Association of Kidney Function With Major Postoperative Events After Noncardiac Ambulatory Surgeries: A Population-Based Cohort Study.

OBJECTIVE: The aim of this study was to estimate the association between estimated glomerular filtration rate (eGFR) and acute myocardial infarction (AMI) or death after ambulatory noncardiac surgery. SUMMARY BACKGROUND DATA: People with chronic kidney disease (CKD) commonly undergo surgical procedures. Although most are performed in an ambulatory setting, the risk of major perioperative outcomes after ambulatory surgery for people with CKD is unknown. METHODS: In this retrospective population-based cohort study using administrative health data from Alberta, Canada, we included adults with measured preoperative kidney function undergoing ambulatory noncardiac surgery between April 1, 2005 and February 28, 2017. Participants were categorized into 6 eGFR categories (in mL/min/1.73m 2 )of ≥60 (G1-2), 45 to 59 (G3a), 30 to 44 (G3b), 15 to 29 (G4), <15 not receiving dialysis (G5ND), and those receiving chronic dialysis (G5D). The odds of AMI or death within 30 days of surgery were estimated using multivariable generalized estimating equation models. RESULTS: We identified 543,160 procedures in 323,521 people with a median age of 66 years (IQR 56-76); 52% were female. Overall, 2338 people (0.7%) died or had an AMI within 30 days of surgery. Compared with the G1-2 category, the adjusted odds ratio of death or AMI increased from 1.1 (95% confidence interval: 1.0-1.3) for G3a to 3.1 (2.6-3.6) for G5D. Emergency Department and Urgent Care Center visits within 30 days were frequent (17%), though similar across eGFR categories. CONCLUSIONS: Ambulatory surgery was associated with a low risk of major postoperative events. This risk was higher for people with CKD, which may inform their perioperative shared decision-making and management.

20-year trends in multimorbidity by race/ethnicity among hospitalized patient populations in the United States.

BACKGROUND: The challenges presented by multimorbidity continue to rise in the United States. Little is known about how the relative contribution of individual chronic conditions to multimorbidity has changed over time, and how this varies by race/ethnicity. The objective of this study was to describe trends in multimorbidity by race/ethnicity, as well as to determine the differential contribution of individual chronic conditions to multimorbidity in hospitalized populations over a 20-year period within the United States. METHODS: This is a serial cross-sectional study using the Nationwide Inpatient Sample (NIS) from 1993 to 2012. We identified all hospitalized patients aged ≥ 18 years old with available data on race/ethnicity. Multimorbidity was defined as the presence of 3 or more conditions based on the Elixhauser comorbidity index. The relative change in the proportion of hospitalized patients with multimorbidity, overall and by race/ethnicity (Black, White, Hispanic, Asian/Pacific Islander, Native American) were tabulated and presented graphically. Population attributable fractions were estimated from modified Poisson regression models adjusted for sex, age, and insurance type. These fractions were used to describe the relative contribution of individual chronic conditions to multimorbidity over time and across racial/ethnic groups. RESULTS: There were 123,613,970 hospitalizations captured within the NIS between 1993 and 2012. The prevalence of multimorbidity increased in all race/ethnic groups over the 20-year period, most notably among White, Black, and Native American populations (+ 29.4%, + 29.7%, and + 32.0%, respectively). In both 1993 and 2012, Black hospitalized patients had a higher prevalence of multimorbidity (25.1% and 54.8%, respectively) compared to all other race/ethnic groups. Native American populations exhibited the largest overall increase in multimorbidity (+ 32.0%). Furthermore, the contribution of metabolic diseases to multimorbidity increased, particularly among Hispanic patients who had the highest population attributable fraction values for diabetes without complications (15.0%), diabetes with complications (5.1%), and obesity (5.8%). CONCLUSIONS: From 1993 to 2012, the secular increases in the prevalence of multimorbidity as well as changes in the differential contribution of individual chronic conditions has varied substantially by race/ethnicity. These findings further elucidate the racial/ethnic gaps prevalent in multimorbidity within the United States. PRIOR PRESENTATIONS: Preliminary finding of this study were presented at the Society of General Internal Medicine (SGIM) Annual Conference, Washington, DC, April 21, 2017.

10-Year Trends in Healthcare Spending among Patients with Schizophrenia in Alberta, Canada.

OBJECTIVES: Schizophrenia is characterized by high levels of disability often resulting in increased healthcare utilization and spending. With expanding healthcare costs across all healthcare sectors, there is a need to understand how healthcare spending has changed over time. We conducted a population-based study using administrative health data from Alberta, Canada, to describe changes in medical complexity and direct healthcare spending among patients with schizophrenia over a 10-year period. METHODS: A serial cross-sectional study from January 1, 2008, to December 31, 2017, was conducted to determine changes in demographic characteristics, medical complexity, and costs among all adults (18 years or older) with schizophrenia. Total healthcare spending and sector-specific costs attributable to hospitalizations, emergency department visits, practitioner billings, and prescriptions were calculated and compared over time. RESULTS: Over the 10-year period the contact prevalence of patients with schizophrenia increased from 0.6% (n = 16,183) to 1.0% (n = 33,176) within the province. There was a marked change in medical complexity with the number of patients living with 3 or more comorbidities increasing from 33.0% to 47.3%. Direct annual healthcare costs increased 2-fold from 321 to 639 million CAD (493 million USD) with a 7-fold increase in medication expenditures over the 10-year time frame. As of 2017, spending on pharmaceutical treatment surpassed hospitalizations as the leading spending category in this population. CONCLUSIONS: Healthcare spending among patients with schizophrenia continues to increase and may be partially attributable to growing rates of multimorbidity within this population. Although promising second-generation antipsychotic medications have entered the market, this has resulted in considerable changes in the distribution of healthcare spending over time. These findings will inform policy discussions around resource allocation and efforts to curb health spending while also improving care for patients with schizophrenia.

Mortality and cardiovascular events in adults with kidney failure after major non-cardiac surgery: a population-based cohort study.

BACKGROUND: People with kidney failure have a high incidence of major surgery, though the risk of perioperative outcomes at a population-level is unknown. Our objective was to estimate the proportion of people with kidney failure that experience acute myocardial infarction (AMI) or death within 30 days of major non-cardiac surgery, based on surgery type. METHODS: In this retrospective population-based cohort study, we used administrative health data to identify adults from Alberta, Canada with major surgery between April 12,005 and February 282,017 that had preoperative estimated glomerular filtration rates (eGFRs) < 15 mL/min/1.73m2 or received chronic dialysis. The index surgical procedure for each participant was categorized within one of fourteen surgical groupings based on Canadian Classification of Health Interventions (CCI) codes applied to hospitalization administrative datasets. We estimated the proportion of people that had AMI or died within 30 days of the index surgical procedure (with 95% confidence intervals [CIs]) following logistic regression, stratified by surgery type. RESULTS: Overall, 3398 people had a major surgery (1905 hemodialysis; 590 peritoneal dialysis; 903 non-dialysis). Participants were more likely male (61.0%) with a median age of 61.5 years (IQR 50.0-72.7). Within 30 days of surgery, 272 people (8.0%) had an AMI or died. The probability was lowest following ophthalmologic surgery at 1.9% (95%CI: 0.5, 7.3) and kidney transplantation at 2.1% (95%CI: 1.3, 3.2). Several types of surgery were associated with greater than one in ten risk of AMI or death, including retroperitoneal (10.0% [95%CI: 2.5, 32.4]), intra-abdominal (11.7% [8.7, 15.5]), skin and soft tissue (12.1% [7.4, 19.1]), musculoskeletal (MSK) (12.3% [9.9, 15.5]), vascular (12.6% [10.2, 15.4]), anorectal (14.7% [6.3, 30.8]), and neurosurgical procedures (38.1% [20.3, 59.8]). Urgent or emergent procedures had the highest risk, with 12.1% experiencing AMI or death (95%CI: 10.7, 13.6) compared with 2.6% (1.9, 3.5) following elective surgery. CONCLUSIONS: After major non-cardiac surgery, the risk of death or AMI for people with kidney failure varies significantly based on surgery type. This study informs our understanding of surgery type and risk for people with kidney failure. Future research should focus on identifying high risk patients and strategies to reduce these risks.

Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends.

INTRODUCTION: Severe maternal morbidity and mortality have increased in the USA in recent years. This trend has not been consistent across all racial groups. The reasons behind this, and the relation between preexisting conditions, pregnancy-associated disease and severe maternal morbidity/mortality, have not been fully explored. MATERIAL AND METHODS: Annual data on delivery hospitalizations between 1993 and 2012 were obtained from the Nationwide Inpatient Sample (NIS), representing a 20% sample of hospital discharges from across the USA. Chi-square tests for trend were used to examine temporal patterns in the proportion of pregnancies affected by comorbidities as defined by the Obstetric Comorbidity Score and were stratified by maternal race. Logistic regression was used to determine the impact of temporal increases in comorbidity on severe maternal morbidity/mortality. RESULTS: In 1993, 34.3% of pregnancies had a comorbidity score of ≥1; this significantly increased to 44.1% by 2012 (p < 0.001). Baseline differences were observed between all races (Whites 33.7%, Blacks 34.5%, Hispanics 28.0%, Asian/Pacific Islanders 28.1%). Although significant increases were observed for all races, the relative rate of change was lowest for Whites (26.1% increase) and highest for Asian/Pacific Islanders (49.1% increase). The odds of severe maternal morbidity/mortality have steadily increased over time; however, adjustment for Obstetric Comorbidity Score significantly attenuates this correlation. CONCLUSION: The rate of both preexisting comorbidities and pregnancy-associated disease is increasing in pregnant women in the USA and varies substantially by race. These trends provide valuable insight into the increasing complexity of pregnancy in the USA and explain a proportion of the observed increase in severe maternal morbidity/mortality.

A Clinical Risk Prediction Tool for 6-Month Mortality After Dialysis Initiation Among Older Adults.

BACKGROUND: Information on an individual's risk for death following dialysis therapy initiation may inform the decision to initiate maintenance dialysis for older adults. We derived and validated a clinical risk prediction tool for all-cause mortality among older adults during the first 6 months of maintenance dialysis treatment. STUDY DESIGN: Prediction model using retrospective administrative and clinical data. SETTING & PARTICIPANTS: We linked administrative and clinical data to define a cohort of 2,199 older adults (age ≥ 65 years) in Alberta, Canada, who initiated maintenance dialysis therapy (excluding acute kidney injury) in May 2003 to March 2012. CANDIDATE PREDICTORS: Demographics, laboratory data, comorbid conditions, and measures of health system use. OUTCOMES: All-cause mortality within 6 months of dialysis therapy initiation. ANALYTICAL APPROACH: Predicted mortality by logistic regression with 10-fold cross-validation. RESULTS: 375 (17.1%) older adults died within 6 months. We developed a 19-point risk score for 6-month mortality that included age 80 years or older (2 points), glomerular filtration rate of 10 to 14.9mL/min/1.73m2 (1 point) or ≥15mL/min/1.73m2 (3 points), atrial fibrillation (2 points), lymphoma (5 points), congestive heart failure (2 points), hospitalization in the prior 6 months (2 points), and metastatic cancer (3 points). Model discrimination (C statistic = 0.72) and calibration (Hosmer-Lemeshow χ2=10.36; P=0.2) were reasonable. As examples, a score < 5 equated to <25% of individuals dying in 6 months, whereas a score > 12 predicted that more than half the individuals would die in the first 6 months. LIMITATIONS: The tool has not been externally validated; thus, generalizability cannot be assessed. CONCLUSIONS: We used readily available clinical information to derive and internally validate a 7-variable tool to predict early mortality among older adults after dialysis therapy initiation. Following successful external validation, the tool may be useful as a clinical decision tool to aid decision making for older adults with kidney failure.

Validity of administrative data for identification of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a common condition associated with significant morbidity and health-care utilization. We determined the validity of an algorithm derived from administrative data for identifying OSA using the respiratory disturbance index (RDI) as the reference standard. We conducted a retrospective cohort study of adults in Alberta, Canada referred for facility and community-based sleep diagnostic testing between July 2005 and August 2007. Validity indices were estimated for several case definitions of OSA derived from outpatient physician billing claims and hospital discharge codes. For each algorithm, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated against several reference standards for OSA (RDI ≥ 5 h-1 , RDI ≥ 15 h-1 or RDI ≥ 30 h-1 ). For the 2149 patients included in the study, an algorithm requiring one hospital discharge code or two outpatient billing claims identifying OSA in a 2-year period had a sensitivity of 24.1%, specificity of 67.8%, PPV of 74.8% and NPV of 18.3% (reference standard RDI ≥ 5 h-1 ). When comorbidities were included in the case definition, the specificity was 90.5% and PPV was 83.3% (reference standard RDI ≥ 5 h-1 ). Similar findings were observed using RDI ≥ 15 h-1 and ≥30 h-1 as the reference standard. We identify a claims-based algorithm that identifies OSA with a high degree of specificity in patients referred for sleep diagnostic testing. This validated algorithm has a good PPV and may be useful when identifying patients with OSA for population studies within a single-payer health-care system.

Estimating the population-level impacts of improved uptake of SGLT2 inhibitors in patients with chronic kidney disease: a cross-sectional observational study using routinely collected Australian primary care data.

Background: Sodium glucose co-transporter 2 (SGLT2) inhibitors reduce the risk of kidney failure and death in patients with chronic kidney disease (CKD) but are underused. We evaluated the number of patients with CKD in Australia that would be eligible for treatment and estimated the number of cardiorenal and kidney failure events that could be averted with improved uptake of SGLT2 inhibitors. Methods: This cross-sectional observational study leveraged nationally representative primary care data from 392 Australian general practices (MedicineInsight) between 1 January 2020 and 31 December 2021. We identified patients that would have met inclusion criteria of key SGLT2 inhibitor trials and applied these data to age and sex-stratified estimates of CKD prevalence for the Australian population (using national census data), estimating the number of preventable events using trial event rates. Key outcomes included cardiorenal events (CKD progression, kidney failure, or death due to cardiovascular or kidney disease) and kidney failure. Findings: In MedicineInsight, 44.2% of adults with CKD would have met CKD eligibility criteria for an SGLT2 inhibitor; baseline use was 4.1%. Applying these data to the Australian population, 230,246 patients with CKD would have been eligible for treatment with an SGLT2 inhibitor. Optimal implementation of SGLT2 inhibitors (75% uptake) could reduce cardiorenal and kidney failure events annually in Australia by 3644 (95% CI 3526-3764) and 1312 (95% CI 1242-1385), respectively. Interpretation: Improved uptake of SGLT2 inhibitors for patients with CKD in Australia has the potential to prevent large numbers of patients experiencing CKD progression or dying due to cardiovascular or kidney disease. Identifying strategies to increase the uptake of SGLT2 inhibitors is critical to realising the population-level benefits of this drug class. Funding: University of New South Wales Scientia Program and Boehringer IngelheimEli Lilly Alliance.

The Prevalence of CKD in Australian Primary Care: Analysis of a National General Practice Dataset.

Introduction: The prevalence of chronic kidney disease (CKD) in Australia varies substantially across reports. Using a large, nationally representative general practice data source, we determined the contemporary prevalence and staging of CKD in the Australian primary care. Methods: We performed a retrospective, community-based observational study of 2,720,529 adults with ≥1 visit to a general practice participating in the MedicineInsight program and ≥1 serum creatinine measurement (with or without a urine albumin-to-creatinine ratio [UACR] measurement) between 2011 and 2020. CKD prevalence was estimated using 3 definitions based on estimated glomerular filtration rate (eGFR) and UACR measurements with varying degrees of rigidity in terms of the number of measurements assessed to define CKD ("least", "moderate" and "most" rigid). Results: CKD prevalence in the cohort progressively increased over the 10-year study period, irrespective of the method used to define CKD. In 2020, CKD prevalence in the cohort was 8.4%, 4.7%, and 3.1% using the least, moderate, and most rigid definition, respectively. The number of patients with UACR measurements was low such that, among those with CKD in 2020, only 3.8%, 3.2%, and 1.5%, respectively, had both eGFR and UACR measurements available in the corresponding year. Patients in whom both eGFR and UACR measurements were available mostly had moderate or high risk of CKD progression (83.6%, 80.6%, and 76.2%, respectively). Conclusion: In this large, nationally representative study, we observed an increasing trend in CKD prevalence in primary care settings in Australia. Most patients with CKD were at moderate to high risk of CKD progression. These findings highlight the need for early detection and effective management to slow progression of CKD.

Identifying Unique Subgroups of High-Cost Patients With Schizophrenia: A Population-Based Study Using Latent Class Analysis.

Schizophrenia does not present uniformly among patients and as a result this patient population is characterized by a diversity in the type and amount of healthcare supports needed for daily functioning. Despite this, little work has been completed to understand the heterogeneity that exists among these patients. In this work we used a data-driven approach to identify subgroups of high-cost patients with schizophrenia to identify potentially actionable interventions for the improvement of outcomes and to inform conversations on how to most efficiently allocate resources in an already strained system. Administrative health data was used to conduct a retrospective analysis of "high-cost" adult patients with schizophrenia residing in Alberta, Canada in 2017. Costs were derived from inpatient encounters, outpatient primary care and specialist encounters, emergency department encounters, and drug costs. Latent class analysis was used to group patients based on their unique clinical profiles. Latent class analysis of 1659 patients revealed the following patient groups: (1) young, high-needs males early in their disease course; (2) actively managed middle-aged patients; (3) elderly patients with multiple chronic conditions and polypharmacy; (4) unstably housed males with low treatment rates; (5) unstably housed females with high acute care use and low treatment rates. This taxonomy may be used to inform policy, including the identification of interventions most likely to improve care and reduce health spending for each subgroup.

Factors associated with high health care spending among patients with schizophrenia. / Facteurs associés aux dépenses élevées en soins de santé chez les patients atteints de schizophrénie.

INTRODUCTION: Understanding the reasons for the wide variation in health care spending among patients with schizophrenia may benefit the development of interventions aimed at improving patient outcomes and health care spending efficiency. The aim of our study was to determine factors associated with high health care spending in the patient population. METHODS: A serial cross-sectional study used the administrative health records of residents of Alberta, Canada between 1 January 2008 and 31 December 2017 and provincial costing methodologies to calculate total health care spending and sector-specific costs. Factors that modified the odds of being a high cost (i.e. 95th percentile or higher) patient with schizophrenia were estimated using generalized estimating equations. RESULTS: This study captured 242 818 person-years of observations among 38 177 unique patients with schizophrenia. Increased odds of being a high-cost patient were associated with younger age (18-29 years), male sex, unstable housing status and requiring care from multiple medical specialties. The strongest estimated associations between high cost status and comorbidity were for metastatic cancer (OR = 2.26) and cirrhosis (OR = 2.07). In contrast, polypharmacy was associated with a decreased odds of being high cost compared with untreated patients. CONCLUSION: Factors associated with being a high-cost patient are the result of complex interactions between individual, structural and treatment-related factors. Efforts to improve patient outcomes and address rising health care costs must consider the value of allocating resources towards early detection and support of patients with schizophrenia along with the prevention/management of comorbidity.

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.

Use of Google Analytics to Explore Dissemination Activities for an Online CKD Clinical Pathway: A Retrospective Study.

Background: Data on dissemination strategies that generate awareness of clinical pathways for kidney care are limited. Objective: This study reports the application of Google Analytics to describe the reach and use of the Chronic Kidney Disease Pathway (CKD-P) using a multi-faceted dissemination strategy. Design: The design of this study is a retrospective descriptive study. Setting: This study was conducted in Alberta, Canada. Patients: Individuals who accessed the CKD-P Web site between November 5, 2014, and May 31, 2019. Measurements: Dissemination activities included print, electronic, in-person meetings, and a laboratory prompt. We used Google Analytics over a 5-year period to evaluate the following CKD-P Web site user metrics: number of sessions, pageviews, visit duration, user path, and bounce rate (when an individual visits a single page of the Web site and leaves the Web site without interacting with additional pages). Methods: We plotted dissemination activities alongside Web site metrics using control charts and described the data using means and percentages. We performed chi-square test for trends to evaluate year-over-year usage. Results: There were 83 294 users, 90 805 sessions, and 231 684 pageviews. The overall bounce rate was 45.7%. Each user had an average of 1.5 sessions and a session duration of 2 minutes and 8 seconds. There was a significant positive trend for total annual users (P = .008), new users (P = .009), number of sessions (P = .006), and pageviews per day (P = .016). Limitations: We were unable to confirm if users were primary care providers and if word-of-mouth dissemination among providers/researchers drove people to use the CKD-P. Conclusions: Google Analytics was a useful and accessible tool for evaluating CKD-P reach and use trends. It was challenging to identify how individual dissemination activities contributed to CKD-P reach; however, repeated dissemination appeared to play a role in increasing CKD-P use. Trial registration: Not applicable-observational study design.

Contexte: Il existe peu de données sur les stratégies de diffusion pour sensibiliser les différents intervenants aux plans d'intervention en santé rénale. Objectif: Cette étude rend compte de l'utilization de Google Analytics pour décrire la portée et l'utilization d'un plan d'intervention en ligne pour l'insuffisance rénale chronique (CKD-P ­ Chronic Kidney Disease Pathway) à l'aide d'une stratégie de diffusion à plusieurs facettes. Conception de l'étude: Étude descriptive rétrospective. Cadre: Alberta, Canada. Sujets: Les individus ayant accédé au site Web CKD-P entre le 5 novembre 2014 et le 31 mai 2019. Mesures: Les activités de diffusion comprenaient des documents imprimés, des documents électroniques, des réunions en personne et un lien internet vers le site web de CKD-P lors de la transmission d'un résultat anormal de laboratoire. Nous avons utilisé Google Analytics pendant cinq ans pour évaluer les mesures suivantes pour les utilisateurs du site Web CKD-P: nombre de sessions, vues de page, durée des visites, chemin d'accès utilisateur et taux de rebond (lorsqu'une personne visite une seule page du site Web et le quitte sans interagir avec d'autres pages). Méthodologie: Les activités de diffusion et les paramètres du site Web sont présentés à l'aide de tableaux de contrôle, et les données à l'aide de moyennes et de pourcentages. Un test de Chi-Deux a servi à déterminer les tendances et évaluer l'utilization d'une année sur l'autre. Résultats: Nous avons répertorié 83 294 utilisateurs, 90 805 sessions et 231 684 pages consultées. Le taux de rebond global était de 45,7 %. En moyenne, chaque utilisateur comptait 1,5 session dont la durée moyenne était de 2 minutes 8 secondes. On a observé une tendance positive significative pour le nombre total annuel d'utilisateurs (P = 0,008), les nouveaux utilisateurs (P = 0,009), le nombre de sessions (P = 0,006) et les vues de pages par jour (P = 0,016). Limites: Il n'a pas été possible de confirmer si les utilisateurs étaient des fournisseurs de soins primaires et si la diffusion de bouche-à-oreille entre les fournisseurs/chercheurs avait amené les gens à utiliser CKD-P. Conclusion: Google Analytics s'est avéré un outil utile et accessible pour évaluer les tendances de portée et d'utilization de CKD-P. Il est difficile d'établir comment les activités de diffusion individuelles contribuent à la portée de CKD-P; la diffusion répétée semble néanmoins jouer un rôle dans l'augmentation de l'utilization de CKD-P. Enregistrement de l'essai: Sans objet ­ étude observationnelle.

Cost of Potentially Preventable Hospitalizations Among Adults With Chronic Kidney Disease: A Population-Based Cohort Study.

BACKGROUND: Prior studies report high hospitalization rates among patients with chronic kidney disease (CKD) and approximately 10% to 20.9% of hospitalizations are potentially preventable. OBJECTIVE: To determine the rate, proportion, and cost of potentially preventable hospitalizations and whether this varied by CKD category. DESIGN: Retrospective cohort study using population-based data. SETTING: Alberta, Canada. PATIENTS: All adults with an outpatient serum creatinine measurement between January 1 and December 31, 2017 in the Alberta Kidney Disease Network data repository. MEASUREMENTS: CKD risk categories were based on measures of proteinuria (where available), eGFR, and use of dialysis. Patients were linked to administrative data to capture frequency and cost of hospital encounters and followed until death or end of study (December 31, 2018). The outcomes of interest were the rate and cost of potentially preventable hospitalizations, as identified using the Canadian Institute for Health Information (CIHI)-defined ambulatory care sensitive condition (ACSC) algorithm and a CKD-related ACSC algorithm. METHODS: Unadjusted and adjusted rates per 1000-patient years, proportions, and cost attributable to preventable hospitalizations were identified for the cohort as a whole and for patients within each CKD risk category. RESULTS: Of the 1,110,895 adults with eGFR and proteinuria measurements, 181,422 had CKD. During a median follow-up of 1 year, there were 62,023 hospitalizations among patients with CKD resulting in a total cost of $946 million CAD; 6907 (11.1%) of these hospitalizations were for CIHI-defined ACSCs while 4323 (7.0%) were for CKD-related ACSCs. Adjusted rates of hospitalization for ACSCs increased with CKD risk category and were highest among patients treated with dialysis. Among CKD patients, the total cost of potentially preventable hospitalizations was $79 million and $58 million CAD for CIHI-defined and CKD-related ACSCs (8.4% and 6.2% of total hospitalization cost, respectively). LIMITATIONS: Based on the ACSC construct, we were unable to determine if these hospitalizations were truly preventable. CONCLUSIONS: Potentially preventable hospitalizations have a substantial cost and burden on the health care system among people with CKD. Effective strategies that reduce preventable admissions among CKD patients may lead to significant cost savings. TRIAL REGISTRATION: Not applicable-observational study design.

CONTEXTE: Des études antérieures font état de taux élevés d'hospitalization chez les patients atteints d'insuffisance rénale chronique (IRC). Environ 10% à 20,9 % de ces hospitalisations seraient évitables. OBJECTIFS: Établir l'incidence et la proportion des hospitalisations potentiellement évitables, de même que les coûts qui y sont attribuables, et vérifier si cela varie en fonction de la catégorie d'IRC. TYPE D'ÉTUDE: Étude de cohorte rétrospective menée à partir de données basées sur une population. CADRE: Alberta, Canada. SUJETS: Tous les adultes pour qui le référentiel de données du Alberta Kidney Disease Network disposait d'une mesure de créatinine sérique en consultation externe entre le 1er janvier et le 31 décembre 2017. MESURES: La mesure de protéinurie (lorsque disponible), le DFGe et la dialyze ont servi à établir les catégories de risque d'IRC. Les patients ont été couplés aux données administratives afin de saisir la fréquence des consultations à l'hôpital et le coût associé à celles-ci. Le suivi s'est poursuivi jusqu'au décès du patient ou jusqu'au 31 décembre 2018 (fin de l'étude). Les critères d'intérêt étaient l'incidence des hospitalisations évitables, de même que les coûts qui y sont attribuables; hospitalisations définies par l'algorithme de l'Institut canadien d'information sur la santé (ICIS) pour les conditions propices aux soins ambulatoires (CPSA) et par un algorithme des CPSA liées à l'IRC. MÉTHODOLOGIE: Les taux corrigés ou non pour 1000 années-patients et les proportions des hospitalisations évitables, de même que les coûts qui y sont attribuables, ont été déterminés pour l'ensemble de la cohorte et pour les patients de chaque catégorie de risque d'IRC. RÉSULTATS: Parmi les 1 110 895 adultes disposant de mesures de protéinurie et de DFGe, 181 422 étaient atteints d'IRC. Au cours d'un suivi médian d'un an, on a répertorié 62 023 hospitalisations de patients atteints d'IRC, ce qui représente un coût total de 946 millions de dollars canadiens. De ces hospitalisations, 6 907 (11,1 %) concernaient des CPSA définies par l'ICIS et 4 323 (7,0 %) concernaient des CPSA liées à l'IRC. Les taux corrigés d'hospitalization pour les CPSA augmentaient selon la catégorie de risque d'IRC et étaient plus élevés chez les patients dialysés. Chez les patients atteints d'IRC, le coût total des hospitalisations évitables s'établissait à 79 millions de dollars pour les CPSA définies par l'ICIS et à 58 millions de dollars canadiens pour les CPSA liées à l'IRC (respectivement 8,4 % et 6,2 % du coût total attribuable aux hospitalisations). LIMITES: La structure des CPSA ne nous a pas permis de déterminer si ces hospitalisations étaient effectivement évitables. CONCLUSION: Les hospitalisations évitables chez les patients atteints d'IRC représentent un fardeau et des coûts considérables pour le système de santé. Des stratégies efficaces qui permettraient de les réduire chez les patients atteints d'IRC entraîneraient des économies substantielles.

Derivation and Internal Validation of a Prediction Model for Pediatric Hand Fracture Triage.

BACKGROUND: Pediatric hand fractures are common, and most can be managed by a period of immobilization. However, it remains challenging to identify those more complex fractures requiring the expertise of a hand surgeon to ensure a good outcome. The purpose of this study was to develop a prediction model for identification of complex pediatric hand fractures requiring care by a hand surgeon. METHODS: A 2-year retrospective cohort study of consecutively referred pediatric (<18 years) hand fracture patients was used to derive and internally validate a prediction model for identification of complex fractures requiring the expertise of a hand surgeon. These complex fractures were defined as those that required surgery, closed reduction, or four or more appointments with a hand surgeon. The model, derived by multivariable logistic regression analysis, was internally validated using bootstrapping and then translated into a risk index. RESULTS: Of 1170 fractures, 416 (35.6%) met criteria for a complex fracture. Multivariable regression analysis identified six significant predictors of complex fracture: open fracture, rotational deformity, angulation, condylar involvement, dislocation or subluxation, and displacement. Internal validation demonstrated good performance of the model (C-statistic = 0.88, calibration curve p = 0.935). A threshold of ≥1 point (ie, any one of the predictors) resulted in a simple, easy-to-use tool with 96.4% sensitivity and 45.5% specificity. CONCLUSIONS: A high-performing and clinically useful decision support tool was developed for emergency and urgent care physicians providing initial assessment for children with hand fractures. This tool will provide the basis for development of a clinical care pathway for pediatric hand fractures.

Antihypertensive Prescribing for Uncomplicated, Incident Hypertension: Opportunities for Cost Savings.

BACKGROUND: A range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides. METHODS: Using a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference. RESULTS: Within our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received ß-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million). CONCLUSIONS: Only 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.

CONTEXTE: De nombreux médicaments tous aussi efficaces les uns que les autres, mais de prix variable, sont recommandés pour le traitement de première intention de l'hypertension non compliquée. Si l'on tient compte du coût du médicament seulement, les thiazides et les diurétiques apparentés aux thiazides sont les options les plus économiques. Nous avons évalué le taux de prescription d'un thiazide pour le traitement de première intention de l'hypertension nouvellement diagnostiquée en Alberta, les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre médicament plus coûteux, ainsi que les économies qui pourraient être réalisées si on prescrivait un thiazide à un plus grand nombre de patients. MÉTHODOLOGIE: Dans le cadre de notre étude de cohorte rétrospective, nous avons déterminé les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre agent à l'aide d'une régression logistique à effets mixtes. Nous avons simulé les économies qui pourraient être réalisées en faisant passer à un thiazide les patients à qui un autre médicament antihypertenseur a été prescrit et en calculant la différence. RÉSULTATS: Dans notre cohorte de 89 548 adultes, seulement 12 % des patients ont reçu un thiazide en première intention; 44 % ont reçu un inhibiteur de l'enzyme de conversion de l'angiotensine; 17 %, un antagoniste des récepteurs de l'angiotensine; 16 %, un inhibiteur calcique; et 10 %, des bêtabloquants. Les agents antihypertenseurs sont généralement prescrits par des omnipraticiens en cabinet (88 %). Le fait d'être un homme et le fait d'obtenir une prescription auprès d'un médecin exerçant depuis au moins 20 ans et ayant une lourde charge de travail clinique étaient associés à une probabilité supérieure de recevoir un agent autre qu'un thiazide. Dans le cas extrême où tous les patients se verraient prescrire un thiazide en première intention, la réduction des dépenses pourrait atteindre 95 % (soit 1,8 million de dollars canadiens). CONCLUSIONS: En Alberta, un thiazide a été prescrit en première intention à seulement 12 % des adultes venant de recevoir un diagnostic d'hypertension non compliquée. Compte tenu des économies qui pourraient être réalisées si un thiazide était prescrit dans ce contexte, il conviendrait d'effectuer des recherches plus poussées pour évaluer le risque de manifestations indésirables et d'effets secondaires associé aux différentes classes de médicaments, et pour déterminer si les coûts liés à la prise en charge de ce risque annuleraient les économies réalisées en augmentant le recours aux thiazides.

Comparing Onset of Biosimilar Versus Generic Competition in the United States.

We sought to compare expected and observed biosimilar and generic entry dates among new drugs approved by the US Food and Drug Administration (FDA) between 2000 and 2012. We defined expected biosimilar and generic entry dates as the later of the expiration of the key patent term or statutory exclusivity (12 years for biologics, 5 years for small molecule drugs not indicated for a rare disease, and 7 years for small molecule drugs indicated for a rare disease; plus 6 months if a pediatric extension had been granted). For drugs with expected entry prior to 2019, we calculated the proportion with observed biosimilar or generic entry. The expected biosimilar entry dates were estimated to be a median of 12.3 years (interquartile range (IQR) 12.0-14.0, n = 60) after FDA approval. The 12-year biologic statutory exclusivity period comprised 98% of the median expected protection period. By contrast, expected generic entry was estimated to be a median of 12.2 years (IQR 8.4-14.0, n=268), or 7.2 years after the 5-year small molecule statutory exclusivity (59% of the total expected market protection period). By 2019, observed biosimilar entry occurred in 12% of cases (3/25) and observed generic entry in 65% (101/155). We concluded that expected US market exclusivity periods are similar for biologic and small molecule drugs. Statutory exclusivity plays a more substantial role in market exclusivity protection for biologics. Biosimilar competition, currently lagging behind generic competition, will likely increase as the biosimilar market becomes established.

Derivation and Internal Validation of a Clinical Risk Prediction Tool for Hyperkalemia-Related Emergency Department Encounters Among Hemodialysis Patients.

BACKGROUND: Approximately 10% of emergency department (ED) visits among dialysis patients are for conditions that could potentially be managed in outpatient settings, such as hyperkalemia. OBJECTIVE: Using population-based data, we derived and internally validated a risk score to identify hemodialysis patients at increased risk of hyperkalemia-related ED events. DESIGN: Retrospective cohort study. SETTING: Ten in-center hemodialysis sites in southern Alberta, Canada. PATIENTS: All maintenance hemodialysis patients (≥18 years) between March 2009 and March 2017. MEASUREMENTS: Predictors of hyperkalemia-related ED events included patient demographics, comorbidities, health-system use, laboratory measurements, and dialysis information. The outcome of interest (hyperkalemia-related ED events) was defined by International Classification of Diseases (10th Revision; ICD-10) codes and/or serum potassium [K+] ≥6 mmol/L. METHODS: Bootstrapped logistic regression was used to derive and internally validate a model of important predictors of hyperkalemia-related ED events. A point system was created based on regression coefficients. Model discrimination was assessed by an optimism-adjusted C-statistic and calibration by deciles of risk and calibration slope. RESULTS: Of the 1533 maintenance hemodialysis patients in our cohort, 331 (21.6%) presented to the ED with 615 hyperkalemia-related ED events. A 9-point scale for risk of a hyperkalemia-related ED event was created with points assigned to 5 strong predictors based on their regression coefficients: ≥1 laboratory measurement of serum K+ ≥6 mmol/L in the prior 6 months (3 points); ≥1 Hemoglobin A1C [HbA1C] measurement ≥8% in the prior 12 months (1 point); mean ultrafiltration of ≥10 mL/kg/h over the preceding 2 weeks (2 points); ≥25 hours of cumulative time dialyzing over the preceding 2 weeks (1 point); and dialysis vintage of ≥2 years (2 points). Model discrimination (C-statistic: 0.75) and calibration were good. LIMITATIONS: Measures related to health behaviors, social determinants of health, and residual kidney function were not available for inclusion as potential predictors. CONCLUSIONS: While this tool requires external validation, it may help identify high-risk patients and allow for preventative strategies to avoid unnecessary ED visits and improve patient quality of life. TRIAL REGISTRATION: Not applicable-observational study design.

CONTEXTE: Environ 10 % des visites aux urgences des patients hémodialysés concernent des affections qui pourraient être prises en charge en ambulatoire, notamment l'hyperkaliémie. OBJECTIF: À l'aide de données populationnelles, nous avons dérivé et validé en interne une cote de risque pour dépister les patients hémodialysés présentant un risque accru de visites aux urgences liées à l'hyperkaliémie. TYPE D'ÉTUDE: Étude de cohorte rétrospective. CADRE: Dix sites d'hémodialyse en center du sud de l'Alberta (Canada). SUJETS: Tous les adultes sous hémodialyse chronique entre mars 2009 et mars 2017. MESURES: Les prédicteurs d'une visite aux urgences liée à l'hyperkaliémie incluaient les données démographiques du patient, les maladies concomitantes, l'utilization du système de santé, les mesures de laboratoire et les informations sur la dialyze. Le résultat d'intérêt (nombre de visites aux urgences liées à l'hyperkaliémie) a été défini par les codes CIM-10 et/ou une kaliémie [K+] égale ou supérieure à 6 mmol/L. MÉTHODOLOGIE: La régression logistique de type « bootstrap ¼ a été utilisée pour dériver et valider en interne un modèle des principaux prédicteurs d'une visites aux urgences liée à l'hyperkaliémie. Un système de pointage a été créé à partir des coefficients de régression. La discrimination du modèle a été évaluée par une statistique C corrigée selon l'optimisme, et l'étalonnage par des déciles de risque et une courbe d'étalonnage. RÉSULTATS: Des 1 533 patients de notre cohorte, 331 (21,6 %) se sont présentés aux urgences pour un total de 615 événements liés à l'hyperkaliémie. Une échelle à neuf points mesurant le risque a été créée, où un pointage a été attribué à cinq puissants prédicteurs en fonction du coefficient de régression: i) au moins une mesure de K+ égale ou supérieure à 6 mmol/L dans les six mois précédents (3 points); ii) au moins une mesure de l'hémoglobine A1C [HbA1C] égale ou supérieure à 8 % dans les 12 mois précédents (1 point); iii) une ultrafiltration moyenne d'au moins 10 mL/kg/heure dans les deux semaines précédentes (2 points); iv) un cumulatif d'au moins 25 heures de dialyze dans les deux semaines précédentes (1 point); et v) le fait d'être en dialyze depuis au moins 2 ans (2 points). La discrimination du modèle (statistique C: 0,75) et l'étalonnage ont été jugés bons. LIMITES: Les mesures relatives aux comportements en matière de santé, aux déterminants sociaux de la santé et à la fonction rénale résiduelle n'étaient pas disponibles pour leur inclusion comme prédicteurs potentiels. CONCLUSION: Bien que cet outil doive être validé en externe, il peut aider à dépister les patients présentant un risque élevé de visiter les urgences pour une hyperkaliémie. Il pourrait également favoriser l'élaboration de stratégies préventives visant à réduire les visites inutiles et à améliorer la qualité de vie des patients. ENREGISTREMENT DE L'ESSAI: Sans objet ­ essai observationnel.

Attributable costs and length of stay of hospital-acquired Clostridioides difficile: A population-based matched cohort study in Alberta, Canada.

OBJECTIVE: To determine the attributable cost and length of stay of hospital-acquired Clostridioides difficile infection (HA-CDI) from the healthcare payer perspective using linked clinical, administrative, and microcosting data. DESIGN: A retrospective, population-based, propensity-score-matched cohort study. SETTING: Acute-care facilities in Alberta, Canada. PATIENTS: Admitted adult (≥18 years) patients with incident HA-CDI and without CDI between April 1, 2012, and March 31, 2016. METHODS: Incident cases of HA-CDI were identified using a clinical surveillance definition. Cases were matched to noncases of CDI (those without a positive C. difficile test or without clinical CDI) on propensity score and exposure time. The outcomes were attributable costs and length of stay of the hospitalization where the CDI was identified. Costs were expressed in 2018 Canadian dollars. RESULTS: Of the 2,916 HA-CDI cases at facilities with microcosting data available, 98.4% were matched to 13,024 noncases of CDI. The total adjusted cost among HA-CDI cases was 27% greater than noncases of CDI (ratio, 1.27; 95% confidence interval [CI], 1.21-1.33). The mean attributable cost was $18,386 (CAD 2018; USD $14,190; 95% CI, $14,312-$22,460; USD $11,046-$17,334). The adjusted length of stay among HA-CDI cases was 13% greater than for noncases of CDI (ratio, 1.13; 95% CI, 1.07-1.19), which corresponds to an extra 5.6 days (95% CI, 3.10-8.06) in length of hospital stay per HA-CDI case. CONCLUSIONS: In this population-based, propensity score matched analysis using microcosting data, HA-CDI was associated with substantial attributable cost.

Quality of Chronic Kidney Disease Management in Canadian Primary Care.

Importance: Although patients with chronic kidney disease (CKD) are routinely managed in primary care settings, no nationally representative study has assessed the quality of care received by these patients in Canada. Objective: To evaluate the current state of CKD management in Canadian primary care practices to identify care gaps to guide development and implementation of national quality improvement initiatives. Design, Setting, and Participants: This cross-sectional study leveraged Canadian Primary Care Sentinel Surveillance Network data from January 1, 2010, to December 31, 2015, to develop a cohort of 46 162 patients with CKD managed in primary care practices. Data analysis was performed from August 8, 2018, to July 31, 2019. Main Outcomes and Measures: The study examined the proportion of patients with CKD who met a set of 12 quality indicators in 6 domains: (1) detection and recognition of CKD, (2) testing and monitoring of kidney function, (3) use of recommended medications, (4) monitoring after initiation of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), (5) management of blood pressure, and (6) monitoring for glycemic control in those with diabetes and CKD. The study also analyzed associations of divergence from these quality indicators. Results: The cohort comprised 46 162 patients (mean [SD] age, 69.2 [14.0] years; 25 855 [56.0%] female) with stage 3 to 5 CKD. Only 4 of 12 quality indicators were met by 75% or more of the study cohort. These indicators were receipt of an outpatient serum creatinine test within 18 months after confirmation of CKD, receipt of blood pressure measurement at any time during follow-up, achieving a target blood pressure of 140/90 mm Hg or lower, and receiving a hemoglobin A1c test for monitoring diabetes during follow-up. Indicators in the domains of detection and recognition of CKD, testing and monitoring of kidney function (specifically, urine albumin to creatinine ratio testing), use of recommended medications, and appropriate monitoring after initiation of treatment with ACEIs or ARBs were not met. Only 6529 patients (18.4%) with CKD received a urine albumin test within 6 months of CKD diagnosis, and 3954 (39.4%) had a second measurement within 6 months of an abnormal baseline urine albumin level. Older age (≥85 years) and CKD stage 5 were significantly associated with not satisfying the criteria for the quality indicators across all domains. Across age categories, younger patients (aged 18-49 years) and older patients (≥75 years) were less likely to be tested for albuminuria (314 of 1689 patients aged 18-49 years [18.5%], 1983 of 11 919 patients aged 75-84 years [61.6%], and 614 of 5237 patients aged ≥85 years [11.7%] received the urine albumin to creatinine ratio test within 6 months of initial estimated glomerular filtration rate <60 mL/min per 1.73 m2; P < .001). Patients aged 18 to 49 years were less commonly prescribed recommended medications (222 of 2881 [7.7%]), whereas patients aged 75 to 84 years were prescribed ACEIs or ARBs most frequently (2328 of 5262 [44.2%]; P < .001). Conclusions and Relevance: The findings suggest that management of CKD across primary care practices in Canada varies according to quality indicator. This study revealed potential priority areas for quality improvement initiatives in Canadian primary care practices.