Estimating the Rates of Undiagnosed Prediabetes and Diabetes Among People Experiencing Homelessness.

OBJECTIVES: The rising prevalence of type 2 diabetes in Canada poses a significant health challenge. Despite the convenience of screening for diabetes with glycated hemoglobin (A1C) concentration, people experiencing homelessness (PEH) often face barriers to accessing diabetes screening, potentially leading to underdiagnosis. In this study, we aim to assess the prevalence of undiagnosed diabetes among PEH in Calgary, Alberta, and contribute insights for planning health-care services and public health initiatives. METHODS: Four screening clinics were held, and participants were recruited through posters and word of mouth. Participants underwent point-of-care A1C testing using the Siemens DCA Vantage point-of-care analyzer. Descriptive statistics were used to identify the proportions of prediabetes and diabetes, whereas CANRISK survey scores were used to identify the pre-test probability of diabetes. RESULTS: The mean age of participants (n=102) was 47.6 years, and the self-reported causes of homelessness among the participants were diverse, including housing and financial issues (n=53), interpersonal and family issues (n=35), and health- or corrections-related factors (n=27). The average A1C was 5.60% (standard deviation 0.57%), with 5 values in the diabetes range and 12 in the prediabetes range, for a total of 17 participants found to have previously undiagnosed dysglycemia. CONCLUSIONS: The high rate of undiagnosed prediabetes and diabetes among PEH reflects at least what is already seen in the general population in Canada. More resources are required to reduce the barriers to screening for diabetes among this population.

[Mobile cardiovascular screening and prevention in the population : useful in Switzerland?] / Dépistage et prévention cardiovasculaire mobile dans la population : utile en Suisse ?

Mobile cardiovascular prevention interventions are still uncommon in Switzerland. Mobile clinics improve access to prevention and enable new diagnoses of hypertension or hypercholesterolemia to be identified in a cost-effective way and has shown benefits in health behaviors such as physical activity, smoking cessation and medication compliance. The Unisanté Bus Santé is a mobile clinic run by nurses that offers screening for cardiovascular risk factors, health advice and, if necessary, referral to medical care. Mobile health initiatives such as the Bus Santé could play a more important role in the Swiss healthcare system, bringing personalized preventive care closer to the population.

Les interventions mobiles de promotion de la santé et de prévention sont encore peu fréquentes en Suisse. Elles permettent pourtant, par exemple, l'identification de nouveaux diagnostics d'hypertension ou d'hypercholestérolémie avec un rapport coût-efficacité favorable et ont également montré des bénéfices sur les comportements de santé comme l'activité physique, le sevrage tabagique et l'observance médicamenteuse. Le Bus santé d'Unisanté est une clinique mobile gérée par des infirmières proposant un dépistage des facteurs de risque cardiovasculaire, des conseils de santé et, si nécessaire, une orientation vers des soins médicaux. Ces interventions mobiles pourraient jouer un rôle plus important dans le système de santé suisse en amenant une offre de prévention personnalisée au plus proche de la population.

Group Versus Individual Diabetes Education for Persons With Experience of Homelessness in Canada.

PURPOSE: The purpose of the study was to explore various forms of diabetes self-management education (DSME), including group and individual sessions, for persons with lived experiences of homelessness (PWLEH) in Canada. METHODS: A qualitative descriptive study using open-ended interviews with health care and homeless sector service providers was utilized to serve those experiencing homelessness in 5 cities across Canada. NVivo qualitative data analysis software was used to facilitate thematic analysis, focusing on variations in DSME for PWLEH. RESULTS: We conducted interviews with 96 unique health and social care providers. Four themes were identified through focused coding of interviews. First, the use of a harm reduction approach during diabetes education tailored to PWLEH considered patients' access to food, medications, and supplies and other comorbidities, including mental health and substance use disorders. The second theme related to the unsuitability of the curriculum in mainstream diabetes education in a group setting for PWLEH. Third, the role of group education in community building is to create supportive relationships among members. The final theme was the importance of trust and confidentiality in DSME, which were most easily maintained during individual education, compared to group formats. CONCLUSIONS: Overall, PWLEH experience unique challenges in managing diabetes. DSME adapted to these individuals' unique needs may be more successful and could be delivered in both individual and group settings.

The contribution of modifiable risk factors to socioeconomic inequities in cardiovascular disease morbidity and mortality: A nationally representative population-based cohort study.

This study examined the individual and joint effects of modifiable risk factors mediating the associations between socioeconomic position (SEP) and morbidity and mortality from cardiovascular diseases (CVD) in a nationally representative sample of adults in Canada. Participants in the Canadian Community Health Survey (n = 289,800) were followed longitudinally for CVD morbidity and mortality using administrative health and mortality data. SEP was measured as a latent variable consisting of household income and individual educational attainment. Mediators included smoking, physical inactivity, obesity, diabetes and hypertension. The primary outcome was CVD morbidity and mortality, defined as the first fatal/nonfatal CVD event during follow-up (median 6.2 years). Generalized structural equation modeling tested the mediating effects of modifiable risk factors in associations between SEP and CVD in the total population and stratified by sex. Lower SEP was associated with 2.5 times increased odds of CVD morbidity and mortality (OR: 2.52, 95% CI: 2.28, 2.76). Modifiable risk factors mediated 74% of associations between SEP and CVD morbidity and mortality in the total population and were more important mediators of associations in females (83%) than males (62%). Smoking mediated these associations independently and jointly with other mediators. The mediating effects of physical inactivity were through joint mediating effects with obesity, diabetes or hypertension. There were additional joint mediating effects of obesity through diabetes or hypertension in females. Findings point to modifiable risk factors as important targets for interventions along with interventions that target structural determinants of health to reduce socioeconomic inequities in CVD.

Patterns and Patients' Characteristics Associated With Use of Sodium-Glucose Cotransporter-2 Inhibitors Among Adults With Type 2 Diabetes: A Population-based Cohort Study.

OBJECTIVES: Our aim in this study was to describe patterns and patient-level factors associated with use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) among adults with diabetes being treated in Alberta, Canada. METHODS: Using linked administrative data sets from 2014 to 2019, we defined a retrospective cohort of adults with prevalent or incident type 2 diabetes with indications for SGLT2i use and who did not have advanced kidney disease (glomerular filtration rate <30 mL/min per 1.73 m2) or previous amputation. We describe medication dispensation patterns of SGLT2is over time in the overall cohort and among the subgroup with cardiovascular disease (CVD). Multivariable logistic regression was used to determine patients' characteristics associated with SGLT2i use. RESULTS: Of the 341,827 patients with diabetes (mean age, 60.7 years; 45.6% female), 107,244 (31.3%) had CVD. The proportion of patients with an SGLT2i prescription increased in a linear fashion to a maximum of 10.8% (95% confidence interval [CI], 10.7% to 10.9%) of the eligible cohort by the end of the observation period (March 2019). The proportion of filled prescriptions was similar for patients with CVD (10.4%; 95% CI, 10.1% to 10.6%) and for those without CVD (10.9%; 95% CI, 10.8% to 11.0%). Patients' characteristics associated with lower odds of filling an SGLT2i prescription included female sex, older age and lower income. CONCLUSIONS: The use of SGLT2is is increasing among patients with diabetes but remains low even in those with CVD. Policy and practice changes to increase prescribing, especially in older adults, may help to reduce morbidity and mortality related to cardiovascular and renal complications.

Identifying subgroups of adult high-cost health care users: a retrospective analysis.

BACKGROUND: Few studies have categorized high-cost patients (defined by accumulated health care spending above a predetermined percentile) into distinctive groups for which potentially actionable interventions may improve outcomes and reduce costs. We sought to identify homogeneous groups within the persistently high-cost population to develop a taxonomy of subgroups that may be targetable with specific interventions. METHODS: We conducted a retrospective analysis in which we identified adults (≥ 18 yr) who lived in Alberta between April 2014 and March 2019. We defined "persistently high-cost users" as those in the top 1% of health care spending across 4 data sources (the Discharge Abstract Database for inpatient encounters; Practitioner Claims for outpatient primary care and specialist encounters; the Ambulatory Care Classification System for emergency department encounters; and the Pharmaceutical Information Network for medication use) in at least 2 consecutive fiscal years. We used latent class analysis and expert clinical opinion in tandem to separate the persistently high-cost population into subgroups that may be targeted by specific interventions based on their distinctive clinical profiles and the drivers of their health system use and costs. RESULTS: Of the 3 919 388 adults who lived in Alberta for at least 2 consecutive fiscal years during the study period, 21 115 (0.5%) were persistently high-cost users. We identified 9 subgroups in this population: people with cardiovascular disease (n = 4537; 21.5%); people receiving rehabilitation after surgery or recovering from complications of surgery (n = 3380; 16.0%); people with severe mental health conditions (n = 3060; 14.5%); people with advanced chronic kidney disease (n = 2689; 12.7%); people receiving biologic therapies for autoimmune conditions (n = 2538; 12.0%); people with dementia and awaiting community placement (n = 2520; 11.9%); people with chronic obstructive pulmonary disease or other respiratory conditions (n = 984; 4.7%); people receiving treatment for cancer (n = 832; 3.9%); and people with unstable housing situations or substance use disorders (n = 575; 2.7%). INTERPRETATION: Using latent class analysis supplemented with expert clinical review, we identified 9 policy-relevant subgroups among persistently high-cost health care users. This taxonomy may be used to inform policy, including identifying interventions that are most likely to improve care and reduce cost for each subgroup.

Apparent failed and discordant adrenal vein sampling: A potential confounding role of cortisol cosecretion?

OBJECTIVE: Adrenal vein sampling (AVS) and computed tomography (CT) often show confusingly discordant lateralisation results in primary aldosteronism (PA). We tested a biochemical algorithm using AVS data to detect cortisol cosecretion as a potential explanation for discordant cases. DESIGN: Retrospective analysis from a large PA + AVS database. PATIENTS: All patients with PA and AVS, 2005-2020. MEASUREMENTS: An algorithm using biochemical data from paired AVS + CT images was devised from physiological first principles and informed by data from unilateral, AVS-CT concordant patients. The algorithm involved calculations based upon the expectation that low cortisol levels exist in adrenal vein effluent opposite an aldosterone-and-cortisol-producing adrenal mass and may reverse lateralisation due to inflated aldosterone/cortisol ratios. MAIN OUTCOMES: The algorithm was applied to cases with discordant CT-AVS lateralisation to determine whether this might be a common or explanatory finding. Clinical and biochemical characteristics of identified cases were collected via chart review and compared to CT-AVS concordant cases to detect evidence of biological plausibility for cortisol cosecretion. RESULTS: From a total of 588 AVS cases, 141 AVS + CT pairs were clear unilateral PA cases, used to develop the three-step algorithm for AVS interpretation. Applied to 88 AVS + CT discordant pairs, the algorithm suggested possible cortisol cosecretion in 40%. Case review showed that the proposed cortisol cosecretors, as identified by the algorithm, had low/suppressed adrenocorticotropic hormone levels, larger average nodule size and lower plasma aldosterone. CONCLUSIONS: Pending external validation and outcome verification by surgery and tissue immunohistochemistry, cortisol cosecretion from aldosteronomas may be a common explanation for discordant CT-AVS results in PA.

Does age matter? Comparing post-treatment psychosocial outcomes in young adult and older adult cancer survivors with their cancer-free peers.

OBJECTIVE: Adolescents and young adult cancer survivors (AYA) are a unique subpopulation with high levels of distress and unmet need. To date, studies have not disentangled distress due to developmental life stage from distress due to cancer survivorship. This population-based study allowed a direct comparison between AYA cancer survivors, older adult (OA) cancer survivors, and their cancer-free peers. METHODS: We combined 4 annual cycles of the Canadian Community Health Survey (CCHS, 2007-2010) to obtain a final sample of 239 316 respondents. We dichotomized the total sample into AYA (15-39 years, n = 83 770) and OA (40+, n = 155 546). Two standardized questions identified cancer survivors (n = 14 592). The self-reported outcomes of interest included self-perceived health and mental health, and health care professional diagnosed mood and anxiety disorders. We used weighted logistic regression models to examine for associations, including an interaction term to assess for effect modification by age. RESULTS: After adjusting for confounders, cancer survivorship in AYAs was strongly associated with higher prevalence of both mood (OR 2.00, 95% CI 1.44-2.77) and anxiety (OR 2.20, 95% CI 1.70-2.86) disorders as compared to their cancer-free peers. OA survivors had a weaker association in the same direction (OR 1.10, 95% CI 1.01-1.21 and OR 1.15, 95% CI 1.02-1.30, respectively). AYA cancer survivors reported higher levels of poor self-perceived mental health than their cancer-free peers (OR 1.49, 95% CI 1.03-2.14), while there was no significant difference from cancer-free peers for OAs (OR 1.03, 95% CI 0.92-1.15). CONCLUSIONS: AYA cancer survivors experience a significantly higher risk of psychosocial distress than both their cancer-free peers and OA survivors.

Clinical factors contributing to high cost hospitalizations in a Canadian tertiary care centre.

BACKGROUND: Like much of the developed world, healthcare costs in Canada are rising. A small proportion of patients account for a large proportion of healthcare spending and much of this spending occurs in acute care settings. The purpose of our study was to determine potentially modifiable factors related to care processes that contribute to high-cost admissions. METHODS: Using a mixed-methods study design, factors contributing to high-cost admissions were identified from literature and case review. We defined pre- and post-admission factors contributing to high-cost admissions. Pre-admission factors included reason for admission (e.g. complex medical, elective surgery, trauma, etc.). Post-admission factors included medical complications, disposition delays, clinical services delays, and inefficient clinical decision-making. We selected a random sample of admissions in the top decile of inpatient cost from the Ottawa Hospital between January 1 and December 31, 2010. A single reviewer classified cases based on the pre- and post-admission factors. We combined this information with data derived from the Ottawa Hospital Data Warehouse to describe patient-level clinical and demographic characteristics and costs incurred. RESULTS: We reviewed 200 charts which represents ~5% of all high cost admissions within the Ottawa Hospital in 2010. Post-admission factors contributing to high-cost admissions were: complications (60%), disposition delays (53%), clinical service delays (39%), and inefficient clinical decision-making (13%). Further, these factors varied substantially across service delivery lines. The mean (standard deviation (SD)) cost per admission was $49,923 CDN ($45,773). The most common reason for admission was "complex medical" (49%) and the overall median (IQR) length of stay was 27 (18-48) days. Approximately 1 in 3 high cost admissions (29%) included time in the intensive care unit (ICU). CONCLUSIONS: While high cost admissions often include time in ICU and have long lengths of stay, a substantial proportion of costs were attributable to complications and potentially preventable delays in care processes. These findings suggest opportunities exist to improve outcomes and reduce costs for this diverse patient population.

Financial barriers and adverse clinical outcomes among patients with cardiovascular-related chronic diseases: a cohort study.

BACKGROUND: Some patients with cardiovascular-related chronic diseases such as diabetes and heart disease report financial barriers to achieving optimal health. Previous surveys report that the perception of having a financial barrier is associated with self-reported adverse clinical outcomes. We sought to confirm these findings using linked survey and administrative data to determine, among patients with cardiovascular-related chronic diseases, if there is an association between perceived financial barriers and the outcomes of: (1) disease-related hospitalizations, (2) all-cause mortality and (3) inpatient healthcare costs. METHODS: We used ten cycles of the nationally representative Canadian Community Health Survey (administered between 2000 and 2011) to identify a cohort of adults aged 45 and older with hypertension, diabetes, heart disease or stroke. Perceived financial barriers to various aspects of chronic disease care and self-management were identified (including medications, healthful food and home care) from the survey questions, using similar questions to those used in previous studies. The cohort was linked to administrative data sources for outcome ascertainment (Discharge Abstract Database, Canadian Mortality Database, Patient Cost Estimator). We utilized Poisson regression techniques, adjusting for potential confounding variables (age, sex, education, multimorbidity, smoking status), to assess for associations between perceived financial barriers and disease-related hospitalization and all-cause mortality. We used gross costing methodology and a variety of modelling approaches to assess the impact of financial barriers on hospital costs. RESULTS: We identified a cohort of 120,752 individuals over the age of 45 years with one or more of the following: hypertension, diabetes, heart disease or stroke. One in ten experienced financial barriers to at least one aspect of their care, with the two most common being financial barriers to accessing medications and healthful food. Even after adjustment, those with at least one financial barrier had an increased rate of disease-related hospitalization and mortality compared to those without financial barriers with adjusted incidence rate ratios of 1.36 (95% CI: 1.29-1.44) and 1.24 (1.16-1.32), respectively. Furthermore, having a financial barrier to care was associated with 30% higher inpatient costs compared to those without financial barriers. DISCUSSION: This study, using novel linked national survey and administrative data, demonstrates that chronic disease patients with perceived financial barriers have worse outcomes and higher resource utilization, corroborating the findings from prior self-report studies. The overall exposure remained associated with the primary outcome even in spite of adjustment for income. This suggests that a patient's perception of a financial barrier might be used in clinical and research settings as an additional measure along with standard measures of socioeconomic status (ie. income, education, social status). CONCLUSIONS: After adjusting for relevant covariates, perceiving a financial barrier was associated with increased rates of hospitalization and mortality and higher hospital costs compared to those without financial barriers. The demonstrable association with adverse outcomes and increased costs seen in this study may provide an impetus for policymakers to seek to invest in interventions which minimize the impact of financial barriers.

Assessing outcomes of enhanced chronic disease care through patient education and a value-based formulary study (ACCESS)-study protocol for a 2×2 factorial randomized trial.

BACKGROUND: Chronic diseases result in significant morbidity and costs. Although medications and lifestyle changes are effective for improving outcomes in chronic diseases, many patients do not receive these treatments, in part because of financial barriers, patient and provider-level knowledge gaps, and low patient motivation. The Assessing outcomes of enhanced chronic disease care through patient education and a value-based formulary study (ACCESS) will determine the impact of two interventions: (1) a value-based formulary which eliminates copayment for high-value preventive medications; and (2) a comprehensive self-management support program aimed at promoting health behavior change and medication adherence, combined with relay of information on medication use to healthcare providers, on cardiovascular events and/or mortality in low-income seniors with elevated cardiovascular risk. METHODS: The ACCESS study will use a parallel, open label, factorial randomized trial design, with blinded endpoint evaluation in 4714 participants who are over age >65 (and therefore have drug insurance provided by Alberta Blue Cross with 30 % co-payment); are at a high risk for cardiovascular events based on a history of any one of the following: coronary heart disease, prior stroke, chronic kidney disease, heart failure, or any two of the following: current cigarette smoking, diabetes mellitus, hypertension, or hypercholesterolemia; and have a household income

The association of income with health behavior change and disease monitoring among patients with chronic disease.

BACKGROUND: Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. METHODS: We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. RESULTS: Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09-2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24-2.40) or glucose (PRR: 1.80, 95%CI: 1.26-2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. CONCLUSIONS: There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.

High positive psychiatric screening rates in an urban homeless population.

OBJECTIVE: To carry out a preliminary assessment of the use of a psychiatric screening tool in an urban homeless population, and to estimate the potential prevalence of undiagnosed and (or) unmanaged mental illness in this population. METHODS: Participants (n = 166) were recruited from the Calgary Drop-in and Rehab Centre to complete a questionnaire containing 6 modules screening for common psychiatric disorders. Summary statistics were used in the analysis. RESULTS: Only 12 respondents (7%) screened negative on each of the 6 modules. The screening process determined that 60.2% of the sample (n = 100) had probable mental illness but reported no history of psychiatric diagnosis or treatment. CONCLUSIONS: A straightforward application of screening (in which screen-positive subjects are referred for assessment) would be difficult in this population as most will screen positive. The results highlight the tremendous burden of psychiatric symptoms in this population.

Objectif : Mener une évaluation préliminaire de l'utilisation d'un outil de dépistage psychiatrique dans une population urbaine sans abri, et estimer la prévalence potentielle de maladie mentale non diagnostiquée et (ou) non traitée dans cette population. Méthodes : Les participants (n = 166) ont été recrutés au Drop-in and Rehab Centre de Calgary pour remplir un questionnaire contenant 6 modules dépistant les troubles psychiatriques communs. Des statistiques sommaires ont été utilisées dans l'analyse. Résultats : Seulement 12 répondants (7 %) ont eu un dépistage négatif à chacun des 6 modules. Le procédé de dépistage a déterminé que 60,2 % de l'échantillon (n = 100) avaient une maladie mentale probable mais ne déclaraient pas d'antécédents de diagnostic ou de traitement psychiatrique. Conclusions : Une application directe du dépistage (dans laquelle les sujets dont le dépistage est positif sont renvoyés à une évaluation) serait difficile dans cette population car la plupart aura un dépistage positif. Les résultats mettent en évidence le fardeau écrasant des symptômes psychiatriques de cette population.