Declining hospitalisation and surgical intervention rates in patients with Crohn's disease: a population-based cohort.

BACKGROUND: Lifetime risk of surgery in patients with Crohn's disease remains high. AIM: To assess population-level markers of Crohn's disease (CD) in the era of biological therapy. METHODS: Population-based cohort study using administrative data from Ontario, Canada including 45 235 prevalent patients in the Ontario Crohn's and Colitis Cohort (OCCC) from 1 April 2003 to 31 March 2014. RESULTS: CD-related hospitalisations declined 32.4% from 2003 to 2014 from 154/1000 (95% confidence interval (CI) [150, 159]) patients to 104/1000 (95% CI [101, 107]) (P < .001). There was a 39.6% decline in in-patient surgeries from 53/1000 (95% CI [50, 55]) to 32/1000 (95% CI [30, 34]) from 2003 to 2014 (P < .001). In-patient surgeries were mostly bowel resections. Out-patient surgeries increased from 8/1000 (95% CI [7, 9]) patients to 12/1000 (95% CI [10, 13]) (P < .001). Out-patient surgeries were largely related to fistulas and perianal disease and for stricture dilations/stricturoplasty. CD-related emergency department (ED) visits declined 28.4% from 141/1000 (95% CI [137, 146]) cases to 101/1000 (95% CI [99, 104]) from 2003 to 2014 (P < .001). Over the same time, patients receiving government drug benefits received infliximab or adalimumab at a combined rate of 2.2% in 2003 which increased to 18.8% of eligible patients by 2014. CONCLUSIONS: Rates of hospitalisations, ED visits and in-patient surgeries markedly declined in Ontario over the study period, while rates of biologic medication use increased markedly for those receiving public drug benefits.

Home Mechanical Ventilation: A 12-Year Population-Based Retrospective Cohort Study.

BACKGROUND: Increasing numbers of individuals are being initiated on home mechanical ventilation, including noninvasive (bi-level) and invasive mechanical ventilation delivered via tracheostomy due to chronic respiratory failure to enable symptom management and promote quality of life. Given the high care needs of these individuals, a better understanding of the indications for home mechanical ventilation, and health-care utilization is needed. METHODS: We performed a retrospective cohort study using provincial health administrative data from Ontario, Canada (population ∼13,000,000). Home mechanical ventilation users were characterized using health administrative data to determine the indications for home mechanical ventilation, the need for acute care at the time of ventilation approval, and their health service use and mortality rates following approval. RESULTS: The annual incidence of home mechanical ventilation approval rose from 1.8/100,000 in 2000 to 5.0/100,000 in 2012, or an annual increase of approximately 0.3/100,000 persons/y. The leading indications were neuromuscular disease, thoracic restriction, and COPD. The indication for the remainder could not be determined due to limitations of the administrative databases. Of the 4,670 individuals, 23.0% commenced home mechanical ventilation following an acute care hospitalization. Among individuals who survived at least 1 y, fewer required hospitalization in the year that followed home mechanical ventilation approval (29.9% vs 39.8%) as compared with the year prior. CONCLUSIONS: Utilization of home mechanical ventilation is increasing in Ontario, Canada, and further study is needed to clarify the factors contributing to this and to further optimize utilization of health-care resources.

A population-based analysis of outcomes after radiotherapy in intensive care unit patients with lung cancer.

BACKGROUND: As the value of radiotherapy (RT) in intensive care unit (ICU) patients with lung cancer is of uncertain efficacy, we evaluated characteristics, outcomes and RT utilization for such patients in Ontario, Canada. METHODS: Multiple administrative databases were linked deterministically using unique encoded identifiers to identify eligible patients between April 1, 2007, and March 31, 2014. Differences in patient, treatment, institution and tumor characteristics between RT and non-RT groups at the level of episode of care were compared. Overall survival (OS) was evaluated using the Kaplan-Meier method, with differences compared using the log-rank test. Univariable and multivariable Cox proportional hazard modeling were performed to assess the effect of RT on survival. RESULTS: RT was delivered in 133 episodes of care to 1.0% (n=131) of the 13,739 unique patients with lung cancer. RT delivery was associated with younger age (median 65 vs. 68, P<0.001), ventilation (79.8% vs. 38.2%, P<0.001) and longer ventilation duration (median 6 vs. 0 days, P<0.001). Pre-ICU disposition via transfer (35.3% vs. 9.7%) or the emergency room (ER) (28.6% vs. 21.9%) was more likely in the RT group (P<0.001). RT delivery varied, with half of the regions treating ≤5 patients each. ICU discharge was common in both RT (n=75, 56.4%) and non-RT (n=10,405, 71.4%) cohorts. One-year OS was poor in both groups, but most notably in the RT group (11.3% vs. 42.4%). RT was associated with inferior 1-year OS on unadjusted modeling (HR =1.99, P<0.001), with ventilation and pre-ICU disposition adjusting this finding towards the null on multivariable modeling (HR =1.17, P=0.095). CONCLUSIONS: Major geographic disparities exist in the rare use of RT for lung cancer in the ICU. A significant proportion of patients receiving RT achieve discharge and a minority achieve prolonged survival, suggesting that RT use may not be futile.

Risk factors for falling among community-dwelling veterans and their caregivers.

PURPOSE: To assess the prevalence and strength of association of risk factors for falling in Canadian veterans of World War II and Korea and their caregivers. METHODS: Questionnaires were sent to addresses of 3,000 Canadian veterans (response rate(1/4)70%). Risk factors for falls and the frequency of falls and injurious falls in the past 12 months were collected. RESULTS: Veterans had more risk factors than did caregivers, and more had fallen in the past year (39.8% vs. 29.7%). Risk factors in the logistic model for veterans included lower extremity disability (odds ratio 1.98, 95% confidence interval 1.5-2.6); lower extremity weakness (OR 1.75, 95% CI 1.3-2.3); worse memory than peers (OR 1.67, 95% CI 1.1-2.5); one or more visits to the family doctor in the past month (OR 1.53, 95% CI 1.2-2.0); and worse memory than 5 years ago (OR 1.36, 95% CI 1.0-1.8). CONCLUSIONS: Veterans appear more frail and prone to falling than their caregivers.

How much are we willing to pay to prevent a fall? Cost-effectiveness of a multifactorial falls prevention program for community-dwelling older adults.

This study examined the cost-effectiveness of a multifactorial falls prevention program and estimated the trade-off between the extra costs of such a program and the additional reduction of unintentional falls. Cost-effectiveness was evaluated using the traditional incremental cost-effectiveness ratio (ICER) and the net benefit regression framework (NBRF). Using the NBRF, decision making was formalized by incorporating values of willingness to pay (WTP) a priori. The results failed to provide evidence that a multifactorial falls prevention program was cost-effective. Participant adherence to recommendations ranged from low (41.3%), to moderate (21.1%), to high (37.6%). A future challenge is to understand more clearly the relationship between the community-dwelling older adult, potentially modifiable risks for falls, adherence to multifactorial risk factor recommendations, costs, and resulting effects of falls prevention practices. Future economic evaluations of falls prevention interventions remain necessary and should consider the NBRF so that regression tools can facilitate cost-effectiveness analysis.