A modeling study exploring the impact of homelessness on rostered primary care utilization in Calgary, Canada.

OBJECTIVE: For patients who belonged to physician rosters at a family medicine practice in the core of Calgary, Canada, we compared primary care utilization for those who were stably housed and those experiencing homelessness. METHODS: This retrospective chart review accessed electronic medical record data for rostered patients who visited their family physician between July 1, 2015 and August 31, 2016. We assessed the association between homelessness status (defined as having been sheltered in overnight shelters and/or emergency/provisional housing during the study period) and the rate of visits to primary care (defined as the count of visits associated with a patient accounting for the length of the patient's relationship with their family physician) using multivariate negative binomial regression. RESULTS: We analyzed 1013 patients belonging to three family physician rosters, of whom 112 experienced homelessness during the study period (11.1%). The mean number of visits for patients who experienced homelessness was 9.6 (SD 10.5), compared to 4.2 (SD 3.6) visits for stably housed patients (p < 0.0001). The rate of accessing primary care for patients experiencing homelessness was 2.02 times greater than the rate for stably housed individuals (rate ratio [RR] 2.02, 95% confidence interval [95% CI] 1.74-2.35; p < 0.0001). CONCLUSION: In the context of an inner-city primary care clinic in Calgary, Canada, homelessness status is associated with an increased rate of visits to primary care. This work has implications for public health and health systems decision-makers involved in developing equitable health policy, as well as for frontline care providers who serve this vulnerable population.

Incidence of Diabetes in Colorectal Cancer Survivors.

BACKGROUND: A higher risk of colorectal cancer (CRC) in patients with diabetes has been well documented. However, little is known regarding diabetes incidence in CRC survivors. This may have substantial impact on CRC survivorship care as well as enhancing the understanding of the interplay between the two diseases. We explored whether the incidence of diabetes was higher among patients with CRC than matched control subjects. METHODS: Using population-based data from Ontario, Canada, we generated a dataset comprising 39 707 incident CRC cases and 198 535 age- and sex-matched control subjects (1:5) dating from April 2002 to March 2010. We used cause-specific hazard models to estimate the hazard ratios (HRs) for diabetes overall and in subgroups stratified by receipt of systemic chemotherapy, diagnosis of metastatic disease, and site of cancer. RESULTS: During a mean follow-up of 4.81 years, the association between CRC and diabetes varied: The rate of developing diabetes was 53% higher among CRC patients compared with control subjects in the first year postdiagnosis (HR = 1.53, 95% confidence interval [CI] = 1.42 to 1.64) and remained increased by 19% in the fifth year postdiagnosis (HR = 1.19, 95% CI = 1.05 to 1.35). Findings were similar in subgroups of patients who had colon cancer, received systemic chemotherapy, or had no evidence of metastasis. CONCLUSION: We found that CRC patients were statistically significantly more likely to develop subsequent diabetes than persons without CRC for up to five years after the diagnosis. Our study suggests that active screening and counseling regarding modifiable risk factors may be warranted in this high-risk group.

Surveillance in Patients With Barrett's Esophagus for Early Detection of Esophageal Adenocarcinoma: A Systematic Review and Meta-Analysis.

OBJECTIVES: Although endoscopic surveillance of patients with Barrett's esophagus (BE) has been widely implemented for early detection of esophageal adenocarcinoma (EAC), its justification has been debated. This systematic review aimed to evaluate benefits, safety, and cost effectiveness of surveillance for patients with BE. METHODS: MEDLINE, EMBASE, EconLit, Scopus, Cochrane, and CINAHL were searched for published human studies that examined screening practices, benefits, safety, and cost effectiveness of surveillance among patients with BE. Reviewers independently reviewed eligible full-text study articles and conducted data extraction and quality assessment, with disagreements resolved by consensus. Random effects meta-analyses were performed to assess the incidence of EAC, EAC/high-grade dysplasia (HGD), and annual stage-specific transition probabilities detected among BE patients under surveillance, and relative risk of mortality among EAC patients detected during surveillance compared with those not under surveillance. RESULTS: A total of 51 studies with 11,028 subjects were eligible; the majority were of high quality based on the Newcastle-Ottawa quality scale. Among BE patients undergoing endoscopic surveillance, pooled EAC incidence per 1,000 person-years of surveillance follow-up was 5.5 (95% confidence interval (CI): 4.2-6.8) and pooled EAC/HGD incidence was 7.7 (95% CI: 5.7-9.7). Pooled relative mortality risk among surveillance-detected EAC patients compared with nonsurveillance-detected EAC patients was 0.386 (95% CI: 0.242-0.617). Pooled annual stage-specific transition probabilities from nondysplastic BE to low-grade dysplasia, high-grade dysplasia, and EAC were 0.019, 0.003, and 0.004, respectively. There was, however, insufficient scientific evidence on safety and cost effectiveness of surveillance for BE patients. CONCLUSIONS: Our findings confirmed a low incidence rate of EAC among BE patients undergoing surveillance and a reduction in mortality by 61% among those who received regular surveillance and developed EAC. Because of knowledge gaps, it is important to assess safety of surveillance and health-care resource use and costs to supplement existing evidence and inform a future policy decision for surveillance programs.