How Would We Know Whether Joint Replacements Are Successful if We Do Not Ask Patients?

Joint replacements are among the most effective and most frequently performed surgeries in Canada. Patient-reported outcome measures (PROMs) are measurement instruments completed by patients about aspects of their health status, including pain and function. PROMs data from three provinces show that approximately nine in 10 patients report higher PROM scores after joint replacement surgery. These data can help identify factors that lead to better care and opportunities to further understand what contributes to a patient's perception of surgical success. Expanding the collection of PROMs to more patients and more provinces is needed to help healthcare planners and clinicians understand these important outcomes.

How do Patient-reported Outcome Scores in International Hip and Knee Arthroplasty Registries Compare?

BACKGROUND: Patient-reported outcome measures (PROMs) are the only systematic approach through which the patient's perspective can be considered by surgeons (in determining a procedure's efficacy or appropriateness) or healthcare systems (in the context of value-based healthcare). PROMs in registries enable international comparison of patient-centered outcomes after total joint arthroplasty, but the extent to which those scores may vary between different registry populations has not been clearly defined. QUESTIONS/PURPOSES: (1) To what degree do mean change in general and joint-specific PROM scores vary across arthroplasty registries, and to what degree is the proportion of missing PROM scores in an individual registry associated with differences in the mean reported change scores? (2) Do PROM scores vary with patient BMI across registries? (3) Are comorbidity levels comparable across registries, and are they associated with differences in PROM scores? METHODS: Thirteen national, regional, or institutional registries from nine countries reported aggregate PROM scores for patients who had completed PROMs preoperatively and 6 and/or 12 months postoperatively. The requested aggregate PROM scores were the EuroQol-5 Dimension Questionnaire (EQ-5D) index values, on which score 1 reflects "full health" and 0 reflects "as bad as death." Joint-specific PROMs were the Oxford Knee Score (OKS) and the Oxford Hip Score (OHS), with total scores ranging from 0 to 48 (worst-best), and the Hip Disability and Osteoarthritis Outcome Score-Physical Function shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score-Physical Function shortform (KOOS-PS) values, scored 0 to 100 (worst-best). Eligible patients underwent primary unilateral THA or TKA for osteoarthritis between 2016 and 2019. Registries were asked to exclude patients with subsequent revisions within their PROM collection period. Raw aggregated PROM scores and scores adjusted for age, gender, and baseline values were inspected descriptively. Across all registries and PROMs, the reported percentage of missing PROM data varied from 9% (119 of 1354) to 97% (5305 of 5445). We therefore graphically explored whether PROM scores were associated with the level of data completeness. For each PROM cohort, chi-square tests were performed for BMI distributions across registries and 12 predefined PROM strata (men versus women; age 20 to 64 years, 65 to 74 years, and older than 75 years; and high or low preoperative PROM scores). Comorbidity distributions were evaluated descriptively by comparing proportions with American Society of Anesthesiologists (ASA) physical status classification of 3 or higher across registries for each PROM cohort. RESULTS: The mean improvement in EQ-5D index values (10 registries) ranged from 0.16 to 0.33 for hip registries and 0.12 to 0.25 for knee registries. The mean improvement in the OHS (seven registries) ranged from 18 to 24, and for the HOOS-PS (three registries) it ranged from 29 to 35. The mean improvement in the OKS (six registries) ranged from 15 to 20, and for the KOOS-PS (four registries) it ranged from 19 to 23. For all PROMs, variation was smaller when adjusting the scores for differences in age, gender, and baseline values. After we compared the registries, there did not seem to be any association between the level of missing PROM data and the mean change in PROM scores. The proportions of patients with BMI 30 kg/m 2 or higher ranged from 16% to 43% (11 hip registries) and from 35% to 62% (10 knee registries). Distributions of patients across six BMI categories differed across hip and knee registries. Further, for all PROMs, distributions also differed across 12 predefined PROM strata. For the EQ-5D, patients in the younger age groups (20 to 64 years and 65 to 74 years) had higher proportions of BMI measurements greater than 30 kg/m 2 than older patients, and patients with the lowest baseline scores had higher proportions of BMI measurements more than 30 kg/m 2 compared with patients with higher baseline scores. These associations were similar for the OHS and OKS cohorts. The proportions of patients with ASA Class at least 3 ranged across registries from 6% to 35% (eight hip registries) and from 9% to 42% (nine knee registries). CONCLUSION: Improvements in PROM scores varied among international registries, which may be partially explained by differences in age, gender, and preoperative scores. Higher BMI tended to be associated with lower preoperative PROM scores across registries. Large variation in BMI and comorbidity distributions across registries suggest that future international studies should consider the effect of adjusting for these factors. Although we were not able to evaluate its effect specifically, missing PROM data is a recurring challenge for registries. Demonstrating generalizability of results and evaluating the degree of response bias is crucial in using registry-based PROMs data to evaluate differences in outcome. Comparability between registries in terms of specific PROMs collection, postoperative timepoints, and demographic factors to enable confounder adjustment is necessary to use comparison between registries to inform and improve arthroplasty care internationally. LEVEL OF EVIDENCE: Level III, therapeutic study.

Increasing Rates of Kidney Failure Care in Canada Strains Demand for Kidney Donors.

The number of patients with kidney failure is on the rise in Canada, leading to a higher need for dialysis treatment and greater demand for kidney transplants, which have superior patient outcomes and lower healthcare system costs than dialysis treatments. This study examines the incidence and prevalence of kidney failure and renal replacement therapies between 2005 and 2014. The number of patients on dialysis has increased by 31% over this decade. The number of annual kidney transplants performed has also increased along with the waiting list for a kidney transplant, resulting in a persistent 2.5 times gap between patients on a waiting list for a kidney and the number of kidney transplants performed. New programs to increase organ donation to kidney failure patients have led to improvements, but have not been able to close this gap. Continued innovations are needed to preserve kidney function for patients with chronic kidney disease and to promote and increase donation rates in Canada to improve the quality of life and survival of thousands of patients, as well as save hundreds of millions of dollars to healthcare systems in Canada.

Sex differences in autism screening: An examination of the Childhood Autism Spectrum Test-Hebrew version.

LAY ABSTRACT: Autism is a neurodevelopmental condition, characterized by social communication alterations and restricted, repetitive behaviors. Typically diagnosed in early childhood, screening and diagnosis at a later age can be challenging, particularly in girls who exhibit a wider range of behaviors and characteristics. Our study set out to examine the effectiveness of the Hebrew translation of the Childhood Autism Spectrum Test, a parent report questionnaire, in identifying these diverse characteristics of autism within an Israeli sample of boys and girls. We examined parent reports on 403 (211 autistic, 192 non-autistic) children, aged 4-12 years. Results revealed the Childhood Autism Spectrum Test-Hebrew version was a valuable tool in differentiating between autistic and typically developing children, correctly identifying 93% of children with autism and 82% of typically developing children. In addition, specific items of the Childhood Autism Spectrum Test-Hebrew version were particularly useful in differentiating between autistic and non-autistic boys and autistic and non-autistic girls. Using these items, in addition to the overall score of the questionnaire, increased the correct identification of children as autistic or typically developing, especially in girls. The Childhood Autism Spectrum Test-Hebrew version test results corresponded well with the Autism Diagnostic Interview-Revised, which relies on parental input, but not with the clinician-administered Autism Diagnostic Observation Schedule-2. Our findings highlight the potential benefits of gender-specific tools to better support correct identification of autism in boys and in girls. More research is recommended to further explore these gender differences and to validate our findings with a larger, diverse group.

Assessing primary healthcare using pan- Canadian indicators of health and health system performance.

Updated primary healthcare (PHC) indicators are now available for use across Canada. The Canadian Institute for Health Information identified and updated two sets of priority indicators - a policy set to meet the needs of policy makers and a provider set to meet the needs of providers of PHC at the practice and organization levels. A total of 51 indicator definitions were updated to ensure that they are measurable and operational, align with clinical practice guidelines and available data sources and reflect important dimensions of PHC performance in Canada.

The Autism-Spectrum Quotient-Hebrew version: Psychometric properties of a full and a short form, adapted for DSM-5.

LAY ABSTRACT: Despite the attempt to diagnose autism at an early age, there are still many individuals who would only get an autism diagnosis in adulthood. For these adults, a questionnaire that could assist in highlighting their need to seek diagnostic assessment is needed. The Autism-Spectrum Quotient is a self-report scale used to assess autistic traits. It was tested cross-culturally, and a short version was recommended to help identify adults who should be referred for an autism assessment. However, its relevance for the up-to-date diagnostic criteria, according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), has not been tested. This study aimed to examine the psychometric properties of the Hebrew version of the Autism-Spectrum Quotient and to create a short version of the Hebrew Autism-Spectrum Quotient, based on items which map on to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. Ninety-three autistic adults (24 females), aged 18-51, clinically diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.), and 147 comparable controls (34 females) filled out the Hebrew version of the Autism-Spectrum Quotient. Ten clinicians who specialize in diagnosing autism in adults classified the Autism-Spectrum Quotient's items according to Diagnostic and Statistical Manual of Mental Disorders (5th ed.) criteria. The short version of the Hebrew Autism-Spectrum Quotient comprised items that best differentiated between adults with and without autism, five items representing each of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) diagnostic domains. The overall probability for participants to be correctly classified as autistic or neurotypical was 86% for the Hebrew version of the Autism-Spectrum Quotient and 88% for the short version of the Hebrew Autism-Spectrum Quotient. We conclude that both versions are reliable and sensitive instruments that can help referring adults for autism assessment.

The impact of polypharmacy on the health of Canadian seniors.

BACKGROUND: Prescription medication use increases with age. Seniors face an increased risk of adverse drug reactions from medications, partly because the kidneys and liver can lose functional ability with increasing age, resulting in the need for changes in dosage. OBJECTIVE: To use population survey data to understand the extent and impact of multiple medication use and adverse drug events among Canadian seniors. METHODS: This study consists of analysis of data from the Canadian Survey of Experiences with Primary Health Care, which was conducted through telephone by Statistics Canada in 2008. These analyses focussed on the 3132 respondents who were ≥ 65 years of age. RESULTS: Twenty-seven per cent of seniors reported taking five or more medications on a regular basis. Within the past year, 12% of seniors taking five or more medications experienced a side effect that required medical attention compared with 5% of seniors taking only one or two medications. Even when controlling for age and number of chronic conditions, the number of prescription medications was associated with the rate of emergency department use. Less than half of all seniors reported having received medication reviews and having the possible side effects of their prescription medications explained to them by their physician. CONCLUSIONS: Many Canadian seniors have an elevated risk of adverse events due to taking a high number of prescription medications and not having the potential side effects and drug interactions explained to them. There are interventions that can potentially reduce polypharmacy and adverse events, including routine medication reviews.

Opportunities to improve diabetes prevention and care in Canada.

The prevalence of diabetes in Canada is expected to more than double by 2030. Additionally, the costs associated with diabetes have nearly doubled between 2000 and 2010 and will continue to rise unless improvements are made. Fortunately, more effective policies and programs can reduce both the prevalence of diabetes and the complications associated with the disease. We used responses from the Canadian Community Health Survey to assess whether Canadians with diabetes report (1) receiving from healthcare professionals the recommended tests to screen for complications, (2) performing sufficient self-care for their diabetes and, (3) for those in lower-income households, receiving less recommended care. The results show that only one in three (32%) Canadian adults with diabetes reported having received all four recommended tests during the previous year. Lower-income Canadians were more likely to report having diabetes and less likely to report receiving the four diabetes care tests. Only half of adults with diabetes reported checking their blood sugar levels daily, and only two in five reported checking their feet for injuries and ulcers. Improvements to adherence to diabetes care guidelines are needed to reduce the likelihood that Canadians, especially lower-income Canadians, will develop complications from diabetes. Bending the cost curve downward is possible through more effective policies and programs that prevent diabetes in the first place and that ensure Canadians with diabetes get both recommended care from their healthcare providers and enough support for effective self-care.

Chronic conditions more than age drive health system use in Canadian seniors.

Which has more impact on health status and the use of healthcare services among seniors: age or the number of chronic conditions? To answer this question, we used responses from the 2008 Canadian Survey of Experiences with Primary Health Care to assess the effect of these two factors on seniors' self-perceived health status, prescription medication use and healthcare service use. We discovered that seniors with at least three chronic conditions were more likely to report poor health, take more prescription medications and use more healthcare services than seniors with two or fewer chronic conditions. The number of chronic conditions is better than age as a predictor of self-reported health status, prescription medication use and healthcare service use by seniors. Seniors with at least three conditions represented 24% of all seniors, but they accounted for 40% of the use of healthcare services. Health policies and programs focused on the prevention and improved management of co-morbidities among seniors could have a significant and positive impact on seniors' health (including self-perceived health status) and their use of healthcare services.

Advancing PROMs for health system use in Canada and beyond.

PROMs are essential to delivering patient-centred health care, and when applied routinely they can enhance communication between patients and providers, inform decisions for value-based health system improvements and improve overall patient care experiences and outcomes. The use of patient-reported outcome measures (PROMs) across Canada varies across provinces and territories, partly because of differences in health care delivery models across these jurisdictions. A national program that coordinates uses of PROMs is needed to ensure that this information is comparable across jurisdictions. This commentary provides a summary look at the development of national PROMs data standards and reporting for hip and knee replacement surgery, including the selection of survey tools, building consensus, developing and promoting standards, and reporting on the results nationally and internationally as well as outlining recent learnings from regional implementation of data standards. In 2017, the Canadian Institute for Health Information published national PROMs data collection standards for hip and knee arthroplasty that included guidelines for survey time points, the minimum data set and PROMs instruments. This broad-scale PROMs collection initiative had stakeholder engagement and support from multiple levels within the health system, including administrators, clinic managers, patients, and health system decision-makers. Learnings from regional implementation of the standards demonstrated the importance of assessing existing infrastructure and information technology requirements, mapping clinical workflows, planning for human and information technology resources, navigating local legislation and hospital policies and ensuring data linkage capabilities. This initiative showed the need for a common regional approach for PROMs collection to be efficient and effective. The learnings from implementation of the national Canadian PROMs program for hip and knee arthroplasty can be used as an example for other jurisdictions and clinical areas such as renal care and mental health. Common data standards allow for secondary use of this data that is valuable for reporting and informing policy and guidelines as well as meeting care delivery goals to further the shift in health care systems becoming more patient-centred to improve the quality-of-life of patients.

Hospitalizations in Dialysis Patients in Canada: A National Cohort Study.

BACKGROUND: Hospitalizations of chronic dialysis patients have not been previously studied at a national level in Canada. Understanding the scope and variables associated with hospitalizations will inform measures for improvement. OBJECTIVE: To describe the risk of all-cause and infection-related hospitalizations in patients on dialysis. DESIGN: Retrospective cohort study using health care administrative databases. SETTING: Provinces and territories across Canada (excluding Manitoba and Quebec). PATIENTS: Incident chronic dialysis patients with a dialysis start date between January 1, 2005, and March 31, 2014. Patients with a prior history of kidney transplantation were excluded. MEASUREMENTS: Patient characteristics were recorded at baseline. Dialysis modality was treated as a time-varying covariate. The primary outcomes of interest were all-cause and dialysis-specific infection-related hospitalizations. METHODS: Crude rates for all-cause hospitalization and infection-related hospitalization were determined per patient year (PPY) at 7 and 30 days, and at 3, 6, and 12 months postdialysis initiation. A stratified, gamma-distributed frailty model was used to assess repeat hospital admissions and to determine the inter-recurrence dependence of hospitalizations within individuals, as well as the hazard ratio (HR) attributed to each covariate of interest. RESULTS: A total of 38 369 incident chronic dialysis patients were included: 38 088 adults and 281 pediatric patients (age less than 18 years). There were 112 374 hospitalizations, of which 11.5% were infection-related hospitalizations. The all-cause hospitalization rate was similar for all adult age groups (age 65 years and older: 1.40, 1.35, and 1.18 admissions PPY at 7 days, 30 days, and 6 months, respectively). The all-cause hospitalization rate was higher for pediatric patients (1.67, 2.48, and 2.47 admissions PPY at 7 days, 30 days, and 6 months, respectively; adjusted HR: 2.73, 95% confidence interval [CI]: 2.37-3.15, referent age group: 45-64 years). Within the first 7 days after dialysis initiation, patients on peritoneal dialysis had a higher risk of all-cause hospitalization (HR: 1.27, 95% CI: 1.07-1.50) and infection-related hospitalization (HR: 2.05, 95% CI: 1.19-3.55) compared with patients on hemodialysis. Beyond 7 days, the risk did not differ significantly by dialysis modality. Female sex and Indigenous race were significant risk factors for all-cause hospitalization. LIMITATIONS: The cohort had too few home hemodialysis patients to examine this subgroup. The outcome of infection-related hospitalization was determined using diagnostic codes. Dialysis patients from Manitoba and Quebec were not included. CONCLUSIONS: In Canada, the rates of hospitalization were not influenced by dialysis modality beyond the initial 7-day period following dialysis initiation; however, the rate of hospitalization in pediatric patients was higher than in adults at every time frame examined.

CONTEXTE: Le taux d'hospitalisation des patients dialysés n'avait jamais fait l'objet d'une étude pancanadienne. Une connaissance approfondie de la portée et des variables associées aux hospitalisations orientera les mesures d'amélioration. OBJECTIF DE L'ÉTUDE: L'étude visait à mieux évaluer les risques d'hospitalisations des patients dialysés; toutes causes confondues ou liées spécifiquement à une infection. TYPE D'ÉTUDE: Il s'agit d'une étude de cohorte rétrospective fondée sur des bases de données administratives en santé. CADRE DE L'ÉTUDE: L'étude couvrait les provinces et territoires du Canada à l'exception du Québec et du Manitoba. PATIENTS: L'étude a porté sur tous les patients dialysés à vie dont le traitement avait commencé entre le 1er janvier 2005 et le 31 mars 2014. Les patients ayant reçu une greffe rénale ont été exclus. MESURES: Les caractéristiques initiales des patients ont été consignées, et la modalité de dialyse a été traitée comme une co-variable sujette à changement dans le temps. La principale issue d'intérêt était une hospitalisation due à une infection directement liée à la dialyse, ou une hospitalisation toutes causes confondues. MÉTHODOLOGIE: Les taux bruts d'hospitalisations toutes causes confondues (global) et d'hospitalisations liées à une infection ont été calculés en années-patients (HAP) à différents moments suivant le début de la dialyse (7 jours, 30 jours, 3 mois, 6 mois et 12 mois). Un modèle stratifié de fragilité à distribution gamma a été employé pour i) répertorier les hospitalisations répétées; ii) déterminer l'interrécurrence et le lien de dépendance entre les hospitalisations pour chaque patient; et iii) établir le rapport de risque (RR) attribué à chaque covariable d'intérêt. RÉSULTATS: En tout, 38 369 patients dialysés, soit 38 088 adultes et 281 patients mineurs (moins de 18 ans) ont été inclus dans l'étude. Au cours de la période étudiée, on a répertorié 112 374 hospitalisations, dont 11,5 % étaient dues à une infection en lien direct avec la dialyse. Le taux d'hospitalisations global était similaire pour tous les groupes d'âge chez les patients adultes. Par exemple, chez les patients âgés de 65 ans et plus, ce taux se situait respectivement à 1,40 HAP, à 1,35 HAP et à 1,18 HAP lorsque calculé 7 jours, 30 jours et 6 mois après l'initiation de la dialyse. Lorsque comparé au groupe des 45-64 ans, le taux d'hospitalisations global s'est avéré plus élevé chez les patients pédiatriques (1,67 HAP à 7 jours, 2,48 HAP à 30 jours et 2,47 HAP à 6 mois) post-initiation de la dialyse (RR: 2,73; IC 95 %: 2,37-3,15). Dans les 7 jours suivant l'initiation du traitement, les patients traités par dialyse péritonéale présentaient un risque plus élevé d'hospitalisation toutes causes confondues (RR: 1,27; IC 95 %: 1,07-1,50) ou d'hospitalisation liée à une infection (RR: 2,05; IC 95 %: 1,19-3,55) que les patients hémodialysés. Par contre, cet écart entre les modalités de dialyse n'était plus observable au-delà des sept premiers jours. Enfin, le fait d'être autochtone ou de sexe féminin s'avérait un facteur de risque d'hospitalisation significatif (toutes causes confondues). LIMITES DE L'ÉTUDE: Plusieurs facteurs limitent la portée des résultats: i) la cohorte comptait trop peu de patients hémodialysés à domicile pour permettre une analyse de ce sous-groupe; ii) les hospitalisations relatives à une infection ont été établies à l'aide de codes diagnostiques; et iii) les patients dialysés résidant au Québec et au Manitoba étaient exclus de l'étude. CONCLUSION: Au Canada, au-delà des sept jours suivant l'initiation de la dialyse, la modalité employée n'a plus d'influence sur les taux d'hospitalisations. Cependant, à tous les moments post-initiation mesurés, les taux d'hospitalisations se sont avérés plus élevés chez les patients pédiatriques que chez les adultes.

The role of CYP2A and CYP2E1 in the metabolism of 3-methylindole in primary cultured porcine hepatocytes.

The accumulation of 3-methylindole (3MI) in uncastrated male pigs (boars) is a major cause of boar taint, which negatively affects the quality of meat from the animal. Previously, CYP2E1 and CYP2A have been identified as cytochrome P450 (P450) isoforms involved in the metabolism of 3MI using porcine liver microsomes. This study further examines the role of these isoforms in the metabolism of 3MI using a primary porcine hepatocyte model by examining metabolic profiles of 3MI after incubation with P450 inhibitors. Incubation of hepatocytes with 4-methylpyrazole resulted in a selective inhibition of CYP2E1 activity as determined by p-nitrophenol hydroxylase activity and an associated significant decrease in the production of the 3MI metabolites 3-hydroxy-3-methyloxindole and 3-methyloxindole. Furthermore, inhibition of CYP2A, as assayed by coumarin 7-hydroxylase activity, using 8-methoxypsoralen and diethyldithiocarbamate was not associated with any further significant inhibition of the production of 3MI metabolites. Treatment with general P450 inhibitors resulted in further decreases in CYP2E1 activity and a more dramatic decrease in the production of 3MI metabolites, suggesting that additional P450s may be involved in the phase 1 metabolism of 3-methylindole. In conclusion, CYP2E1 activity levels are more important than CYP2A activity levels for the metabolism of 3-methylindole in isolated pig hepatocytes.