Gastroschisis and septo-optic-pituitary dysplasia: Is there an association?

AIM: There are several case reports describing patients with both optic nerve hypoplasia/septo-optic-pituitary dysplasia (ONH/SOD) and gastroschisis (GS). Our aim was to investigate whether ONH/SOD is associated with GS. METHODS: A retrospective population-based study was undertaken using the Population Research Data Repository at the Manitoba Center for Health Policy in Manitoba, Canada to investigate if any patient with ONH/SOD also had GS. In addition, Winnipeg's Surgical Database of Outcomes and Management (WiSDOM), a hospital-based paediatric surgical database, was searched to ascertain if any of the patients with GS also have ONH/SOD. RESULTS: Cases were 124 patients with ONH/SOD diagnosed during 1990-2019. None had GS. The surgical database had 188 patients from Manitoba with GS during 1991-2019. None had ONH/SOD. CONCLUSION: There does not appear to be an association between ONH/SOD and GS in our cohorts of patients with these two disorders.

Adherence to Psychotropic Medication Before and During COVID-19: A Population-Wide Retrospective Observational Study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and associated public health measures have shifted the way people access health care. We aimed to study the effects of the COVID-19 pandemic on psychotropic medication adherence. METHODS: A retrospective cohort study using administrative data from the Manitoba Centre for Health Policy Manitoba Population Research Data Repository was conducted. Outpatients who received at least 1 prescription for an antidepressant, antipsychotic, anxiolytic/sedative-hypnotic, cannabinoid, lithium, or stimulants from 2015 to 2020 in Manitoba, Canada, were included. Adherence was measured using the proportion of individuals with a mean possession ratio of ≥0.8 over each quarter. Each quarter of 2020 after COVID-19-related health measures were implemented was compared with the expected trend using autoregression models for time series data plus indicator variables. Odds ratio of drug discontinuation among those previously adherent in 2020 was compared with each respective quarter of 2019. RESULTS: There were 1,394,885 individuals in the study population in the first quarter of 2020 (mean [SD] age, 38.9 [23.4] years; 50.3% female), with 36.1% having a psychiatric diagnosis in the preceding 5 years. Compared with the expected trend, increases in the proportions of individuals adherent to antidepressants and stimulants were observed in the fourth quarter (October-December) of 2020 (both P < 0.001). Increases in the proportions of individuals with anxiolytic and cannabinoid adherence were observed in the third quarter (July-September) of 2020 (both P < 0.05), whereas a decrease was seen with stimulants in the same quarter ( P < 0.0001). No significant changes were observed for antipsychotics. All drug classes except lithium had decreases in drug discontinuation in previously adherent patients during the pandemic compared with 2019. CONCLUSIONS: Improved adherence to most psychotropic medications in the 9 months after public health restrictions were enacted was observed. Patients who were already adherent to their psychotropic medications were less likely to discontinue them during the pandemic.

Effect of Air Transport Delay on Mortality in Critical Illness: A Population-Based Cohort Study.

OBJECTIVE: For critically ill patients in remote areas, we assessed the association of transport delay via fixed wing air ambulance on 30-day mortality, excluding interhospital transports. METHODS: This was a retrospective cohort analysis of all such adult transports in Manitoba, Canada, over 5.4 years. Causal mediation analysis was used, with the Acute Physiology and Chronic Health Evaluation II Acute Physiology Score at the destination intensive care unit as the mediator. The covariates were age, sex, comorbidities, socioeconomic status, and physiologic variables from the sending site. RESULTS: The primary cohort was composed of 554 patients; 113 (20.4%) died within 30 days. The total transport delay (mean ± standard deviation) was 5.1 ± 1.7 hours. Compared with no delay, the average 5-hour transport delay was associated with an odds ratio for mortality of 1.34 with a 95% confidence interval from 40% lower to 270% higher, with 60% of the influence of total travel time attributable to worsening of patients' acute physiologic status during the delay in intensive care unit admission due to transport. CONCLUSIONS: Although these findings provide insufficient evidence for an effect of fixed wing air transport delay on mortality among critically ill patients, they underscore the need for additional and larger studies on this topic.

Primary medication nonadherence in a large primary care population: Observational study from Manitoba.

OBJECTIVE: To analyze primary medication nonadherence across several prescription indications and test the predictors of drug nonadherence in an adult primary care population. DESIGN: Retrospective observational study using primary care provider prescriptions linked to pharmacy-based dispensing data from 2012 to 2014. SETTING: Manitoba. PARTICIPANTS: Patients in the Manitoba Primary Care Research Network. MAIN OUTCOME MEASURES: Prevalence of primary medication nonadherence by drug class. Multivariable logistic regression models were used to test the associations of patient demographic and clinical or provider characteristics with primary medication nonadherence. The C statistic was used to assess the models' discriminative performance. RESULTS: A total of 91,660 unique prescriptions were assessed from a cohort of more than 200,000 patients. Primary medication nonadherence ranged from 13.7% (antidepressants) to 30.3% (antihypertensives). In conditions that typically present symptomatically (eg, infections, anxiety) nonadherence ranged from 13.7% to 17.5%. The range was 21.2% to 30.0% for medications related to asymptomatic conditions or those typically detected by screening. The discriminative performance of the models based on patient demographic, clinical, or provider characteristics was weak. CONCLUSION: Primary medication nonadherence is common, occurring more often in asymptomatic conditions. The poor predictability of the models suggests that caution is required when considering characteristic-based interventions or prediction tools to improve primary medication nonadherence.

Disparities in management and outcomes of myocardial infarction in multiple sclerosis: A matched cohort study.

BACKGROUND: Although multiple sclerosis (MS) confers an elevated risk of acute myocardial infarction (AMI), little is known about how it influences management of AMI. METHODS: Using population-based administrative (health) data from two Canadian provinces, we conducted a retrospective matched cohort study. We identified people with MS who had an incident AMI, and up to five AMI controls without MS matched on age, sex, and region. We compared the likelihood of undergoing cardiac catheterization within 30 days of AMI, time to revascularization, use of recommended pharmacotherapy post-AMI, and mortality at 30 and 365 days post-AMI using multivariable regression models adjusting for potential confounders. We pooled findings across provinces using meta-analysis. RESULTS: We identified 559 MS cases and 2523 matched controls. In the matched cohort, the MS cohort was less likely to undergo cardiac catheterization within 30 days of admission (odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.49-0.77), revascularization (hazard ratio (HR) = 0.78; 95% CI = 0.69-0.88), or to fill a prescription for recommended therapy. Mortality risk was higher in the MS cohort than in the matched cohort at 30 and 365 days post-AMI. CONCLUSION: Rates of diagnostic and therapeutic care, and survival after AMI were lower in the MS population than in a matched population.

Rates of readmission and death associated with leaving hospital against medical advice: a population-based study.

BACKGROUND: Leaving hospital against medical advice may have adverse consequences. Previous studies have been limited by evaluating specific types of patients, small sample sizes and incomplete determination of outcomes. We hypothesized that leaving hospital against medical advice would be associated with increases in subsequent readmission and death. METHODS: In a population-based analysis involving all adults admitted to hospital and discharged alive in Manitoba from Apr. 1, 1990, to Feb. 28, 2009, we evaluated all-cause 90-day mortality and 30-day hospital readmission. We used multivariable regression, adjusted for age, sex, socioeconomic status, year of hospital admission, patient comorbidities, hospital diagnosis, past frequency of admission to hospital, having previously left hospital against medical advice and data clustering (patients with multiple admissions). For readmission, we assessed both between-person and within-person effects of leaving hospital against medical advice. RESULTS: Leaving against medical advice occurred in 21 417 of 1 916 104 index hospital admissions (1.1%), and was associated with higher adjusted rates of 90-day mortality (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.18-2.89), and 30-day hospital readmission (within-person OR 2.10, CI 1.99-2.21; between-person OR 3.04, CI 2.79-3.30). In our additional analyses, elevated rates of readmission and death associated with leaving against medical advice were manifest within 1 week and persisted for at least 180 days after discharge. INTERPRETATION: Adults who left the hospital against medical advice had higher rates of hospital readmission and death. The persistence of these effects suggests that they are not solely a result of incomplete treatment of acute illness. Interventions aimed at reducing these effects may need to include longitudinal interventions extending beyond admission to hospital.

Epidemiology of critically ill patients in intensive care units: a population-based observational study.

INTRODUCTION: Epidemiologic assessment of critically ill people in Intensive Care Units (ICUs) is needed to ensure the health care system can meet current and future needs. However, few such studies have been published. METHODS: Population-based analysis of all adult ICU care in the Canadian province of Manitoba, 1999 to 2007, using administrative data. We calculated age-adjusted rates and trends of ICU care, overall and subdivided by age, sex and income. RESULTS: In 2007, Manitoba had a population of 1.2 million, 118 ICU beds in 21 ICUs, for 9.8 beds per 100,000 population. Approximately 0.72% of men and 0.47% of women were admitted to ICUs yearly. The age-adjusted, male:female rate ratio was 1.75 (95% CI 1.64 to 1.88). Mean age was 64.5 ± 16.4 years. Rates rose rapidly after age 40, peaked at age 75 to 80, and declined for the oldest age groups. Rates were higher among residents of lower income areas, for example declining from 7.9 to 4.4 per 100,000 population from the poorest to the wealthiest income quintiles (p <0.0001). Rates of ICU admission slowly declined over time, while cumulative yearly ICU bed-days slowly rose; changes were age-dependent, with faster declines in admission rates with older age. There was a high rate of recidivism; 16% of ICU patients had received ICU care previously. CONCLUSIONS: These temporal trends in ICU admission rates and cumulative bed-days used have significant implications for health system planning. The differences by age, sex and socioeconomic status, and the high rate of recidivism require further research to clarify their causes, and to devise strategies for reducing critical illness in high-risk groups.

A population-based analysis of leaving the hospital against medical advice: incidence and associated variables.

BACKGROUND: Prior studies of patients leaving hospital against medical advice (AMA) have been limited by not being population-based or assessing only one type of patient. METHODS: We used administrative data at the Manitoba Centre for Health Policy to evaluate all adult residents of Manitoba, Canada discharged alive from acute care hospitals between April 1, 1990 and February 28, 2009. We identified the rate of leaving AMA, and used multivariable logistic regression to identify socio-demographic and diagnostic variables associated with leaving AMA. RESULTS: Of 1,916,104 live hospital discharges, 21,417 (1.11%) ended with the patient leaving AMA. The cohort contained 610,187 individuals, of whom 12,588 (2.06%) left AMA once and another 2986 (0.49%) left AMA more than once. The proportion of AMA discharges did not change over time. Alcohol and drug abuse was the diagnostic group with the highest proportion of AMA discharges, at 11.71%. Having left AMA previously had the strongest association with leaving AMA (odds ratio 170, 95% confidence interval 156-185). Leaving AMA was more common among men, those with lower average household incomes, histories of alcohol or drug abuse or HIV/AIDS. Major surgical procedures were associated with a much lower chance of leaving the hospital AMA. CONCLUSIONS: The rate of leaving hospital AMA did not systematically change over time, but did vary based on patient and illness characteristics. Having left AMA in the past was highly predictive of subsequent AMA events.

The accuracy of administrative data for identifying the presence and timing of admission to intensive care units in a Canadian province.

BACKGROUND: A prerequisite for using administrative data to study the care of critically ill patients in intensive care units (ICUs) is that it accurately identifies such care. Only limited data exist on this subject. OBJECTIVE: To assess the accuracy of administrative data in the Canadian province of Manitoba for identifying the existence, number, and timing of admissions to adult ICUs. RESEARCH DESIGN: For the period 1999 to 2008, we compared information about ICU care from Manitoba hospital abstracts, with the criterion standard of a clinical ICU database that includes all admissions to adult ICUs in its largest city of Winnipeg. Comparisons were made before and after a national change in administrative data requirements that mandated specific data elements identifying the existence and timing of ICU care. RESULTS: In both time intervals, hospital abstracts were extremely accurate in identifying the presence of ICU care, with positive predictive values exceeding 98% and negative predictive values exceeding 99%. Administrative data correctly identified the number of separate ICU admissions for 93% of ICU-containing hospitalizations; inaccuracy increased with more ICU stays per hospitalization. Hospital abstracts were highly accurate for identifying the timing of ICU care, but only for hospitalizations containing a single ICU admission. CONCLUSIONS: Under current national-reporting requirements, hospital administrative data in Canada can be used to accurately identify and quantify ICU care. The high accuracy of Manitoba administrative data under the previous reporting standards, which lacked standardized coding elements specific to ICU care, may not be generalizable to other Canadian jurisdictions.

Constructing episodes of inpatient care: data infrastructure for population-based research.

BACKGROUND: Databases used to study the care of patients in hospitals and Intensive Care Units (ICUs) typically contain a separate entry for each segment of hospital or ICU care. However, it is not uncommon for patients to be transferred between hospitals and/or ICUs, and when transfers occur it is necessary to combine individual entries to accurately reconstruct the complete episodes of hospital and ICU care. Failure to do so can lead to erroneous lengths-of-stay, and rates of admissions, readmissions, and death. METHODS: This study used a clinical ICU database and administrative hospital abstracts for the adult population of Manitoba, Canada from 2000-2008. We compared five methods for identifying patient transfers and constructing hospital episodes, and the ICU episodes contained within them. Method 1 ignored transfers. Methods 2-5 considered the time gap between successive entries (≤1 day vs. ≤2 days), with or without use of data fields indicating inter-hospital transfer. For the five methods we compared the resulting number and lengths of hospital and ICU episodes. RESULTS: During the study period, 48,551 hospital abstracts contained 53,246 ICU records. For Method 1 these were also the number of hospital and ICU episodes, respectively. Methods 2-5 gave remarkably similar results, with transfers included in approximately 25% of ICU-containing hospital episodes, and 10% of ICU episodes. Comparison with Method 1 showed that failure to account for such transfers resulted in overestimating the number of episodes by 7-10%, and underestimating mean or median lengths-of-stay by 9-30%. CONCLUSIONS: In Manitoba is it not uncommon for critically ill patients to be transferred between hospitals and between ICUs. Failure to account for transfers resulted in inaccurate assessment of parameters relevant to researchers, clinicians, and policy-makers. The details of the method used to identify transfers, at least among the variations tested, made relatively little difference. In addition, we showed that these methods for constructing episodes of hospital and ICU care can be implemented in a large, complex dataset.

Administrative Data Is Insufficient to Identify Near-Future Critical Illness: A Population-Based Retrospective Cohort Study.

Background: Prediction of future critical illness could render it practical to test interventions seeking to avoid or delay the coming event. Objective: Identify adults having >33% probability of near-future critical illness. Research Design: Retrospective cohort study, 2013-2015. Subjects: Community-dwelling residents of Manitoba, Canada, aged 40-89 years. Measures: The outcome was a near-future critical illness, defined as intensive care unit admission with invasive mechanical ventilation, or non-palliative death occurring 30-180 days after 1 April each year. By dividing the data into training and test cohorts, a Classification and Regression Tree analysis was used to identify subgroups with ≥33% probability of the outcome. We considered 72 predictors including sociodemographics, chronic conditions, frailty, and health care utilization. Sensitivity analysis used logistic regression methods. Results: Approximately 0.38% of each yearly cohort experienced near-future critical illness. The optimal Tree identified 2,644 mutually exclusive subgroups. Socioeconomic status was the most influential variable, followed by nursing home residency and frailty; age was sixth. In the training data, the model performed well; 41 subgroups containing 493 subjects had ≥33% members who developed the outcome. However, in the test data, those subgroups contained 429 individuals, with 20 (4.7%) experiencing the outcome, which comprised 0.98% of all subjects with the outcome. While logistic regression showed less model overfitting, it likewise failed to achieve the stated objective. Conclusions: High-fidelity prediction of near-future critical illness among community-dwelling adults was not successful using population-based administrative data. Additional research is needed to ascertain whether the inclusion of additional types of data can achieve this goal.

Psychotropic Medication Use Before and During COVID-19: A Population-Wide Study.

Background: The coronavirus disease 2019 (COVID-19) pandemic and public health measures that took place have led to concerns regarding mental health and receipt of psychotropic medications. We aimed to study the changes in psychotropic medication dispensation rates before and during the COVID-19 pandemic in the general population. Methods: Administrative health data from the Canadian province of Manitoba was used to describe the quarterly incidence and prevalence of antipsychotics, antidepressants, and anxiolytic/sedative-hypnotics from January 1, 2015 to December 31, 2020. Individuals who received at least one prescription within each quarter were considered exposed to the medication. The denominator was the total population within each quarter. Incidence was defined as no receipt of medication in the 3 years prior to the quarter of interest. Autoregression models for time series data plus indicator variables were used to compare each quarter of 2020 after public health measures were implemented in March 2020 in relation to the expected trend. Analyses were stratified by age and sex. Results: There were 1,394,885 individuals in the first quarter of 2020, with a mean (SD) age of 38.9 (23.4) years, 50.3% were female, and 36.1% had a psychiatric diagnosis in the previous 5 years. A significant decrease was observed for incident antidepressant use (p < 0.05 for both sexes and all age groups except for those 65 years and older) and anxiolytic use (p < 0.05 for both sexes and all age groups except 80 years and older) in the second quarter (April-June) of 2020 compared to the expected trend. Females and those aged 40 years and older had a significantly higher incidence of antidepressant and antipsychotic use in the final quarter of 2020 compared to the expected trend (p < 0.05). Conclusion: Our findings indicate a decrease in new prescriptions for antidepressants and anxiolytics in the 3 months after COVID-19 in-person restrictions were first implemented. We then observed an increase in the new use of antidepressants and antipsychotics at the end of 2020, in females and people aged 40 years and older, with the highest rates of use in the population 80 years and older.

Outpatient oral anticancer agent utilization and costs in Manitoba from 2003 to 2016: a population-based study.

INTERVENTION: In April 2012, the Manitoba Home Cancer Drug Program (HCDP) was introduced to allow 100% coverage for eligible oral anticancer agents (OAA) and supportive medications for Manitobans with cancer requiring these therapies. RESEARCH QUESTIONS: What is the extent of use and cost of OAAs among outpatients in Manitoba from 2003/04 to 2015/16? Did the HCDP change OAA user and prescription patterns? METHODS: This was a retrospective, population-based study using administrative data to measure the prevalence of drug utilization over time and the impact of HCDP on OAA use and prescriptions using generalized linear models. Manitobans with cancer who filled an OAA or supportive medication covered by HCDP from 2003/04 to 2015/16 were included. RESULTS: This study included 22,393 people with cancer who filled an OAA prescription. The prevalence of OAA use increased from 222 per 100,000 to 328 per 100,000 from 2003/04 to 2015/16. Hormone therapy for breast cancer was the most common class of OAA used (increased from 154 per 100,000 to 231 per 100,000). We observed a 2.6-fold decrease in the prevalence of oral alkylating agents and a 10.7-fold increase in the prevalence of protein kinase inhibitors during the study period. The total cost of targeted OAAs per year for all Manitobans with cancer increased from $1.8 million to $19 million. CONCLUSION: We observed an increase in OAA prevalence and the cost of oral targeted chemotherapy is high. Our findings underline the need for addressing these high-cost medications in future developments of a national drug program.

RéSUMé: INTERVENTION: Le Manitoba a introduit en avril 2012 le Programme de médicaments anticancéreux pris à domicile (HCDP en anglais), qui offre un accès entièrement gratuit aux agents anticancéreux oraux (AAO) admissibles et aux médicaments d'appoint aux Manitobains atteints de cancer qui ont besoin de ces traitements. QUESTIONS DE RECHERCHE: Quelle a été l'utilisation des AAO par les malades externes au Manitoba entre 2003-2004 et 2015-2016 et quel en a été le coût? Le programme HCDP a-t-il changé les modes d'utilisation et de prescription des AAO? MéTHODE: Cette étude populationnelle rétrospective a utilisé des données administratives pour mesurer la prévalence de l'utilisation des médicaments au fil du temps et l'incidence du programme HCDP sur l'utilisation et la prescription des AAO à l'aide de modèles linéaires généralisés. Les Manitobains atteints de cancer qui ont fait exécuter une ordonnance pour un AAO ou un médicament d'appoint couvert par le programme HCDP entre 2003-2004 et 2015-2016 ont été inclus. RéSULTATS: L'étude a inclus 22 393 personnes atteintes de cancer ayant fait exécuter une ordonnance d'AAO. La prévalence de l'utilisation des AAO a augmenté, passant de 222 pour 100 000 à 328 pour 100 000 entre 2003-2004 et 2015-2016. L'hormonothérapie pour le cancer du sein a représenté la classe d'AAO la plus communément utilisée (en hausse de 154 pour 100 000 à 231 pour 100 000). Nous avons observé une diminution par un facteur de 2,6 de la prévalence des agents alcoylants oraux et une augmentation par un facteur de 10,7 de la prévalence des inhibiteurs de protéine kinase au cours de la période de l'étude. Le coût total annuel des AAO ciblés pour tous les Manitobains atteints de cancer est passé de 1,8 millions de dollars à 19 millions de dollars. CONCLUSION: Nous avons observé une augmentation de la prévalence des AAO, et le coût des agents chimiothérapeutiques oraux ciblés est élevé. Nos constatations confirment la nécessité d'aborder ces médicaments coûteux dans les versions futures d'un programme de médicaments national.

Primary prescription adherence for obstructive lung disease in a primary care population.

BACKGROUND: The objective of this study was to determine primary prescription adherence for obstructive lung diseases (e.g., asthma, COPD) in an adult primary care patient population over a 3-year period. METHODS: A retrospective analysis of electronic medical record and administrative data was performed to determine primary adherence, defined as dispensation of a new prescription within 90 days of the date the prescription was written. Multivariable logistic regression models were used to test predictors of prescription primary adherence. RESULTS: Of 13,220 prescriptions for obstructive airway disease, 75.9% (N = 10,038) were filled. In multivariate analysis, depression, certain age groups (18-44 years), higher income quartile were associated with reduced prescription adherence. However, 1-2 ER visits in the previous year (compared to no ER visits), number of ambulatory visits in the previous year, and number of hospitalizations in the previous year, did not increase the likelihood of prescription adherence. INTERPRETATION: This study provides important insights about factors associated with prescription nonadherence and is the first study examining primary medication adherence with medications for obstructive lung disease in adults, providing indications of prescription nonadherence patterns among a broad population.

Comparing administrative and survey data for ascertaining cases of irritable bowel syndrome: a population-based investigation.

BACKGROUND: Administrative and survey data are two key data sources for population-based research about chronic disease. The objectives of this methodological paper are to: (1) estimate agreement between the two data sources for irritable bowel syndrome (IBS) and compare the results to those for inflammatory bowel disease (IBD); (2) compare the frequency of IBS-related diagnoses in administrative data for survey respondents with and without self-reported IBS, and (3) estimate IBS prevalence from both sources. METHODS: This retrospective cohort study used linked administrative and health survey data for 5,134 adults from the province of Manitoba, Canada. Diagnoses in hospital and physician administrative data were investigated for respondents with self-reported IBS, IBD, and no bowel disorder. Agreement between survey and administrative data was estimated using the kappa statistic. The chi2 statistic tested the association between the frequency of IBS-related diagnoses and self-reported IBS. Crude, sex-specific, and age-specific IBS prevalence estimates were calculated from both sources. RESULTS: Overall, 3.0% of the cohort had self-reported IBS, 0.8% had self-reported IBD, and 95.3% reported no bowel disorder. Agreement was poor to fair for IBS and substantially higher for IBD. The most frequent IBS-related diagnoses among the cohort were anxiety disorders (34.4%), symptoms of the abdomen and pelvis (26.9%), and diverticulitis of the intestine (10.6%). Crude IBS prevalence estimates from both sources were lower than those reported previously. CONCLUSIONS: Poor agreement between administrative and survey data for IBS may account for differences in the results of health services and outcomes research using these sources. Further research is needed to identify the optimal method(s) to ascertain IBS cases in both data sources.

Accuracy of Administrative Hospital Data to Identify Use of Life Support Modalities. A Canadian Study.

Rationale: Accurately identifying use of life support in hospital administrative data enhances the data's value for quality improvement and research in critical illness.Objectives: To assess the accuracy of administrative hospital data for identifying invasive mechanical ventilation (IMV), acute renal replacement therapy (RRT), and intravenous vasoactive drugs in unselected adult intensive care unit (ICU) patients.Methods: We employed the administrative dataset of the Discharge Abstract Database from the Province of Manitoba during 2007-2012, using nationally standardized diagnosis and procedure codes to identify the three types of life support. The criterion standard was the Winnipeg ICU Database, which contains daily clinical information about all admissions to all 11 adult ICUs within the Winnipeg Regional Health Authority. For all individuals aged 40 years or older at ICU admission, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value of the administrative data for identifying life support. We also assessed the ability of the administrative data to identify overlapping use of the forms of life support.Results: Over the study period, there were 20,764 eligible ICU admissions; 52.6% (10,914) involved IMV, 46.8% (9,724) involved vasoactive agents, and 4.4% (907) involved acute RRT. Identification of IMV from administrative data procedure codes was good, with all four parameters exceeding 90%. The procedure code for use of selected vasoactive drugs had a sensitivity of zero; addition of diagnosis codes for shock raised the sensitivity to only 23% (95% confidence interval [CI], 22-24%). Both the sensitivity and specificity for acute RRT procedure codes exceeded 92%, but owing to low prevalence of RRT, the PPV was only 55% (95% CI, 53-58%). Addition of diagnosis codes for acute renal failure did not appreciably improve performance. Overlapping use of the three types of life support was substantial. Among those receiving any one of the types of life support, 68-76% received at least one of the two other types assessed. Considering use of any one or more of the three forms of life support, the administrative data had a PPV of 97% (95% CI, 96-97%) and a negative predictive value of 69% (95% CI, 68-70%).Conclusions: Administrative data accurately identify IMV but not use of vasoactive drugs or acute RRT.

Traditional risk factors may not explain increased incidence of myocardial infarction in MS.

OBJECTIVE: To compare the risk of incident acute myocardial infarction (AMI) in the multiple sclerosis (MS) population and a matched population without MS, controlling for traditional vascular risk factors. METHODS: We conducted a retrospective matched cohort study using population-based administrative (health claims) data in 2 Canadian provinces, British Columbia and Manitoba. We identified incident MS cases using a validated case definition. For each case, we identified up to 5 controls without MS matched on age, sex, and region. We compared the incidence of AMI between cohorts using incidence rate ratios (IRR). We used Cox proportional hazards regression to compare the hazard of AMI between cohorts adjusting for sociodemographic factors, diabetes, hypertension, and hyperlipidemia. We pooled the provincial findings using meta-analysis. RESULTS: We identified 14,565 persons with MS and 72,825 matched controls. The crude incidence of AMI per 100,000 population was 146.2 (95% confidence interval [CI] 129.0-163.5) in the MS population and 128.8 (95% CI 121.8-135.8) in the matched population. After age standardization, the incidence of AMI was higher in the MS population than in the matched population (IRR 1.18; 95% CI 1.03-1.36). After adjustment, the hazard of AMI was 60% higher in the MS population than in the matched population (hazard ratio 1.63; 95% CI 1.43-1.87). CONCLUSION: The risk of AMI is elevated in MS, and this risk may not be accounted for by traditional vascular risk factors.

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.

Adherence with epinephrine autoinjector prescriptions in primary care.

BACKGROUND: The aim of this study was to estimate primary adherence for epinephrine autoinjector (EA) prescriptions in primary care practices in Manitoba, Canada. METHODS: A retrospective analysis of electronic medical record and administrative data was performed to determine primary adherence, defined as dispensation of a new EA prescription within 90 days of the date the prescription was written. Multivariable logistic regression models were used to test predictors of filling an EA prescription. RESULTS: Of 1212 EA prescriptions written between 2012 and 2014, only 69.9% (N = 847) were filled. An increased number of prescriptions for non-EA mediations was associated with an increased odds ratio of not filling an EA prescription. INTERPRETATION: This is the first study in Canada to examine adherence for EA prescriptions. The non-adherence rate identified is higher than rates previously reported in the literature, and indicates that many EA prescriptions for adults seen in primary care may never be filled. It also suggests that prescriptions of EAs for all patients at risk of anaphylaxis in community settings should consistently be accompanied by concise information about the importance of having the EA prescription filled and having the EA readily available.

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.