Manitoba 2020: How centralizing the healthcare supply chain helped with pandemic management.

A case study design was used to understand Manitoba's response to accessing Personal Protective Equipment (PPE) in the first wave of the global coronavirus pandemic. By evolving early on in the pandemic to a provincially led structure dedicated to the healthcare supply chain, Manitoba was able to avoid major shortages in access to PPE. Leadership was focused on the possibilities for action and implementation (ie, dynamic, adaptive, and collaborative) rather than trying to respond within the status quo (ie, a more linear and traditional approach). As a result, few structural items other than the creation of an effective, province-wide digital network to fully visualize the healthcare supply chain are needed going forward. Manitoba's healthcare supply chain had a number of successes during the initial wave of the global pandemic including many new processes like the local production of PPE and the establishment of new supplier relationships.

Regional consolidation of orthopedic surgery: impacts on hip fracture surgery access and outcomes.

BACKGROUND: Timely access to orthopedic trauma surgery is essential for optimal outcomes. Regionalization of some types of surgery has shown positive effects on access, timeliness and outcomes. We investigated how the consolidation of orthopedic surgery in 1 Canadian health region affected patients requiring hip fracture surgery. METHODS: We retrieved administrative data on all regional emergency department visits for lower-extremity injury and all linked inpatient stays from January 2010 through March 2013, identifying 1885 hip-fracture surgeries. Statistical process control and interrupted time series analysis controlling for demographics and comorbidities were used to assess impacts on access (receipt of surgery within 48-h benchmark) and surgical outcomes (complications, in-hospital/30-d mortality, length of stay). RESULTS: There was a significant increase in the proportion of patients receiving surgery within the benchmark. Complication rates did not change, but there appeared to be some decrease in mortality (significant at 6 mo). Length of stay increased at a hospital that experienced a major increase in patient volume, perhaps reflecting challenges associated with patient flow. CONCLUSION: Regionalization appeared to improve the timeliness of surgery and may have reduced mortality. The specific features of the present consolidation (including pre-existing interhospital performance variation and the introduction of daytime slates at the referral hospital) should be considered when interpreting the findings.

CONTEXTE: En traumatologie, l'accès rapide à la chirurgie orthopédique est essentiel pour l'obtention de résultats optimaux. La régionalisation de certains types de chirurgie a eu des effets positifs sur l'accès aux soins, leur rapidité et leurs résultats. Nous avons vérifié l'effet qu'a eu la consolidation des soins chirurgicaux orthopédiques dans une région sanitaire canadienne sur les patients qui ont eu recours à la chirurgie pour une fracture de la hanche. MÉTHODES: Nous avons obtenu les données administratives concernant toutes les consultations dans les services d'urgence régionaux pour des blessures aux membres inférieurs et nous les avons corrélées avec les séjours hospitaliers de janvier 2010 à mars 2013. Nous avons ainsi recensé 1885 chirurgies pour fracture de la hanche. Nous avons utilisé la maîtrise statistique des procédés et le modèle chronologique interrompu et nous avons tenu compte des caractéristiques démographiques et des comorbidités pour évaluer les impacts sur l'accès aux interventions (attente limite de 48 h pour obtenir la chirurgie) et leurs résultats (complications, mortalité perhospitalière à 30 j et durée des séjours). RÉSULTATS: On a noté une augmentation significative de la proportion de patients traités par chirurgie à l'intérieur des délais. Les taux de complications n'ont pas varié, mais il semble y avoir eu une certaine diminution de la mortalité (significative à 6 mois). La durée des séjours a augmenté dans un hôpital qui a connu un accroissement majeur de sa clientèle, témoignant peut-être de difficultés liées à l'afflux de patients. CONCLUSION: La régionalisation a semblé améliorer l'accès rapide à la chirurgie et pourrait avoir réduit la mortalité. Il faut tenir compte des caractéristiques spécifiques de la présente consolidation (y compris la variation préexistante du rendement interhospitalier et la création de listes de jour à l'hôpital de référence) avant d'interpréter ces conclusions.

Patient characteristics associated with longer emergency department stay: a rapid review.

BACKGROUND: Prolonged emergency department (ED) stays make a disproportionate contribution to ED overcrowding, but the factors associated with longer stays have not been systematically reviewed. OBJECTIVE: To identify the patient characteristics associated with ED length of stay (LOS) and ascertain whether a predictive model existed. METHODS: This rapid systematic review included published, English-language studies that assessed at least one patient-level predictor of ED LOS (defined as a continuous or dichotomous variable) in an adult or mixed adult/paediatric population within an Organization for Economic Cooperation and Development country. Findings were synthesised narratively. RESULTS: We identified 35 relevant studies; most included multiple predictors, but none developed a predictive model. The factors most commonly associated with long ED LOS were need for admission (10 of 10 studies) and older age (which may be a proxy for age-related differences in health condition and severity; 9 of 10), receipt of diagnostic tests or consults (8 of 8) and ambulance arrival (4 of 5). Acuity often showed a bell-shaped relationship with LOS (ie, patients with moderate acuity stayed longest). LIMITATIONS: Methodological choices made in the interests of rapidity limited the review's comprehensiveness and depth. CONCLUSIONS: Despite a sizeable body of literature, the available information is insufficiently precise to inform clinical or service-planning decisions; there is a need for a predictive model, including specific patient complaints. Deeper understanding of the determinants of ED LOS could help to identify patients and/or populations who require special intervention or resources to prevent a protracted stay.

Adverse events in elderly users of antipsychotic pharmacotherapy in the province of Manitoba: a retrospective cohort study.

BACKGROUND: Antipsychotic medications have been widely used in elderly patients for treatment of a variety of diagnoses. The aim of our study was to compare the incidence of cerebrovascular and cardiac events as well as mortality in elderly persons treated with second-generation antipsychotics (SGAs) with that of elderly persons treated with conventional first-generation agents (FGAs) in the province of Manitoba. METHODS: A population-based retrospective cohort study of all residents of Manitoba aged 65 and older, who were dispensed antipsychotic medications for the first time during the period from April 1, 2000, to March 31, 2007, was conducted using Manitoba Health administrative databases. Cox proportional hazards models were used to compare risks of adverse events in FGA and SGA users. RESULTS: After controlling for potential confounders (demographics, comorbidity, and medication use), SGA use was not associated with a significantly greater risk of cerebrovascular events, cardiac arrhythmia, and congestive heart failure compared to FGA use (adjusted hazard ratios [HR], respectively: 1.136; 95% CI, 0.961-1.344; 0.865; 95% CI, 0.336-2.232; 1.127, 95% CI, 0.902-1.409). Second-generation antipsychotics users were found to be at a lower risk of mortality (adjusted HR, 0.683; 95% CI, 0.577-0.809), but at a higher risk of myocardial infarction (adjusted HR, 1.614; 95% CI, 1.024-2.543) compared to FGA users. CONCLUSIONS: Among elderly users of antipsychotic medications, the risk of cerebrovascular events, cardiac arrhythmia, and congestive heart failure was similar in FGA and SGA users. Whereas SGA users were at a higher risk of nonfatal myocardial infarction, the use of FGAs was associated with an increased risk of death. Antipsychotic pharmacotherapy in older persons needs to be chosen with careful consideration of all risks and benefits.

Impact of a regional acute care surgery model on patient access and outcomes.

BACKGROUND: The consolidation of acute care surgery (ACS) services at 3 of 6 hospitals in a Canadian health region sought to alleviate a relative shortage of surgeons able to take emergency call. We examined how this affected patient access and outcomes. METHODS: Using the generalized linear model and statistical process control, we analyzed ACS-related episodes that occurred between 39 months prior to and 17 months after the model's implementation (n = 14,713). RESULTS: Time to surgery increased after the consolidation. Wait times increased primarily for patients presenting at nonreferral hospitals who were likely to require transfer to a referral hospital. Although ACS teams enabled referral hospitals to handle a much higher volume of patients without increasing within-hospital wait times, overall system wait times were lengthened by the growing frequency of patient transfers. Wait times for inpatient admission were difficult to interpret because there was a trend toward admitting patients directly to the ACS service, bypassing the emergency department (ED). For patients who did go through the ED, wait times for inpatient admission increased after the consolidation; however, this trend was cancelled out by the apparently zero waits of patients who bypassed the ED. Regionalization showed no impact on length of stay, readmissions, mortality or complications. CONCLUSION: Consolidation enabled the region to ensure adequate surgical coverage without harming patients. The need to transfer patients who presented at nonreferral hospitals led to longer waits.

CONTEXTE: Le regroupement des services chirurgicaux d'urgence (SCU) dans 3 hôpitaux sur 6 d'une région sanitaire canadienne visait à contrer une relative pénurie de chirurgiens capables d'effectuer les interventions d'urgence. Nous en avons analysé l'impact sur l'accessibilité des services et sur les résultats chez les patients. MÉTHODES: À l'aide du modèle linéaire généralisé et d'un contrôle statistique des procédés, nous avons analysé les cas adressés aux SCU entre 39 mois précédant et 17 mois suivant l'entrée en vigueur du regroupement des services (n = 14 713). RÉSULTANTS: L'intervalle avant l'intervention chirurgicale s'est allongé après le regroupement des services. Les temps d'attente ont principalement augmenté pour les patients qui consultaient dans un hôpital de premier recours d'où ils étaient susceptibles d'être réorientés vers un hôpital de référence. Même si les équipes des SCU ont permis aux hôpitaux de référence de gérer un volume beaucoup plus important de patients sans augmentation du temps d'attente à l'hôpital même, le temps d'attente dans son ensemble s'est prolongé à l'échelle du système en raison de l'accroissement du nombre de transferts. Les temps d'attente pour les hospitalisations ont été difficiles à interpréter parce qu'on avait tendance à admettre les patients directement aux SCU, en contournant les services d'urgences. Pour les patients qui passaient par les urgences, les temps d'attente pour une hospitalisation ont augmenté après le regroupement; toutefois, cette tendance a été compensée par l'attente pour ainsi dire nulle des patients qui contournaient les services d'urgence. La régionalisation n'a exercé aucun impact sur la durée du séjour, les réadmissions, la mortalité ou les complications. CONCLUSIONS: Le regroupement a permis à la région d'assurer une couverture chirurgicale adéquate sans nuire aux patients. La nécessité de réorienter des patients vers les hôpitaux de référence a contribué à prolonger les temps d'attente.

Despite Interventions, Emergency Flow Stagnates in Urban Western Canada.

Purpose: This paper reports the quantitative component of a mixed-methods study of patient flow in the 10 urban health regions/zones of Western Canada. We assessed whether jurisdictions differed meaningfully in their emergency flow performance, defined as mean emergency department length of stay (ED LOS). Methods: We used hierarchical linear modelling to compare ED LOS across jurisdictions, based on nationally reported data for 2017 to 2018. We also explored 36-month performance trends. Admitted and discharged patients were analyzed separately. Results: With the exception of one high performer, no region's performance differed significantly from average for both admitted and discharged patients. The regions' levels of performance remained largely static throughout the study period. Conclusions: Results precluded any mixed-methods comparison of high- and low-performing regions. However, they converged with our qualitative findings, which suggested that most regions were pursuing similar flow-improvement strategies with limited effectiveness. Deeper changes may be required to address persistent misalignment between capacity and demand.

The relative efficacies of gastroprotective strategies in chronic users of nonsteroidal anti-inflammatory drugs.

BACKGROUND & AIMS: There are numerous gastroprotective strategies recommended for reducing the risk of upper gastrointestinal (GI) complications in long-term users of nonsteroidal anti-inflammatory drugs (NSAIDs). The relative efficacy of the different strategies alone or in combination is uncertain. METHODS: We used the Manitoba Population Health Research Data Repository to perform a population-based matched case-control analysis. All NSAID users (nonselective and cyclooxygenase [COX]-2-specific) users admitted to the hospital with a primary diagnosis for an upper gastrointestinal complication were matched to NSAID-using controls in the community. We used conditional logistic regression analysis to determine the relative efficacy of different gastroprotective strategies (proton pump inhibitors [PPIs], COX-2 inhibitors, and low-dose/high-dose misoprostol) either alone or in combination and to adjust for multiple pertinent covariates. RESULTS: A total of 1382 NSAID/COX-2 users with upper GI complications were matched to 33,957 age- and sex-matched controls. Cotherapy with PPIs or misoprostol or use of a COX-2 inhibitor all significantly reduced the risk of upper GI complications. COX-2 inhibitors were not statistically more likely to prevent upper GI complications than PPIs, although they were superior to low-dose misoprostol. The combination of COX-2 inhibitors with a PPI was associated with the greatest degree of upper GI complication risk reduction. CONCLUSIONS: All of the commonly accepted gastroprotective strategies reduce the risk of upper GI complications in NSAID users, although the combination of COX-2 inhibitors with PPIs promotes the greatest risk reduction for NSAID-related upper GI complications. Celecoxib use specifically may be superior to the combination of nonselective NSAIDs with a PPI.

Selective serotonin reuptake inhibitors are associated with a modest increase in the risk of upper gastrointestinal bleeding.

OBJECTIVES: The use of the common antidepressant class of serotonin-specific reuptake inhibitors (SSRIs) is associated with an increased risk of upper gastrointestinal bleeding (UGIB). Proton pump inhibitors (PPIs) have been demonstrated to reduce the risk of gastrointestinal bleeding secondary to other risk factors, most notably non-steroidal anti-inflammatory drug (NSAID) use. The role for PPIs in chronic SSRI users without other risk factors remains uncharacterized. METHODS: We used the Manitoba Population Health Research Data Repository to perform a population-based matched case-control analysis. All patients admitted to the hospital with a primary diagnosis of UGIB were matched to non-bleeding controls. We used conditional regression analysis to determine the risk of UGIB associated with SSRI use, and the risk reduction associated with concomitant PPI use, both for users and non-users of NSAIDs. RESULTS: SSRI use was associated with a modest increase in the risk of UGIB (odds ratio (OR), 1.43; 95% confidence interval (CI), 1.09-1.89). The addition of an SSRI to NSAID therapy did not significantly increase the risk of UGIB (OR, 1.20; 95% CI, 0.78-1.92) over use of an NSAID alone. PPI co-therapy significantly reduced the risk of SSRI-related UGIB (OR, 0.39; 95% CI, 0.16-0.94). CONCLUSIONS: SSRI use is associated with a modestly increased risk of UGIB, which may be significantly reduced with PPI co-therapy. SSRI use is not a major risk factor for NSAID-related UGIB.

Fracture risk in androgen deprivation therapy: a Canadian population based analysis.

INTRODUCTION: Prostate cancer is the most common noncutaneous malignancy diagnosed in men. The use of androgen deprivation therapy (ADT) is the mainstay of treatment for metastatic disease. The use of ADT has been reported to increase the risk of osteoporosis in men with prostate cancer, with higher risk of fracture than age matched controls. We sought to confirm the higher fracture risk of men with prostate cancer on ADT in the Canadian population. METHODS: We used the Population Health Research Data Repository housed at Manitoba Centre for Health Policy to identify all cases of fractures of the hip, vertebra, or wrist in men aged 50 years and older occurring between 1996 and 2004. Each case was matched with up to three controls by age, sex, ethnicity and medical comorbidity. We calculated the odds ratios (OR) for fracture with prostate cancer, and with or without ADT, after adjusting for possible confounding variables. RESULTS: There were 4696 cases of fracture matched with 14080 controls. After controlling for confounding variables, there was no significant association between prostate cancer and fracture risk (adjusted OR = 0.97, 95% confidence intervals [CI]: 0.83-1.15). We detected a significant association between ADT and fracture risk in men. The adjusted ORs for current and past ADT usage were 1.71 (95% CI: 1.13 - 2.58) and 2.42 (95% CI: 1.42-4.12) respectively. CONCLUSION: Our findings suggest that prostate cancer itself does not increase the risk of fracture and corroborate published results demonstrating an association between ADT and fractures.

Pushing for partnership: physician engagement and resistance in primary care renewal.

PURPOSE: Healthcare policymakers and managers struggle to engage private physicians, who tend to view themselves as independent of the system, in new models of primary care. The purpose of this paper is to examine this issue through a social identity lens. DESIGN/METHODOLOGY/APPROACH: Through in-depth interviews with 33 decision-makers and 31 fee-for-service family physicians, supplemented by document review and participant observation, the authors studied a Canadian province's early efforts to engage physicians in primary care renewal initiatives. FINDINGS: Recognizing that the existing physician-system relationship was generally distant, decision-makers invested effort in relationship-building. However, decision-makers' rhetoric, as well as the design of their flagship initiative, evinced an attempt to proceed directly from interpersonal relationship-building to the establishment of formal intergroup partnership, with no intervening phase of supporting physicians' group identity and empowering them to assume equal partnership. The invitation to partnership did not resonate with most physicians: many viewed it as an inauthentic offer from an out-group ("bureaucrats") with discordant values; others interpreted partnership as a mere transactional exchange. Such perceptions posed barriers to physician participation in renewal activities. PRACTICAL IMPLICATIONS: The pursuit of a premature degree of intergroup closeness can be counterproductive, heightening physician resistance. ORIGINALITY/VALUE: This study revealed that even a relatively subtle misalignment between a particular social identity management strategy and its intergroup context can have highly problematic ramifications. Findings advance the literature on social identity management and may facilitate the development of more effective engagement strategies.

Use of proton pump inhibitors and risk of osteoporosis-related fractures.

BACKGROUND: The use of proton pump inhibitors has been associated with an increased risk of hip fracture. We sought to further explore the relation between duration of exposure to proton pump inhibitors and osteoporosis-related fractures. METHODS: We used administrative claims data to identify patients with a fracture of the hip, vertebra or wrist between April 1996 and March 2004. Cases were each matched with 3 controls based on age, sex and comorbidities. We calculated adjusted odds ratios (OR) for the risk of hip fracture and all osteoporosis-related fractures for durations of proton pump inhibitor exposure ranging from 1 or more years to more than 7 years. RESULTS: We matched 15 792 cases of osteoporosis-related fractures with 47 289 controls. We did not detect a significant association between the overall risk of an osteoportic fracture and the use of proton pump inhibitors for durations of 6 years or less. However, exposure of 7 or more years was associated with increased risk of an osteoporosis-related fracture (adjusted OR 1.92, 95% confidence interval [CI] 1.16-3.18, p = 0.011). We also found an increased risk of hip fracture after 5 or more years of exposure (adjusted OR 1.62, 95% CI 1.02-2.58, p = 0.04), with even higher risk after 7 or more years exposure (adjusted OR 4.55, 95% CI 1.68-12.29, p = 0.002). INTERPRETATION: Use of proton pump inhibitors for 7 or more years is associated with a significantly increased risk of an osteoporosis-related fracture. There is an increased risk of hip fracture after 5 or more years exposure. Further study is required to determine the clinical importance of this finding and to determine the value of osteoprotective medications for patients with long-term use of proton pump inhibitors.

Postfracture care for older women: gaps between optimal care and actual care.

OBJECTIVE: To investigate rates of assessment and treatment of osteoporosis among older women during the year after they have had fractures. DESIGN: Observational, historical, population-based cohort study. SETTING: Manitoba, which maintains a comprehensive population-based repository of health care services provided and has a publicly funded health care system. PARTICIPANTS: Women 50 years old and older who had suffered fractures between 1997 and 2002. These women were chosen from among approximately 175,000 women of this age in Manitoba. METHODS: We examined each woman's annual medical record between April 1, 1997, and March 31, 2002, to find any International Classification of Diseases fracture codes that have been consistently associated with osteoporosis. We looked for postfracture care during the first 12 months after fractures: bone mineral density (BMD) testing or treated with osteoporosis pharmacotherapy. Analysis was stratified by type of fracture: designated type 1 fractures (spine or hip) and type 2 fractures (not spine or hip). MAIN OUTCOME MEASURES: Use of BMD testing or osteoporosis pharmacotherapy during the first 12 months following fractures. RESULTS: For type 1 fractures, BMD assessment during the first year after fracture increased from 2.6% in 1997-1998 to 4.6% in 2001-2002 (P for trend .0004). Rates of therapy with osteoporosis medication increased from 4.9% in 1997-1998 to 17.6% in 2001-2002 (P for trend < .0001). Results were similar for type 2 fractures. In the final year of the study, only 20.5% of women with either type of fracture underwent any identifiable intervention (BMD assessment or osteoporosis pharmacotherapy). The intervention rate was substantially higher among women 50 to 64 years old (26.4%) than among those 75 years old or older (17.9%, P for trend < .0001). CONCLUSION: Women at highest risk of future fractures are assessed infrequently for osteoporosis with BMD testing and given pharmacotherapy to prevent future fractures just as infrequently. This gap in care was particularly striking for BMD testing despite the fact that testing is free in Manitoba's publicly funded system. Data from this study could be educational for physicians treating osteoporosis and should encourage them to improve their practice patterns and optimize patient care.

Clinical risk factors for fracture in postmenopausal Canadian women: a population-based prevalence study.

Clinical risk factor assessment can be used to enhance fracture risk estimation based upon bone densitometry alone. Population- and age-specific risk factor prevalence data are required for the construction of these risk models. Our objective was to derive population-based prevalence estimates of specific clinical risk factors for postmenopausal women resident in the Province of Manitoba, Canada. A random sample of 40,300 women age 50 or older identified from the provincial health plan was mailed a validated self-report risk factor survey. The response rate was 8747 (21.7%) with a final study population of 8027 women after exclusions. The individual prevalence for each clinical risk factor ranged from 5.8% for hyperthyroidism to 33.0% for a fall in the preceding 12 months. Most point prevalence estimates were similar to other large cohort studies, though the prevalences of inactivity and poor mobility were higher than expected while height at age 25 and the prevalence of any fracture after age 50 were lower than expected. Most of the respondents (86.9%) had at least one non-age clinical risk factor, 60.6% had two or more, and 33.5% had three or more. Age affected risk factor prevalence, and older age was associated with a higher rate of multiple risk factors. The availability of age-specific risk factor prevalence rates in this population may allow for more accurate fracture risk modeling.

Prognostic value of lung sestamibi uptake in myocardial perfusion imaging of patients with known or suspected coronary artery disease.

OBJECTIVES: We sought to determine whether lung uptake of technetium-99m (99mTc)-based myocardial perfusion tracers predicts cardiac events. BACKGROUND: Increased lung uptake of thallium-201 during myocardial perfusion scintigraphy can predict important clinical outcomes. It is unclear whether lung uptake of 99mTc-based myocardial perfusion tracers can be used in a similar way. METHODS: Stress lung-to-heart ratio (sLHR) was determined in 718 patients undergoing 99mTc-sestamibi single-photon emission computed tomographic stress imaging. The primary outcome was acute myocardial infarction or death. RESULTS: During a mean follow-up of 5.6 years, a primary end point occurred in 114 patients (16%). The sLHR was significantly greater in those with an adverse outcome (p < 0.00001). The likelihood of an adverse outcome increased by a factor of 1.5 (95% confidence interval 1.2 to 1.7) for each standard deviation increase in sLHR after adjustment for all other variables. The sLHR provided a small but significant improvement in risk stratification when added to clinical, stress test, perfusion, and left ventricular volume information (global chi-square 168.6 vs. 150.7, p < 0.00001). CONCLUSIONS: Stress LHR is an adjunctive prognostic measure in patients with known or suspected coronary artery disease.

Prognostic value of automated quantification of 99mTc-sestamibi myocardial perfusion imaging.

UNLABELLED: Although human interpretation of (99m)Tc-sestamibi SPECT myocardial perfusion imaging has been repeatedly validated in the diagnostic and prognostic assessment of coronary artery disease, it remains unclear if automated computer-derived quantitative indices of perfusion have similar or independent prognostic information. METHODS: We studied 718 patients referred for (99m)Tc-sestamibi SPECT myocardial perfusion imaging who were followed for 5.6 +/- 1.1 y (mean +/- SD). The SPECT studies were initially interpreted visually without benefit of computer-based analysis and were then subjected to a blinded reprocessing to extract quantitative indices of perfusion. Follow-up was through the Manitoba Population Health Research Data Repository. Acute myocardial infarction or cardiac death occurred in 79 individuals (11.0% of the cohort). RESULTS: Visual and quantitative categorization of scan perfusion abnormalities showed similar prognostic value for predicting acute myocardial infarction or cardiac death. Discordance between the visual and quantitative categorizations defined a group at intermediate risk. There was a gradient of risk with increasing severity of the summed stress score (SSS) or summed difference score (SDS). The automated SSS and SDS provided incremental prognostic information over that obtained from visual interpretation. CONCLUSION: Automated quantification of (99m)Tc-sestamibi SPECT myocardial perfusion scans provides objective prognostic information and may complement the conventional visual image interpretation.

An examination of the effect of cytochrome P450 drug interactions of hydroxymethylglutaryl-coenzyme A reductase inhibitors on health care utilization: a Canadian population-based study.

BACKGROUND: Cytochrome P450-related drug interactions can lead to adverse effects that may affect health care resource utilization. OBJECTIVE: The purpose of this study was to quantify the impact of drug interactions involving hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) on health care resource utilization. METHODS: Using the Manitoba Health Research database, we identified patients who had used statins between January 1, 1995, and March 31, 1998. New statin users (NSUs) were those who received a first prescription for a statin after April 30, 1995; old statin users (OSUs) were those who had a statin prescription before January 1, 1995. The number of hospitalizations, physician visits, and prescriptions, and their associated costs to the Manitoba health care system were calculated. Statin interacters were defined as users with >1 prescription for an interacting drug while receiving a statin. Interacting drugs were classified into 2 groups: group A included drugs whose levels increased as a result of the statin prescription; drugs in group B increased statin levels. The Wilcoxon rank-sum test was used to analyze differences by statin on health care resource use. RESULTS: A total of 28,705 statin users (18, 181 NSUs and 10,524 OSUs) were identified. During the study period, 24,496 (85.3%) individuals took 1 statin, 3751 (13.1%) took 2 statins, and 458 (1.6%) took 3 to 5 statins. The most common coadministered group A interacting drugs were diclofenac (5.8%), amitriptyline (4.9%), warfarin (4.5%), and ibuprofen (1.8%). The most common group B interacting drugs were erythromycin (8.2%), omeprazole (5.5%), cimetidine (3.6%), and clarithromycin (3.5%). Statin interacters consumed significantly more health care resources than did noninteracters for both incident and prevalent analyses (P < 0.001). In the prevalent analysis (NSUs + OSUs), pravastatin users taking interacting drugs had significantly fewer hospitalizations (mean, 1.3), fewer physician visits (mean, 24.2), and lower health care costs (mean, 5,526 dollars) compared with prevalent users of lovastatin (1.7, 28.0, and 6,925 dollars, respectively) and fewer physician visits than simvastatin users (25.6, P < 0.001). In the incident analysis, pravastatin users had significantly less physician visits (20.8 vs 23.5, P < 0.001) and lower health care costs (4,739 dollars vs 6,323 dollars, P < 0.001) than lovastatin users. CONCLUSION: Pravastatin was associated with fewer hospitalizations, physician visits, and overall health care resource utilization in prevalent users than lovastatin, possibly due to a lack of drug interaction effects.

Automated quantification of 99mTc sestamibi myocardial perfusion compared with visual analysis.

OBJECTIVES: The visual interpretation of 99mTc sestamibi single photon emission computed tomography (SPECT) myocardial perfusion images can be challenging due to the quantity of scan information generated, the large number of normal variants, attenuation artifacts and gender differences. The development of automated, computer derived, quantitative indices of perfusion can assist in this interpretation by providing an objective measure. It is important to verify that similar results can be obtained when the software is used in centres outside those where the algorithms were initially developed. Our objective was to assess the degree of concordance between the visual and automated diagnostic assessments of 99mTc sestamibi SPECT. METHODS: We studied 718 patients referred for 99mTc sestamibi SPECT myocardial perfusion imaging. The SPECT studies were initially interpreted visually without benefit of computer based analysis, and were then subjected to blinded reprocessing to extract quantitative indices of perfusion. RESULTS: There was very good agreement between the visual and quantitative diagnostic classifications. When a visual abnormality was taken to be the reference standard, the automated summed stress score (SSS) showed agreement (SSS>3) in 80% (kappa 0.60, P<0.0001). The area under the receiver operating characteristic (ROC) curve was 0.89 (95% confidence interval (CI), 0.86-0.91). Concordance was greater in those with previous myocardial infarction or severe perfusion defects, but was not affected by age, prior revascularization, stress procedure or heart rate. Concordance over the presence or absence of visual reversibility and the summed difference score (SDS) in abnormal scans was slightly lower (overall agreement 73% (kappa 0.36, P<0.00001) and ROC area 0.84 (95% CI, 0.77-0.90)). CONCLUSION: Automated quantification of 99mTc sestamibi SPECT myocardial perfusion with the SSS and SDS provides objective diagnostic information and concordance when compared with conventional visual image interpretation.

Management competencies for Canadian health executives: views from the field.

In August 2003, a national survey of 485 (56% response rate) Canadian health service managers and executives ranked the importance and assessed their proficiency in 31 managerial competencies. While the survey respondents appear to agree with the importance of the 31 competencies, we have identified a gap between the perceived level of importance and self-assessed proficiency level that should be addressed by the Canadian College of Health Service Executives.

Temporal trends in obesity, osteoporosis treatment, bone mineral density, and fracture rates: a population-based historical cohort study.

Diverging international trends in fracture rates have been observed, with most reports showing that fracture rates have stabilized or decreased in North American and many European populations. We studied two complementary population-based historical cohorts from the Province of Manitoba, Canada (1996-2006) to determine whether declining osteoporotic fracture rates in Canada are attributable to trends in obesity, osteoporosis treatment, or bone mineral density (BMD). The Population Fracture Registry included women aged 50 years and older with major osteoporotic fractures, and was used to assess impact of changes in osteoporosis treatment. The BMD Registry included all women aged 50 years and older undergoing BMD tests, and was used to assess impact of changes in obesity and BMD. Model-based estimates of temporal changes in fracture rates (Fracture Registry) were calculated. Temporal changes in obesity and BMD and their association with fracture rates (BMD Registry) were estimated. In the Fracture Registry (n=27,341), fracture rates declined 1.6% per year (95% confidence interval [CI], 1.3% to 2.0%). Although osteoporosis treatment increased from 5.6% to 17.4%, the decline in fractures was independent of osteoporosis treatment. In the BMD Registry (n=36,587), obesity increased from 12.7% to 27.4%. Femoral neck BMD increased 0.52% per year and lumbar spine BMD increased 0.32% per year after covariate adjustment (p<0.001). Major osteoporotic fracture rates decreased in models that did not include femoral neck BMD (fully adjusted annual change -1.8%; 95% CI, -2.9 to -0.5), but adjusting for femoral neck BMD accounted for the observed reduction (annual change -0.5%; 95% CI, -1.8 to +1.0). In summary, major osteoporotic fracture rates declined substantially and linearly from 1996 to 2006, and this was explained by improvements in BMD rather than greater rates of obesity or osteoporosis treatment.