Sex-Related Differences in Dispensation of Rheumatic Medications in Older Patients With Inflammatory Arthritis: A Population-Based Study.

OBJECTIVE: The aim of our study was to compare dispensation of rheumatic medications between older male and female patients with early rheumatoid arthritis (RA) and psoriatic arthritis (PsA). METHODS: This retrospective cohort study was performed using health administrative data from Ontario, Canada (years 2010-2017), on patients with incident RA and PsA, who were aged ≥ 66 years at the time of diagnosis. Yearly dispensation of rheumatic drugs was compared between older male and female patients for 3 years after diagnosis using multivariable regression models, after adjusting for confounders. The groups of drugs included in the analysis were disease-modifying antirheumatic drugs (DMARDs) classified as conventional synthetic DMARDs (csDMARDs) and advanced therapy (biologic DMARDs and targeted synthetic DMARDs), nonsteroidal antiinflammatory drugs (NSAIDs), opioids, and oral corticosteroids. Results were reported as odds ratios (ORs) with 95% CIs. RESULTS: We analyzed 13,613 patients (64% female) with RA and 1116 patients (57% female) with PsA. Female patients with RA were more likely to receive opioids (OR 1.39, 95% CI 1.22-1.58 to OR 1.51, 95% CI 1.32-1.72) and NSAIDs (OR 1.14, 95% CI 1.04-1.25 to OR 1.16, 95% CI 1.04-1.30). Dispensation of DMARDs showed no sex difference in either group. Subgroup analyses showed more intense use of advanced therapy in the RA cohort and of csDMARDs in the PsA cohort when patient and physician sex was concordant. CONCLUSION: This study did not identify any sex difference in the use of DMARDs among older patients with RA and PsA. The reasons for the higher use of opioids and NSAIDs among female patients with RA warrant further research.

Understanding sex-related differences in healthcare utilisation among patients with inflammatory arthritis: a population-based study.

OBJECTIVES: Our aim was to compare patterns of musculoskeletal-related healthcare utilisation between male and female patients before and after the diagnosis of inflammatory arthritis (IA). METHODS: We used Ontario administrative health data to create three inception cohorts of adult patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS) and psoriatic arthritis (PsA) diagnosed between April 2010 and March 2017. Healthcare utilisation indicators including visits to physicians, and use of musculoskeletal imaging and laboratory tests were assessed in each year for 3 years before and after diagnosis and compared between male and female patients using regression models adjusting for sociodemographic factors and comorbidities. Results were reported as ORs with 95% CIs for female patients compared with male patients. RESULTS: A total of 41 277 patients with RA (69% female), 8150 patients with AS (51% female) and 6446 patients with PsA (54% female) were analysed.Similar trends of sex-related differences were observed in all three cohorts. Before diagnosis, female patients were more likely to visit rheumatologists (OR 1.32-2.28) and family physicians (OR 1.03-1.15) for musculoskeletal reasons, whereas male patients were more likely to visit the emergency for musculoskeletal reasons (OR 0.76-0.87). A similar female predominance was observed regarding musculoskeletal imaging and laboratory tests before diagnosis. After diagnosis, female patients were more likely to remain in rheumatology care (OR 1.12-1.24). CONCLUSION: Female patients with IA have higher healthcare utilisation than male patients which may indicate biological differences in disease course or sociocultural differences in healthcare-seeking behaviour.

Factors associated with loneliness in immigrant and Canadian-born older adults in Ontario, Canada: a population-based study.

BACKGROUND: While loneliness is common in older adults, some immigrant groups are at higher risk. To inform tailored interventions, we identified factors associated with loneliness among immigrant and Canadian-born older adults living in Ontario, Canada. METHODS: We conducted a cross-sectional analysis of 2008/09 data from the Canadian Community Health Survey (Healthy Aging Cycle) and linked health administrative data for respondents 65 years and older residing in Ontario, Canada. Loneliness was measured using the Three-Item Loneliness Scale, with individuals categorized as 'lonely' if they had an overall score of 4 or greater. For immigrant and Canadian-born older adults, we developed separate multivariable logistic regression models to assess individual, relationship and community-level factors associated with loneliness. RESULTS: In a sample of 968 immigrant and 1703 Canadian-born older adults, we found a high prevalence of loneliness (30.8% and 34.0%, respectively). Shared correlates of loneliness included low positive social interaction and wanting to participate more in social, recreational or group activities. In older immigrants, unique correlates included: widowhood, poor health (i.e., physical, mental and social well-being), less time in Canada, and lower neighborhood-level ethnic diversity and income. Among Canadian-born older adults, unique correlates were: female sex, poor mental health, weak sense of community belonging and living alone. Older immigrant females, compared to older immigrant males, had greater prevalence (39.1% vs. 21.9%) of loneliness. CONCLUSIONS: Although both groups had shared correlates of loneliness, community-level factors were more strongly associated with loneliness in immigrants. These findings enhance our understanding of loneliness and can inform policy and practice tailored to immigrants.

The Impact of Sex and Gender on Prescribing Cascades in Older Adults.

Prescribing cascades occur when an adverse drug event is misinterpreted as a new medical condition, leading clinicians to prescribe an additional medication. Studies using ICES data have detected a number of common prescribing cascades, particularly among older adult populations. These findings have contributed to international initiatives aimed at optimizing prescribing practices in this population, with the goal of minimizing the risk of drug-related harms. Examining prescribing cascades through a sex and gender lens will better inform guidelines and recommendations tailored to older men and women.

Rates of health services use among residents of retirement homes in Ontario: a population-based cohort study.

BACKGROUND: Because there are no standardized reporting systems specific to residents of retirement homes in North America, little is known about the health of this distinct population of older adults. We evaluated rates of health services use by residents of retirement homes relative to those of residents of long-term care homes and other populations of older adults. METHODS: We conducted a retrospective cohort study using population health administrative data from 2018 on adults 65 years or older in Ontario. We matched the postal codes of individuals to those of licensed retirement homes to identify residents of retirement homes. Outcomes included rates of hospital-based care and physician visits. RESULTS: We identified 54 733 residents of 757 retirement homes (mean age 86.7 years, 69.0% female) and 2 354 385 residents of other settings. Compared to residents of long-term care homes, residents of retirement homes had significantly higher rates per 1000 person months of emergency department visits (10.62 v. 4.48, adjusted relative rate [RR] 2.61, 95% confidence interval [CI] 2.55 to 2.67), hospital admissions (5.42 v. 2.08, adjusted RR 2.77, 95% CI 2.71 to 2.82), alternate level of care (ALC) days (6.01 v. 2.96, adjusted RR 1.51, 95% CI 1.48 to 1.54), and specialist physician visits (6.27 v. 3.21, adjusted RR 1.64, 95% CI 1.61 to 1.68), but a significantly lower rate of primary care visits (16.71 v. 108.47, adjusted RR 0.13, 95% CI 0.13 to 0.14). INTERPRETATION: Residents of retirement homes are a distinct population with higher rates of hospital-based care. Our findings can help to inform policy debates about the need for more coordinated primary and supportive health care in privately operated congregate care homes.

Prescribing cascades: we see only what we look for, we look for only what we know.

Prescribing cascades are increasingly recognized since they were described in the mid-1990s. Cascades are more likely in older people with multimorbidity and associated polypharmacy where multiple medications can induce a variety of side effects that manifest with various non-specific symptoms that may be misidentified as new geriatric syndromes such as falls, dizziness and new-onset incontinence. Geriatricians encounter medication side effects frequently and will usually consider if an older patient presenting with new symptoms could be experiencing an adverse drug reaction or event. However, most medications prescribed to multimorbid older patients are initiated and continued by prescribers without specialist geriatric training who may not detect medication-induced morbidity. Therefore, novel approaches to the detection and management of prescribing cascades in older people are needed. Currently, the knowledge base surrounding prescribing cascades in older people is evolving towards better methods for cascade detection and secondary prevention. However, the large number of cascades described in the literature, the wide-ranging symptomatology of cascades and the rapidly increasing number of multimorbid older people at risk of cascades represent major challenges for prescribers. Furthermore, prospective prevalence studies of prescribing cascades in older people are lacking. To detect and correct prescribing cascades during routine medication review in multimorbid older people, awareness of cascades is essential. Prescribing cascade awareness in turn requires novel explicit ways of defining cascades to facilitate their rapid detection and correction during medication review. Given that prescribing cascades represent another aspect of inappropriate prescribing (IP), explicit cascades criteria should be integrated with other explicit IP criteria.

Liver enzymes after short-term acetaminophen error in critically ill children: a cohort study.

Drug-associated harm is common but difficult to detect in the hospital setting. In critically ill children, we sought to evaluate drug-associated hepatic injury following enteral acetaminophen error, defined as acetaminophen dosing that exceeds daily maximum recommendations. This retrospective cohort study took place in two pediatric intensive care units within a pediatric hospital center. The included patients are children (< 18 years of age) admitted to the pediatric and cardiac intensive care unit between January 2008 and January 2018, and receiving enteral acetaminophen. We defined acetaminophen dosing error as exceeding daily acetaminophen dosing by > 10% the upper limit of maximum recommended dose for weight and age (> 82.5 mg/kg/day or > 4400 mg/day). We included 14,146 admissions, who received 147,485 doses of acetaminophen. Acetaminophen dosing errors occurred 1 in every 9.5 patient-days on acetaminophen. ALT and AST decreased significantly over the course of ICU admission (p < 0.0001). In patients with acetaminophen errors, ALT and AST measured in the 24 to 96 h post error were not significantly different than when measured outside this window. A sensitivity analysis using > 100 mg/kg/day as the upper daily acetaminophen error cut-off did not reveal any subsequent significant increase in ALT or ALT in the 24 to 96-h post-error window, compared to measurements taken outside the window. CONCLUSION: Although the administration of acetaminophen in critically ill children frequently exceeds the daily recommended limit and vigilance is needed, we did not find any associated increase in liver transaminases following acetaminophen errors. WHAT IS KNOWN: • Acetaminophen dosing errors are common in pediatric outpatients. • Excessive acetaminophen dosing can be associated with harm, including hepatic injury. WHAT IS NEW: • Exceeding daily acetaminophen dosing limit occurs 1 in every 9.5 patient-days in children admitted to the critical care unit. • In patients with daily dose excess of acetaminophen, we did not find a significant increase in the measured liver enzymes in the 24 to 96 h following the overdosing.

Examining the association between loneliness and emergency department visits using Canadian Longitudinal Study of Aging (CLSA) data: a retrospective cross-sectional study.

BACKGROUND: Loneliness is a public health concern and its influence on morbidity and mortality are well documented. The association between loneliness and emergency department visits is less clear. Further, while sex and gender-related factors are known to be associated with loneliness and health services use, little research looks at the relationship by gender. Our study aimed to estimate the association between loneliness and emergency department use in the previous 12 months. We aimed to determine if this association differed based on gender identity and gender-related characteristics. METHODS: We used a retrospective cohort study design to analyze population-based survey data from the Canadian Longitudinal Study on Aging (CLSA). We analysed data from the baseline and follow-up 1 survey respondents (2015-2018) from both the tracking (telephone interviews) and comprehensive (in-home data collection) cohorts (n=44816). Loneliness was assessed using a dichotomous measure (lonely/not lonely) from a validated scale. Emergency department visits were dichotomous (yes/no) by self-reported emergency department use in the 12 months prior to the survey date. Multivariable logistic regression analyses using analytic weights examined the association between loneliness and emergency department visit, controlling for other demographic, social, and health related factors. RESULTS: We identified 44,413 respondents to the baseline and follow-up 1 survey. The prevalence of loneliness in our sample was 23.1% (n=10263). Of those who had been to the emergency department in the previous year, 27.2% (n=2793) were lonely. Lonely respondents had higher odds of an emergency department visit (aOR: 1.13, 95% CI: 1.05-1.21), adjusted for various demographic and health factors. Loneliness was associated with emergency department visits more so in women (aOR: 1.15, 95% CI: 1.05-1.25) than in men (aOR: 1.10, 95% CI: 0.99-1.22). CONCLUSIONS: In our study, loneliness was associated with emergency department visits in the previous 12 months. When our analysis was disaggregated by gender, we found differences in the odds of emergency department visit for men, women, and gender-diverse respondents. The odds of ED visit were higher in women than men. These findings highlight the general importance of identifying loneliness in both primary care and hospital. Care providers in ED need resources to refer patients who present in this setting with health issues complicated by social conditions such as loneliness.

Potential diabetes overtreatment and risk of adverse events among older adults in Ontario: a population-based study.

AIMS/HYPOTHESIS: More than 25% of older adults (age ≥75 years) have diabetes and may be at risk of adverse events related to treatment. The aim of this study was to assess the prevalence of intensive glycaemic control in this group, potential overtreatment among older adults and the impact of overtreatment on the risk of serious events. METHODS: We conducted a retrospective, population-based cohort study of community-dwelling older adults in Ontario using administrative data. Participants were ≥75 years of age with diagnosed diabetes treated with at least one anti-hyperglycaemic agent between 2014 and 2015. Individuals were categorised as having intensive or conservative glycaemic control (HbA1c <53 mmol/mol [<7%] or 54-69 mmol/mol [7.1-8.5%], respectively), and as undergoing treatment with high-risk (i.e. insulin, sulfonylureas) or low-risk (other) agents. We measured the composite risk of emergency department visits, hospitalisations, or death within 30 days of reaching intensive glycaemic control with high-risk agents. RESULTS: Among 108,620 older adults with diagnosed diabetes in Ontario, the mean (± SD) age was 80.6 (±4.5) years, 49.7% were female, and mean (± SD) diabetes duration was 13.7 (±6.3) years. Overall, 61% of individuals were treated to intensive glycaemic control and 21.6% were treated to intensive control using high-risk agents. Using inverse probability treatment weighting with propensity scores, intensive control with high-risk agents was associated with nearly 50% increased risk of the composite outcome compared with conservative glycaemic control with low-risk agents (RR 1.49, 95% CI 1.08, 2.05). CONCLUSIONS/INTERPRETATION: Our findings underscore the need to re-evaluate glycaemic targets in older adults and to reconsider the use of anti-hyperglycaemic medications that may lead to hypoglycaemia, especially in setting of intensive glycaemic control.

Morbidity and mortality associated with prescription cannabinoid drug use in COPD.

INTRODUCTION: Respiratory-related morbidity and mortality were evaluated in relation to incident prescription oral synthetic cannabinoid (nabilone, dronabinol) use among older adults with chronic obstructive pulmonary disease (COPD). METHODS: This was a retrospective, population-based, data-linkage cohort study, analysing health administrative data from Ontario, Canada, from 2006 to 2016. We identified individuals aged 66 years and older with COPD, using a highly specific, validated algorithm, excluding individuals with malignancy and those receiving palliative care (n=185 876 after exclusions). An equivalent number (2106 in each group) of new cannabinoid users (defined as individuals dispensed either nabilone or dronabinol, with no dispensing for either drug in the year previous) and controls (defined as new users of a non-cannabinoid drug) were matched on 36 relevant covariates, using propensity scoring methods. Cox proportional hazard regression was used. RESULTS: Rate of hospitalisation for COPD or pneumonia was not significantly different between new cannabinoid users and controls (HR 0.87; 95% CI 0.61-1.24). However, significantly higher rates of all-cause mortality occurred among new cannabinoid users compared with controls (HR 1.64; 95% CI 1.14-2.39). Individuals receiving higher-dose cannabinoids relative to controls were observed to experience both increased rates of hospitalisation for COPD and pneumonia (HR 2.78; 95% CI 1.17-7.09) and all-cause mortality (HR 3.31; 95% CI 1.30-9.51). CONCLUSIONS: New cannabinoid use was associated with elevated rates of adverse outcomes among older adults with COPD. Although further research is needed to confirm these observations, our findings should be considered in decisions to use cannabinoids among older adults with COPD.

Levothyroxine dose and risk of atrial fibrillation: A nested case-control study.

Contemporary data on the effect of levothyroxine dose on the occurrence of atrial fibrillation (AF) are lacking, particularly in the older population. Our objective was to determine the effect of cumulative levothyroxine exposure on risk of AF and ischemic stroke in older adults. METHODS: We conducted a population-based observational study using health care databases from Ontario, Canada. We identified adults aged ≥66 years without a history of AF who filled at least 1 levothyroxine prescription between April 1, 2007, and March 31, 2016. Cases were defined as cohort members who had incident AF (emergency room visit or hospitalization) between the date of first levothyroxine prescription and December 31, 2017. Index date was date of AF. Cases were matched with up to 5 controls without AF on the same index date. Secondary outcome was ischemic stroke. Cumulative levothyroxine exposure was estimated based on total milligrams of levothyroxine dispensed in the year prior to index date. Using nested case-control approach, we compared outcomes between older adults who received high (≥0.125 mg/d), medium (0.075-0.125 mg/d), or low (0-0.075 mg/d) cumulative levothyroxine dose. We compared outcomes between current, recent past, and remote past levothyroxine use. RESULTS: Of 183,360 older adults treated with levothyroxine (mean age 82 years; 72% women), 30,560 (16.1%) had an episode of AF. Compared to low levothyroxine exposure, high and medium exposure was associated with significantly increased risk of AF after adjustment for covariates (adjusted odds ratio [aOR] 1.29, 95% CI 1.23-1.35; aOR 1.08, 95% CI 1.04-1.11; respectively). No association was observed between levothyroxine exposure and ischemic stroke. Compared with current levothyroxine use, older adults with remote levothyroxine use had lower risks of AF (aOR 0.56, 95% CI 0.52-0.59) and ischemic stroke (aOR 0.61, 95% CI 0.56-0.67). CONCLUSIONS: Among older persons treated with levothyroxine, levothyroxine at doses >0.075 mg/d is associated with an increased risk of AF compared to lower exposure.

Identifying prescribing cascades in Alzheimer's disease and related dementias: The calcium channel blocker-diuretic prescribing cascade.

PURPOSE: Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans. METHODS: We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry. RESULTS: There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade). CONCLUSIONS: We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.

Perspectives on ageing: a qualitative study of the expectations, priorities, needs and values of older people from two Canadian provinces.

BACKGROUND: Understanding the needs and values of older people is vital to build responsive policies, services and research agendas in this time of demographic transition. Older peoples' expectations and priorities for ageing, as well as their beliefs regarding challenges facing ageing societies, are multi-faceted and require regular updates as populations' age. OBJECTIVE: To develop an understanding of self-perceptions of ageing and societal ageing among Canadian retirees of the education sector to define a meaningful health research agenda. METHODS: We conducted four qualitative focus groups among 27 members of a Canadian retired educators' organisation. Data were analysed using an inductive thematic approach. RESULTS: We identified four overarching themes: (1) vulnerability to health challenges despite a healthier generation, (2) maintaining health and social connection for optimal ageing, (3) strengthening person-centred healthcare for ageing societies and (4) mobilising a critical mass to enact change. Participants' preconceptions of ageing differed from their personal experiences. They prioritised maintaining health and social connections and felt that current healthcare practices disempowered them to manage and optimise their health. Although the sheer size of their demographic instilled optimism of their potential to garner positive change, participants felt they lacked mechanisms to contribute to developing solutions to address this transition. CONCLUSION: Our findings suggest a need for health research that improves perceptions of ageing and supports health system transformations to deliver person-centred care. Opportunities exist to harness their activism to engage older people as partners in shaping solution-oriented research that can support planning for an ageing society.

Safety of Systemic Medications Among Older Adults With Psoriasis and Atopic Dermatitis: A Systematic Review of Observational Studies.

BACKGROUND: Psoriasis and atopic dermatitis are common among older adults (≥65 years old), but clinical trials often exclude that population. OBJECTIVE: To synthesize evidence from observational studies on the safety of systemic therapies (conventional or biologic) for psoriasis and atopic dermatitis among older adults in a systematic review. METHODS: We searched MEDLINE and EMBASE (inception to October 31, 2019) and included observational studies reporting adverse events among older people treated with systemic therapy for psoriasis or atopic dermatitis. Outcomes were death, hospitalization, emergency department visits, infections, major cardiovascular events, renal toxicity, hepatotoxicity, and cytopenias. We assessed study quality using the Newcastle-Ottawa Scale. RESULTS: We included 22 studies on treatment for psoriasis and 2 for atopic dermatitis. Most studies were small and non-comparative and 20 of 24 were low quality. Studies comparing safety between medications or medication classes or between older and younger adults did not show apparent differences but had wide confidence intervals around relative effect estimates. Heterogeneity of study design and reporting precluded quantitative synthesis. CONCLUSIONS: There is scant evidence on the safety of conventional systemic and biologic medications for older adults with psoriasis or atopic dermatitis; older adults and their clinicians should be aware of this evidence gap.

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.

BACKGROUND: Long-term care (LTC) homes have been the epicentre of the coronavirus disease 2019 (COVID-19) pandemic in Canada to date. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had worse COVID-19 outcomes than nonprofit homes. METHODS: We conducted a retrospective cohort study of all LTC homes in Ontario, Canada, from Mar. 29 to May 20, 2020, using a COVID-19 outbreak database maintained by the Ontario Ministry of Long-Term Care. We used hierarchical logistic and count-based methods to model the associations between profit status of LTC homes (for-profit, nonprofit or municipal) and COVID-19 outbreaks in LTC homes, the extent of COVID-19 outbreaks (number of residents infected), and deaths of residents from COVID-19. RESULTS: The analysis included all 623 Ontario LTC homes, comprising 75 676 residents; 360 LTC homes (57.7%) were for profit, 162 (26.0%) were nonprofit, and 101 (16.2%) were municipal homes. There were 190 (30.5%) outbreaks of COVID-19 in LTC homes, involving 5218 residents and resulting in 1452 deaths, with an overall case fatality rate of 27.8%. The odds of a COVID-19 outbreak were associated with the incidence of COVID-19 in the public health unit region surrounding an LTC home (adjusted odds ratio [OR] 1.91, 95% confidence interval [CI] 1.19-3.05), the number of residents (adjusted OR 1.38, 95% CI 1.18-1.61), and older design standards of the home (adjusted OR 1.55, 95% CI 1.01-2.38), but not profit status. For-profit status was associated with both the extent of an outbreak in an LTC home (adjusted risk ratio [RR] 1.96, 95% CI 1.26-3.05) and the number of resident deaths (adjusted RR 1.78, 95% CI 1.03-3.07), compared with nonprofit homes. These associations were mediated by a higher prevalence of older design standards in for-profit LTC homes and chain ownership. INTERPRETATION: For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths, but not the likelihood of outbreaks. Differences between for-profit and nonprofit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy.

Melanoma incidence, stage, and survival after solid organ transplant: A population-based cohort study in Ontario, Canada.

BACKGROUND: Risk of melanoma is increased with potentially worse outcomes after solid organ transplant. OBJECTIVE: To estimate the incidence, stage, and survival in transplant recipients with melanoma. METHODS: Population-based, retrospective, observational study using linked administrative databases. Adults receiving their first solid organ transplant from 1991 through 2012 were followed to December 2013. RESULTS: We identified 51 transplant recipients with melanoma, 11 369 recipients without melanoma, and 255 matched patients with melanoma from the nontransplant population. Transplant recipients were at increased risk of melanoma (standardized incidence ratio, 2.29; 95% confidence interval [CI], 2.07-2.49) and more likely to be diagnosed at stages II through IV (adjusted odds ratio, 4.29; 95% CI, 2.04-9.00) compared with the nontransplant population. Melanoma-specific mortality was increased in transplant recipients compared with the nontransplant population (adjusted hazard ratio, 1.93; 95% CI, 1.03-3.63). Among transplant recipients, all-cause mortality was increased after melanoma compared with those without melanoma (stage T1/T2: adjusted hazard ratio, 2.18; 95% CI, 1.13-4.21; T3/T4: adjusted hazard ratio, 4.07; 95% CI, 2.36-7.04; III/IV: adjusted hazard ratio, 7.92; 95% CI, 3.76-16.70). LIMITATIONS: The databases did not contain data on immunosuppressive drugs; ascertainment of melanoma metastasis relied on pathology reports. CONCLUSION: Melanoma after solid organ transplant is more often diagnosed at a later stage and leads to increased mortality, even for early-stage tumors.

Readmission rates following heart failure: a scoping review of sex and gender based considerations.

BACKGROUND: Although hospital readmission for heart failure (HF) is an issue for both men and women, little is known about differences in readmission rates by sex. Consequently, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear. Our study aims were: (1) to identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender. METHODS: We conducted a scoping review using the Arksey and O'Malley framework to include full text articles published between 2002 and 2017 drawn from multiple databases (MEDLINE, EMBASE), grey literature (i.e. National Technical information, Duck Duck Go), and expert consultation. Eligible articles included an index heart failure episode, readmission rates, and sex/gender-based analysis. RESULTS: The search generated 5887 articles, of which 746 underwent full abstract text consideration for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies stratified data for sex. Good inter-rater agreement was reached: 83% title/abstract; 88% full text; kappa: 0.69 (95%CI: 0.53-0.85). Twelve of 34 studies reported higher heart failure readmission rates for men and six studies reported higher heart failure readmission rates for women. Using non composite endpoints, five studies reported higher HF readmission rates for men compared to three studies reporting higher HF readmission rates for women. Overall, there was heterogeneity between studies when examined by sex, but one observation emerged that was related to the timing of readmissions. Readmission rates for men were higher when follow-up duration was longer than 1 year. Women were more likely to experience higher readmission rates than men when time to event was less than 1 year. CONCLUSIONS: Future studies should consider different time horizons in their designs and avoid the use of composite measures, such as readmission rates combined with mortality, which are highly skewed by sex. Co-interventions and targeted post-discharge approaches with attention to sex would be of benefit to the HF patient population.

A modified Delphi to define drug dosing errors in pediatric critical care.

BACKGROUND: There is no globally accepted definition for dosing error in adult or pediatric practice. The definition of pediatric dosing error varies greatly in the literature. The objective of this study was to develop a framework, informed by a set of principles, for a clinician-based definition of drug dosing errors in critically ill children, and to identify the range that practitioners agree is a dosing error for different drug classes and clinical scenarios. METHODS: We conducted a nationwide three staged modified Delphi from May to December 2019. Expert clinicians included Canadian pediatric intensive care unit (PICU) physicians, pharmacists and nurses, with a least 5 years' experience. Outcomes were underlying principles of drug dosing, and error thresholds, as defined by proportion above and below reference range, for common PICU medications and clinical scenarios. RESULTS: Forty-four participants met eligibility, and response rates were 95, 86 and 84% for all three rounds respectively. Consensus was achieved for 13 of 15 principles, and 23 of 30 error thresholds. An over-dosed drug that is intercepted, an under-dose of a possibly life-saving medication, dosing 50% above or below target range and not adjusting for a drug interaction were agreed principles of dosing error. Altough there remained much uncertainty in defining dosing error, expert clinicians agreed that, for most medication categories and clinical scenarios, dosing over or below 10% of reference range was considered an error threshold. CONCLUSION: Dosing principles and threshold are complex in pediatric critical care, and expert clinicians were uncertain about whether many scenarios were considered in error. For most intermittent medications, dosing over 10% below or above reference range was considered a dosing error, although this was largely influenced by clinical context and drug properties. This consensus driven error threshold will help guide routine clinical dosing practice, standardized reporting and drug quality improvement in pediatric critical care.

Improved keratinocyte carcinoma outcomes with annual dermatology assessment after solid organ transplantation: Population-based cohort study.

Solid organ transplant recipients have a high risk of keratinocyte carcinoma (non-melanoma skin cancer). Consensus-based transplant guidelines recommend annual dermatological examination but the impact on skin cancer-related outcomes is unclear. We conducted a population-based, retrospective, inception cohort study using administrative health databases in Ontario, Canada to evaluate the association between adherence to annual dermatology assessments (time-varying exposure) and keratinocyte carcinoma-related morbidity and mortality after transplantation. The primary outcome was the time to first advanced (highly morbid or fatal) keratinocyte carcinoma. Among 10 183 adults receiving their first transplant from 1994 to 2012 and followed for a median of 5.44 years, 4.9% developed an advanced keratinocyte carcinoma after transplant. Adherence to annual dermatology assessments for at least 75% of the observation time after transplant was associated with a 34% reduction in keratinocyte carcinoma-related morbidity or death compared with adherence levels below 75% (adjusted hazard ratio 0.66, 95% CI 0.48-0.92). Adherence levels were universally low (median proportion of time spent in adherence 0%, inter-quartile range 0-27%). Only 45% of transplant recipients had ever seen a dermatologist and 2.1% were fully adherent during the entire observation period. Strategies are needed to improve adherence rates in order to help decrease long-term morbidity after transplant.

Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis.

BACKGROUND: Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS: MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS: Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I2 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I2 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I2 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I2 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I2 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I2 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I2 74%, n = 9). The quality of evidence was rated very low. DISCUSSION: Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.