very small decreases in drug prescriptions and decreases of 18% and 16% in ED and hospital visits for complications.

CONCLUSIONS

We observed disruptions to both structure and processes measures of diabetes care in Ontario during the first wave of the pandemic.

Development and validation of a predictive algorithm for risk of dementia in the community setting

Background

Most dementia algorithms are unsuitable for population-level assessment and planning as they are designed for use in the clinical setting. A predictive risk algorithm to estimate 5-year dementia risk in the community setting was developed.

Methods

The Dementia Population Risk Tool (DemPoRT) was derived using Ontario respondents to the Canadian Community Health Survey (survey years 2001 to 2012). Five-year incidence of physician-diagnosed dementia was ascertained by individual linkage to administrative healthcare databases and using a validated case ascertainment definition with follow-up to March 2017. Sex-specific proportional hazards regression models considering competing risk of death were developed using self-reported risk factors including information on socio-demographic characteristics, general and chronic health conditions, health behaviours and physical function.

Results

Among 75 460 respondents included in the combined derivation and validation cohorts, there were 8448 cases of incident dementia in 348 677 person-years of follow-up (5-year cumulative incidence, men: 0.044, 95% CI: 0.042 to 0.047; women: 0.057, 95% CI: 0.055 to 0.060). The final full models each include 90 df (65 main effects and 25 interactions) and 28 predictors (8 continuous). The DemPoRT algorithm is discriminating (C-statistic in validation data: men 0.83 (95% CI: 0.81 to 0.85); women 0.83 (95% CI: 0.81 to 0.85)) and well-calibrated in a wide range of subgroups including behavioural risk exposure categories, socio-demographic groups and by diabetes and hypertension status.

Conclusions

This algorithm will support the development and evaluation of population-level dementia prevention strategies, support decision-making for population health and can be used by individuals or their clinicians for individual risk assessment.

Influence of the competing risk of death on estimates of disease recurrence in trials of adjuvant endocrine therapy for early-stage breast cancer: A secondary analysis of MA.27, MA.17 and MA.17R

BACKGROUND

Many women diagnosed with early-stage hormone-sensitive breast cancer die of causes other than their breast cancer. These competing risks can create challenges in analysing and clearly communicating data on risk of breast cancer recurrence or death. Here, we quantify the impact of competing risks on estimates of disease recurrence and benefit from therapy.

PATIENTS AND METHODS

Using data from the MA.27, MA.17 and MA.17R trials of adjuvant endocrine therapy in early breast cancer, we compared Kaplan-Meier (KM) and competing risk methods for disease-free survival (DFS) and distant recurrence-free survival (DRFS). Each trial was analysed separately. In KM analyses, participants were censored at the time of non-breast cancer death. Competing risk analyses comprised cumulative incidence functions in which non-breast cancer death was a competing risk.

RESULTS

Non-breast cancer deaths were observed more often in older participants, in those with lower risk of breast cancer and after longer follow-up. Compared with conventional analyses, estimates of the proportion of participants with DFS or DRFS events were lower in competing risk analyses, with this difference increasing over the course of follow-up. The absolute treatment benefit was similar or modestly lower in competing risk analyses.

CONCLUSION

Compared with KM methods, competing risk analyses result in lower estimates of DFS and DRFS events and similar or modestly lower absolute benefit from experimental endocrine therapy. Over a long time horizon, competing risk methods may be preferable to KM methods when estimating future risk of recurrence in early-stage hormone-sensitive breast cancer.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov; NCT00003140, NCT00754845, NCT00066573.

Development and validation of a multivariable prediction model for major adverse cardiovascular events after early stage breast cancer: a population-based cohort study

AIMS

Develop a score to predict the risk of major adverse cardiovascular events (MACE) after early stage breast cancer (EBC) to facilitate personalized decision-making about potentially cardiotoxic treatments and interventions to reduce cardiovascular risk.

METHODS AND RESULTS

Using administrative databases, we assembled a cohort of women diagnosed with EBC in Ontario between 2003 and 2014, with follow-up through 2015. Two-thirds of the cohort were used for risk score derivation; the remainder were reserved for its validation. The outcome was a composite of hospitalizations for acute myocardial infarction, unstable angina, transient ischaemic attack, stroke, peripheral vascular disease, heart failure (HF), or cardiovascular death. We developed the score by regressing MACE incidence against candidate predictors in the derivation sample using a Fine-Gray model. Discrimination was assessed in the validation sample using Wolber's c-index for prognostic models with competing risks, while calibration was assessed by comparing predicted and observed MACE incidence. The risk score was derived in 60 294 women and validated in 29 810 women. Age, hypertension, diabetes, ischaemic heart disease, atrial fibrillation, HF, cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic kidney disease were significantly associated with MACE incidence and incorporated into the score. Ten-year MACE incidence was >40-fold higher for patients in the highest score decile compared to the lowest. The c-index was 81.9% (95% confidence interval 80.9-82.9%) at 5 years and 79.8% (78.8-80.8%) at 10 years in the validation cohort, with good agreement between predicted and observed MACE incidence.

CONCLUSION

Cardiovascular prognosis after EBC can be estimated using patients' pre-treatment characteristics.

The Risk of Heart Failure and Other Cardiovascular Hospitalizations After Early Stage Breast Cancer: A Matched Cohort Study

Background

Data are limited regarding the risk of heart failure (HF) requiring hospital-based care after early stage breast cancer (EBC) and its relationship to other types of cardiovascular disease (CVD).

Methods

We conducted a population-based, retrospective cohort study of EBC patients (diagnosed April 1, 2005–March 31, 2015) matched 1:3 on birth-year to cancer-free control subjects. We identified hospitalizations and emergency department visits for CVD through March 31, 2017. We used cumulative incidence function curves to estimate CVD incidence and cause-specific regression models to compare CVD rates between cohorts. All statistical tests were two-sided.

Results

We identified 78 318 EBC patients and 234 954 control subjects. The 10-year incidence of CVD hospitalization was 10.8% (95% confidence interval [CI] = 10.5% to 11.1%) after EBC and 9.1% (95% CI = 8.9% to 9.2%) in control subjects. Ischemic heart disease was the most common reason for CVD hospitalization after EBC. After regression adjustment, the relative rates compared with control subjects remained statistically significantly elevated for HF (hazard ratio [HR] = 1.21, 95% CI = 1.14 to 1.29, P < .001), arrhythmias (HR = 1.31, 95% CI = 1.23 to 1.39, P < .001), and cerebrovascular disease (HR 1.10, 95% CI = 1.04 to 1.17, P = .002) hospitalizations. It was rare for HF hospital presentations (2.9% of cases) to occur in EBC patients without recognized risk factors (age >60 years, hypertension, diabetes, prior CVD). Anthracycline and/or trastuzumab were used in 28 950 EBC patients; they were younger than the overall cohort with lower absolute rates of CVD, hypertension, and diabetes. However, they had higher relative rates of CVD in comparison with age-matched control subjects.

Conclusions

Atherosclerotic diagnoses, rather than HF, were the most common reasons for CVD hospitalization after EBC. HF hospital presentations were often preceded by risk factors other than chemotherapy, suggesting potential opportunities for prevention.

Importance of Considering Competing Risks in Time-to-Event Analyses: Application to Stroke Risk in a Retrospective Cohort Study of Elderly Patients With Atrial Fibrillation

Supplemental Digital Content is available in the text.

Background:

Ignoring competing risks in time-to-event analyses can lead to biased risk estimates, particularly for elderly patients with multimorbidity. We aimed to demonstrate the impact of considering competing risks when estimating the cumulative incidence and risk of stroke among elderly atrial fibrillation patients.

Methods and Results:

Using linked administrative databases, we identified patients with atrial fibrillation aged ≥66 years discharged from hospital in ON, Canada between January 1, 2007, and March 31, 2011. We estimated the cumulative incidence of stroke hospitalization using the complement of the Kaplan–Meier function and the cumulative incidence function. This was repeated after stratifying the cohort by presence of prespecified comorbidities: chronic kidney disease, chronic obstructive pulmonary disease, cancer, or dementia. The full cohort was used to regress components of the CHA₂DS₂VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, sex) score on the hazard of stroke hospitalization using the Fine-Gray and Cox methods. These models were subsequently used to predict the 5-year risk of stroke hospitalization. Among 136 156 patients, the median CHA₂DS₂VASc score was 4 and 84 728 patients (62.2%) had ≥1 prespecified comorbidity. The 5-year cumulative incidence of stroke was 5.4% (95% confidence interval, 5.3%–5.5%), whereas that of death without stroke was 48.8% (95% confidence interval, 48.5%–49.1%). The incidence of both events was overestimated by the Kaplan–Meier method; stroke incidence was overestimated by a relative factor of 39%. The degree of overestimation was larger among patients with non-CHA₂DS₂VASc comorbidity because of higher incidence of death without stroke. The Fine-Gray model demonstrated better calibration than the Cox model, which consistently overpredicted stroke incidence.

Conclusions:

The incidence of death without stroke was 9-fold higher than that of stroke, leading to biased estimates of stroke risk with traditional time-to-event methods. Statistical methods that appropriately account for competing risks should be used to mitigate this bias.

A Population-Based Study of Cardiovascular Mortality Following Early-Stage Breast Cancer

Importance

There is increasing interest in the effect of cardiovascular disease on cancer survivors. However, there are limited contemporary population-based data on the risk of cardiovascular death after early-stage breast cancer.

Objective

To describe the incidence of cardiovascular death in a contemporary population of women with early-stage breast cancer while accounting for competing risks.

Design, Setting, and Participants

A population-based cohort study was conducted among 98 999 women diagnosed with early-stage breast cancer between April 1, 1998, and March 31, 2012. Patients were followed up until death or were censored on December 31, 2013. Baseline characteristics were determined from administrative databases and the Ontario Cancer registry. Vital statistics data were used to determine the cause of death. Cumulative incidence functions were used to estimate the incidence of cause-specific mortality. We studied the association between baseline characteristics and rates of cardiovascular death using cause-specific hazard functions. The analyses accounted for competing risks of noncardiovascular death. Statistical analysis was performed from July 16, 2015, to August 4, 2016.

Exposures

Early-stage breast cancer, age, cardiovascular disease, hypertension, and diabetes.

Main Outcomes and Measures

Cause of death, which was classified as breast cancer, cardiovascular disease, other cancers, or other noncancer causes.

Results

Of the 98 999 women (median age, 60 years [interquartile range, 50-71 years]) in the study, 21 123 (21.3%) died during follow-up. The median time to death was 4.2 years (IQR, 2.2-7.1 years). Breast cancer was the most common cause of death (10 550 deaths [49.9%]); 3444 deaths [16.3%] were from cardiovascular causes. Cardiovascular death was infrequent in women younger than 66 years without prior cardiovascular disease, diabetes, or hypertension. Among women 66 years or older, the risks of breast cancer death and cardiovascular death at 10 years were 11.9% (95% CI, 11.6%-12.3%) and 7.6% (95% CI, 7.3%-7.9%), respectively. Among patients with prior cardiovascular disease, the risk of death from breast cancer and cardiovascular disease were equivalent for the first 5 years, after which death from cardiovascular causes was more frequent (10-year cumulative incidence, 14.6% [95% CI, 13.7%-15.4%] for breast cancer vs 16.9% [95% CI, 16.0%-17.8%] for cardiovascular disease). For women 66 years or older who survived 5 years or more after diagnosis of breast cancer, cardiovascular disease exceeded breast cancer as the leading cause of death at 10 years after diagnosis, when the cumulative incidence of each was 5%.

Conclusions and Relevance

Cardiovascular death is an important competing risk for older women with early-stage breast cancer. This finding mandates adequate attention to cardiovascular preventive therapy after diagnosis of breast cancer.

The relationship between hospital adoption and use of high technology medical imaging and in-patient mortality and length of stay

PURPOSE

The purpose of this paper is to investigate the relationship between hospital adoption and use of computed tomography (CT) scanners, and magnetic resonance imaging (MRI) machines and in-patient mortality and length of stay.

DESIGN/METHODOLOGY/APPROACH

This study used panel data (2007-2010) from 124 hospital corporations operating in Ontario, Canada. Imaging use focused on medical patients accounting for 25 percent of hospital discharges. Main outcomes were in-hospital mortality rates and average length of stay. A model for each outcome-technology combination was built, and controlled for hospital structural characteristics, market factors and patient characteristics.

FINDINGS

In 2010, 36 and 59 percent of hospitals had adopted MRI machines and CT scanners, respectively. Approximately 23.5 percent of patients received CT scans and 3.5 percent received MRI scans during the study period. Adoption of these technologies was associated with reductions of up to 1.1 percent in mortality rates and up to 4.5 percent in length of stay. The imaging use-mortality relationship was non-linear and varied by technology penetration within hospitals. For CT, imaging use reduced mortality until use reached 19 percent in hospitals with one scanner and 28 percent in hospitals with 2+ scanners. For MRI, imaging use was largely associated with decreased mortality. The use of CT scanners also increased length of stay linearly regardless of technology penetration (4.6 percent for every 10 percent increase in use). Adoption and use of MRI was not associated with length of stay.

RESEARCH LIMITATIONS/IMPLICATIONS

These results suggest that there may be some unnecessary use of imaging, particularly in small hospitals where imaging is contracted out. In larger hospitals, the results highlight the need to further investigate the use of imaging beyond certain thresholds. Independent of the rate of imaging use, the results also indicate that the presence of CT and MRI devices within a hospital benefits quality and efficiency.

ORIGINALITY/VALUE

To the authors' knowledge, this study is the first to investigate the combined effect of adoption and use of medical imaging on outcomes specific to CT scanners and MRI machines in the context of hospital in-patient care.

Bayesian synthesis using prior information on fracture risk from randomized trials to analyze post-market data

OBJECTIVE

To conduct a Bayesian evidence synthesis using commonly available statistical procedures to estimate fracture risk for postmenopausal women undergoing hormonal therapy for breast cancer.

STUDY DESIGN AND SETTING

Using linked administrative data, we conducted a retrospective cohort study of women aged 66 years or older diagnosed with stage I to III breast cancer in Ontario, Canada, between April 1, 2003, and February 28, 2010. We used data augmentation to perform Bayesian Cox regression of the hazard of a hip, spine, or wrist/forearm fracture, adjusting for age, history of fragility fracture, corticosteroid use, osteoporosis, rheumatoid arthritis, dementia, or diabetes diagnoses.

RESULTS

Of 10,259 included in the sample, 3,733 initiated on tamoxifen and 6,526 on an aromatase inhibitor. Posterior probabilities that the hazard ratio (HR) exceeded 1 for aromatase inhibitor compared with tamoxifen were 46% (HR = 0.99, 95% credible interval [CrI] 0.71, 1.25), 35% (HR = 0.94, 95% CrI 0.78, 1.26), and 76% (HR = 1.08, 95% CrI 0.88, 1.32) with an uninformative prior, and 63% (HR = 1.04, 95% CrI 0.83, 1.3), 84% (HR = 1.12, 95% CrI 0.89, 1.4), and 89% (HR = 1.13, 95% CrI 0.93, 1.36) with an informative prior, for hip, spine, and wrist/forearm fractures, respectively.

CONCLUSIONS

Prior information resulted in higher posterior probabilities. The strength of evidence for increased risk varied by fracture site.

Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework

Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.

Reframing autism as a behavioral syndrome and not a specific mental disorder: Implications of genetic and phenotypic heterogeneity

Clinical and molecular genetics have advanced current knowledge on genetic disorders associated with autism. A review of diverse genetic disorders associated with autism is presented and for the first time discussed extensively with regard to possible common underlying mechanisms leading to a similar cognitive-behavioral phenotype of autism. The possible role of interactions between genetic and environmental factors, including epigenetic mechanisms, is in particular examined. Finally, the pertinence of distinguishing non-syndromic autism (isolated autism) from syndromic autism (autism associated with genetic disorders) will be reconsidered. Given the high genetic and etiological heterogeneity of autism, autism can be viewed as a behavioral syndrome related to known genetic disorders (syndromic autism) or currently unknown disorders (apparent non-syndromic autism), rather than a specific categorical mental disorder. It highlights the need to study autism phenotype and developmental trajectory through a multidimensional, non-categorical approach with multivariate analyses within autism spectrum disorder but also across mental disorders, and to conduct systematically clinical genetic examination searching for genetic disorders in all individuals (children but also adults) with autism.

Variation in Emergency Department Transfer Rates from Nursing Homes in Ontario, Canada

BACKGROUND

Nursing home (NH) residents are frequently transferred to the emergency department (ED) but there is little data on inter-facility variation, which has implications for intervention planning and implementation.

OBJECTIVES

To describe variation in ED transfer rates (TRs) across NHs and the association with NH characteristics.

DESIGN/SETTING

Retrospective cohort study using linked administrative data from Ontario.

PARTICIPANTS

71,780 residents of 604 NHs in 2010 and followed for one year.

MEASUREMENTS

Funnel plots were used to identify high transfer NHs and logistic regression to test the association with NH location, size, ownership and historical ED transfer rate.

RESULTS

One-year ED transfer rates ranged from 4.3% to 58.6% (mean 28.4%); 115 (19%) NHs were considered high. Being within five minutes of an ED, larger size and high historical ED transfer rate were associated with being a high ED transfer home.

CONCLUSION

There was substantial variation across NHs. Consideration of characteristics such as proximity to an ED may be important in the development and targeting of different interventions for NHs.

Nursing Home Profit Status and Quality of Care: Is There Any Evidence of an Association?

This article critically reviews the association between the profit status of North American nursing homes and the quality of care. Studies were identified by searching MEDLINE (January 1990-October 2002), reference lists, letters, commentaries, and editorials. The quality indicator(s) used to measure quality of care, and its relationship to profit status, was extracted from each publication. The study design and risk-adjustment methodologies used were also extracted. The interrater reliability for the extraction of these three items was determined to be 1.0, 0.6, and 0.8, respectively. Aqualitative systematic review was performed using Donabedian’s framework of structure, process, and outcome for analyzing medical quality of care. Empirical research in the past 12 years has found that systematic differences exist between for-profit and not-for-profit nursing homes. Forprofit nursing homes appear to provide lower quality of care in many important areas of process and outcome.

Optimal Statistical Decisions for Hospital Report Cards

Purpose. Hospital report cards provide information designed to help patients and providers to make decisions. The purpose of this study was to place the design of hospital report cards into a decision-theoretic framework. The authors’ objectives were 2-fold: 1st, to determine what the choice of significance level implies about the relative value of the different types of misclassifications that can arise. Second, to determine optimal significance levels for specific cost functions describing the relative costs associated with different types of misclassifications. Methods. Using a previously published theoretical model for hospital mortality, the authors computed false positive (i.e., falsely classified as providing poor-quality care) and false negative (falsely classified as providing good-quality care) rates. First, they determined the cost functions for false negatives and false positives that are implicitly associated with the use of significance levels of 0.05 and 0.01 for identifying hospitals with higher than average mortality. Second, they determined the levels of statistical significance that should be chosen to minimize predefined cost functions, thus minimizing costs associated with misclassifying hospitals. Results. The lower the statistical significance level required for identifying hospitals with higher than average mortality, the lower the implicit cost of false negatives compared to false positives. For a given significance level, the greater the number of patients treated at each hospital or the greater the proportion of truly poorly performing hospitals, the lower the value of the implicit cost incurred by a false negative compared to that for a false positive. For cost functions that put a high relative penalty on false negatives compared to false positives, the use of significance levels of 0.05 or 0.01 does not result in optimal decisions across expected number of patients treated at each hospital or proportions of truly poor-quality care. Conclusions. Hospital report cards that use significance levels of either 0.05 or 0.01 to identify hospitals that have statistically significantly higher than average mortality make implicit assumptions about cost functions, and the values of the optimal cost function vary across scenarios.

Rehabilitation of Older Adults with Dementia After Hip Fracture

OBJECTIVES

To evaluate the effects of postoperative rehabilitation on the outcomes of older adults with dementia who experienced hip fracture.

DESIGN

Retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Community-dwelling adults with dementia who underwent hip fracture surgery between 2003 and 2011. Participants were categorized as no rehabilitation, complex continuing care (CCC), home-care based rehabilitation (HCR), and inpatient rehabilitation (IPR).

MEASUREMENTS

Time to long-term care (LTC) placement, mortality, and risk of repeat hip fracture and falls.

RESULTS

Of 11,200 individuals with dementia who experienced a hip fracture during the study period, 4,494 (40.1%) received no rehabilitation, 2,474 (22.1%) were admitted to CCC, 1,157 (10.3%) received HCR, and 3,075 (27.4%) received IPR. HCR and IPR were associated with less risk of LTC admission after discharge from hospital than no rehabilitation. All three forms of rehabilitation were associated with lower risk of mortality than no rehabilitation, with the greatest effect observed with IPR. HCR was associated with a higher risk of falls than no rehabilitation (P=.03); there were no other significant between-group differences in risk of falls or repeat fractures (P>.05).

CONCLUSION

Postfracture rehabilitation for older adults with dementia is associated with lower risk of LTC placement and mortality. Improving access to rehabilitation services for this vulnerable population may improve postfracture outcomes.

Leptin Responsive and GABAergic Projections to the Rostral Preoptic Area in Mice

The adipocyte-derived hormone leptin plays a critical role in the control of reproduction via signalling in hypothalamic neurones. The drivers of the hypothalamic-pituitary-gonadal axis, the gonadotrophin-releasing hormone (GnRH) neurones, do not have the receptors for leptin. Therefore, intermediate leptin responsive neurones must provide leptin-to-GnRH signalling. We investigated the populations of leptin responsive neurones that provide input to the rostral preoptic area (rPOA) where GnRH cell bodies reside. Fluorescent retrograde tracer beads (RetroBeads; Lumafluor Inc., Naples, FL, USA) were injected into the rPOA of transgenic leptin receptor enhanced green fluorescent protein (Lepr-eGFP) reporter mice. Uptake of the RetroBeads by Lepr-eGFP neurones was assessed throughout the hypothalamus. RetroBead uptake was most evident in the medial arcuate nucleus (ARC), the dorsomedial nucleus (DMN) and the ventral premammillary nucleus (PMV) of the hypothalamus. The uptake of RetroBeads specifically by Lepr-eGFP neurones was highest in the medial ARC (18% of tracer-labelled neurones Lepr-eGFP-positive). Because neurones that are both leptin responsive and GABAergic play a critical role in the regulation of fertility by leptin, we next focussed on the location of these populations. To address whether GABAergic neurones in leptin-responsive hypothalamic regions project to the rPOA, the experiment was repeated in GABA neurone reporter mice (Vgat-tdTomato). Between 10% and 45% of RetroBead-labelled neurones in the ARC were GABAergic, whereas uptake of tracer by GABAergic neurones in the DMN and PMV was very low (< 5%). These results show that both leptin responsive and GABAergic neurones from the ARC project to the region of the GnRH cell bodies. Our findings suggest that LEPR-expressing GABA neurones from the ARC may be mediators of leptin-to-GnRH signalling.

Insulin Does Not Target CamkIIα Neurones to Critically Regulate the Neuroendocrine Reproductive Axis in Mice

Insulin signalling in the brain plays an important role in the central regulation of energy homeostasis and fertility, such that mice exhibiting widespread deletion of insulin receptors (InsR) throughout the brain and peripheral nervous system display diet sensitive obesity and hypothalamic hypogonadism. However, the specific cell types mediating the central effects of insulin on fertility remain largely unidentified. To date, the targeted deletion of InsR from individual neuronal populations implicated in the metabolic control of fertility has failed to recapitulate the hypogonadic and subfertile phenotype observed in brain-specific InsR knockout mice. Because insulin and leptin share similar roles as centrally-acting metabolic regulators of fertility, we used the Cre-loxP system to generate mice with a selective inactivation of the Insr gene from the same widespread neuronal population previously shown to mediate the central effects of leptin on fertility by crossing Insr-flox mice with calcium/calmodulin-dependent protein kinase type IIα (CamkIIα)-Cre mice. Multiple reproductive and metabolic parameters were then compared between male and female Insr-flox/Cre-positive (CamK-IRKO) and Insr-flox/Cre-negative control mice. Consistent with brain-specific InsR knockout mice, CamK-IRKO mice exhibited a mild but significant obesogenic phenotype. Unexpectedly, CamK-IRKO mice exhibited normal reproductive maturation and function compared to controls. No differences in the age of puberty onset, oestrous cyclicity or fecundity were observed between CamK-IRKO and control mice. We conclude that the central effects of insulin on the neuroendocrine reproductive axis are not critically mediated via the same neuronal populations targeted by leptin.

Variability in Antibiotic Use Across Nursing Homes and the Risk of Antibiotic-Related Adverse Outcomes for Individual Residents

IMPORTANCE

Antibiotics are frequently and often inappropriately prescribed to patients in nursing homes. These antibiotics pose direct risks to recipients and indirect risks to others residing in the home.

OBJECTIVE

To examine whether living in a nursing home with high antibiotic use is associated with an increased risk of antibiotic-related adverse outcomes for individual residents.

DESIGN, SETTING, AND PARTICIPANTS

In this longitudinal open-cohort study performed from January 1, 2010, through December 31, 2011, we studied 110,656 older adults residing in 607 nursing homes in Ontario, Canada.

EXPOSURES

Nursing home-level antibiotic use was defined as use-days per 1000 resident-days, and facilities were classified as high, medium, and low use according to tertile of use. Multivariable logistic regression modeling was performed to assess the effect of nursing home-level antibiotic use on the individual risk of antibiotic-related adverse outcomes.

MAIN OUTCOMES AND MEASURES

Antibiotic-related harms included Clostridium difficile, diarrhea or gastroenteritis, antibiotic-resistant organisms (which can directly affect recipients and indirectly affect nonrecipients), allergic reactions, and general medication adverse events (which can affect only recipients).

RESULTS

Antibiotics were provided on 2,783,000 of 50,953,000 resident-days in nursing homes (55 antibiotic-days per 1000 resident-days). Antibiotic use was highly variable across homes, ranging from 20.4 to 192.9 antibiotic-days per 1000 resident-days. Antibiotic-related adverse events were more common (13.3%) in residents of high-use homes than among residents of medium-use (12.4%) or low-use homes (11.4%) (P < .001); this trend persisted even among the residents who did not receive antibiotic treatments. The primary analysis indicated that residence in a high-use nursing home was associated with an increased risk of a resident experiencing an antibiotic-related adverse event (adjusted odds ratio, 1.24; 95% CI, 1.07-1.42; P = .003). A sensitivity analysis examining nursing home-level antibiotic use as a continuous variable confirmed an increased risk of resident-level antibiotic-related harms (adjusted odds ratio, 1.004 per additional day of nursing home antibiotic use; 95% CI, 1.001-1.006; P = .01).

CONCLUSIONS AND RELEVANCE

Antibiotic use is highly variable across nursing homes; residents of high-use homes are exposed to an increased risk of antibiotic-related harms even if they have not directly received these agents. Antibiotic stewardship is needed to improve the safety of all nursing home residents.

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario

BACKGROUND

Breast cancer stage at diagnosis is an important predictor of survival. Our goal was to compare breast cancer stage at diagnosis (by American Joint Committee on Cancer criteria) in Chinese and South Asian women with stage at diagnosis in the remaining general population in Ontario.

METHODS

We used the Ontario population-based cancer registry to identify all women diagnosed with breast cancer during 2005-2010, and we applied a validated surname algorithm to identify South Asian and Chinese women. We used logistic regression to compare, for Chinese or South Asian women and for the remaining general population, the frequency of diagnoses at stage ii compared with stage i and stages ii-iv compared with stage i.

RESULTS

The registry search identified 1304 Chinese women, 705 South Asian women, and 39,287 women in the remaining general population. The Chinese and South Asian populations were younger than the remaining population (mean: 54, 57, and 61 years respectively). Adjusted for age, South Asian women were more often diagnosed with breast cancer at stage ii than at stage i [odds ratio (or): 1.28; 95% confidence interval (ci): 1.08 to 1.51] or at stages ii-iv than at stage i (or: 1.27; 95% ci: 1.08 to 1.48); Chinese women were less likely to be diagnosed at stage ii than at stage i (or: 0.82; 95% ci: 0.72 to 0.92) or at stages ii-iv than at stage i (or: 0.73; 95% ci: 0.65 to 0.82).

CONCLUSIONS

Breast cancers were diagnosed at a later stage in South Asian women and at an earlier stage in Chinese women than in the remaining population. A more detailed analysis of ethnocultural factors influencing breast screening uptake, retention, and care-seeking behavior might be needed to help inform and evaluate tailored health promotion activities.

Evidence that insulin signalling in gonadotrophin-releasing hormone and kisspeptin neurones does not play an essential role in metabolic regulation of fertility in mice

Insulin in the brain plays an important role in regulating reproductive function, as demonstrated via conditional brain-specific insulin receptor (Insr) deletion (knockout). However, the specific neuronal target cells mediating the central effects of insulin on the reproductive axis remain unidentified. We first investigated whether insulin can act via direct effects on gonadotrophin-releasing hormone (GnRH) neurones. After clearly detecting Insr mRNA in an immunopurified GnRH cell fraction, we confirmed the presence of insulin receptor protein (InsR) in approximately 82% of GnRH neurones using dual-label immunohistochemistry. However, we did not observe any insulin-induced phospho-Akt (pAkt) or phospho-extracellular-signal-regulated kinase 1/2 in GnRH neurones, and therefore we investigated whether insulin signals via kisspeptin neurones to modulate GnRH release. Using dual-label immunohistochemistry, InsRs were detected only in approximately 5% of kisspeptin-immunoreactive cells. Insulin-induced pAkt was not observed in any kisspeptin-immunoreactive cells in either the rostral periventricular region of the third ventricle or arcuate nucleus in response to 200 mU of insulin treatment, although a more pharmacological dose (10 U) induced pronounced (> 20%) pAkt-kisspeptin coexpression in both regions. To confirm that insulin signalling via kisspeptin neurones does not critically modulate reproductive function, we generated kisspeptin-specific InsR knockout (KIRKO) mice and assessed multiple reproductive and metabolic parameters. No significant differences in puberty onset, oestrous cyclicity or reproductive competency were observed in the female or male KIRKO mice compared to their control littermates. However, significantly decreased fasting insulin (P < 0.05) and a nonsignificant trend towards reduced body weight were observed in male KIRKO mice. Thus, InsR signalling in kisspeptin cells is not critical for puberty onset or reproductive competency, although it may have a small metabolic effect in males.

Modelling preventive effectiveness to estimate the equity tipping point: at what coverage can individual preventive interventions reduce socioeconomic disparities in diabetes risk?

INTRODUCTION

Most individual preventive therapies potentially narrow or widen health disparities depending on the difference in community effectiveness across socioeconomic position (SEP). The equity tipping point (defined as the point at which health disparities become larger) can be calculated by varying components of community effectiveness such as baseline risk of disease, intervention coverage and/or intervention efficacy across SEP.

METHODS

We used a simple modelling approach to estimate the community effectiveness of diabetes prevention across SEP in Canada under different scenarios of intervention coverage.

RESULTS

Five-year baseline diabetes risk differed between the lowest and highest income groups by 1.76%. Assuming complete coverage across all income groups, the difference was reduced to 0.90% (144 000 cases prevented) with lifestyle interventions and 1.24% (88 100 cases prevented) with pharmacotherapy. The equity tipping point was estimated to be a coverage difference of 30% for preventive interventions (100% and 70% coverage among the highest and lowest income earners, respectively).

CONCLUSION

Disparities in diabetes risk could be measurably reduced if existing interventions were equally adopted across SEP. However, disparities in coverage could lead to increased inequity in risk. Simple modelling approaches can be used to examine the community effectiveness of individual preventive interventions and their potential to reduce (or increase) disparities. The equity tipping point can be used as a critical threshold for disparities analyses.

Benzodiazepine drug use and adverse respiratory outcomes among older adults with COPD

Our purpose was to evaluate the association of new benzodiazepine use relative to non-use with adverse clinical respiratory outcomes among older adults with chronic obstructive pulmonary disease (COPD). This was a retrospective population-based cohort study of Ontario, Canada, residents between 2003 and 2010. A validated algorithm was applied to health administrative data to identify adults aged 66 years and older with COPD. Relative risks (RRs) of several clinically important respiratory outcomes were examined within 30 days of incident benzodiazepine use compared with non-use, applying propensity score matching. New benzodiazepine users were at significantly higher risk for outpatient respiratory exacerbations (RR 1.45, 95% CI 1.36-1.54) and emergency room visits for COPD or pneumonia (RR 1.92, 95% CI 1.69-2.18) compared to non-users. Risk of hospitalisation for COPD or pneumonia was also increased in benzodiazepine users, but was nonsignificant (RR 1.09, 95% CI 1.00-1.20). There were no significant differences in intensive care unit admissions between the two groups and all-cause mortality was slightly lower among new versus non-users. Benzodiazepines were associated with increased risk for several serious adverse respiratory outcomes among older adults with COPD. The findings suggest that decisions to use benzodiazepines in older patients with COPD need to consider potential adverse respiratory outcomes.

Evidence that hypothalamic RFamide related peptide-3 neurones are not leptin-responsive in mice and rats

Leptin, a permissive hormonal regulator of fertility, provides information about the body's energy reserves to the hypothalamic gonadotrophin-releasing hormone (GnRH) neuronal system that drives reproduction. Leptin does not directly act on GnRH neurones, and the neuronal pathways that it uses remain unclear. RFamide-related peptide-3 (RFRP-3) neurones project to GnRH neurones and primarily inhibit their activity. We tested whether leptin could act via RFRP-3 neurones to potentially modulate GnRH activity. First, the effects of leptin deficiency or high-fat diet-induced obesity on RFRP-3 cell numbers and gene expression were assessed in male and female mice. There was no significant difference in Rfrp mRNA levels or RFRP-3-immunoreactive cell counts in wild-type versus leptin-deficient ob/ob animals, or in low-fat versus high-fat diet fed wild-type mice. Second, the presence of leptin-induced signalling in RFRP-3 neurones was examined in male and female wild-type mice and rats. Dual label immunohistochemistry revealed leptin-induced phosphorylated signal transducer and activator of transcription-3 in close proximity to RFRP-3 neurones, although there was very little (2-13%) colocalisation and no significant differences between vehicle and leptin-treated animals. Furthermore, we were unable to detect leptin receptor mRNA in a semi-purified RFRP-3 cell preparation. Because GABA neurones form critical leptin-responsive GnRH inputs, we also determined whether RFRP-3 and GABA cells were colocalised. No such colocalisation was detected. These results support the concept that leptin has little or no effects on RFRP-3 neurones, and that these neurones are unlikely to be an important neuronal pathway for the metabolic regulation of fertility by leptin.

Effects of dementia on postoperative outcomes of older adults with hip fractures: a population-based study

OBJECTIVE

To evaluate the association between dementia and postoperative outcomes of older adults with hip fractures.

DESIGN

Population-based, retrospective cohort study.

SETTING

Province of Ontario, Canada.

PARTICIPANTS

All individuals with hip fractures who underwent hip fracture surgery in Ontario, Canada between April 1, 2003 and March 31, 2010 were identified. Physician-diagnosed dementia, prior to hip fracture, was identified using a diagnostic algorithm in the administrative databases.

MEASUREMENTS

The preoperative characteristics of older adults with and without dementia were compared separately for individuals admitted to hospital from community or long-term care (LTC). Multivariable regression was used to compare postoperative health service utilization, time with LTC admission, and mortality for individuals with and without dementia.

RESULTS

A total of 45,602 older adults had hip fractures and individuals with dementia accounted for 23.9% and 83.5% of all hip fractures from the community and LTC settings, respectively. Compared with those without dementia, individuals with dementia were less likely to be admitted to rehabilitation facilities. Among community-dwelling older adults, dementia was associated with an increased risk of LTC admission [hazard ratio (HR) = 2.49, 95% confidence interval (CI): 2.38-2.61, P < .0001]. Dementia was also associated with a higher mortality for older adults from community (HR = 1.47, 95% CI: 1.41-1.52, P < .0001) and LTC (HR = 1.10; 95% CI: 1.02-1.18, P = .005) settings.

CONCLUSIONS

Dementia is common among older adults with hip fractures and associated with poor prognosis following hip fracture surgery. Specialized services targeting the growing number of older adults with dementia may help to prevent hip fractures and optimize postoperative care for this vulnerable population.

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada

OBJECTIVES

We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.

METHODS

We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.

RESULTS

Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable.

CONCLUSIONS

We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Effects of impairment in activities of daily living on predicting mortality following hip fracture surgery in studies using administrative healthcare databases

BACKGROUND

Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative databases lack information on ADL function. We evaluated the impact of ADL function on predicting postoperative mortality among older adults with hip fractures in Ontario, Canada.

METHODS

Sociodemographic and medical correlates of ADL impairment were first identified in a population of older adults with hip fractures who had ADL information available prior to hip fracture. A logistic regression model was developed to predict 360-day postoperative mortality and the predictive ability of this model were compared when ADL impairment was included or omitted from the model.

RESULTS

The study sample (N = 1,329) had a mean age of 85.2 years, were 72.8% female and the majority resided in long-term care (78.5%). Overall, 36.4% of individuals died within 360 days of surgery. After controlling for age, sex, medical comorbidity and medical conditions correlated with ADL impairment, addition of ADL measures improved the logistic regression model for predicting 360 day mortality (AIC = 1706.9 vs. 1695.0; c -statistic = 0.65 vs 0.67; difference in - 2 log likelihood ratios: χ(2) = 16.9, p = 0.002).

CONCLUSIONS

Direct measures of ADL impairment provides additional prognostic information on mortality for older adults with hip fractures even after controlling for medical comorbidity. Observational studies using administrative databases without measures of ADLs may be potentially prone to confounding and bias and case-mix adjustment for hip fracture outcomes should include ADL measures where these are available.

Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study

OBJECTIVE

More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia.

DESIGN

Retrospective cohort study.

SETTING

Population based in Ontario, Canada, from 2002 to 2011.

POPULATION

Ontario women aged 15-49 years who gave birth to a liveborn or stillborn singleton infant.

METHODS

Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy.

MAIN OUTCOME MEASURES

The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators.

RESULTS

Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28-2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04-2.85), preterm birth (aOR 1.75, 95% CI 1.46-2.08), SGA (aOR 1.49, 95% CI 1.19-1.86), and LGA (aOR 1.53, 95% CI 1.17-1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity.

CONCLUSIONS

Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

Kisspeptin neurones do not directly signal to RFRP-3 neurones but RFRP-3 may directly modulate a subset of hypothalamic kisspeptin cells in mice

The neuropeptides kisspeptin (encoded by Kiss1) and RFamide-related peptide-3 (also known as GnIH; encoded by Rfrp) are potent stimulators and inhibitors, respectively, of reproduction. Whether kisspeptin or RFRP-3 might act directly on each other's neuronal populations to indirectly modulate reproductive status is unknown. To examine possible interconnectivity of the kisspeptin and RFRP-3 systems, we performed double-label in situ hybridisation (ISH) for the RFRP-3 receptors, Gpr147 and Gpr74, in hypothalamic Kiss1 neurones of adult male and female mice, as well as double-label ISH for the kisspeptin receptor, Kiss1r, in Rfrp-expressing neurones of the hypothalamic dorsal-medial nucleus (DMN). Only a very small proportion (5-10%) of Kiss1 neurones of the anteroventral periventricular region expressed Gpr147 or Gpr74 in either sex, whereas higher co-expression (approximately 25%) existed in Kiss1 neurones in the arcuate nucleus. Thus, RFRP-3 could signal to a small, primarily arcuate, subset of Kiss1 neurones, a conclusion supported by the finding of approximately 35% of arcuate kisspeptin cells receiving RFRP-3-immunoreactive fibre contacts. By contrast to the former situation, no Rfrp neurones co-expressed Kiss1r in either sex, and Tacr3, the receptor for neurokinin B (NKB; a neuropeptide co-expressed with arcuate kisspeptin neurones) was found in <10% of Rfrp neurones. Moreover, kisspeptin-immunoreactive fibres did not readily appose RFRP-3 cells in either sex, further excluding the likelihood that kisspeptin neurones directly communicate to RFRP-3 neurones. Lastly, despite abundant NKB in the DMN region where RFRP-3 soma reside, NKB was not co-expressed in the majority of Rfrp neurones. Our results suggest that RFRP-3 may modulate a small proportion of kisspeptin-producing neurones in mice, particularly in the arcuate nucleus, whereas kisspeptin neurones are unlikely to have any direct reciprocal actions on RFRP-3 neurones.

Parental broader autism subphenotypes in ASD affected families: relationship to gender, child's symptoms, SSRI treatment, and platelet serotonin

Relationships between parental broader autism phenotype (BAP) scores, gender, selective serotonin reuptake inhibitor (SSRI) treatment, serotonin (5HT) levels, and the child's symptoms were investigated in a family study of autism spectrum disorder (ASD). The Broader Autism Phenotype Questionnaire (BAPQ) was used to measure the BAP of 275 parents. Fathers not taking SSRIs (F-SSRI; n = 115) scored significantly higher on BAP Total and Aloof subscales compared to mothers not receiving treatment (M-SSRI; n = 136.) However, mothers taking SSRIs (M + SSRI; n = 19) scored higher than those not taking medication on BAP Total and Rigid subscales, and they were more likely to be BAPQ Total, Aloof, and Rigid positive. Significant correlations were noted between proband autism symptoms and parental BAPQ scores such that Total, Aloof, and Rigid subscale scores of F-SSRI correlated with proband restricted repetitive behavior (RRB) measures on the ADOS, CRI, and RBS-R. However, only the Aloof subscale score of M + SSRI correlated with proband RRB on the ADOS. The correlation between the BAPQ scores of mothers taking SSRIs and child scores, as well as the increase in BAPQ scores of this group of mothers, requires careful interpretation and further study because correlations would not withstand multiple corrections. As expected by previous research, significant parent-child correlations were observed for 5HT levels. However, 5HT levels were not correlated with behavioral measures. Study results suggest that the expression of the BAP varies not only across parental gender, but also across individuals using psychotropic medication and those who do not.

A systematic review and methodological evaluation of published cost-effectiveness analyses of aromatase inhibitors versus tamoxifen in early stage breast cancer

BACKGROUND

A key priority in developing policies for providing affordable cancer care is measuring the value for money of new therapies using cost-effectiveness analyses (CEAs). For CEA to be useful it should focus on relevant outcomes and include thorough investigation of uncertainty. Randomized controlled trials (RCTs) of five years of aromatase inhibitors (AI) versus five years of tamoxifen in the treatment of post-menopausal women with early stage breast cancer, show benefit of AI in terms of disease free survival (DFS) but not overall survival (OS) and indicate higher risk of fracture with AI. Policy-relevant CEA of AI versus tamoxifen should focus on OS and include analysis of uncertainty over key assumptions.

METHODS

We conducted a systematic review of published CEAs comparing an AI to tamoxifen. We searched Ovid MEDLINE, EMBASE, PsychINFO, and the Cochrane Database of Systematic Reviews without language restrictions. We selected CEAs with outcomes expressed as cost per life year or cost per quality adjusted life year (QALY). We assessed quality using the Neumann checklist. Using structured forms two abstractors collected descriptive information, sources of data, baseline assumptions on effectiveness and adverse events, and recorded approaches to assessing parameter uncertainty, methodological uncertainty, and structural uncertainty.

RESULTS

We identified 1,622 citations and 18 studies met inclusion criteria. All CE estimates assumed a survival benefit for aromatase inhibitors. Twelve studies performed sensitivity analysis on the risk of adverse events and 7 assumed no additional mortality risk with any adverse event. Sub-group analysis was limited; 6 studies examined older women, 2 examined women with low recurrence risk, and 1 examined women with multiple comorbidities.

CONCLUSION

Published CEAs comparing AIs to tamoxifen assumed an OS benefit though none has been shown in RCTs, leading to an overestimate of the cost-effectiveness of AIs. Results of these CEA analyses may be suboptimal for guiding policy.

Incidence of diabetes among postmenopausal breast cancer survivors

AIMS/HYPOTHESIS

Evidence is emerging of an association between breast cancer and diabetes; however, it is uncertain whether diabetes incidence is increased in postmenopausal breast cancer survivors compared with women without breast cancer. The objective of this study was to determine whether postmenopausal women who develop breast cancer have a higher incidence of diabetes than those who do not develop breast cancer.

METHODS

We used population-based data from Ontario, Canada to compare the incidence of diabetes among women with breast cancer, aged 55 years or older, from 1996 to 2008, with that of age-matched women without breast cancer. We used Cox proportional hazard models to estimate the effect of breast cancer on the cause-specific hazard of developing diabetes overall and in the subgroup of women who received adjuvant chemotherapy.

RESULTS

Of 24,976 breast cancer survivors and 124,880 controls, 9.7% developed diabetes over a mean follow-up of 5.8 years. The risk of diabetes among breast cancer survivors compared with women without breast cancer began to increase 2 years after diagnosis (HR 1.07 [95% CI, 1.02, 1.12]), and rose to an HR of 1.21 (95% CI, 1.09, 1.35) after 10 years. Among those who received adjuvant chemotherapy (n = 4,404), risk was highest in the first 2 years after diagnosis (HR 1.24 [95% CI 1.12, 1.38]) and then declined.

CONCLUSIONS/INTERPRETATION

We found a modest increase in the incidence of diabetes among postmenopausal breast cancer survivors that varied over time. In most women the risk began to increase 2 years after cancer diagnosis but the highest risk was in the first 2 years in those who received adjuvant therapy. Our study suggests that greater diabetes screening and prevention strategies among breast cancer survivors may be warranted.

Older men with dementia are at greater risk than women of serious events after initiating antipsychotic therapy

OBJECTIVES

To understand how drug therapy differently affects older women and men.

DESIGN

Population-based, retrospective cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Twenty-one thousand five hundred twenty-six older adults (13,760 women, 7,766 men) with dementia newly started on oral atypical antipsychotic therapy between April 1, 2007, and March 1, 2010.

MEASUREMENTS

Numbers and rates of serious events. Serious events were defined as a hospital admission or death within 30 days of treatment initiation. Unadjusted and adjusted odds ratios of women and men were compared in the full cohort and in strata based on setting of care, age, Charlson Comorbidity Index (CCI), and antipsychotic dose.

RESULTS

Of 21,526 older adults with a median age of 84, 1,889 (8.8%) had a serious event (1,044 women, 7.6%; 845 men, 10.9%). Of these, 363 women (2.6%) and 355 men (4.6%) died. Men were more likely than women to be hospitalized or die during the 30-day follow-up period (adjusted odds ratio = 1.47, 95% confidence interval = 1.33-1.62) and consistently more likely to experience a serious event in each stratum. A gradient of risk according to drug dose was found for the development of a serious event in women and men.

CONCLUSION

The risk of developing a serious event shortly after the initiation of antipsychotic therapy was high in women and men with dementia but was consistently higher in older men. This pattern remained the same in strata based on setting of care, age, CCI, and antipsychotic dose.

Comparative ability of comorbidity classification methods for administrative data to predict outcomes in patients with chronic obstructive pulmonary disease

PURPOSE

Administrative healthcare databases are used for health services research, comparative effectiveness studies, and measuring quality of care. Adjustment for comorbid illnesses is essential to such studies. Validation of methods to account for comorbid illnesses in administrative data for patients with chronic obstructive pulmonary disease (COPD) has been limited. Our objective was to compare the ability of the Charlson index, the Elixhauser method, and the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict outcomes in patients with COPD.

METHODS

Retrospective cohorts constructed using population-based administrative data of patients with incident (n = 216,735) and prevalent (n = 638,926) COPD in Ontario, Canada, were divided into derivation and validation datasets. The primary outcome was all-cause death within 1 year. Secondary outcomes included all-cause hospitalization, COPD-specific hospitalization, non-COPD hospitalization, and COPD exacerbations.

RESULTS

In both the incident and prevalent COPD cohorts, the three methods had comparable discrimination for predicting mortality (c-statistics in the validation sample of incident patients of 0.819 for the Charlson method versus 0.822 for the Elixhauser method versus 0.830 for the ADG method). All three methods had lower predictive accuracy for predicting nonfatal outcomes.

CONCLUSIONS

In a disease-specific cohort of COPD patients, all three methods allowed for accurate prediction of mortality, with the Johns Hopkins ADGs having marginally higher discrimination.

Systematic review of bone health in older women treated with aromatase inhibitors for early-stage breast cancer

OBJECTIVES

To review data from randomized controlled trials (RCTs) that evaluate adverse bone outcomes in older women using aromatase inhibitors (AIs) for early-stage hormone receptor-positive breast cancer.

DESIGN

Systematic review.

SETTING

International RCTs referenced in Medline and EMBASE databases through August 1, 2011.

PARTICIPANTS

Postmenopausal women with early-stage hormone receptor-positive breast cancer receiving adjuvant endocrine therapy.

MEASUREMENTS

Fracture rates and changes in bone turnover markers and bone mineral density.

RESULTS

Eleven RCTs were identified. The majority of trials included women with a mean age in the 60s; and women aged 75 and older and 80 and older were excluded from two studies. Fracture rates ranged from 0.9% to 11%, with AIs having a 1.5 times higher risk than tamoxifen or placebo. Fracture data were not systematically collected in many of these trials. In a small subpopulation of women, AIs were associated with higher markers of bone turnover and lower bone density. The relationship between age and fracture was not described.

CONCLUSION

AIs are associated with low bone density and high fracture risk in women with a mean age in their early 60s. There is a paucity of data describing the effect of baseline fracture risk factors, particularly age, and the longer-term effects on bone health in older women. Future research is needed regarding baseline fracture risk, interventions, and long-term effects on bone in this vulnerable population to inform management decisions to optimize AI duration and ensure quality of life after breast cancer.

Association between evidence-based standardized protocols in emergency departments with childhood asthma outcomes: a Canadian population-based study

OBJECTIVE

To determine whether children treated in emergency departments (EDs) with evidence-based standardized protocols (EBSPs) containing evidence-based content and format had lower risk of hospital admission or ED return visit and greater follow-up than children treated in EDs with no standardized protocols in Ontario, Canada.

DESIGN

Retrospective population-based cohort study of children with asthma. We used multivariable logistic regression to estimate risk of outcomes.

SETTING

All EDs in Ontario (N = 146) treating childhood asthma from April 2006 to March 2009.

PARTICIPANTS

Thirty-one thousand one hundred thirty-eight children (aged 2 to 17 years) with asthma. MAIN EXPOSURE Type of standardized protocol (EBSPs, other standardized protocols, or none).

MAIN OUTCOME MEASURES

Hospital admission, high-acuity 7-day return visit to the ED, and 7-day outpatient follow-up visit. RESULTS The final cohort made 46 510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%) were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350 (17.4%) had ED return visits and outpatient follow-up visits, respectively. The EBSPs were not associated with hospitalizations, return visits, or follow-up (adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95% CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively).

CONCLUSIONS

The EBSPs were not associated with improvements in rates of hospital admissions, return visits to the ED, or follow-up. Our findings suggest the need to address gaps linking improved processes of asthma care with outcomes.

Family physicians providing regular care to residents in Ontario long-term care homes: characteristics and practice patterns

OBJECTIVE

To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies.

DESIGN

Cross-sectional study involving a 2005 province-wide census of LTC residents' charts linked to additional health care administrative databases.

SETTING

All LTC homes in Ontario.

PARTICIPANTS

Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care.

MAIN OUTCOME MEASURES

Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns.

RESULTS

The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents).

CONCLUSION

About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.

Quality measures for medication continuity in long-term care facilities, using a structured panel process

BACKGROUND

Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described.

OBJECTIVE

The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization.

METHODS

A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data.

RESULTS

The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications.

CONCLUSION

A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.

Using the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict 1-year mortality in population-based cohorts of patients with diabetes in Ontario, Canada

AIMS

There are limited validated methods to ascertain comorbidities for risk adjustment in ambulatory populations of patients with diabetes using administrative health-care databases. The objective was to examine the ability of the Johns Hopkins' Aggregated Diagnosis Groups to predict mortality in population-based ambulatory samples of both incident and prevalent subjects with diabetes.

METHODS

Retrospective cohorts constructed using population-based administrative data. The incident cohort consisted of all 346,297 subjects diagnosed with diabetes between 1 April 2004 and 31 March 2008. The prevalent cohort consisted of all 879,849 subjects with pre-existing diabetes on 1 January, 2007. The outcome was death within 1 year of the subject's index date.

RESULTS

A logistic regression model consisting of age, sex and indicator variables for 22 of the 32 Johns Hopkins' Aggregated Diagnosis Group categories had excellent discrimination for predicting mortality in incident diabetes patients: the c-statistic was 0.87 in an independent validation sample. A similar model had excellent discrimination for predicting mortality in prevalent diabetes patients: the c-statistic was 0.84 in an independent validation sample. Both models demonstrated very good calibration, denoting good agreement between observed and predicted mortality across the range of predicted mortality in which the large majority of subjects lay. For comparative purposes, regression models incorporating the Charlson comorbidity index, age and sex, age and sex, and age alone had poorer discrimination than the model that incorporated the Johns Hopkins' Aggregated Diagnosis Groups.

CONCLUSIONS

Logistical regression models using age, sex and the John Hopkins' Aggregated Diagnosis Groups were able to accurately predict 1-year mortality in population-based samples of patients with diabetes.

Neighborhood income and stroke care and outcomes

OBJECTIVE

To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas.

METHODS

We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors.

RESULTS

There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29).

CONCLUSIONS

In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors.

Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): a population-based study in Ontario, Canada

PURPOSE

There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada.

METHODS

We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15-49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived.

RESULTS

The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007-2009 than in 1996-1998 (95% confidence interval [CI] 1.04-1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36-0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25-0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20-24, 25-29, 35-39 and 40-44 years, but the increase was not always statistically significant. Among women aged 20-24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70-1.22).

CONCLUSIONS

The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing.

Use of clarithromycin and adverse cardiovascular events among older patients receiving donepezil: a population-based, nested case-control study

BACKGROUND

Donepezil is a commonly used drug in older people that due to its procholinergic effects can provoke bradycardia and neurocardiogenic syncope. Donepezil is metabolized by the cytochrome P450 isozyme 3A4 (CYP3A4). Clarithromycin is a potent inhibitor of CYP3A4, and patients taking both of these drugs may be at increased risk of cardiac adverse events.

OBJECTIVE

The aim of this study was to evaluate the association between recent use of clarithromycin and adverse cardiovascular events in elderly patients receiving donepezil.

METHODS

A population-based, nested case-control study using provincial healthcare databases was conducted. The base cohort was made up of persons 66 years of age or older who were prescribed donepezil and also were prescribed clarithromycin, erythromycin, azithromycin, cefuroxime, moxifloxacin or levofloxacin. Cases were those members of the base cohort hospitalized for bradycardia, syncope or complete atrioventricular block. For each case patient, five controls were matched according to age, sex and residence (community or long-term care).

RESULTS

Between July 2002 and March 2010, 17,712 patients continuously receiving donepezil were prescribed one of the antibacterials. In 1400 person-years of follow-up, 59 cases were identified. As compared with azithromycin, there was no statistically significant association between use of clarithromycin in donepezil users and subsequent adverse cardiovascular events (odds ratio 0.67; 95% CI 0.28, 1.63). There was no significant risk associated with exposure to either cefuroxime or respiratory quinolones.

CONCLUSIONS

The use of clarithromycin in elderly donepezil users did not significantly increase the risk of adverse cardiovascular outcomes. However, our study cannot rule out a possible small increase in risk. Although antibacterials can be beneficial, care should be taken in selecting antibacterials for use in older people receiving donepezil.