Beta-Blockers, Digoxin, or Both Following an Incident Diagnosis of Atrial Fibrillation: A Prospective Cohort Study.

BACKGROUND: Atrial fibrillation is one of the most common arrhythmias, but the optimal drug choice for a rate control strategy remains uncertain. METHODS: A retrospective cohort claims database study of patients with an incident hospital discharge diagnosis of atrial fibrillation between 2011 and 2015. The exposure variables were a discharge prescription for beta-blockers, digoxin, or both. The primary outcome was a composite of total in-hospital mortality or a repeat cardiovascular (CV) hospitalization. Baseline confounding was controlled with propensity score inverse probability weighting using a entropy balancing algorithm and the prespecified estimand was the average treatment effect among the treated. Treatment effects for the weighted samples were calculated from a Cox proportional hazards model. RESULTS: A total of 12,723 patients were discharged on beta-blockers alone, 406 on digoxin alone, and 1499 discharged on combined beta-blocker and digoxin therapy with a median follow-up time of 356 days. After baseline covariate adjustment, the digoxin alone (hazard ratio [HR], 1.24; 95% confidence interval [CI], 0.85-1.81) and the combined group (HR, 1.09; 95% CI, 0.90-1.31) were not associated with increased risk for the composite endpoint compared with the beta- blocker-alone group. These results were robust to sensitivity analyses. CONCLUSIONS: Patients hospitalized for incident atrial fibrillation and discharged on digoxin alone or the combination of digoxin and a beta-blocker were not associated with an increase in the composite outcome of recurrent CV hospitalizations and death compared with those discharged on isolated beta-blocker therapy. However, additional studies are required to refine the precision of these estimates.

Amiodarone vs Dronedarone for Atrial Fibrillation: A Retrospective Cohort Study.

Background: Atrial fibrillation is one of the most common arrhythmias, but the optimal drug choice for a rhythm-control strategy remains uncertain. Methods: This article reports on a retrospective cohort claims database study conducted using the Truven Health Market Scan Commercial Claims and Encounters and Medicare Supplemental databases. Patients with a new diagnosis of atrial fibrillation, and a discharge date between 2011 and 2015, were included. The exposure variables of interest were a discharge prescription for amiodarone or dronedarone. The average treatment effect for the composite of total mortality or a repeat cardiovascular (CV)-related hospitalization was the primary outcome. Sensitivity analyses with other treatment effect metrics were performed. Baseline covariate imbalances between the groups were adjusted using propensity-score methods with inverse probability weighting. Results: A total of 1735 patients were discharged on amiodarone, and 338 were discharged on dronedarone, with a median follow-up time of 357 days. A total of 43 (12.7%) CV-related hospitalizations occurred in the dronedarone group, and 146 (8.4%) occurred in the amiodarone group (risk difference 4.3%, 95% confidence interval [CI] 0.4%-8.3%, P = 0.02). A total of 4 (1.2%) deaths occurred in the dronedarone group, and 31 (1.8%) deaths occurred with amiodarone (risk difference -0.6%, 95% CI -2.1%-0.9%, P = 0.6). After adjusting for baseline covariates, the dronedarone hazard ratio for the composite endpoint was 1.47 (95% CI 1.01-2.12). This result was generally robust to sensitivity analyses. Conclusion: In this incident cohort of patients hospitalized for atrial fibrillation, compared to those discharged on amiodarone, patients who received a dronedarone discharge prescription had an increase in the composite endpoint of recurrent CV-related hospitalization and death, over a median 1-year follow-up period.

Contexte: La fibrillation auriculaire est l'une des arythmies les plus fréquentes, mais ce qui constitue un choix optimal en matière de médicament dans le cadre d'une stratégie de normalisation du rythme cardiaque demeure incertain. Méthodologie: Cet article présente une étude de cohorte rétro-spective menée à partir des renseignements accessibles dans les bases de données MarketScan Commercial Claims and Encounters et Medicare Supplemental de Truven Health Analytics à propos des réclamations. Les patients qui avaient reçu leur congé de l'hôpital entre 2011 et 2015 après un nouveau diagnostic de fibrillation auriculaire ont été inclus dans l'étude. La variable d'exposition d'intérêt était la prescription d'amiodarone ou de dronédarone à la sortie de l'hôpital. L'effet moyen du traitement sur la variable composite, soit la mortalité totale et la réhospitalisation d'origine cardiovasculaire (CV), constituait le paramètre d'évaluation principal. Des analyses de sensibilité fondées sur d'autres indicateurs de l'effet du traitement ont été effectuées. Les déséquilibres intergroupes touchant les covariables de base ont été corrigés par pondération de probabilité inverse selon l'indice de propension. Résultats: À leur sortie de l'hôpital, 1 735 patients s'étaient vu prescrire de l'amiodarone et 338, de la dronédarone. Le temps de suivi médian était de 357 jours. Le nombre total d'hospitalisations d'origine CV atteignait 43 (12,7 %) sous dronédarone et 146 (8,4 %) sous amiodarone (différence de risque : 4,3 %; intervalle de confiance [IC] à 95 % : 0,4-8,3 %, P = 0,02). Par ailleurs, le nombre total de décès était de quatre (1,2 %) sous dronédarone et de 31 (1,8 %) sous amiodarone (différence de risque : -0,6 %; IC à 95 % : -2,1 %-0,9 %, P = 0,6). Après correction en fonction des covariables de base, le rapport des risques instantanés s'établissait à 1,47 (IC à 95 % : 1,01-2,12) au regard de la variable composite chez les patients sous dronédarone, et ce résultat s'est généralement maintenu dans les analyses de sensibilité. Conclusion: Au sein de la cohorte incidente de patients hospitalisés pour cause de fibrillation auriculaire, une augmentation des cas de réhospitalisation d'origine CV et de la mortalité (variable composite à l'étude) a été notée au cours d'une période médiane de suivi de un an chez les patients qui s'étaient vu prescrire de la dronédarone plutôt que de l'amiodarone à leur sortie de l'hôpital.

A longitudinal view of successful aging with HIV: role of resilience and environmental factors.

PURPOSE: The purpose of this study is to estimate the extent to which people aging with HIV meet criteria for successful aging as operationalized through HRQL and maintain this status over time. A second objective is to identify factors that place people at promise for continued successful aging, including environmental and resilience factors. METHODS: Participants were members of the Positive Brain Health Now (BHN) cohort. People ≥ 50 years (n = 513) were classified as aging successfully if they were at or above norms on 7 or 8 of 8 health-related quality of life domains from the RAND-36. Group-based trajectory analysis, regression tree analysis, a form of machine learning, and logistic regression were applied to identify factors predicting successful aging. RESULTS: 73 (14·2%) met criteria for successful aging at entry and did not change status over time. The most influential factor was loneliness which split the sample into two groups with the prevalence of successful aging 28·4% in the "almost never" lonely compared to 4·6% in the "sometimes/often" lonely group. Other influential factors were feeling safe, social network, motivation, stigma, and socioeconomic status. These factors identified 17 sub-groups with at least 30 members with the proportions classified as aging successfully ranging from 0 to 79·4%. The nine variables important to classifying successful aging had a predictive accuracy of 0.862. Self-reported cognition but not cognitive test performance improved this accuracy to 0.895. The two groups defined by successful aging status did not differ on age, sex or viral load, nadir and current. CONCLUSION: The results indicate the important role of social determinants of health in successful aging among people living with HIV.

Statin Use and Risk of Vascular Events Among Cancer Patients After Radiotherapy to the Thorax, Head, and Neck.

Background This study aimed to explore whether statins reduce radiation-induced vascular complications in cancer patients postradiotherapy to the thorax, head, and neck. Methods and Results We conducted a retrospective cohort study within a provincial linked database of 5718 cardiac patients with thorax and head or neck cancer having undergone radiotherapy between 2000 and 2011. One thousand five hundred fifty-two patients were identified as nonstatin users and 4166 as statin users. The primary outcome of interest was the composite of cerebrovascular (transient ischemic attack, and fatal or nonfatal stroke) or cardiovascular events (fatal or nonfatal myocardial infarction). Time-dependent Cox proportional hazard analyses were performed. The crude event rate was 10.31% for nonusers and 9.03% for statin users (hazard ratio of 0.92 [95% CI 0.76-1.10, P=0.3451]), over a mean time to event/censoring of 534±687 days for nonusers and 594±706 days for the statin users. After adjusting for age, sex, prior history of stroke/transient ischemic attack or myocardial infarction, diabetes mellitus, dyslipidemia, atrial fibrillation, chronic kidney disease, heart failure, and hypertension, statin use postradiotherapy was associated with a nonsignificant 15% relative risk reduction, but a strong trend toward reducing the primary outcome (hazard ratio=0.85 95% CI 0.69-1.04, P=0.0811). The use of statins was associated with a significant reduction of 32% for the outcome of stroke alone (hazard ratio=0.68, 95% CI 0.48-0.98, P=0.0368). Conclusions Statin use post radiation therapy was associated with a significant reduction in stroke, with a trend toward significantly reducing cardiovascular and cerebrovascular events.

Studying additive interaction in a healthcare database: Case study of NSAIDs, cardiovascular profiles, and acute myocardial infarction.

PURPOSE: There are clinical trial data on risk of acute myocardial infarction (MI) with nonsteroidal anti-inflammatory drugs (NSAIDs) in patients at increased cardiovascular (CV) risk requiring chronic daily treatment. This study investigated whether risks of acute MI with real-world prescription NSAIDs, such as low-dose or intermittent use, vary according to an individual's CV profile. METHODS: Nested case-control analyses were carried out on an administrative health cohort from Quebec, Canada by randomly selecting 10 controls per case matched on age ± 1 year, sex, and month and year of cohort entry. We measured the additive joint effects on acute MI of current NSAID use and presence of hypertension, coronary heart disease (CHD), history of previous MI, or concomitant use of cardioprotective aspirin. The endpoint was the relative excess risk due to interaction (RERI). To verify the robustness of interaction findings, we performed sensitivity analyses with varying specifications of NSAID exposure-related variables. RESULTS: The cohort consisted of 233 816 elderly individuals, including 21 256 acute MI cases. For hypertension, CHD, and previous MI, we identified additive interactions on MI risk with some but not all NSAIDs, which also depended on the definition of NSAID exposure. Hypertension was sub-additive with naproxen but not with the other NSAIDs. Celecoxib and CHD were sub-additive in the primary analysis only (modelling NSAID dose on index date or up to 7 days before-best-fitting base model) whereas celecoxib and rofecoxib were super-additive with a history of previous MI in the secondary analysis only (modelling NSAID use on index date). For cardioprotective aspirin we found no evidence for an additive interaction with any of the NSAIDs. CONCLUSIONS: Alternative specifications of NSAID exposure concurred in finding that concomitant use of cardioprotective aspirin does not attenuate the risks of acute MI with NSAIDs. However we were unable to demonstrate consistent interactions between an individual's cardiovascular comorbidities and NSAID-associated acute MI. Our study highlights challenges of studying additive interactions in a healthcare database and underscores the need for sensitivity analyses.

Risk of acute myocardial infarction with real-world NSAIDs depends on dose and timing of exposure.

PURPOSE: Real-life use of nonsteroidal anti-inflammatory drugs (NSAIDs) is dynamic. This study aimed to characterize the temporal association between time-varying NSAID exposure and acute myocardial infarction (MI). METHODS: Nested case-control analyses were conducted on a Quebec administrative health cohort. NSAID dose, confounders, and outcome status were determined for each day of follow-up. To better account for dose and timing of past exposures, flexible weighted cumulative exposure models were also fitted. RESULTS: The cohort consisted of 233 816 older adults including 21 256 acute MI cases. Dose-related increased risks of MI were found with current use of all NSAIDs. In models not accounting for duration of use, ORs (95%CI) for the most common current daily dose vs. no current exposure were: celecoxib 200 mg: 1.16 (1.10, 1.22), diclofenac 150 mg: 1.59 (1.38, 1.84), ibuprofen 1200 mg: 1.42 (1.17, 1.74), naproxen 750 mg: 1.38 (1.21, 1.58), and rofecoxib 25 mg: 1.54 (1.43, 1.66). Weighted cumulative exposure models confirmed that all NSAIDs-including naproxen-are associated with an increased risk of MI and suggested that doses taken up to 3 weeks ago for rofecoxib, ibuprofen, and naproxen and up to 75 days ago for diclofenac and celecoxib may contribute to the current MI risk. However, the celecoxib risk seems to require continuous use for more than 30 days, whereas for other NSAIDs, a heightened MI risk occurs within 7 days. CONCLUSIONS: Weighted cumulative exposure analysis uncovered NSAID-specific differences in the immediate MI risk and how this risk seems to accumulate. KEY POINTS Accurate assessment of drug safety requires an etiologically correct model encompassing all relevant aspects of exposure. Weighted cumulative exposure models suggest that the relative importance of past doses on the risk of MI differs among NSAIDs. All common NSAIDs are associated with an increased MI risk. Celecoxib MI risk seems to depend on continuously using the drug for more than 30 days, whereas for ibuprofen, rofecoxib, diclofenac, and naproxen, a heightened MI risk occurs within 7 days of use.

Risk of acute myocardial infarction with NSAIDs in real world use: bayesian meta-analysis of individual patient data.

Objective To characterise the determinants, time course, and risks of acute myocardial infarction associated with use of oral non-steroidal anti-inflammatory drugs (NSAIDs).Design Systematic review followed by a one stage bayesian individual patient data meta-analysis.Data sources Studies from Canadian and European healthcare databases.Review methods Eligible studies were sourced from computerised drug prescription or medical databases, conducted in the general or an elderly population, documented acute myocardial infarction as specific outcome, studied selective cyclo-oxygenase-2 inhibitors (including rofecoxib) and traditional NSAIDs, compared risk of acute myocardial infarction in NSAID users with non-users, allowed for time dependent analyses, and minimised effects of confounding and misclassification bias. Exposure and outcomes Drug exposure was modelled as an indicator variable incorporating the specific NSAID, its recency, duration of use, and dose. The outcome measures were the summary adjusted odds ratios of first acute myocardial infarction after study entry for each category of NSAID use at index date (date of acute myocardial infarction for cases, matched date for controls) versus non-use in the preceding year and the posterior probability of acute myocardial infarction.Results A cohort of 446 763 individuals including 61 460 with acute myocardial infarction was acquired. Taking any dose of NSAIDs for one week, one month, or more than a month was associated with an increased risk of myocardial infarction. With use for one to seven days the probability of increased myocardial infarction risk (posterior probability of odds ratio >1.0) was 92% for celecoxib, 97% for ibuprofen, and 99% for diclofenac, naproxen, and rofecoxib. The corresponding odds ratios (95% credible intervals) were 1.24 (0.91 to 1.82) for celecoxib, 1.48 (1.00 to 2.26) for ibuprofen, 1.50 (1.06 to 2.04) for diclofenac, 1.53 (1.07 to 2.33) for naproxen, and 1.58 (1.07 to 2.17) for rofecoxib. Greater risk of myocardial infarction was documented for higher dose of NSAIDs. With use for longer than one month, risks did not appear to exceed those associated with shorter durations.Conclusions All NSAIDs, including naproxen, were found to be associated with an increased risk of acute myocardial infarction. Risk of myocardial infarction with celecoxib was comparable to that of traditional NSAIDS and was lower than for rofecoxib. Risk was greatest during the first month of NSAID use and with higher doses.

The Association Between Home Palliative Care Services and Quality of End-of-Life Care Indicators in the Province of Québec.

CONTEXT: In Canada, governments have increased spending on home care to promote better end-of-life care. In the province of Québec, Canada, home palliative care (PC) services (HPCS) are provided by Public Local Community-Based Health Care Service providers (Centres Locaux de Services Communautaires [CLSC]) with universal coverage. Accordingly, there should be no regional variations of these services and their effect on quality of end-of-life PC (QEoLPC) indicators. OBJECTIVES: To test if all the CLSCs provided the same level of HPCS to cancer patients in the province of Québec, Canada, and the association between level of HPCS and QEoLPC indicators. METHODS: Characteristics of 52,316 decedents with cancer were extracted from administrative databases between 2003 and 2006. Two gender-specific "adjusted performance of CLSCs in delivering HPCS" models were created using gender-specific hierarchical regression adjusted for patient and CLSC neighborhood characteristics. Using the same approach, the strength of the association between the adjusted performance of CLSCs in delivering HPCS and the QEoLPC indicators was estimated. RESULTS: Overall, 27,255 (52.1%) decedents had at least one HPCS. Significant variations in the adjusted performance of CLSC in delivering HPCS were found. Higher performance led to a lower proportion of men having more than one emergency room visit during the last month of life (risk ratio [RR] 0.924; 95% CI 0.867-0.985), and for women, a higher proportion dying at home (RR 2.255; 95% CI 1.703-2.984) and spending less time in hospital (RR 0.765; 95% CI 0.692-0.845). CONCLUSION: Provision of HPCS remained limited in Québec, but when present, they were associated with improved QEoLPC indicators.

Patterns of community-based opioid prescriptions in people dying of cancer.

CONTEXT: Studies of opioid use in cancer patients have been cross-sectional or have focused on mean consumption over a specific time interval. OBJECTIVES: This study aimed to determine the temporal pattern of prescribed opioids at a population level. METHODS: Using Quebec administrative databases, we ascertained details of cancer-related deaths and filled community-based opioid prescriptions (COPs) in 48,420 decedents from 2003 to 2006. RESULTS: Using group-based trajectory modeling, based on when people started to fill COPs, our population-based study demonstrated patterns of filled COPs with six distinct trajectories. An earlier start in opioid consumption resulted in a higher group average morphine daily dose; those who were already filling COPs at study entry (5.2%) had a final dose of more than 300mg by the time of death. Remarkably, 58.8% of people had not filled COPs with a biweekly average greater than 1mg earlier than two weeks before death, marking the end of follow-up. Breast cancer in women, prostate or colorectal cancer in men, and younger age and multiple myeloma in both sexes were positively associated with earlier filling of COPs. CONCLUSION: Patients dying of cancer require increasing doses of opioids over time; although we cannot distinguish the relative contributions of disease progression and opioid tolerance, age and certain cancers seem related to this phenomenon. Given the potentially prohibitive cost of prospective epidemiological studies, more elaborate clinical administrative databases that include regular pain assessment are necessary to determine optimal opioid use and factors associated with dose increases over time at a population level.

Effect of oral bisphosphonates for osteoporosis on development of skeletal metastases in women with breast cancer: results from a pharmaco-epidemiological study.

BACKGROUND: Treatment with bisphosphonates in women with breast cancer and established bone metastasis delays further skeletal-related events. Evidence is emerging that bisphosphonates are beneficial for secondary prevention of bone metastasis. The study aimed to estimate the effect of oral bisphosphonates for treatment or prevention of osteoporosis on development of bone metastasis in a population of women with breast cancer. METHODS: A historical cohort of 21664 women diagnosed with breast cancer was created from health administrative data in Quebec, Canada. The primary outcome was time to develop bone metastasis; exposure was bisphosphonate use prediagnosis, postdiagnosis, both, or neither and a cumulative index of drug exposure. The sample was stratified according to stage (0-II or III) at time of diagnosis. Cox proportional hazards tested the effect of bisphosphonate use on time to develop bone metastases. RESULTS: Taking bisphosphonates postdiagnosis of breast cancer only or continuing bisphosphonates started prior to diagnosis after diagnosis was associated with a reduction in risk of bone metastasis from 45% to 28% in women with local disease at diagnosis. In women with regional disease, postdiagnosis bisphosphonate use, with or without prediagnosis use, reduced risk by almost 50%. A statistically significant dose-response trend was observed relating increased use to lower risk (slope = 0.94, 95% confidence interval = 0.90 to 0.99). Bisphosphonates were also associated with a decreased risk of all-cause mortality similar to that of the development of bone metastasis. CONCLUSION: Low-dose oral bisphosphonates administered for prevention or treatment of postmenopausal osteoporosis were associated with lower risk of skeletal metastasis in patients with early- or more advanced-stage breast cancer.

Telepathology for intraoperative consultations and expert opinions: the experience of the Eastern Québec Telepathology Network.

CONTEXT: The Eastern Québec Telepathology Network was created to provide uniform diagnostic telepathology services in a huge territory with a low population density. OBJECTIVES: To evaluate the diagnostic concordance and turnaround times of intraoperative consultations (IOCs) and the turnaround time of expert opinions by telepathology. DESIGN: For the IOC part of the study, the first 104 IOC diagnoses from a single hospital were compared with those in the final pathology report. The turnaround time of the IOC was calculated from the arrival of the specimen at the pathology laboratory until the time of the call to the surgeon. For the expert opinion part of this study, the first 94 expert opinions from 5 hospitals were reviewed by comparing the time of the initial request until the time of the final report. RESULTS: Of the 104 cases in the IOC study, 8 diagnoses (7.7%) were slightly discrepant because of differences in terminology but remained in the same category of interpretation. Two cases (1.9%) were significantly discordant. Therefore, 102 cases (98.1%) were either concordant or had no clinically significant discrepancies. The average turnaround time for IOCs was 20 minutes (range, 8-43). For the expert opinion part of the study, reports were signed out within 24 hours in 64 cases (68%) and within 72 hours in 80 cases (85.1%). CONCLUSIONS: The Eastern Québec Telepathology Network allows a rapid, high-quality IOC service to be maintained for a hospital where no pathologist was available on site. It also provides a fast, expert opinion service to pathologists working alone.

Patterns of care at end of life for people with primary intracranial tumors: lessons learned.

To determine the variability in processes of care in the last 6 months of life experienced by patients dying of primary intracranial tumors and potential predictors of place of death, a death-backwards cohort was assembled using historical data and 1,623 decedents were identified. 90 % of people had ≥ 1 admission to an acute care hospital and 23 % spent ≥ 3 months of their last 6 months of life in acute care. 44 % had ≥ 1 ER visits and 30 % were admitted ≥ 1 times to ICU. Only 18 % had a home visit by a physician. 10 % died at home but 49 % died in hospital, while 40 % died in a palliative care facility. Age, comorbidities, and being diagnosed with grade 4 astrocytoma were associated with greater burden of care. Level of care burden and age were associated with higher odds of dying in a treatment intensive place of death, being diagnosed with grade 4 astrocytoma had opposite effect. Despite valuable research efforts to improve the treatment of primary intracranial tumors that focus on biology, refinements to surgery, radiation, and chemotherapy, there is also room to improve aspects of care at the end of life situation. An integrative approach for this patients' population, from diagnosis to death, could potentially reduce the care burden in the final period on the health care system, patient's family and improve access to a better place of death.

MyRisk_Stroke Calculator: A Personalized Stroke Risk Assessment Tool for the General Population.

BACKGROUND AND PURPOSE: There is a variety of stroke risk factors, and engaging individuals in reducing their own personal risk is hugely relevant and could be an optimal dissemination strategy. The aim of the present study was to estimate the stroke risk for specific combinations of health- and lifestyle-related factors, and to develop a personalized stroke-risk assessment tool for health professionals and the general population (called the MyRisk_Stroke Calculator). METHODS: This population-based, longitudinal study followed a historical cohort formed from the 1992 or 1998 Santé Québec Health Surveys with information for linkage to health administrative databases. Stroke risk factors were ascertained at the time of survey, and stroke was determined from hospitalizations and death records. Cox proportional hazards models were used, modeling time to stroke in relationship to all variables. RESULTS: A total of 358 strokes occurred among a cohort of 17805 persons (men=8181) who were followed for approximately 11 years (i.e., -200000 person-years). The following regression parameters were used to produce 10-year stroke-risk estimates and assign risk points: for age (1 point/year after age 20 years), male sex (3 points), low education (4 points), renal disease (8 points), diabetes (7 points), congestive heart failure (5 points), peripheral arterial disease (2 points), high blood pressure (2 points), ischemic heart disease (1 point), smoking (8 points), >7 alcoholic drinks per week (3 points), low physical activity (2 points), and indicators of anger (4 points), depression (4 points), and anxiety (3 points). According to MyRisk_Stroke Calculator, a person with <50, 75, and 90 risk points has a 10-year stroke risk of <3%, 28%, and >75%, respectively. CONCLUSIONS: The MyRisk_Stroke Calculator is a simple method of disseminating information to the general population about their stroke risk.

The effect of obesity on antibiotic treatment failure: a historical cohort study.

PURPOSE: Obesity, a major health issue, is also an important risk factor for infections. Evidence demonstrates that excess weight affects the disposition of antibiotics but little work has been done to explore if this results in antibiotic treatment failure (ATF). ATF has serious adverse health outcomes and may increase treatment resistance. Given that obese patients often have other health issues, it is important to determine if excess weight independently increases the likelihood of ATF. METHODS: Consenting patients (N = 18 014), randomly sampled from Santé Québec Health surveys (1992, 1998), were linked with administrative health databases. Patients were within the normal, overweight, and obese weight categories aged 20-79 years old, receiving at least one course of antibiotic therapy from the survey date until December 2005. ATF was defined as any additional antibiotic prescriptions or hospitalizations for infections within the 30 days after initial therapy. Logistic regression was used to assess the impact of excess weight on ATF after adjusting for patient characteristics, comorbidities, history of antibiotic use, antibiotic resistance, and flu season. RESULTS: Of the final sample size (N = 6 179), 39.0% were overweight and 21.4% were obese. The most frequently prescribed antibiotics were amoxicillin (16.0%), ciprofloxacin (9.2%), phenoxymethylpenicillin (8.8%), trimethroprim/sulfamethoxazole (8.6%), and clarithromycin (8.5%). ATF occurred in 828 (13.4%) of the 6 179 study patients. Obesity was a significant predictor of ATF (adjusted OR 1.26; 95% CI 1.03-1.52). CONCLUSION: Obesity is a significant risk factor for ATF, and this association may be due to the current "one size fits all" dosing strategy, which warrants further investigation.

Improving post-stroke health outcomes: can facilitated care help?

OBJECTIVES: The objectives of this study were (1) identifying the patterns of post-stroke care, (2) determining the care-provider and patient characteristics associated with optimal management of post-stroke care and (3) estimating the potential influence of various facilitated care policies on outcomes. METHODOLOGY: The 3946 subjects included in the study were admitted to one of Quebec's acute-care hospitals with confirmed diagnosis of stroke and subsequently discharged to their home. The records related to fee-for-service billings of this sample were obtained for the 3 months following discharge and used to define the care-provider path for each stroke survivor. These paths were analyzed and the potential impact of various facilitated care interventions was estimated via a Markov model. RESULTS: The rate of mortality for this sample was 3.2% during the first 3 months after discharge. For the patients who were re-hospitalized, however, the mortality rates were up to 10.3% depending on the care-provider visited prior to re-hospitalization. Our analyses indicate that by avoiding such critical sub-paths via facilitated care, it is possible to achieve improvements in health outcomes as well as cost. DISCUSSION: There is a window of opportunity for improving community-based post-stroke care. Facilitated care policies concerning planned visits upon discharge from hospital or following ER visits can improve the outcomes.

Bridging the gap: the effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke.

OBJECTIVES: to test the hypothesis as to whether persons newly discharged into the community following an acute stroke and assigned a stroke case manager would experience, compared to usual post-hospital care, better health-related quality of life (HRQL), fewer emergency room visits and less non-elective hospitalisations. DESIGN: a stratified, balanced, evaluator-blinded, randomised clinical trial. SETTING: five university-affiliated acute-care hospitals in Montreal, Quebec, Canada. PARTICIPANTS: persons (n = 190) returning home directly from the acute-care hospital following a first or recurrent stroke with a need for health care supervision post-discharge because of low function, co-morbidity, or isolation. INTERVENTION: for 6 weeks following hospital discharge a nurse stroke care manager maintained contact with patients through home visits and telephone calls designed to coordinate care with the person's personal physician and link the stroke survivor into community-based stroke services. MEASUREMENTS: the primary outcome was the Physical Component Summary (PCS) of the Short-Form (SF)-36 survey. A secondary outcome was utilisation of health services. Also measured was the impact of stroke on functioning. Measurements were made at hospital discharge (baseline), following the 6-week intervention and at 6-months post-stroke. RESULTS: the average age of the participants was 70 years. Discharge was achieved on average 12 days post-stroke and most participants had had a stroke of moderate severity. There were no differences between groups on the primary outcome measure, health services utilisation, or any of the secondary outcome measures. CONCLUSION: for this population, there was no evidence that this type of passive case management inferred any added benefit in terms of improvement in health-related quality of life or reduction in health services utilisation and stroke impact, than usual post-discharge management.

The evolution of stroke in Quebec: a 15-year perspective.

OBJECTIVE: To estimate changes in rates of cerebral infarction and intracerebral hemorrhage, comorbidity profile, and case fatality rates in Quebec over 15 years. METHODS: A population-based admission-to-discharge cohort study was conducted, selecting first stroke events from hospital discharge data (MedEcho) from 1988 to 2002. RESULTS: In this study (involving 101,831 persons with cerebral infarctions and 11,215 persons with intracerebral hemorrhages), there was a downturn in the rates of cerebral infarction over 15 years, especially during the last 5 years (32.5% decline for men and 25.5% for women). A concomitant increase in rates of intracerebral hemorrhage, 28% increase for men (2%/year) and 22% for women (1.6%/year), was also noted. Although age and comorbidity of the population increased, case fatality decreased over time. Age and type of stroke were strong predictors for early (< or =7 days) and later (8 to 30 days) case fatality, whereas comorbidity was important only for later death. In-hospital bed stay declined dramatically over time for all discharge destinations. CONCLUSIONS: A significant decrease in rates of cerebral infarction and a rise in rates of intracerebral hemorrhage were noted in Quebec over 15 years. Age and comorbidity of the population increased. Although stroke is increasingly a condition of the elderly, ill population, case fatality and in-hospital bed stay declined over time.

Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly?

BACKGROUND: Case-mix adjustment is widely used in health services research to ensure that groups being compared are equivalent on variables predicting outcome. There has been considerable development and testing of comorbidity indices derived from diagnostic codes recorded in administrative databases, but increasingly, the benefit of clinical information and patient reported ratings of health and functional status is being recognized. One type of information that is highly valued but has so far not been captured by administrative health databases is functional status indicators (FSI). OBJECTIVE: The purpose of this study was to estimate the extent to which prediction of health outcomes can be improved on by including information on functional status indicators (FSI). RESEARCH DESIGN: The data for the current study was obtained from a clustered randomized trial evaluating computerized decision support for managing drug therapy in the elderly, conducted from 1997 to 1998. A total of 107 primary care physicians participated in this trial and 6465 of their patients (51%) completed a generic health status measure-the SF-12-before the intervention. C statistics and R were used to compare the predictive value of sociodemographic factors, 2 comorbidity indices, and 11 FSI predictor variables derived from the SF-12 and coded (possible for 8) using the International Classification of Functioning (ICF). RESULTS: Using stepwise logistic regression, FSI, particularly limitation in stair climbing or doing moderate activities like housework, were found to be strong and independent predictors of all outcomes, even after controlling for sociodemographics and comorbidity. CONCLUSION: This study indicates that FSI provided as robust a prediction of health events as did complex comorbidity indices. Additionally, the ICF coding system provides a mechanism whereby information on FSI could be incorporated into administrative databases through the use of electronic health records that include a health or functional status measure.