Interventions for increasing solid organ donor registration.

BACKGROUND: A solution for increasing the number of available organs for transplantation is to encourage more individuals to register a commitment for deceased organ donation. However, the percentage of the population registered for organ donation remains low in many countries. OBJECTIVES: To evaluate the benefits and harms of various interventions used to increase deceased organ donor registration. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 11 August 2020 through contact with an Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: We included all randomised controlled trials (RCTs), cluster RCTs and quasi-RCTs of interventions to promote deceased organ donor registration. We included studies if they measured self-reported or verified donor registration, intention to donate, intention to register a decision or number of individuals signing donor cards as outcomes. DATA COLLECTION AND ANALYSIS: Two authors independently assessed retrieved studies and extracted data from included studies. We assessed studies for risk of bias. We obtained summary estimates of effect using a random-effects model and expressed results as risk ratios (RR) (95% confidence intervals; CI) for dichotomous outcomes and mean difference (MD; 95% CI) or standardised mean difference (SMD; 95% CI) for continuous outcomes. In multi-arm trials, data were pooled to create single pair-wise comparisons. Analyses were stratified by specific intervention setting where available. MAIN RESULTS: Our search strategy identified 46 studies (47 primary articles, including one abstract) comprising 24 parallel RCTs, 19 cluster RCTs and 3 quasi-RCTs. Sample sizes ranged from 138 to 1,085,292 (median = 514). A total of 16 studies measured registration behaviour, 27 measured intention to register/donate and three studies measured both registration behaviour and intention to register. Interventions were delivered in a variety of different settings: schools (14 studies), driver's motor vehicle (DMV) centres (5), mail-outs (4), primary care centres (3), workplaces (1), community settings (7) and general public (12). Interventions were highly varied in terms of their content and included strategies such as educational sessions and videos, leveraging peer leaders, staff training, message framing, and priming. Most studies were rated as having high or unclear risk of bias for random sequence generation and allocation concealment and low risk for the remainder of the domains. Data from 34/46 studies (74%) were available for meta-analysis. Low certainty evidence showed organ donation registration interventions had a small overall effect on improving registration behaviour (16 studies, 1,294,065 participants: RR 1.30, 95% CI 1.19 to 1.43, I2 = 84%), intention to register/donate (dichotomous) (10 studies, 10,838 participants: RR 1.21, 95% CI 1.03 to 1.42, I2 = 91%) and intention to register/donate (continuous) (9 studies, 3572 participants: SMD 0.23, 95% CI 0.11 to 0.36, I2 = 67%). Classroom-based interventions delivered in a lecture format by individuals from the transplant community may be effective at increasing intention to register/donate (3 studies, 675 participants: RR 1.33, 95% CI 1.15 to 1.55, I² = 0%). Community interventions targeting specific ethnic groups were generally effective at increasing registration rates (k = 5, n = 4186; RR 2.14, 95% CI 1.35 to 3.40, I² = 85%), although heterogeneity was high. In particular, interventions delivered in the community by trained peer-leaders appear to be effective (3 studies, 3819 participant: RR 2.09, 95% CI 1.08 to 4.06, I² = 87%), although again, the data lacked robustness. There was some evidence that framing messages (e.g. anticipated regret) and priming individuals (e.g. reciprocity) in a certain way may increase intention to register/donate, however, few studies measured this effect on actual registration. Overall, the studies varied significantly in terms of design, setting, content and delivery. Selection bias was evident and a quarter of the studies could not be included in the meta-analysis due to incomplete outcome data reporting. No adverse events were reported. AUTHORS' CONCLUSIONS: In our review, we identified a variety of approaches used to increase organ donor registration including school-based educational sessions and videos, leveraging peer leaders in the community, DMV staff training, targeted messaging and priming. The variability in outcome measures used and incompleteness in reporting meant that most data could not be combined for analysis. When data were combined, overall effect sizes were small in favour of intervention groups over controls, however, there was significant variability in the data. There was some evidence that leveraging peer-leaders in the community to deliver organ donation education may improve registration rates and classroom-based education from credible individuals (i.e. members of the transplant community) may improve intention to register/donate, however, there is no clear evidence favouring any particular approach. There was mixed evidence for simple, low-intensity interventions utilising message framing and priming. However, it is likely that interest in these strategies will persist due to their reach and scalability. Further research is therefore required to adequately address the question of the most effective interventions for increasing deceased organ donor registration.

ESRD among Immigrants to Ontario, Canada: A Population-Based Study.

Background The epidemiology of ESRD requiring maintenance dialysis (ESRD-D) in large, diverse immigrant populations is unclear.Methods We estimated ESRD-D prevalence and incidence among immigrants in Ontario, Canada. Adults residing in Ontario in 2014 were categorized as long-term Canadian residents or immigrants according to administrative health and immigration datasets. We determined ESRD-D prevalence among these adults and calculated age-adjusted prevalence ratios (PRs) comparing immigrants to long-term residents. Among those who immigrated to Ontario between 1991 and 2012, age-adjusted ESRD-D incidence was calculated by world region and country of birth, with immigrants from Western nations as the referent group.Results Among 1,902,394 immigrants and 8,860,283 long-term residents, 1700 (0.09%) and 8909 (0.10%), respectively, presented with ESRD-D. Age-adjusted ESRD-D prevalence was higher among immigrants from sub-Saharan Africa (PR, 2.17; 95% confidence interval [95% CI], 1.84 to 2.57), Latin America and the Caribbean (PR, 2.11; 95% CI, 1.90 to 2.34), South Asia (PR, 1.45; 95% CI, 1.32 to 1.59), and East Asia and the Pacific (PR, 1.34; 95% CI, 1.22 to 1.46). Immigrants from Somalia (PR, 4.18; 95% CI, 3.11 to 5.61), Trinidad and Tobago (PR, 2.88; 95% CI, 2.23 to 3.73), Jamaica (PR, 2.88; 95% CI, 2.40 to 3.44), Sudan (PR, 2.84; 95% CI, 1.53 to 5.27), and Guyana (PR, 2.69; 95% CI, 2.19 to 3.29) had the highest age-adjusted ESRD-D PRs relative to long-term residents. Immigrants from these countries also exhibited higher age-adjusted ESKD-D incidence relative to Western Nations immigrants.Conclusions Among immigrants in Canada, those from sub-Saharan Africa and the Caribbean have the highest ESRD-D risk. Tailored kidney-protective interventions should be developed for these susceptible populations.

Six-Month Real-World Study to Assess the Effectiveness of Ixekizumab After Switching from IL-23 Inhibitors and Other Biologic Therapies: The CorEvitas Psoriasis Registry.

BACKGROUND: Prior work showed that patients from the CorEvitas Psoriasis Registry who had previously failed a prior biologic and then initiated ixekizumab demonstrated improvements in disease severity and patient-reported outcomes after 6 months. However, newer therapies such as interleukin-23 inhibitors (IL-23i) were not considered. Here, with more recent data including IL-23i, 6-month effectiveness of ixekizumab following a switch from any biologic was assessed as well as whether 6-month effectiveness of ixekizumab was impacted by prior biologic class. METHODS: We included CorEvitas Psoriasis Registry patients who initiated ixekizumab after discontinuing another biologic therapy and had a corresponding 6-month follow-up visit following ixekizumab initiation (N = 743, 2016-2023). Immediate prior biologic class was categorized as tumor necrosis factor inhibitor (TNFi) or interleukin-12/23 inhibitors (IL-12/23i, n = 405), non-ixekizumab interleukin-17i (IL-17i, n = 237), or IL-23i (n = 101). Adjusted mean changes in body surface area (BSA), Dermatology Life Quality Index (DLQI), itch, and skin pain were calculated for prior biologic class groups using analysis of covariance (ANCOVA). Proportions achieving ≥ 75%, ≥ 90%, and ≥ 100% improvement in Psoriasis Area and Severity Index (PASI75, PASI90, and PASI100, respectively), Investigator's Global Assessment (IGA) 0/1, and DLQI 0/1 were calculated for all patients and compared among prior biologic classes via relative risks (RRs) and 95% confidence intervals (CIs) using multivariable modified Poisson regression. RESULTS: Mean improvements in BSA, DLQI, itch, and skin pain, were 7.6, 3.6, 23.3, and 16.7, respectively, for ixekizumab patients who switched from TNFi or IL-12/23i (all p < 0.05); 6.8, 3.3, 19.6, and 14.1, respectively, for those who switched from non-ixekizumab IL-17i (all p < 0.05); and 7.8, 3.4, 22.2, and 12.8, respectively, for those who switched from IL-23i (all p < 0.05). Overall, 54%, 41%, and 31% of ixekizumab initiators achieved PASI75, PASI90, and PASI100, respectively, 50% maintained or achieved IGA 0/1, and 48% maintained or achieved DLQI 0/1. The prior TNFi or IL-12/23i group was 31% more likely to achieve PASI100 (RR = 1.31, 95% CI 1.01, 1.69) and 32% more likely to maintain or achieve IGA 0/1 (RR = 1.32, 95% CI 1.11, 1.57), but not significantly more likely to achieve PASI90. The prior IL-23i group was 45% more likely to achieve PASI90 (RR = 1.45, 95% CI 1.10, 1.91), 55% more likely to achieve PASI100 (RR = 1.55, 95% CI 1.12, 2.13), and 39% more likely to maintain or achieve IGA 0/1 (RR = 1.39, 95% CI 1.12, 1.73) compared to the prior non-ixekizumab IL-17i group. Achievement of PASI75 and DLQI 0/1 was consistent across the prior TNFi or IL-12/23i, IL-23i, and non-ixekizumab IL-17i groups. CONCLUSIONS: These updated findings with IL-23i data reaffirm that patients with psoriasis who switch to ixekizumab after discontinuing another biologic demonstrate improvement in disease severity and patient-reported outcomes at 6 months in real-world settings. Compared to patients who switched from another IL-17i, patients who switched class from a TNFi or IL-12/23i were more likely to achieve PASI100 and IGA 0/1, and patients who switched class from an IL-23i were more likely to achieve PASI90 in addition to PASI100 and IGA 0/1.

Identifying behaviour change techniques within randomized trials of interventions promoting deceased organ donation registration.

OBJECTIVE: Increasing deceased organ donation registration may increase the number of available organs for transplant to help save lives. This study aimed to identify which behaviour change techniques (BCTs; or 'active ingredients') are reported within randomized trials of interventions promoting deceased organ donation registration and of those, which are associated with a larger intervention effect. METHODS: We conducted a secondary analysis of 45 trials included in a Cochrane systematic review of deceased organ donation registration interventions. Two researchers used the BCT Taxonomy v1 to independently code intervention content in all trial groups. Outcome data were pooled and we used meta-regression to explore associations between individual and combinations of recurring BCTs and effect on registration intention and/or registration behaviour. RESULTS: A total of 27 different BCTs (mean = 3.7, range = 1-9) were identified in intervention groups across the 45 trials. The five most common BCTs were: 'Information about health consequences' (71%); 'Instruction on how to perform the behaviour' (47%); 'Salience of consequences' (40%); 'Adding objects to the environment' (28%); and 'Credible source' (27%). Comparator groups in 20/45 trials also included identifiable BCTs (n = 12, mean = 3.1, range = 1-7). Meta-regression revealed that a combination of the three most common BCTs was associated with a larger intervention effect size for registration behaviour (k = 8, ß = .19, p = .02). CONCLUSIONS: Trials of deceased organ donation registration interventions focus predominantly on providing information, instruction, and a means to register. While potentially effective, a much wider set of possible BCTs could be leveraged to address known barriers to registration.

Risk Factors and Outcomes of Early Hospital Readmission in Canadian Kidney Transplant Recipients: A Population-Based Multi-Center Cohort Study.

BACKGROUND: Early hospital readmissions (EHRs) occur commonly in kidney transplant recipients. Conflicting evidence exists regarding risk factors and outcomes of EHRs. OBJECTIVE: To determine risk factors and outcomes associated with EHRs (ie, hospitalization within 30 days of discharge from transplant hospitalization) in kidney transplant recipients. DESIGN: Population-based cohort study using linked, administrative health care databases. SETTING: Ontario, Canada. PATIENTS: We included 5437 kidney transplant recipients from 2002 to 2015. MEASUREMENTS: Risk factors and outcomes associated with EHRs. We assessed donor, recipient, and transplant risk factors. We also assessed the following outcomes: total graft failure, death-censored graft failure, death with a functioning graft, mortality, and late hospital readmission. METHODS: We used multivariable logistic regression to examine the association of each risk factor and the odds of EHR. To examine the relationship between EHR status (yes vs no [reference]) and the outcomes associated with EHR (eg, total graft failure), we used a multivariable Cox proportional hazards model. RESULTS: In all, 1128 kidney transplant recipients (20.7%) experienced an EHR. We found the following risk factors were associated with an increased risk of EHR: older recipient age, lower income quintile, several comorbidities, longer hospitalization for initial kidney transplant, and older donor age. After adjusting for clinical characteristics, compared to recipients without an EHR, recipients with an EHR had an increased risk of total graft failure (adjusted hazard ratio [aHR]: 1.46, 95% CI: 1.29, 1.65), death-censored graft failure (aHR: 1.62, 95% CI: 1.36, 1.94), death with graft function (aHR: 1.34, 95% CI: 1.13, 1.59), mortality (aHR: 1.41, 95% CI: 1.22, 1.63), and late hospital readmission in the first 0.5 years of follow-up (eg, 0 to <0.25 years: aHR: 2.11, 95% CI: 1.85, 2.40). LIMITATIONS: We were not able to identify which readmissions could have been preventable and there is a potential for residual confounding. CONCLUSIONS: Results can be used to identify kidney transplant recipients at risk of EHR and emphasize the need for interventions to reduce the risk of EHRs. TRIAL REGISTRATION: This is not applicable as this is a population-based cohort study and not a clinical trial.

CONTEXTE: Les réadmissions précoces à l'hôpital (RPH) sont fréquentes chez les receveurs d'une greffe rénale. Les données sur les facteurs de risque d'une RPH et sur les résultats qui y sont associés restent toutefois contradictoires. OBJECTIF: Définir les facteurs de risque et les effets associés à une RPH (soit une hospitalization dans les 30 jours suivant la sortie de l'hôpital après la transplantation) chez les receveurs de greffe rénale. TYPE D'ÉTUDE: Étude de cohorte représentative d'une population, réalisée à partir des bases de données administratives en santé. CADRE: Ontario, Canada. SUJETS: Ont été inclus 5 437 adultes receveurs d'une greffe rénale entre 2002 et 2015. MESURES: Les facteurs de risque et les résultats associés à une RPH. Nous avons évalué les facteurs de risque du donneur, du receveur et de la transplantation. Nous avons également évalué les résultats suivants : l'échec du greffon, l'échec du greffon censuré par le décès, le décès avec un greffon fonctionnel, la mortalité et les réadmissions tardives. MÉTHODOLOGIE: Nous avons utilisé la régression logistique multivariée pour examiner l'association de chaque facteur de risque et les probabilités de RPH. Un modèle multivarié des risques proportionnels de Cox a par ailleurs servi à examiner la relation entre le statut des RPH (oui vs non [référence]) et les résultats associés à celles-ci (p. ex., l'échec de la greffe). RÉSULTATS: Dans la cohorte étudiée, 1 128 receveurs d'une greffe rénale (20,7 %) ont été réadmis précocement à l'hôpital. Les facteurs de risque suivants ont été associés à un risque accru de RPH : âge plus avancé du receveur, provenance d'un quartier au quintile de revenu inférieur, présence de plusieurs comorbidités, hospitalization initiale plus longue pour la transplantation rénale et âge plus avancé du donneur. Après ajustement pour les caractéristiques cliniques, par rapport aux receveurs de greffe qui n'avaient pas été réadmis précocement, les patients avec une RPH présentaient un risque accru d'échec du greffon (risque relatif corrigé [RRc] : 1,46; IC 95 % : 1,29-1,65), d'échec du greffon censuré par le décès (RRc: 1,62; IC 95 % : 1,36-1,94), de décès avec un greffon fonctionnel (RRc: 1,34; IC 95 % : 1,13-1,59), de mortalité (RRc: 1,41; IC 95 % : 1,22-1,63) et de réadmission tardive au cours des premiers six mois de suivi (p. ex., entre 0 et moins de 0,25 an de suivi, le RRc était de 2,11; [IC 95 % : 1,85-2,40]). LIMITES: Nous n'avons pas été en mesure d'identifier les réadmissions qui auraient pu être prévenues et il existe un risque de facteurs de confusion résiduels. CONCLUSION: Ces résultats peuvent être employés pour identifier les receveurs d'une greffe rénale susceptibles d'être réadmis rapidement à l'hôpital. Ces résultats soulignent en outre la nécessité d'interventions pour réduire le risque de RPH. ENREGISTREMENT DE L'ESSAI: Sans objet puisqu'il s'agit d'une étude de cohorte basée sur la population et non d'un essai clinique.

How often can meta-analyses of individual-level data individualize treatment? A meta-epidemiologic study.

BACKGROUND: One of the claimed main advantages of individual participant data meta-analysis (IPDMA) is that it allows assessment of subgroup effects based on individual-level participant characteristics, and eventually stratified medicine. In this study, we evaluated the conduct and results of subgroup analyses in IPDMA. METHODS: We searched PubMed, EMBASE and the Cochrane Library from inception to 31 December 2014. We included papers if they described an IPDMA based on randomized clinical trials that investigated a therapeutic intervention on human subjects and in which the meta-analysis was preceded by a systematic literature search. We extracted data items related to subgroup analysis and subgroup differences (subgroup-treatment interaction p < 0.05). RESULTS: Overall, 327 IPDMAs were eligible. A statistically significant subgroup-treatment interaction for the primary outcome was reported in 102 (36.6%) of 279 IPDMAs that reported at least one subgroup analysis. This corresponded to 187 different statistically significant subgroup-treatment interactions: 124 for an individual-level subgrouping variable (in 76 IPDMAs) and 63 for a group-level subgrouping variable (in 36 IPDMAs). Of the 187, only 7 (3.7%; 6 individual and 1 group-level subgrouping variables) had a large difference between strata (standardized effect difference d ≥ 0.8). Among the 124 individual-level statistically significant subgroup differences, the IPDMA authors claimed that 42 (in 21 IPDMAs) should lead to treating the subgroups differently. None of these 42 had d ≥ 0.8. CONCLUSIONS: Availability of individual-level data provides statistically significant interactions for relative treatment effects in about a third of IPDMAs. A modest number of these interactions may offer opportunities for stratified medicine decisions.

Management Strategies and Patient Selection After a Hospital Funding Reform for Prostate Cancer Surgery in Canada.

Importance: Hospital funding reforms for prostate cancer surgery may have altered management of localized prostate cancer in the province of Ontario, Canada. Objective: To determine whether changes in hospital funding policy aimed at improving health care quality and value were associated with changes in the management of localized prostate cancer or the characteristics of patients receiving radical prostatectomy (RP) for localized prostate cancer. Design, Setting, and Participants: This population-based, interrupted time series study used linked population-based administrative data regarding adults in Ontario with incidental localized prostate cancer and those who underwent RP for localized prostate cancer. Patients who underwent RP were compared with patients who underwent surgical procedures for localized renal cell carcinoma, which was not included in the policy change but was subjected to similar secular trends and potential confounders. Monthly outcomes were analyzed using interventional autoregressive integrated moving average models. Data were collected from January 2011 to November 2017 and analyzed in January 2019. Exposures: Funding policy change in April 2015 from flexible block funding for all hospital-based care to prespecified payment amounts per procedure for treatment of localized prostate cancer, coupled with the dissemination of a diagnosis-specific handbook outlining best practices. Main Outcomes and Measures: Initial management (RP vs radiation therapy vs active surveillance) and tumor risk profiles per management strategy among incident cases of localized prostate cancer. Additional outcomes were case volume, mean length of stay, proportion of patients returning to hospital or emergency department within 30 days, proportion of patients older than 65 years, mean Charlson Comorbidity Index, and proportion of minimally invasive surgical procedures among patients undergoing RP for localized prostate cancer. Results: A total of 33 128 patients with incident localized prostate cancer (median [interquartile range (IQR)] age, 67 [61-73] years; median [IQR] cases per monthly observation interval, 466 [420-516]), 17 159 patients who received radical prostatectomy (median [IQR] age, 63 [58-68] years; median [IQR] cases per monthly observation interval, 209 [183-225]), and 5762 individuals who underwent surgery for renal cell carcinoma (median [IQR] age, 62 [53-70] years; median [IQR] cases per monthly observation interval, 71 [61-77]) were identified. By the end of the observation period, radical prostatectomy and radiation therapy were used in comparable proportions (30.3% and 28.9%, respectively) and included only a small fraction of low-risk patients (6.4% and 2.9%, respectively). No statistically significant association of the funding policy change with most outcomes was found. Conclusions and Relevance: The implementation of funding reform for hospitals offering RP was not associated with changes in the management of localized prostate cancer, although it may have encouraged more appropriate selection of patients for RP. Mostly preexisting trends toward guideline-conforming practice were observed. Co-occurring policy changes and/or guideline revisions may have weakened signals from the policy change.

Trends in Early Hospital Readmission After Kidney Transplantation, 2002 to 2014: A Population-Based Multicenter Cohort Study.

BACKGROUND: Early hospital readmission (EHR) is associated with morbidity, mortality, and significant healthcare costs. However, trends over time in EHR events in kidney transplant recipients have not been examined. We conducted a population-based cohort study using linked healthcare databases from Ontario, Canada, to determine whether the EHR incidence has changed from 2002 to 2014 in kidney transplant recipients. METHODS: We defined EHR as an unplanned admission for any reason to an acute care hospital within 30 days of being discharged from the hospital for transplantation; admissions for elective procedures were excluded. RESULTS: We included 5437 kidney transplant recipients. More recently transplanted recipients (2011 to 2014 vs 2002 to 2004) were older and more likely to have coronary artery disease. A total of 1128 (20.7%) kidney transplant recipients experienced an EHR. There was no trend in EHR across eras with a 30-day cumulative incidence of 23.0%, 21.4%, 18.4%, and 21.0% (P for trend =0.197) for the years 2002 to 2004, 2005 to 2007, 2008 to 2010, and 2011 to 2014, respectively. In the multivariable Cox proportional hazards model, we found no association between era of transplant and EHR. When examining variation in EHR across the 6 adult transplant centers, we found the 30-day cumulative incidence varied significantly from 15.5% to 27.1% (P < 0.001). CONCLUSIONS: One in 5 kidney transplant recipients will experience an EHR; however, an increase in EHR over time has not been observed despite increasing recipient age and comorbidities.

Evaluation of a Hockey Deceased Organ Donation Awareness Campaign: A Population-Based Cohort Study.

BACKGROUND: The Kidney Foundation of Canada developed a pilot campaign to educate persons attending junior hockey league games in London, Ontario, Canada, on deceased organ donation. OBJECTIVE: To evaluate the impact of a hockey campaign on the number of new organ and tissue donor registrants. DESIGN: Population-based retrospective cohort study. SETTING: Residents of London, Ontario. PATIENTS: We included 255 476 individuals eligible to register for organ donation with a London, Ontario postal code. MEASUREMENTS: We compared the number of new deceased organ donor registrants in London, Ontario, during the campaign period (March 12 to April 16, 2015) with 3 different time periods (December 30, 2014 to February 3, 2015; February 4 to March 11, 2015; April 17 to May 22, 2015). We also compared registration rates in London with 2 Ontario cities (Kitchener-Waterloo and Hamilton) matching in a 1:1 ratio on age, sex, and income quintile. METHODS: To compare registrations across time periods, we used binomial regression with an identity link function and generalized estimating equations with an independence correlation structure. We used modified Poisson regression to compare registration rates between cities. RESULTS: During the campaign period, there were slightly more registrations (1218 registered of 252 832 unregistered individuals [0.48%]) compared with an earlier time period (risk difference: 0.09%; 95% confidence interval [CI]: 0.05%-0.12%). However, there was no significant difference compared with 2 time periods immediately before and after the campaign. London had slightly more registrations during the campaign period compared with the matched city of Hamilton (1180 registered of 236 582 unregistered individuals [0.50%] vs 490 registered of 236 582 unregistered individuals [0.21%]; risk ratio: 2.41; 95% CI: 2.17-2.68). The registration rate in London did not significantly differ from Kitchener-Waterloo. LIMITATIONS: Unable to conclude whether the minor increase in deceased organ donor registration was the result of the campaign or other factors (e.g., simultaneous organ registration events, seasonality). CONCLUSIONS: Overall, a minor increase in deceased organ donor registration was observed during the hockey organ donation awareness campaign; however, the specific impact of the campaign on organ donor registration could not be determined.

CONTEXTE: La Fondation canadienne du rein a développé une campagne pilote pour sensibiliser les gens qui assistent à des matchs de hockey junior à London en Ontario (Canada) sur le don d'organes post-mortem. OBJECTIF DE L'ÉTUDE: Évaluer l'impact qu'une campagne de sensibilisation auprès des gens assistant à des parties de hockey pouvait avoir sur le nombre de nouvelles inscriptions à la liste des donneurs d'organes et de tissus. TYPE D'ÉTUDE: Il s'agit d'une étude rétrospective de cohorte menée au sein de la population. CADRE DE L'ÉTUDE: L'étude a été réalisée auprès de résidents de London en Ontario. PARTICIPANTS: Nous avons inclus un total de 255 476 individus ayant un code postal inscrit à London en Ontario et qui étaient admissibles à faire un don d'organe. MESURES: Nous avons répertorié le nombre de nouvelles inscriptions à la liste de donneurs d'organes à London en Ontario au cours de la période de la campagne, soit du 12 mars au 16 avril 2015. Nous avons comparé ce résultat aux nombres de nouvelles inscriptions obtenus lors de trois autres périodes, soit du 30 décembre 2014 au 3 février 2015; du 4 février au 11 mars 2015 et du 17 avril au 22 mai 2015. De plus, nous avons comparé le taux de nouvelles inscriptions de London à celui de deux autres villes de l'Ontario, soit Kitchener-Waterloo et Hamilton. La comparaison a été établie selon un ratio de 1:1 où les participants étaient appariés sur la base de leur âge, de leur sexe et de leur revenu. MÉTHODOLOGIE: Pour comparer le nombre de nouvelles inscriptions entre les périodes choisies, nous avons utilisé un modèle de régression binomiale comportant une fonction de lien d'identité, de même que des équations d'estimation généralisées avec structure de corrélation de l'indépendance. Une version modifiée du modèle de régression de Poisson a été utilisée pour comparer les taux d'inscription entre les villes. RÉSULTATS: Au cours de la campagne de sensibilisation, nous avons observé une faible hausse des inscriptions (1 218 nouvelles inscriptions [0,48%]) par rapport à une période antérieure (différence de risque: 0,09%; IC 95%: 0,05% - 0,12%). Cependant, aucune différence significative n'a été observée par rapport aux périodes immédiatement avant et après la campagne de sensibilisation. Un nombre légèrement plus élevé d'inscriptions a eu lieu dans la ville de London pour la période étudiée par rapport à la ville de Hamilton (1 180 inscrits et 236 582 non-inscrits [0,50%] contre 490 inscrits et 236 582 non-inscrits [0,21%]; risque relatif = 2,41; IC 95% = 2,17-2,68). Aucune différence significative n'a été observée entre le taux d'inscription à London et celui de Kitchener-Waterloo. LIMITES DE L'ÉTUDE: Il a été impossible de déterminer si la campagne de sensibilisation a contribué à la légère augmentation du nombre d'inscriptions à la liste de donneurs d'organes post-mortem ou si celle-ci résulte d'autres facteurs (p. ex. événements spontanés d'inscriptions à la liste des donneurs, caractère saisonnier). CONCLUSIONS: Dans l'ensemble, une légère augmentation du nombre d'inscriptions à la liste des donneurs d'organes post-mortem a été observée au cours de la campagne de sensibilisation menée pendant les parties de hockey. Toutefois, il a été impossible d'établir si la campagne de sensibilisation a eu un effet réel sur le nombre d'inscriptions.

The Risk of Cardiovascular Disease Is Not Increasing Over Time Despite Aging and Higher Comorbidity Burden of Kidney Transplant Recipients.

BACKGROUND: Cardiovascular death remains the leading cause of mortality in kidney transplant recipients. Cardiovascular events are associated with significant morbidity. However, current trends in cardiovascular events after kidney transplantation are poorly understood. METHODS: We conducted a retrospective study using healthcare databases in Ontario, Canada, to determine whether the incidence of cardiovascular events after kidney transplantation has changed from 1994 to 2009. Our primary endpoint was a 3-year composite outcome of posttransplant death or major cardiovascular event (myocardial infarction, coronary angioplasty, coronary artery bypass graft surgery, stroke). RESULTS: Recipients (n = 4954) were older and had more baseline comorbidity in recent years. A total of 445 recipients (9.0%) died or experienced a major cardiovascular event within 3 years of transplantation. There was no significant change in the incidence of the composite outcome or death-censored cardiovascular events over time (P = 0.41 and 0.92, respectively). After adjusting for age, sex, and comorbidities, the risk of death or major cardiovascular event steadily declined across the years of transplant (2006-2009 adjusted hazard ratio, 0.70; P = 0.009; referent 1994-1997). When recipients were matched on age, sex, and date of cohort entry to members of the general population and to the chronic kidney disease population, the risk was lowest in the general population and highest in the chronic kidney disease population. CONCLUSION: Despite transplant centers accepting recipients who are older with more comorbidities in recent years, the 3-year cumulative incidence of death or major cardiovascular event has remained stable over time.

Promoting deceased organ and tissue donation registration in family physician waiting rooms (RegisterNow-1 trial): study protocol for a pragmatic, stepped-wedge, cluster randomized controlled registry.

BACKGROUND: There is a worldwide shortage of organs available for transplant, leading to preventable mortality associated with end-stage organ disease. While most citizens in many countries with an intent-to-donate "opt-in" system support organ donation, registration rates remain low. In Canada, most Canadians support organ donation but less than 25% in most provinces have registered their desire to donate their organs when they die. The family physician office is a promising yet underused setting in which to promote organ donor registration and address known barriers and enablers to registering for deceased organ and tissue donation. We developed a protocol to evaluate an intervention to promote registration for organ and tissue donation in family physician waiting rooms. METHODS/DESIGN: This protocol describes a planned, stepped-wedge, cluster randomized registry trial in six family physician offices in Ontario, Canada to evaluate the effectiveness of reception staff providing patients with a pamphlet that addresses barriers and enablers to registration including a description of how to register for organ donation. An Internet-enabled tablet will also be provided in waiting rooms so that interested patients can register while waiting for their appointments. Family physicians and reception staff will be provided with training and/or materials to support any conversations about organ donation with their patients. Following a 2-week control period, the six offices will cross sequentially into the intervention arm in randomized sequence at 2-week intervals until all offices deliver the intervention. The primary outcome will be the proportion of patients visiting the office who are registered organ donors 7 days following their office visit. We will evaluate this outcome using routinely collected registry data from provincial administrative databases. A post-trial qualitative evaluation process will assess the experiences of reception staff and family physicians with the intervention and the stepped-wedge trial design. DISCUSSION: Promoting registration for organ donation in family physician offices is a potentially useful strategy for increasing registration for organ donation. Increased registration may ultimately help to increase the number of organs available for transplant. The results of this trial will provide important preliminary data on the effectiveness of using family physician offices to promote registration for organ donation. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT03213171 . Registered on 11 July 2017.

Fracture risk in kidney transplant recipients: a systematic review.

BACKGROUND: Fractures in men and women after kidney transplantation are associated with morbidity (including acute and chronic pain), mortality, and high economic costs. METHODS: We systematically reviewed cohort studies that provided estimates on incidence and risk factors for fracture in kidney transplant recipients. We abstracted data in duplicate and assessed the methodological quality of each study on a 17-point scale (17 representing the highest quality). RESULTS: We screened 2715 articles, reviewed 81, and included 10 studies totaling 262,678 recipients (study mean, 26,268 recipients; range, 61-77,430). The average follow-up ranged from 1.7 to 5.3 years. The study quality scores ranged from 8 to 13. Fracture sites varied by study resulting in a highly variable incidence rate ranging from 3.3 to 99.6 fractures per 1000 person-years. Similarly, the 5-year cumulative incidence for fracture varied ranging from 0.85% to 27%. Common factors associated with an increased fracture risk were older age, female sex, the presence of diabetes, and receipt of dialysis before transplantation. Other less common but statistically significant risk factors were a previous history of fracture and receipt of a kidney from a deceased (vs. living) donor. CONCLUSIONS: There is poor consensus on the incidence and risk factors for fractures in kidney transplant recipients. Previous studies vary substantially in quality, fracture definitions, and the characteristics of recipients studied. Future research should clarify fracture incidence and risk, which will inform the design of future prevention trials and guide prognostication.