Diabetes during pregnancy among Métis people in Alberta: a retrospective cohort study.

BACKGROUND: Diabetes in pregnancy is an important public health concern for Indigenous populations. We sought to evaluate the prevalence and outcomes of pre-existing and gestational diabetes among Métis pregnancies compared with other pregnancies in Alberta, Canada. METHODS: We conducted a retrospective cohort study using administrative health data from 2006 to 2016 and the Métis Nation of Alberta Identification Registry to compare the prevalence of pre-existing and gestational diabetes among all singleton Métis births with non-Métis births. We compared 10 maternal and neonatal outcomes using adjusted odds ratios (ORs) and 95% confidence intervals (CIs) in multivariable analyses. RESULTS: The study population included 7902 Métis and 471 886 non-Métis births. The age-standardized prevalence of pre-existing diabetes was 1.7% (95% CI 1.4%-2.1%) for Métis and 1.1% (95% CI 1.1%-1.2%) for non-Métis pregnancies. For gestational diabetes, the age-standardized prevalence was 6.3% (95% CI 5.6%-6.9%) for Métis and 5.4% (95% CI 5.3%-5.4%) for non-Métis pregnancies. After adjusting for parity, maternal weight, age, smoking during pregnancy and material and social deprivation, Métis pregnancies had 1.72 times higher prevalence of preexisting diabetes (adjusted OR 1.72, 95% CI 1.15-2.56) and 1.30 times higher prevalence of gestational diabetes (adjusted OR 1.30, 95% CI 1.08-1.57) than non-Métis pregnancies. Métis pregnancies with pre-existing diabetes had nearly 3 times the odds of developing preeclampsia (adjusted OR 2.96, 95% CI 1.27-6.90), while those with gestational diabetes had 48% higher odds of large-for-gestational-age infants (adjusted OR 1.48, 95% CI 1.00-2.19). INTERPRETATION: Métis pregnancies have an increased prevalence of pre-existing and gestational diabetes than non-Métis pregnancies and an elevated risk of some perinatal outcomes. Interventions to tackle these health inequities should address both physiologic and cultural dimensions of health, informed by Métis perspectives.

Interventions to improve consultations in the emergency department: A systematic review.

OBJECTIVES: Emergency department (ED) consultations with specialists are necessary for safe and effective patient care. Delays in the ED consultation process, however, have been shown to increase ED length of stay (LOS) and contribute to ED crowding. This review aims to describe and evaluate the effectiveness of interventions to improve the ED consultation process. METHODS: Eight primary literature databases and the gray literature were searched to identify comparative studies assessing ED-based interventions to improve the specialist consultation process. Two independent reviewers identified eligible studies, assessed study quality, and extracted data. Individual or pooled meta-analysis for continuous outcomes were calculated as mean differences (MDs) with 95% confidence intervals (CIs) using a random-effects model was conducted. RESULTS: Thirty-five unique comparative intervention studies were included. While the interventions varied, four common components/themes were identified including interventions to improve consultant responsiveness (n = 11), improve access to consultants in the ED (n = 9), expedite ED consultations (n = 8), and bypass ED consultations (n = 7). Studies on interventions to improve consult responsiveness consistently reported a decrease in consult response times in the intervention group with percent changes between 10% and 71%. Studies implementing interventions to improve consult responsiveness (MD -2.55, 95% CI -4.88 to -0.22) and interventions to bypass ED consultations (MD -0.99, 95% CI -1.43 to -0.56) consistently reported a decrease in ED LOS; however, heterogeneity was high (I2  = 99%). Evidence on whether any of the interventions were effective at reducing the proportion of patients consulted or subsequently admitted varied. CONCLUSIONS: The various interventions impacting the consultation process were predominately successful in reducing ED LOS, with evidence suggesting that interventions improving consult responsiveness and improving access to consultants in the ED also improve consult response times. Health care providers looking to implement interventions to improve the ED consultation process should identify key areas in their setting that could be targeted.

Association between the antepartum oral glucose tolerance test and the risk of future diabetes mellitus among women with gestational diabetes: A systematic review and meta-analysis.

OBJECTIVES: The antepartum oral glucose tolerance test (OGTT) has re-emerged as associated with risk of diabetes among women with gestational diabetes (GDM). This systematic review summarized evidence on associations between antepartum OGTT and risk of diabetes in GDM (PROSPERO CRD42018100316). METHODS: MEDLINE, EMBASE, Web of Science, and CENTRAL were searched from January 1, 1982 to February 2020. Studies assessing associations between antepartum OGTT and risk of diabetes among women with GDM were included. Data on study characteristics, participants, OGTT values, and diabetes outcomes were extracted. Estimates on the association between antepartum OGTT and diabetes at follow-up were recorded. Pooled odds ratios for developing diabetes were calculated by study design. FINDINGS AND CONCLUSIONS: Of 6423 citations, 17 studies were included. Both elevated fasting blood glucose (FBG; OR: 3.62 ([95% CI 1.30, 10.12], I2 = 36%, p < 0.05)) and 2 h OGTT (OR: 3.96 [1.17, 13.40], I2 = 87%, p < 0.05) were associated with diabetes. These associations were attenuated (FBG: OR: 1.91 ([95% CI 0.80, 24.54], I2 = 83%, p = NS) and 1.58 ([95% CI 0.92, 2.74] I2 = 83%, p = NS) for prospective and retrospective data, respectively; 2 h OGTT: ORa: 1.95 ([95% CI 0.43, 8.93], I2 = 94%, p = NS)) after adjustments for common confounders. Further research is needed before clinical recommendations can be made.

Prevalence of diabetes in pregnancy among Indigenous women in Australia, Canada, New Zealand, and the USA: a systematic review and meta-analysis.

BACKGROUND: Indigenous peoples in countries with similar colonial histories have disproportionate burdens of disease compared with non-Indigenous peoples. We aimed to systematically identify and collate studies describing the prevalence of pre-existing diabetes and gestational diabetes, and compare the prevalence of these conditions between Indigenous and non-Indigenous pregnant women in Australia, Canada, New Zealand, and the USA. METHODS: For this systematic review and meta-analysis, an information specialist did a comprehensive search of eight databases (Ovid MEDLINE, Ovid Embase, Ovid Global Health, CINAHL [EBSCO], Scopus, ProQuest Dissertations and Theses Global, PROSPERO, and the Wiley Cochrane Library) in June, 2019, for studies published between inception and June 25, 2019, without restrictions on language, publication type, or year of publication. Database searches were supplemented by grey literature searches of the Bielefield Academic Search Engine and Google Scholar, and the reference lists of relevant articles were also manually searched. We included observational epidemiological studies comparing the prevalence of pre-existing diabetes or gestational diabetes in Indigenous and non-Indigenous pregnant women in Australia, Canada, New Zealand, and the USA. Two independent reviewers assessed study eligibility and risk of bias. We used a standardised data extraction form to collect information from the published reports of eligible studies, and, if needed, we contacted authors for further information. We did a Mantel-Haenszel random-effects meta-analysis to obtain the pooled unadjusted prevalence odds ratios (PORs) of pre-existing diabetes and gestational diabetes in Indigenous women compared with non-Indigenous women. We stratified meta-analyses by country and type of diabetes. The study is registered with PROSPERO, number CRD42018095971. FINDINGS: Our search identified 1348 studies, of which 43 studies with 32 952 441 participants from Australia, Canada, New Zealand, and the USA were included in the systematic review, and 39 of these studies were included in the meta-analysis. 40 of the included studies used a cohort design. Pre-existing diabetes was more prevalent in Indigenous women than in non-Indigenous women, with pooled PORs ranging from 1·81 (95% CI 1·53-2·13) for women in the USA to 3·63 (2·35-5·62) for women in Australia. Similarly, gestational diabetes was more prevalent in Indigenous women than in non-Indigenous women, with PORs ranging from 1·42 (1·24-1·63) for women in Australia to 2·04 (1·46-2·84) for women in Canada. Risk of bias was low in 37·2% of studies, unclear in 34·8% of studies, and high in 27·9% of studies. Heterogeneity between studies was predominantly high (I2=97-100%), with one exception of moderate heterogeneity (I2=48%); however, the magnitude and direction of the PORs from individual studies indicated an association between pre-existing diabetes or gestational diabetes and indigeneity among pregnant women. INTERPRETATION: The prevalence of pre-existing diabetes and gestational diabetes was higher in Indigenous pregnant women than in non-Indigenous pregnant women in four countries (Australia, Canada, New Zealand and the USA) with similar histories of colonialism. These findings have implications for prenatal care services and the monitoring of Indigenous women in industrialised countries. FUNDING: Canadian Institute of Health Research and the Women's and Children's Health Research Institute.

Injury-related health services use and mortality among Métis people in Alberta.

OBJECTIVES: To examine injury-related health services use, defined as hospital admissions and emergency department (ED) visits, as well as mortality among Métis people in Alberta, and to compare those results with the entire Alberta population. METHODS: This population-based descriptive epidemiological research used administrative data maintained by the Alberta Ministry of Health (AH), for the year 2013. Hospital morbidity data and Alberta Vital Statistics registry were extracted and included a unique personal number to identify individuals across multiple records. To identify injury and mortality cases among the Métis people in Alberta, administrative databases were linked to the Métis Nation of Alberta (MNA) Identification Registry. Age-standardized rates of injury-related health services usage and mortality were calculated and compared between Métis people and the entire Alberta population. RESULTS: Age-standardized incidence rates (ASIRs) of all causes combined of injury-related visits to the ED and hospital admissions were 35% (p < 0.01) and 26% (p = 0.05) higher among Métis people compared with the overall Alberta population. Among the MNA, ASIRs of health service use were higher in rural areas (p < 0.01) and among men (p < 0.01). The injury-related mortality rate was not significantly higher among the MNA compared with the Alberta population. However, among the MNA, Métis males had a significantly higher injury mortality rate than females (p < 0.02). CONCLUSION: Results from the current study suggest that injuries are a concern among Métis people. Health planners should design and implement strategies directed to reduce the burden of injury and associated complications for Métis people, especially in rural areas and among Métis males.

Effectiveness of written action plans for acute asthma: A systematic review.

OBJECTIVE: Self-management is an essential part of achieving asthma control and improving long-term outcomes. While guidelines recommend the provision of written asthma action plans (AAPs), few patients presenting to emergency departments (ED) have one. This systematic review examined if individualized written AAPs reduce relapses in adults following an ED visit for acute asthma. DATA SOURCES: Comprehensive searches of seven electronic databases and grey literature were conducted. STUDY SELECTIONS: Randomized controlled trials (RCTs) examining the effectiveness of individualized written AAPs to reduce relapses after ED visits for acute asthma were included. Study quality was determined using the Cochrane Risk of Bias (RoB) tool; intervention fidelity was assessed. RESULTS: From 695 potentially relevant studies, three RCTs were included. The RoB was low in two studies and high in one study; description of intervention fidelity varied across studies. The provision of individualized written AAPs in adults following an ED visit for acute asthma did not reduce the risk of relapse after ED discharge (risk ratio [RR] = 0.66; 95% confidence intervals [CI]: 0.36, 1.23; I2 = 40%). There was a 49% reduction in the risk of relapse after ED discharge when only studies with low RoB were pooled (RR = 0.51; 95% CI: 0.31, 0.83; I2 = 0%). CONCLUSION: This review did not provide conclusive evidence to support the consideration of individualized written AAPs for the reduction of relapses after an ED visit; however, the low frequency of events, small number of studies and samples, and their methodological quality might play an important role in this overall finding.

Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma.

BACKGROUND: Inhaled short-acting anticholinergics (SAAC) and short-acting beta2-agonists (SABA) are effective therapies for adult patients with acute asthma who present to the emergency department (ED). It is unclear, however, whether the combination of SAAC and SABA treatment is more effective in reducing hospitalisations compared to treatment with SABA alone. OBJECTIVES: To conduct an up-to-date systematic search and meta-analysis on the effectiveness of combined inhaled therapy (SAAC + SABA agents) vs. SABA alone to reduce hospitalisations in adult patients presenting to the ED with an exacerbation of asthma. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, SCOPUS, LILACS, ProQuest Dissertations & Theses Global and evidence-based medicine (EBM) databases using controlled vocabulary, natural language terms, and a variety of specific and general terms for inhaled SAAC and SABA drugs. The search spanned from 1946 to July 2015. The Cochrane Airways Group provided search results from the Cochrane Airways Group Register of Trials which was most recently conducted in July 2016. An extensive search of the grey literature was completed to identify any other potentially relevant studies. SELECTION CRITERIA: Included studies were randomised or controlled clinical trials comparing the effectiveness of combined inhaled therapy (SAAC and SABA) to SABA treatment alone to prevent hospitalisations in adults with acute asthma in the emergency department. Two independent review authors assessed studies for inclusion using pre-determined criteria. DATA COLLECTION AND ANALYSIS: For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RR) or odds ratios (OR) with 95% confidence intervals (CI) using a random-effects model and reporting heterogeneity (I²). For continuous outcomes, we reported individual trial results using mean differences (MD) and pooled results as weighted mean differences (WMD) or standardised mean differences (SMD) with 95% CIs using a random-effects model. MAIN RESULTS: We included 23 studies that involved a total of 2724 enrolled participants. Most studies were rated at unclear or high risk of bias.Overall, participants receiving combination inhaled therapy were less likely to be hospitalised (RR 0.72, 95% CI 0.59 to 0.87; participants = 2120; studies = 16; I² = 12%; moderate quality of evidence). An estimated 65 fewer patients per 1000 would require hospitalisation after receiving combination therapy (95% 30 to 95), compared to 231 per 1000 patients receiving SABA alone. Although combination inhaled therapy was more effective than SABA treatment alone in reducing hospitalisation in participants with severe asthma exacerbations, this was not found for participants with mild or moderate exacerbations (test for difference between subgroups P = 0.02).Participants receiving combination therapy were more likely to experience improved forced expiratory volume in one second (FEV1) (MD 0.25 L, 95% CI 0.02 to 0.48; participants = 687; studies = 6; I² = 70%; low quality of evidence), peak expiratory flow (PEF) (MD 36.58 L/min, 95% CI 23.07 to 50.09; participants = 1056; studies = 12; I² = 25%; very low quality of evidence), increased percent change in PEF from baseline (MD 24.88, 95% CI 14.83 to 34.93; participants = 551; studies = 7; I² = 23%; moderate quality of evidence), and were less likely to return to the ED for additional care (RR 0.80, 95% CI 0.66 to 0.98; participants = 1180; studies = 5; I² = 0%; moderate quality of evidence) than participants receiving SABA alone.Participants receiving combination inhaled therapy were more likely to experience adverse events than those treated with SABA agents alone (OR 2.03, 95% CI 1.28 to 3.20; participants = 1392; studies = 11; I² = 14%; moderate quality of evidence). Among patients receiving combination therapy, 103 per 1000 were likely to report adverse events (95% 31 to 195 more) compared to 131 per 1000 patients receiving SABA alone. AUTHORS' CONCLUSIONS: Overall, combination inhaled therapy with SAAC and SABA reduced hospitalisation and improved pulmonary function in adults presenting to the ED with acute asthma. In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild-moderate exacerbations, who were at a lower risk to be hospitalised. A single dose of combination therapy and multiple doses both showed reductions in the risk of hospitalisation among adults with acute asthma. However, adults receiving combination therapy were more likely to experience adverse events, such as tremor, agitation, and palpitations, compared to patients receiving SABA alone.

Emergency Department Use: Influence of Connection to a Family Physician on ED Use and Attempts to Avoid Presentation.

Some low-acuity emergency department (ED) presentations are potentially avoidable with improved primary care access. The majority of ED patients (74.4%) in this study had a family physician, but the frequency of visits varied substantially. The variable frequency of patients' visits to these providers calls into question the validity of linkage assumptions. Several sociodemographic factors were associated with having a family physician, including female sex, being married/common law, race (Caucasian), being employed over the previous 12 months and having received a flu shot in the past year. These factors need to be explored further.

Low-acuity presentations to the emergency department in Canada: exploring the alternative attempts to avoid presentation.

OBJECTIVE: ED visits have been rising year on year worldwide. It has been suggested that some of these visits could be avoided if low-acuity patients had better primary care access. This study explored patients' efforts to avoid ED presentation and alternative care sought prior to presentation. METHODS: Consecutive adult patients presenting to three urban EDs in Edmonton, Canada, completed a questionnaire collecting demographics, actions attempted to avoid presentation and reasons for presentation. Survey data were cross-referenced to a minimal patient dataset containing ED and demographic information. RESULTS: A total of 1402 patients (66.5%) completed the survey. Although 89.3% of the patients felt that the ED was their best care option, the majority of patients (60.1%) sought alternative care or advice prior to presentation. Men, individuals who presented with injury only, and individuals with less than a high school education were all less likely to seek alternative care. Alternative care actions included visiting a physician (54.1%) or an alternative healthcare professional (eg, chiropractor, physiotherapist, etc; 21.2%), calling physician offices (47%) or the regional health information line (13%). Of those who called their physicians, the majority received advice to present to the ED (67.5%). CONCLUSIONS: Most low-acuity patients attempt to avoid ED presentation by seeking alternative care. This analysis identifies groups of individuals in the study region who are less likely to seek alternative care first and may benefit from targeted interventions/education. Other regions may wish to complete a similar profile to determine which patients are less likely to seek alternative care first.

Effectiveness of Educational Interventions to Increase Primary Care Follow-up for Adults Seen in the Emergency Department for Acute Asthma: A Systematic Review and Meta-analysis.

OBJECTIVES: Patients with asthma commonly present to emergency departments (ED) with exacerbations. Asthma guidelines recommend close follow-up with a primary care provider (PCP) after ED discharge; however, this linkage is often delayed or absent. The objective of this study was to assess whether ED-directed educational interventions improve office follow-up with PCPs after ED discharge for acute asthma. METHODS: Comprehensive literature searches were conducted in seven electronic databases (1946 to 2014). Randomized controlled clinical trials examining the effectiveness of educational interventions to increase office follow-up with a PCP were included. Study quality was determined using the Cochrane risk of bias tool; fidelity of the interventions was assessed using the Treatment Fidelity Assessment Grid. Using study data, risk ratios (RRs),and the number needed to treat for benefit (NNTB) with 95% confidence intervals (CI) were calculated using random-effects models. RESULTS: From 427 potentially relevant studies, five (n = 825) were included. The overall risk of bias was unclear, and the description of intervention fidelity varied across the studies. Educational interventions targeting either patients or PCPs led to a greater likelihood of having primary care follow-up after ED discharge (RR = 1.6; 95% CI = 1.31 to 1.87; I(2)  = 0%). The number needed to treat for benefit was six (95% CI = 4 to 11). No significant benefit was observed in reductions of relapses (RR = 1.3; 95% CI = 0.82 to 1.98; I(2)  = 23%) and admissions (RR = 0.51; 95% CI = 0.24 to 1.06; I(2)  = 0%). Due to the small number of studies for each comparison, publication bias was not formally assessed. CONCLUSIONS: ED-directed educational interventions targeting either patients or providers increase the chance of having office follow-up visits with PCPs after asthma exacerbations. Their impact on health-related outcomes (e.g., relapse and admissions) remains unclear.