RÉSUMÉ
OBJECTIVE: To examine the association between Muslim religious affiliation and suicide and self-harm presentations among first- and second-generation immigrant youth. METHODS: We performed a population-based cohort study involving individuals aged 12 to 24 years, living in Ontario, who immigrated to Canada between 1 January 2003 and 31 May 2017 (first generation) and those born to immigrant mothers (second generation). Health administrative and demographic data were used to analyze suicide and self-harm presentations. Sex-stratified logistic regression models generated odds ratios (OR) for suicide and negative binomial regression models generated rate ratios (aRR) for self-harm presentations, adjusting for refugee status and time since migration. RESULTS: Of 1,070,248 immigrant youth (50.1% female), there were 129,919 (23.8%) females and 129,446 (24.2%) males from Muslim-majority countries. Males from Muslim-majority countries had lower suicide rates (3.8/100,000 person years [PY]) compared to males from Muslim-minority countries (5.9/100,000 PY) (OR: 0.62, 95% CI, 0.42-0.92). Rates of suicide between female Muslim-majority and Muslim-minority groups were not different (Muslim-majority 1.8/100,000 PY; Muslim-minority 2.2/100,000 PY) (OR: 0.82, 95% CI, 0.46-1.47). Males from Muslim-majority countries had lower rates of self-harm presentations than males from Muslim-minority (<10%) countries (Muslim majority: 12.2/10,000 PY, Muslim-minority: 14.1/10,000 PY) (aRR: 0.82, 95% CI, 0.75, 0.90). Among female immigrants, rates of self-harm presentations were not different among Muslim-majority (30.1/10,000 PY) compared to Muslim-minority (<10%) (32.9/10,000 PY) (aRR: 0.93, 95% CI, 0.87-1.00) countries. For females, older age at immigration conferred a lower risk of self-harm presentations. CONCLUSION: Being a male from a Muslim-majority country may confer protection from suicide and self-harm presentations but the same was not observed for females. Approaches to understanding the observed sex-based differences are warranted.
Sujet(s)
Émigrants et immigrants , Comportement auto-agressif , Suicide , Humains , Mâle , Femelle , Adolescent , Ontario/épidémiologie , Études de cohortes , Islam , Comportement auto-agressif/épidémiologieRÉSUMÉ
PURPOSE: Continuity is a core component of primary care and known to differ by patient characteristics. It is unclear how primary care physician payment and organization are associated with continuity. METHODS: We analyzed administrative data from 7,110,036 individuals aged 16+ in Ontario, Canada who were enrolled to a physician and made at least 2 visits between October 1, 2017 and September 30, 2019. Continuity with physician and practice group was quantified using the usual provider of care index. We used log-binomial regression to assess the relationship between enrollment model and continuity adjusting for patient characteristics. RESULTS: Mean physician and group continuity were 67.3% and 73.8%, respectively, for patients enrolled in enhanced fee-for-service, 70.7% and 76.2% for nonteam capitation, and 70.6% and 78.7% for team-based capitation. These differences were attenuated in regression models for physician-level continuity and group-level continuity. Older age was the most notable factor associated with continuity. Compared with those 16 to 34, those 80 and older had 1.45 times higher continuity with their physician. CONCLUSION: Our results suggest that continuity does not differ substantially by physician payment or organizational model among primary care patients who are formally enrolled with a physician in a setting with universal health insurance.
Sujet(s)
Médecins , Soins de santé primaires , Humains , Rémunération par capitation , Prestations des soins de santé , Régimes de rémunération à l'acte , Ontario , Continuité des soinsRÉSUMÉ
BACKGROUND: Despite the increase in nurse practitioners (NPs) working in primary healthcare, little standardized data are available to understand NP activities at the system level. The Nurse Practitioner Access Reporting system (NPAR), a pilot project underway at 40 family health teams in Ontario, involves NPs recording and submitting standardized codes. The codes are intended to reflect NPs' clinical activities, using an existing physician claim system. The study compared how well data collected through NPAR reflect NPs' activities. METHODS: The mixed-methods approach was used involving NPAR data, focus groups and time and motion data. RESULTS: All data sources indicated that NPs spent the majority of their time on direct patient care. Qualitative data and time and motion data revealed gaps in NPAR data, for example, codes that fail to capture activities unique to the NP role. CONCLUSION: Analysis of NPAR, time and motion and qualitative data provided a distinctive opportunity to examine NP-reported activities and patient characteristics; however, NPAR data did not adequately describe the scope or breadth of activities of NPs practising in primary healthcare.
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Santé de la famille/classification , Mémorisation et recherche des informations/normes , Infirmières praticiennes/tendances , Santé de la famille/statistiques et données numériques , Main-d'oeuvre en santé/statistiques et données numériques , Main-d'oeuvre en santé/tendances , Humains , Infirmières praticiennes/statistiques et données numériques , OntarioRÉSUMÉ
BACKGROUND: Young maternal age is associated with lower birthweight and higher rates of preterm birth and childhood hospitalisations. Internationally, teen pregnancy rates vary widely, reflecting differences in social, welfare, and health care factors in different cultural contexts. OBJECTIVES: To determine whether the increased risk of adverse infant outcomes among teenage mothers varies by country, reflecting different national teenage birth rates and country-specific social/welfare policies, in Scotland (higher teenage pregnancy rates), England, New South Wales (NSW; Australia), Ontario (Canada), and Sweden (lower rates). METHODS: We used administrative hospital data capturing 3 002 749 singleton births surviving to postnatal discharge between 2010 and 2014 (2008-2012 for Sweden). We compared preterm birth (24-36 weeks' gestation), mortality within 12 months of postnatal discharge, unplanned hospital admissions, and emergency department visits within 12 months of postnatal discharge, for infants born to mothers aged 15-19, 20-24, 25-29, and 30-34 years. RESULTS: Compared to births to women aged 30-34 years, risks of adverse outcomes among teenage mothers were higher in all countries, but the magnitude of effects was not related to country-specific rates of teenage births. Teenage mothers had between 1.2% (95% confidence interval [CI] 0.7, 1.7, Sweden) and 2.0% (95% CI 1.4, 2.5, NSW) more preterm births, and between 9.8 (95% CI 7.2, 12.4, England) and 19.7 (95% CI 8.7, 30.6, Scotland) more deaths per 10 000 infants, compared with mothers aged 30-34. Between 6.4% (95% CI 5.5, 7.4, NSW) and 25.4% (95% CI 24.7, 26.1, Ontario), more infants born to teenage mothers had unplanned hospital contacts compared with those born to mothers aged 30-34. CONCLUSIONS: Regardless of country, infants born to teenage mothers had universally worse outcomes than those born to older mothers. This excess risk did not vary by national rates of livebirths to teenage mothers. Current mechanisms to support teenage mothers have not eliminated maternal age-related disparities in infant outcomes; further strategies to mitigate excess risk in all countries are needed.
Sujet(s)
Naissance prématurée , Adolescent , Enfant , Études de cohortes , Femelle , Hôpitaux , Humains , Nourrisson , Nouveau-né , Mères , Ontario , Grossesse , Issue de la grossesse/épidémiologie , Naissance prématurée/épidémiologieRÉSUMÉ
Importance: Prescribing the first biologic treatment for rheumatoid arthritis (RA) is an important decision for patients, their physicians, and payers, with considerable costs and clinical implications. Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) have known effectiveness and safety profiles and are less expensive; therefore, determining the variables contributing to csDMARD treatment duration is an essential question for patients, physicians, and payers. Objectives: To describe access to the first biologic DMARD prescription in a population of patients with RA and identical comprehensive health insurance coverage in Ontario, Canada, and to explore the associations of patient, prescriber, and geographic region with differences in time to first biologic prescription. Design, Setting, and Participants: This cohort study of incident patients with RA used administrative data with surveillance and patient-level data collected at yearly intervals. A total of 17â¯672 patients were included in the study; they were residents of Ontario, Canada, had an incident RA diagnosis at age 67 or older between 2002 and 2015, and received at least 1 csDMARD. Data were analyzed in November 2017. Exposure: Patient variables were age, sex, disease duration, socioeconomic status, distance to care, and supply of care in the patient's area of residence. Prescriber covariates were year of graduation, specialty of practice, and supply of rheumatologic care in the patient's geographic region. Main Outcomes and Measures: Time from first csDMARD prescription to receipt of first biologic medication. Results: Of 17â¯672 patients, 11â¯598 (65.6%) were women, and the mean (SD) age was 75.2 (5.8) years. Characteristics associated with longer time to receipt of a biologic prescription were older age (HR for every 5-year increase, 0.66; 95% CI, 0.62-0.71; P < .001), male sex (HR, 0.76; 95% CI, 0.66-0.89; P < .001), and distance to the nearest rheumatologist (HR per 10-km increase, 0.99; 95% CI, 0.98-0.99; P < .001). Prescribers were primarily rheumatologists (151 of 214 [70.6%]) and primary care physicians (26 of 214 [12.1%]). After adjusting for the number of patients eligible to receive biologic DMARDs, rheumatologists' preferences (ie, yearly prescription rates) for using biologic DMARDs increased over time, from 1.7% in 2001 to 4.9% in 2015. After adjusting for calendar year and patient-, prescriber-, and region-level characteristics, substantial variation between prescribers in rates of prescribing a first biologic DMARD were found (65% variance). Conclusions and Relevance: This study found variation in time to receipt of first biologic DMARD after prescription of first csDMARD in a population with RA after adjustment for individual-level patient, prescriber, and geographic area covariates, despite identical universal health insurance coverage.
Sujet(s)
Antirhumatismaux/usage thérapeutique , Polyarthrite rhumatoïde/traitement médicamenteux , Produits biologiques/usage thérapeutique , Types de pratiques des médecins/statistiques et données numériques , Ordonnances/statistiques et données numériques , Sujet âgé , Sujet âgé de 80 ans ou plus , Études de cohortes , Femelle , Géographie , Humains , Couverture d'assurance , Mâle , Ontario , Soins de santé primaires/statistiques et données numériques , Rhumatologues/statistiques et données numériquesRÉSUMÉ
Primary care payment reform in the US and elsewhere usually involves capitation, often combined with bonuses and incentives. In capitation systems, providing care within the practice group is needed to contain costs and ensure continuity of care, yet this is challenging in settings that allow patient choice in access to services. We used linked population-based administrative databases in Ontario, Canada, to examine a substantial payment called the "access bonus" designed to incentivize primary care access and to minimize primary care visits outside of capitation practices. We found that the access bonus flowed disproportionately to physicians outside large cities and to those whose patients made fewer primary care visits, received less after-hours care, made more emergency department visits, and had higher adjusted ambulatory costs. Our findings indicate a lack of alignment between these payments and their intended purpose. Financial incentives should be prospectively evaluated and frequently revisited to ensure relevance, alignment with system goals, efficiency, and equity.
Sujet(s)
Régimes de rémunération à l'acte/économie , Réforme des soins de santé/législation et jurisprudence , Personnel de santé/organisation et administration , , Soins de santé primaires/organisation et administration , Remboursement incitatif/économie , Canada , Rémunération par capitation , Bases de données factuelles , Femelle , Dépenses de santé , Humains , Mâle , Ontario , Études rétrospectives , RécompenseRÉSUMÉ
INTRODUCTION: Opioid-related mortality appears to be increasing in Canada. We examined the true extent of the problem and the impact of the introduction of long-acting oxycodone. METHODS: We examined trends in the prescribing of opioid analgesics in the province of Ontario from 1991 to 2007. We reviewed all deaths related to opioid use between 1991 and 2004. We linked 3271 of these deaths to administrative data to examine the patients' use of health care services before death. Using time-series analysis, we determined whether the addition of long-acting oxycodone to the provincial drug formulary in January 2000 was associated with an increase in opioid-related mortality. RESULTS: From 1991 to 2007, annual prescriptions for opioids increased from 458 to 591 per 1000 individuals. Opioid-related deaths doubled, from 13.7 per million in 1991 to 27.2 per million in 2004. Prescriptions of oxycodone increased by 850% between 1991 and 2007. The addition of long-acting oxycodone to the drug formulary was associated with a 5-fold increase in oxycodone-related mortality (p<0.01) and a 41% increase in overall opioid-related mortality (p=0.02). The manner of death was deemed unintentional by the coroner in 54.2% and undetermined in 21.9% of cases. Use of health care services in the month before death was common: for example, of the 3066 patients for whom data on physician visits were available, 66.4% had visited a physician in the month before death; of the 1095 patients for whom individual-level prescribing data were available, 56.1% had filled a prescription for an opioid in the month before death. INTERPRETATION: Opioid-related deaths in Ontario have increased markedly since 1991. A significant portion of the increase was associated with the addition of long-acting oxycodone to the provincial drug formulary. Most of the deaths were deemed unintentional. The frequency of visits to a physician and prescriptions for opioids in the month before death suggests a missed opportunity for prevention.
Sujet(s)
Analgésiques morphiniques/intoxication , Oxycodone/usage thérapeutique , Médicaments sur ordonnance/intoxication , Analgésiques morphiniques/usage thérapeutique , Prestations des soins de santé/statistiques et données numériques , Humains , Mortalité/tendances , Ontario/épidémiologie , Intoxication/mortalité , Intoxication/prévention et contrôle , Médicaments sur ordonnance/usage thérapeutiqueRÉSUMÉ
Influenza vaccination has been associated with adverse events including Guillain-Barré syndrome. Because the safety of influenza vaccination in patients with myasthenia gravis (MG) has not been established, some clinicians discourage vaccination for these patients. We explored whether the administration of influenza vaccine to patients with MG might increase the risk of myasthenic crisis. Using population-based healthcare data from Ontario, Canada, from 1992 to 2007, we utilized the self-matched, case-series method of detecting adverse events following vaccination. We studied patients with established myasthenia who were hospitalized for MG within 42 weeks of influenza vaccination. We defined the primary risk interval as the 6 weeks following vaccination. Between January 1, 1992 and March 31, 2006, we identified 3667 hospital admissions for MG. No seasonal trend in MG admissions was evident. In 513 instances, hospitalization occurred within 42 weeks following vaccination in patients previously diagnosed with MG. Among these patients, 266 (52%) were men, the median age was 74 years, and 86 (17%) had previously undergone thymectomy. The estimated relative incidence of admission for MG in the primary risk interval compared with the control interval was 0.84 (95% confidence interval 0.65-1.09). We found similar results in stratified analyses according to gender, age, and thymectomy status. Vaccination of patients with MG against influenza was not found to be associated with exacerbations of the disease. Our findings do not support the practice of withholding influenza vaccination in patients with MG.
Sujet(s)
Sous-type H1N1 du virus de la grippe A , Vaccins antigrippaux/effets indésirables , Grippe humaine/prévention et contrôle , Myasthénie/immunologie , Adulte , Sujet âgé , Évolution de la maladie , Femelle , Syndrome de Guillain-Barré/étiologie , Hospitalisation , Humains , Vaccins antigrippaux/administration et posologie , Mâle , Adulte d'âge moyen , Myasthénie/anatomopathologie , Vaccination/effets indésirablesRÉSUMÉ
BACKGROUND: Most proton pump inhibitors inhibit the bioactivation of clopidogrel to its active metabolite. The clinical significance of this drug interaction is unknown. METHODS: We conducted a population-based nested case-control study among patients aged 66 years or older who commenced clopidogrel between Apr. 1, 2002, and Dec. 31, 2007, following hospital discharge after treatment of acute myocardial infarction. The cases in our study were those readmitted with acute myocardial infarction within 90 days after discharge. We performed a secondary analysis considering events within 1 year. Event-free controls (at a ratio of 3:1) were matched to cases on age, percutaneous coronary intervention and a validated risk score. We categorized exposure to proton pump inhibitors before the index date as current (within 30 days), previous (31-90 days) or remote (91-180 days). RESULTS: Among 13 636 patients prescribed clopidogrel following acute myocardial infarction, we identified 734 cases readmitted with myocardial infarction and 2057 controls. After extensive multivariable adjustment, current use of proton pump inhibitors was associated with an increased risk of reinfarction (adjusted odds ratio [OR] 1.27, 95% confidence interval [CI] 1.03-1.57). We found no association with more distant exposure to proton pump inhibitors or in multiple sensitivity analyses. In a stratified analysis, pantoprazole, which does not inhibit cytochrome P450 2C19, had no association with readmission for myocardial infarction (adjusted OR 1.02, 95% CI 0.70-1.47). INTERPRETATION: Among patients receiving clopidogrel following acute myocardial infarction, concomitant therapy with proton pump inhibitors other than pantoprazole was associated with a loss of the beneficial effects of clopidogrel and an increased risk of reinfarction.
Sujet(s)
Interactions médicamenteuses , Infarctus du myocarde/traitement médicamenteux , Réadmission du patient/statistiques et données numériques , Inhibiteurs de la pompe à protons/effets indésirables , Ticlopidine/analogues et dérivés , Répartition par âge , Sujet âgé , Sujet âgé de 80 ans ou plus , Angioplastie coronaire par ballonnet/méthodes , Études cas-témoins , Clopidogrel , Études de cohortes , Intervalles de confiance , Continuité des soins , Association de médicaments , Femelle , Études de suivi , Humains , Incidence , Mâle , Analyse multifactorielle , Infarctus du myocarde/diagnostic , Infarctus du myocarde/épidémiologie , Infarctus du myocarde/thérapie , Odds ratio , Sortie du patient , Inhibiteurs de la pompe à protons/administration et posologie , Récidive , Appréciation des risques , Répartition par sexe , Taux de survie , Ticlopidine/administration et posologie , Ticlopidine/effets indésirablesRÉSUMÉ
BACKGROUND: Population rates of upper gastrointestinal (GI) hemorrhage have been observed to increase with the introduction and rapid uptake of selective cyclooxygenase-2 (COX-2) inhibitors. Changes in COX-2 inhibitor use and upper GI bleeding rates in regions with relatively restrictive drug policies (e.g., British Columbia) have not been compared with changes in regions with relatively less restrictive drug policies (e.g., Ontario). METHODS: We collected administrative data for about 1.4 million people aged 66 years and older in British Columbia and Ontario for the period January 1996 to November 2002. We examined temporal changes in the prevalence of NSAID use and admissions to hospital because of upper GI hemorrhage in both provinces using cross-sectional time series analysis. RESULTS: During the period studied, the prevalence of NSAID use in British Columbia's population of older people increased by 25% (from 8.7% to 10.9%; p < 0.01), as compared with a 51% increase in Ontario (from 10.9% to 16.5%; p < 0.01). Hospital admissions because of upper GI hemorrhage increased significantly in Ontario by about 16% on average, or about 2 admissions per 10 000 elderly people, above expected values (p < 0.01). A similar increase was not observed in British Columbia. INTERPRETATION: More restrictive drug coverage policies, although limiting access to drugs and their potential benefits, may protect the population from adverse drug effects.
Sujet(s)
Inhibiteurs des cyclooxygénases/effets indésirables , Inhibiteurs des cyclooxygénases/usage thérapeutique , Hémorragie gastro-intestinale/induit chimiquement , Hémorragie gastro-intestinale/épidémiologie , Sujet âgé , Anti-inflammatoires non stéroïdiens/effets indésirables , Anti-inflammatoires non stéroïdiens/usage thérapeutique , Colombie-Britannique/épidémiologie , Études transversales , Femelle , Politique de santé , Hospitalisation/statistiques et données numériques , Humains , Mâle , Ontario/épidémiologie , Prévalence , Études rétrospectivesRÉSUMÉ
Limited evidence suggests that broad-spectrum fluoroquinolones such as gatifloxacin and moxifloxacin are more likely to cause Clostridium difficile-associated disease than levofloxacin. In a population-based case-control study of outpatients prescribed fluoroquinolones, we found no increased risk of C. difficile-associated disease requiring hospitalization among patients prescribed gatifloxacin or moxifloxacin compared to levofloxacin.
Sujet(s)
Clostridioides difficile/effets des médicaments et des substances chimiques , Entérocolite pseudomembraneuse/induit chimiquement , Fluoroquinolones/pharmacologie , Sujet âgé , Sujet âgé de 80 ans ou plus , Composés aza/pharmacologie , Études cas-témoins , Clostridioides difficile/isolement et purification , Entérocolite pseudomembraneuse/microbiologie , Femelle , Gatifloxacine , Humains , Lévofloxacine , Mâle , Moxifloxacine , Ofloxacine/pharmacologie , Quinoléines/pharmacologieSujet(s)
Antibactériens/effets indésirables , Anticoagulants/effets indésirables , Hémorragie/induit chimiquement , Lévofloxacine , Ofloxacine/effets indésirables , Warfarine/effets indésirables , Maladie aigüe , Facteurs âges , Sujet âgé , Sujet âgé de 80 ans ou plus , Études cas-témoins , Interactions médicamenteuses , Femelle , Humains , Mâle , Odds ratio , Ontario , Thrombose/prévention et contrôleRÉSUMÉ
The effectiveness of the different angiotensin-converting enzyme (ACE) inhibitors in the treatment of patients with congestive heart failure (CHF) was compared by performing a retrospective cohort study using linked administrative databases on elderly patients admitted to the hospital for the treatment of CHF. Relative to those initiated on enalapril, no significant differences in the combined end point of readmission to the hospital for CHF or mortality were observed among users of lisinopril, ramipril, or other ACE inhibitors. In terms of effectiveness for the treatment of patients with CHF, the findings of this study suggest a class effect among ACE inhibitors.
Sujet(s)
Inhibiteurs de l'enzyme de conversion de l'angiotensine/administration et posologie , Services de santé pour personnes âgées/normes , Défaillance cardiaque/traitement médicamenteux , Défaillance cardiaque/épidémiologie , Réadmission du patient/statistiques et données numériques , Sujet âgé , Inhibiteurs de l'enzyme de conversion de l'angiotensine/classification , Études de cohortes , Bases de données factuelles , Énalapril/administration et posologie , Femelle , Défaillance cardiaque/sang , Défaillance cardiaque/mortalité , Humains , Lisinopril/administration et posologie , Mâle , Ontario/épidémiologie , Ramipril/administration et posologie , Études rétrospectives , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: Non-selective, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with an increased risk of congestive heart failure, but little is known about the cardiovascular effects of a newer group of NSAIDS called selective cyclo-oxygenase (COX)-2 inhibitors. We aimed to compare rates of admission for congestive heart failure in elderly patients who were newly dispensed COX-2 inhibitors or non-selective NSAIDs. METHODS: In this population-based retrospective cohort study we identified NSAID-naive individuals aged 66 years or older, who were started on rofecoxib (n=14,583), celecoxib (n=18,908), and non-selective NSAIDs (n=5,391), and randomly selected non-NSAID users as controls (n=100,000). FINDINGS: Relative to non-NSAID users, patients on rofecoxib and non-selective NSAIDS had an increased risk of admission for congestive heart failure (adjusted rate ratio 1.8, 95% CI 1.5-2.2, and 1.4, 1.0-1.9, respectively), but not celecoxib (1.0, 0.8-1.3). Compared with celecoxib users, admission was significantly more likely in users of non-selective NSAIDs (1.4, 1.0-1.9) and rofecoxib (1.8, 1.4-2.4). Risk of admission for rofecoxib users was higher than that for non-selective NSAID users (1.5, 1.1-2.1). Of patients with no admission in the past 3 years, only rofecoxib users were at increased risk of subsequent admission relative to controls (1.8, 1.4-2.3). INTERPRETATION: These findings suggest a higher risk of admission for congestive heart failure in users of rofecoxib and non-selective NSAIDs, but not celecoxib, relative to non-NSAID controls.
Sujet(s)
Anti-inflammatoires non stéroïdiens/effets indésirables , Inhibiteurs des cyclooxygénases/effets indésirables , Défaillance cardiaque/induit chimiquement , Lactones/effets indésirables , Sulfonamides/effets indésirables , Sujet âgé , Anti-inflammatoires non stéroïdiens/usage thérapeutique , Célécoxib , Études de cohortes , Inhibiteurs des cyclooxygénases/usage thérapeutique , Femelle , Défaillance cardiaque/complications , Défaillance cardiaque/physiopathologie , Hospitalisation , Humains , Hypertension artérielle/complications , Hypertension artérielle/traitement médicamenteux , Lactones/usage thérapeutique , Mâle , Modèles des risques proportionnels , Pyrazoles , Études rétrospectives , Facteurs de risque , Sulfonamides/usage thérapeutique , SulfonesSujet(s)
Anti-inflammatoires non stéroïdiens/effets indésirables , Inhibiteurs des cyclooxygénases/effets indésirables , Hémorragie gastro-intestinale/induit chimiquement , Isoenzymes/antagonistes et inhibiteurs , Facteurs âges , Sujet âgé , Études transversales , Cyclooxygenase 2 , Inhibiteurs de la cyclooxygénase 2 , Femelle , Hémorragie gastro-intestinale/épidémiologie , Humains , Mâle , Protéines membranaires , Ontario/épidémiologie , Prévalence , Prostaglandin-endoperoxide synthases , Facteurs de risque , Facteurs sexuelsRÉSUMÉ
BACKGROUND: Recent debate has emerged regarding the cardiovascular safety of selective cyclooxygenase 2 inhibitors and the possible cardioprotective effect of naproxen sodium. We compared the rates of acute myocardial infarction (AMI) among elderly patients dispensed selective cyclooxygenase 2 inhibitors, naproxen, and nonselective nonnaproxen nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: We conducted a population-based retrospective cohort study using administrative health care data from Ontario, Canada, from April 1, 1998, to March 31, 2001. We identified NSAID-naive cohorts of subjects aged 66 years and older in whom treatment was initiated with celecoxib (n = 15 271), rofecoxib (n = 12 156), naproxen (n = 5669), and nonnaproxen nonselective NSAIDs (n = 33 868), along with a randomly selected control cohort not exposed to NSAIDs (n = 100 000). Multivariate Cox proportional hazards models were used to compare AMI rates between study drug groups while controlling for potential confounders. RESULTS: Relative to control subjects, the multivariate model showed no significant differences in AMI risk for new users of celecoxib (adjusted rate ratio [aRR], 0.9; 95% confidence interval [CI], 0.7-1.2), rofecoxib (aRR, 1.0; 95% CI, 0.8-1.4), naproxen (aRR, 1.0; 95% CI, 0.6-1.7), or nonnaproxen nonselective NSAIDs (aRR, 1.2; 95% CI, 0.9-1.4). CONCLUSIONS: The findings of this observational study suggest no increase in the short-term risk of AMI among users of selective cyclooxygenase 2 inhibitors as commonly used in clinical practice. Furthermore, the findings do not support a short-term reduced risk of AMI with naproxen.
Sujet(s)
Anti-inflammatoires non stéroïdiens/effets indésirables , Inhibiteurs des cyclooxygénases/effets indésirables , Infarctus du myocarde/induit chimiquement , Naproxène/effets indésirables , Sujet âgé , Études cas-témoins , Célécoxib , Femelle , Humains , Lactones/effets indésirables , Mâle , Infarctus du myocarde/épidémiologie , Ontario/épidémiologie , Modèles des risques proportionnels , Pyrazoles , Études rétrospectives , Facteurs de risque , Sulfonamides/effets indésirables , SulfonesRÉSUMÉ
OBJECTIVE: To compare rates of upper gastrointestinal haemorrhage among elderly patients given selective cyclo-oxygenase-2 (COX 2) inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). DESIGN: Observational cohort study. SETTING: Administrative data from Ontario, Canada, used from 17 April 2000 to 31 March 2001 to identify population based, NSAID-naive cohorts of patients. PATIENTS: Subjects aged > or =66 years who started taking non-selective NSAIDs (n=5391), diclofenac plus misoprostol (n=5087), rofecoxib (n=14 583), or celecoxib (n=18 908) and a randomly selected control cohort not exposed to NSAIDs (n=100 000). MAIN OUTCOME MEASURES: Rate ratios of hospital admission for upper gastrointestinal haemorrhage in each drug cohort with adjustment for potential confounders. RESULTS: Relative to controls, the multivariate model revealed an increased short term risk of upper gastrointestinal haemorrhage for users of non-selective NSAIDs (adjusted rate ratio 4.0 (95% confidence intervals 2.3 to 6.9)), diclofenac plus misoprostol (3.0 (1.7 to 5.6)), and rofecoxib (1.9 (1.3 to 2.8)) but not celecoxib (1.0 (0.7 to 1.6)). Relative to celecoxib, significantly higher risks of upper gastrointestinal haemorrhage were observed for non-selective NSAIDs (4.4 (2.3 to 8.5)), diclofenac plus misoprostol (3.2 (1.6 to 6.5)), and rofecoxib (1.9 (1.2 to 2.8)). Relative to rofecoxib, non-selective NSAID users were at significantly higher risk of upper gastrointestinal haemorrhage (1.9 (1.0 to 3.5)). CONCLUSIONS: This population based observational study found a lower short term risk of upper gastrointestinal haemorrhage for selective COX-2 inhibitors compared with non-selective NSAIDs.