Overuse of Tests and Treatments: Has Canada Made Progress?

Overuse of healthcare services is a complex issue. Also known as low-value care, these are tests, treatments and procedures that are commonly ordered despite clear evidence that they do not help with patient care and may even cause harm. National clinician societies have developed over 450 Choosing Wisely Canada (CWC) recommendations to spur conversation about what is appropriate and necessary treatment. The latest report from the Canadian Institute for Health Information and CWC measured the trends and variation in the use over time of tests and treatments related to 12 CWC recommendations (CIHI 2022). Reductions in overuse were observed in eight of the 12 tests and treatments examined; findings for two of these measures - chronic benzodiazepine use and red blood cell transfusions - are highlighted. Despite some progress on reducing overuse, there remains considerable room for improvement in the appropriate and judicious use of tests and treatments in Canada.

How Children and Youth with Medical Complexity Use Hospital and Emergency Department Care across Canada.

Children and youth with medical complexity are a diverse group with uncommon diagnoses, a spectrum of needs and varying access to supports. Although this population represents a small proportion of all children, their unique needs lead to substantial use of healthcare services. With its first pan-Canadian report on children and youth with medical complexity, the Canadian Institute for Health Information examined how this population uses healthcare services. Key findings include the wide variation in the rate of medical complexity among children and youth across Canada. Children and youth with medical complexity were found to require a high proportion of hospital and emergency department care; however, their readmission rates were found to be lower than that of the general pediatric population.

Measuring Access to Home and Community Care and to Mental Health and Addictions Services in Canada.

Federal, provincial and territorial governments endorsed agreements in August of 2017 to focus on the shared health priorities of home, community, mental health and addictions care (Government of Canada 2017). The related $11 billion federal investment over a 10-year period aims to improve access for Canadians to effective and appropriate services in these areas (Government of Canada 2019).

Measuring the frequency and variation of unnecessary care across Canada.

BACKGROUND: Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS: Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS: Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS: The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.

The Determinants of the Technical Efficiency of Acute Inpatient Care in Canada.

OBJECTIVE: To evaluate the technical efficiency of acute inpatient care at the pan-Canadian level and to explore the factors associated with inefficiency-why hospitals are not on their production frontier. DATA SOURCES/STUDY SETTING: Canadian Management Information System (MIS) database (CMDB) and Discharge Abstract Database (DAD) for the fiscal year of 2012-2013. STUDY DESIGN: We use a nonparametric approach (data envelopment analysis) applied to three peer groups (teaching, large, and medium hospitals, focusing on their acute inpatient care only). The double bootstrap procedure (Simar and Wilson 2007) is adopted in the regression. DATA COLLECTION/EXTRACTION METHODS: Information on inpatient episodes of care (number and quality of outcomes) was extracted from the DAD. The cost of the inpatient care was extracted from the CMDB. PRINCIPAL FINDINGS: On average, acute hospitals in Canada are operating at about 75 percent efficiency, and this could thus potentially increase their level of outcomes (quantity and quality) by addressing inefficiencies. In some cases, such as for teaching hospitals, the factors significantly correlated with efficiency scores were not related to management but to the social composition of the caseload. In contrast, for large and medium nonteaching hospitals, efficiency related more to the ability to discharge patients to postacute care facilities. The efficiency of medium hospitals is also positively related to treating more clinically noncomplex patients. CONCLUSIONS: The main drivers of efficiency of acute inpatient care vary by hospital peer groups. Thus, the results provide different policy and managerial implications for teaching, large, and medium hospitals to achieve efficiency gains.

Care and Outcomes of Patients With Cancer Admitted to the Hospital on Weekends and Holidays: A Retrospective Cohort Study.

BACKGROUND: Patients admitted to the hospital on weekends experience worse outcomes than those admitted on weekdays. Patients with cancer may be especially vulnerable to the effects of weekend care. Our objective was to compare the care and outcomes of patients with cancer admitted urgently to the hospital on weekends and holidays versus those of patients with cancer admitted at other times. MATERIALS AND METHODS: This was a retrospective study of all adult patients with cancer having an urgent hospitalization in Canada from 2010 to 2013. Patients admitted to hospital on weekends/holidays were compared with those admitted on weekdays. The primary outcome was 7-day in-hospital mortality. We also compared performance of procedures in the first 2 days of hospital admission and admission to critical care after the first 24 hours. RESULTS: 290,471 hospital admissions were included. Patients admitted to hospital on weekends/holidays had an increased risk of 7-day in-hospital mortality (4.8% vs 4.3%; adjusted odds ratio [OR], 1.13; 95% CI, 1.08-1.17), corresponding to 137 excess deaths per year compared with the weekday group. This risk persisted after restricting the analysis to patients arriving by ambulance (7.1% vs 6.4%; adjusted OR, 1.11; 95% CI, 1.04-1.18). Among those who had procedures in the first 4 days of admission, fewer weekend/holiday-admitted patients had them performed in the first 2 days, for 8 of 9 common procedure groups. There was no difference in critical care admission risk after the first 24 hours. CONCLUSIONS: Patients with cancer admitted to the hospital on weekends/holidays experience higher mortality relative to patients admitted on weekdays. This may result from different care processes for weekend/holiday patients, including delayed procedures. Future research is needed to identify key outcome-driving procedures, and ensure timely access to these on all days of the week.

Physician Follow-up after Hospital Discharge in Alberta and Saskatchewan.

The period immediately after discharge from hospital can potentially be high risk and a vulnerable transition point for patients. This analysis from the Canadian Institute for Health Information assessed adherence to best practices for patient follow-up in the community after hospitalization in Alberta and Saskatchewan. For three selected conditions - acute myocardial infarction, heart failure and chronic obstructive pulmonary disease - the majority of patients (77-92%) saw a physician within a month of their discharge. However, fewer patients saw a physician within the first week (35-56%).

All-cause readmission to acute care for cancer patients.

A recent Canadian Institute for Health Information report on all-cause readmission identified that cancer patients had higher-than-average readmission rates. This study provides further insight on the experience of cancer patients, exploring the risk factors associated with readmission at patient, hospital and community levels. An analysis showed that patient characteristics, including the reason for initial hospitalization, sex, co-morbidity levels, admission through the emergency department and the number of previous acute care admissions, were associated with readmission for cancer patients. In addition, we found that the readmission rate for these patients varied by hospital size and whether the patients lived in rural or urban locations.

Outcomes in multiple gestation pregnancies among Canadian women age 35 years and older.

Multiple gestations are associated with an increased risk of maternal morbidity and mortality independent of maternal age. Previous reports by the Canadian Institute for Health Information established the overall association between advanced maternal age and complications related to pregnancy and childbirth. This article takes a more focused look at the association between advanced maternal age and maternal outcomes in multiple gestation pregnancies. We found, for mothers aged 35 years and older carrying multiples--after adjusting for mothers' parity, neighbourhood income and residence (rural/urban)--an increased risk of pregnancy complications including pre-existing hypertension, gestational hypertension, pre-eclampsia/eclampsia, gestational diabetes and placenta previa and an increased risk for Caesarean delivery.

Babies admitted to NICU/ICU: province of birth and mode of delivery matter.

Neonatal intensive care units (NICUs) and intensive care units (ICUs) provide care for newborns in need of specialized medical attention. Across Canada, rates of NICU/ICU admission vary. Due to the high cost of monitoring and interventions these admissions cost more than general newborn stays - whether the newborn is in a specialized NICU or in an ICU in those facilities without specialized units for newborns. This study explores the variation in NICU/ICU admissions and the characteristics of mothers and newborns associated with an increased likelihood of NICU/ICU admission. We focus further on the association between NICU/ICU admission and Caesarean section (C-section). After excluding multiple births, preterm births, small for gestational age births and those delivered by women with select complications, we find an increased risk for NICU/ICU admission for babies born by C-section as their only indication. NICU/ICU admission following C-section alone may not represent the most desirable pathway of care for these newborns.

Bariatric surgery in Canada: a focus on day surgery procedures.

Given the rise in obesity rates, increasing capacity for bariatric surgery has become a focus for some provincial planners. Four types of bariatric procedures are now performed in Canada; however, funding for the procedures varies by jurisdiction. This article provides an update to our previous article documenting the volume of in-patient bariatric procedures but focuses on the extent to which Canadians are increasingly receiving bariatric procedures in day surgery settings.

Recent oral contraceptive use and adverse birth outcomes.

OBJECTIVE: To examine the possible association between oral contraceptive use and adverse birth outcomes. STUDY DESIGN: We conducted a population-based cohort study of pregnant women who used oral contraceptives within 3 months before their last menstrual period. Subjects were divided into three groups, according to the interval (0-30, 31-60, and 61-90 days) between the dispensing date and their last menstrual period. For each exposed subject, 4 subjects without exposure to oral contraceptives were individually matched by infant's year of birth and plurality and by mother's age and parity. RESULTS: Oral contraceptive use within 30 days prior to the last menstrual period was associated with increased risks of very low birth weight (OR: 3.24, 95% CI: 1.18, 8.92), low birth weight (OR: 1.93, 95% CI: 1.17, 3.20), and preterm birth (OR: 1.61, 95% CI: 1.01, 2.55); however, oral contraceptive use 31-90 days prior to the last menstrual period did not increase the risk of low birth weight or preterm birth. CONCLUSION: Our results indicate the use of oral contraceptives near the time of conception may be associated with an increased risk of low birth weight and preterm birth.

In vitro fertilization is associated with an increased risk for preeclampsia.

OBJECTIVE: To assess the association of intrauterine insemination, in vitro fertilization (IVF) and ovulation induction with the risk of preeclampsia. METHODS: We conducted a population based retrospective cohort study of pregnancies conceived by assisted reproductive technology (1357 exposure subjects, 5190 controls) based on 2005 Niday Perinatal Database for Ontario, Canada. All pregnancies conceived by assisted reproductive technology were identified as exposure group. Four controls were randomly matched for each exposure subject by maternal age, parity, plurality, and delivery hospital level and residence area. The risks for preeclampsia associated with intrauterine insemination, IVF, and ovulation induction were evaluated through conditional logistic regression models compared with their corresponding controls. RESULTS: With adjustment of maternal age, smoking during pregnancy and initiating time of prenatal care, in vitro fertilization was associated with an increased risk for preeclampsia (OR=1.78, 95% CI: 1.05, 3.06), whereas intrauterine insemination (OR=2.44, 95% CI: 0.74, 8.06) and ovulation induction (OR=1.34, 95% CI: 0.31, 5.75) was not associated with the risk for preeclampsia. CONCLUSION: There was a higher incidence of preeclampsia among pregnancies conceived by IVF, but no significant association was found in intrauterine insemination and ovulation induction.

Perinatal outcomes of normal cotwins in twin pregnancies with one structurally anomalous fetus: a population-based retrospective study.

We examined the impact of the presence of one anomalous fetus in a twin pregnancy on perinatal outcomes in the normal cotwin. Perinatal outcomes in cotwins with an anomalous twin and cotwins without an anomalous twin were compared using data from the 1995 to 1997 United States Matched Multiple Births dataset. The two groups were matched by maternal age, parity, birth order, gender, and sex concordance (1:4 matching). The risks of preterm birth, low birth weight, small-for-gestational-age birth, fetal distress, the use of assisted ventilation, low Apgar score, fetal death, neonatal death, and infant death in the 3307 normal cotwins with a twin affected by structural anomalies were significantly higher than those of the 12,813 matched cotwins without an anomalous twin. The presence of one structurally anomalous fetus in a twin pregnancy increases the risks of adverse perinatal outcomes in the cotwin without a fetal anomaly.

Increased risks of neonatal and postneonatal mortality associated with teenage pregnancy had different explanations.

OBJECTIVE: To determine the potential pathway of the association between teenage pregnancy and neonatal and postneonatal mortality. STUDY DESIGN AND SETTING: We carried out a retrospective cohort study of 4,037,009 nulliparous pregnant women under 25 years old who had a live singleton birth during 1995 to 2000, based on linked birth and infant death data set of the United States. RESULTS: Teenage pregnancy (10-19 years old) was associated with increased neonatal mortality (odds ratio [OR]: 1.20, 95% confidence interval [CI]=1.16-1.24) and postneonatal mortality (OR: 1.47, 95% CI=1.41-1.54) after adjustment for potential confounders. With further adjustment for weight gain during pregnancy, teenage pregnancy was still associated with increased risk of neonatal (OR: 1.23, 95% CI=1.19-1.28) and postneonatal mortality (OR: 1.48, 95% CI=1.42-1.55). When adjustment was made for gestational age at birth, there was no association of teenage pregnancy with neonatal mortality (OR: 0.98, 95% CI=0.95-1.02), whereas there was significant association with postneonatal mortality (OR: 1.40, 95% CI=1.34-1.46). CONCLUSION: The increased risk of neonatal death associated with teenage pregnancy is largely attributable to higher risk of preterm births, whereas increased postneonatal mortality is independent of the known confounders and gestational age at birth.

Paternal age and adverse birth outcomes: teenager or 40+, who is at risk?

BACKGROUND: Most previous studies on the effect of paternal age have focused on the association of advanced paternal age with congenital anomalies. The objective of this study was to determine whether paternal age is associated with the risk of adverse birth outcomes, independent of maternal confounders. METHODS: We carried out a retrospective cohort study of 2 614 966 live singletons born to married, nulliparous women aged 20-29 years between 1995 and 2000 in the USA. Multiple logistic regressions were applied to estimate the independent effect of paternal age on adverse birth outcomes. RESULTS: Compared with infants born to fathers aged 20-29 years, infants fathered by teenagers (<20 years old) had an increased risk of preterm birth [odds ratio (OR) = 1.15, 95% confidence interval (CI): 1.10, 1.20], low birth weight (OR = 1.13, 95% CI: 1.08, 1.19), small-for-gestational-age births (OR = 1.17, 95% CI: 1.13, 1.22), low Apgar score (OR = 1.13, 95% CI: 1.01, 1.27), neonatal mortality (OR = 1.22, 95% CI: 1.01, 1.49) and post-neonatal mortality (OR = 1.41, 95% CI: 1.09, 1.82). Advanced paternal age (> or =40 years) was not associated with the risk of adverse birth outcomes. CONCLUSIONS: Teenage fathers carry an increased risk of adverse birth outcomes that is independent of maternal confounders, whereas advanced paternal age is not an independent risk factor for adverse birth outcomes.

Folic acid supplementation in early second trimester and the risk of preeclampsia.

OBJECTIVE: The objective of the study was to evaluate the association between folic acid supplementation in early second trimester and the risk of developing preeclampsia. STUDY DESIGN: We carried out a prospective cohort study between October 2002-December 2005. We recruited women who had their prenatal care visit (12-20 weeks' gestation) at the Ottawa Hospital and Kingston General Hospital. All charts for participants with a diagnosis of preeclampsia were audited and blindly adjudicated by 4 study investigators to validate the diagnosis. RESULTS: A total of 2951 pregnant women were included in the final analysis. Supplementation of multivitamins containing folic acid was associated with increased serum folate (on average 10.51 micromol/L), decreased plasma homocysteine (on average 0.39 micromol/L), and reduced risk of preeclampsia (adjusted odds ratio, 0.37; 95% confidence interval, 0.18-0.75). CONCLUSION: Supplementation of multivitamins containing folic acid in the second trimester is associated with reduced risk of preeclampsia.

Effects of repeated courses of antenatal corticosteroids on somatic development in children 6 to 10 years of age.

This study assessed the effects of repeated courses of antenatal corticosteroids on biometric characteristics, salivary cortisol, and heart function in children 6 to 10 years of age using a retrospective cohort study. Twenty-nine children whose mothers had received two or more courses of antenatal corticosteroids were identified from hospital charts. Eighty-seven children whose mothers did not receive antenatal corticosteroids were frequency matched with the exposed group by child's age, sex, and ethnicity. The body development, heart function, and salivary corticosteroid level were evaluated at 6 to 10 years of age. The percentiles of body measurements were calculated based on the 2000 Centers for Disease Control and Prevention growth charts. The general linear models were applied to assess the observed association. Decreased head circumference ( P=0.017) and body mass index (BMI) ( P=0.047) in children 6 to 10 years of age were associated with repeated courses of antenatal corticosteroids. Morning salivary cortisol level was lower in the exposed group than the unexposed group ( P=0.048). No difference was found in height, weight, blood pressure, heart rate, and echocardiogram measurements between the two groups. Repeated courses of antenatal corticosteroid therapy are associated with decreased head circumference, BMI, and salivary cortisol level in children 6 to 10 years of age.

Hypertensive disorders of pregnancy and long-term risk of hypertension: what do Ontario prenatal care providers know, and what do they communicate?

OBJECTIVES: The objective of this study was to ascertain the knowledge base of Ontario maternity care providers (family physicians, obstetrician-gynaecologists, and midwives) regarding the future health risks of gestational hypertension and preeclampsia and the practices with respect to communication of these risks. METHODS: In 2004, all obstetricians (639) and midwives (249) in Ontario and a random sample of 600 Ontario family physicians were mailed a survey and a reminder. Non-responders were also sent a second, and in some cases, a third copy of the survey. The survey addressed areas of knowledge, reported practices, and both patient and interprofessional communication. Descriptive analysis was used for the responses. RESULTS: The overall response rate was 42%. The majority of respondents were familiar with the long-term risks of gestational hypertension and preeclampsia. Although maternity care providers stated that they inform women with these conditions about their subsequent risks and recommend follow-up, only 36% usually inform the women's primary care providers about that subsequent risk. Only 58% of family physicians reported that they are usually informed by the maternity care providers about their patients who developed hypertension in pregnancy, compared with the 83% of maternity care providers who reported that they usually communicate this information to family physicians. CONCLUSION: We have identified weaknesses in knowledge base and communication amongst Ontario maternity care providers that suggest that the identification and follow-up of women with hypertensive disorders of pregnancy is not occurring. These deficiencies would be amenable to directed educational activities, including reviews, presentations, and the development and implementation of guidelines.

New-onset hypertension in late pregnancy and fetal growth: different associations between singletons and twins.

OBJECTIVE: To compare the effects of new-onset hypertension (NOH) in late pregnancy on fetal growth in singletons and twins. METHODS: A retrospective cohort study was conducted to evaluate the effect of NOH on fetal growth in 17, 720, 900 singletons and 463, 104 twins born in the United States between 1995 and 2000. RESULTS: NOH was associated with lower mean birth weight in both preterm and term singletons. Increased risk of low birth weight and decreased risk of high birth weight was associated with NOH in preterm and term singletons. NOH was associated with increased risk for small-for-gestational-age (SGA) births and decreased risk for large-for-gestational-age (LGA) births in preterm singletons, whereas it was associated with increased risk of both SGA and LGA births in term singletons. NOH was associated with higher mean birth weight in early preterm twins, and lower mean birth weight in term twins. Decreased risk for low birth weight was found in the NOH group among early preterm twins, and increased risk for low birth weight in term twins. NOH was associated with increased risk of SGA births and decreased risk for large-for-gestational-age (LGA) births in early preterm twins, while increased risk of SGA births in term twins. CONCLUSION: NOH is associated with slower fetal growth in singletons delivered at different gestational ages, but the effect varies in twins depending on gestational age at delivery with faster growth in early preterm twins.