Priorities among effective clinical preventive services in British Columbia, Canada.

BACKGROUND: Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing. METHODS: We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained. RESULTS: Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services. CONCLUSIONS: These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

The Adaptive Gain Integrating Pixel Detector at the European XFEL.

The Adaptive Gain Integrating Pixel Detector (AGIPD) is an X-ray imager, custom designed for the European X-ray Free-Electron Laser (XFEL). It is a fast, low-noise integrating detector, with an adaptive gain amplifier per pixel. This has an equivalent noise of less than 1 keV when detecting single photons and, when switched into another gain state, a dynamic range of more than 104 photons of 12 keV. In burst mode the system is able to store 352 images while running at up to 6.5 MHz, which is compatible with the 4.5 MHz frame rate at the European XFEL. The AGIPD system was installed and commissioned in August 2017, and successfully used for the first experiments at the Single Particles, Clusters and Biomolecules (SPB) experimental station at the European XFEL since September 2017. This paper describes the principal components and performance parameters of the system.

The economic benefits of fruit and vegetable consumption in Canada.

OBJECTIVES: The objectives of this study were to determine the proportion of the population that meets or exceeds Canada's Food Guide (CFG) recommendations regarding the number of daily servings of fruits and vegetables (F/V), to assess trends in this proportion between 2000 and 2013, to estimate the annual economic burden attributable to inadequate F/V consumption within the context of other important risk factors, and to estimate the short- and long-term costs that could be avoided if modest improvements were made to F/V consumption in Canada. METHODS: We used a previously developed methodology based on population-attributable fractions and a prevalence-based cost-of-illness approach to estimate the economic burden associated with low F/V consumption. RESULTS: Over three quarters of Canadians are not meeting CFG recommendations regarding the number of daily servings of F/V, leading to an annual economic burden of $4.39 billion. If a 1% relative increase in F/V consumption occurred annually between 2013 and 2036, the cumulative reduction in economic burden over the 23-year period would reach $8.4 billion. Consumption levels of F/V, and the resulting economic burden, varied by sex, age and province. CONCLUSION: A significant majority of Canadians are not consuming the recommended daily servings of F/V, with important consequences to their health and the Canadian economy. Programs and policies are required to encourage F/V consumption in Canada.

Editorial -- The weight of our nation. / Éditorial -- Le poids de notre nation.

Canadians spent an estimated $228 billion on health care in 2016. That represents 11.1% of our total economy, or $6,299 per person. Almost 40% of all public expenditures are allocated to fund health care. Put succinctly, that is a lot of money! This issue of Health Promotion and Chronic Disease Prevention in Canada places a spotlight on three diseases that contribute to this economic burden of health care in Canada.

INTRODUCTION: En 2016, les Canadiens ont dépensé environ 228 milliards de dollars en soins de santé, soit 11,1 % de notre économie totale, ou 6 299 dollars par habitant. Presque 40 % des dépenses publiques sont consacrées au financement des soins de santé. En résumé, cela fait beaucoup d'argent! Ce numéro de Promotion de la santé et prévention des maladies chroniques au Canada met l'accent sur trois maladies contribuant à ce fardeau économique des soins de santé au Canada.

Detector developments at DESY.

With the increased brilliance of state-of-the-art synchrotron radiation sources and the advent of free-electron lasers (FELs) enabling revolutionary science with EUV to X-ray photons comes an urgent need for suitable photon imaging detectors. Requirements include high frame rates, very large dynamic range, single-photon sensitivity with low probability of false positives and (multi)-megapixels. At DESY, one ongoing development project - in collaboration with RAL/STFC, Elettra Sincrotrone Trieste, Diamond, and Pohang Accelerator Laboratory - is the CMOS-based soft X-ray imager PERCIVAL. PERCIVAL is a monolithic active-pixel sensor back-thinned to access its primary energy range of 250 eV to 1 keV with target efficiencies above 90%. According to preliminary specifications, the roughly 10 cm × 10 cm, 3.5k × 3.7k monolithic sensor will operate at frame rates up to 120 Hz (commensurate with most FELs) and use multiple gains within 27 µm pixels to measure 1 to ∼100000 (500 eV) simultaneously arriving photons. DESY is also leading the development of the AGIPD, a high-speed detector based on hybrid pixel technology intended for use at the European XFEL. This system is being developed in collaboration with PSI, University of Hamburg, and University of Bonn. The AGIPD allows single-pulse imaging at 4.5 MHz frame rate into a 352-frame buffer, with a dynamic range allowing single-photon detection and detection of more than 10000 photons at 12.4 keV in the same image. Modules of 65k pixels each are configured to make up (multi)megapixel cameras. This review describes the AGIPD and the PERCIVAL concepts and systems, including some recent results and a summary of their current status. It also gives a short overview over other FEL-relevant developments where the Photon Science Detector Group at DESY is involved.

Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity.

OBJECTIVES: Tobacco smoking, excess weight and physical inactivity contribute substantially to the preventable disease burden in Canada. The purpose of this paper is to determine the potential reduction in economic burden if all provinces achieved prevalence rates of these three risk factors (RFs) equivalent to those of the province with the lowest rates, and to update and address a limitation noted in our previous model. METHODS: We used a previously developed approach based on population attributable fractions to estimate the economic burden associated with these RFs. Sex-specific relative risk and age-/sex-specific prevalence data were used in the modelling. The previous model was updated using the most current data for developing resource allocation weights. RESULTS: In 2012, the prevalence of tobacco smoking, excess weight and physical inactivity was the lowest in British Columbia. If age- and sex-specific prevalence rates from BC were applied to populations living in the other provinces, the annual economic burden attributable to these three RFs would be reduced by $5.3 billion. Updating the model resulted in a considerable shift in economic burden from smoking to excess weight, with the estimated annual economic burden attributable to excess weight now 25% higher compared to that of tobacco smoking ($23.3 vs. $18.7 billion). CONCLUSION: Achieving RF prevalence rates equivalent to those of the province with the lowest rates would result in a 10% reduction in economic burden attributable to excess weight, smoking and physical inactivity in Canada. This study shows that using current resource use data is important for this type of economic modelling.

Prevalence of Individuals Experiencing the Effects of Stroke in Canada: Trends and Projections.

BACKGROUND AND PURPOSE: Previous estimates of the number and prevalence of individuals experiencing the effects of stroke in Canada are out of date and exclude critical population groups. It is essential to have complete data that report on stroke disability for monitoring and planning purposes. The objective was to provide an updated estimate of the number of individuals experiencing the effects of stroke in Canada (and its regions), trending since 2000 and forecasted prevalence to 2038. METHODS: The prevalence, trends, and projected number of individuals experiencing the effects of stroke were estimated using region-specific survey data and adjusted to account for children aged <12 years and individuals living in homes for the aged. RESULTS: In 2013, we estimate that there were 405 000 individuals experiencing the effects of stroke in Canada, yielding a prevalence of 1.15%. This value is expected to increase to between 654 000 and 726 000 by 2038. Trends in stroke data between 2000 and 2012 suggest a nonsignificant decrease in stroke prevalence, but a substantial and rising increase in the number of individuals experiencing the effects of stroke. Stroke prevalence varied considerably between regions. CONCLUSIONS: Previous estimates of stroke prevalence have underestimated the true number of individuals experiencing the effects of stroke in Canada. Furthermore, the projected increases that will result from population growth and demographic changes highlight the importance of maintaining up-to-date estimates.

Care delivery in youth with type 2 diabetes - are we meeting clinical practice guidelines?

BACKGROUND: Studies indicate high rates of treatment failure and early onset diabetes-related complications in youth-onset type 2 diabetes (T2D). We aim to describe the quality of care provided to children and youth with T2D. METHODS: This prospective cohort study used administrative datasets to describe individuals aged 10-24 yr diagnosed with T2D at <20 yr of age (488 individuals; 2111 person-years). The primary outcome was being 'at goal' for adherence to Canadian clinical practice guidelines (CPGs). This was defined as having either optimal [three diabetes-related physician visits/year, three hemoglobin A1C (A1C) tests/year, and all recommended screening tests for complications (i.e., retinopathy, nephropathy)] or good (two diabetes-related physician visits/year, two A1C tests/year, and at least two screening tests) adherence to CPGs. Descriptive statistics and logistic regression modeling were used. RESULTS: Sixty eight percentage person-years had poor adherence to CPGs (<2 physician visits and A1c tests/year and no screening tests). Only 29% and 25% were at goal for adherence in the 15-19 and 20-24 yr age groups, respectively. There was a 52% decreased odds of being at goal for adherence 4 yr after diagnosis of T2D (p < 0.001). For every year increase in age at diagnosis, there was a 5% decreased odds of being at goal (p = 0.04). CONCLUSIONS: Youth with T2D are not receiving high quality care, and older youth and young adults are particularly at risk. Future research is needed to understand the effectiveness of care in the context of poor adherence as well as patient, physician, and health system factors that might improve adherence.

The economic benefits of risk factor reduction in Canada: tobacco smoking, excess weight and physical inactivity.

OBJECTIVE: Tobacco smoking, excess weight and physical inactivity contribute substantially to the preventable disease burden in Canada. The purpose of this paper is to apply a recently developed approach in addressing the issue of double counting in estimating the combined current economic burden of these risk factors (RFs) and to estimate the economic benefits of long-term RF reduction in Canada. METHODS: We used an approach based on population attributable fractions (PAF) to estimate the economic burden associated with the various RFs. Sex-specific relative risk and age-/sex-specific prevalence data were used in the modelling when available. Excess weight was modelled as a trichotomous exposure (normal weight, overweight, obese) while tobacco smoking was modelled as a tetrachotomous exposure (non-smoker, light, medium or heavy smoker). All costs are given in constant 2012 Canadian dollars. RESULTS: The annual economic burden of the RFs of tobacco smoking, excess weight and physical inactivity in Canada are estimated at $50.3 billion in 2012. Sensitivity analysis suggests a range for the economic burden of $41.6 to $58.7 billion. Of the $50.3 billion, $21.3 ($20.0 to $22.6) billion is attributable to tobacco smoking, $19.0 ($13.8 to $24.0) billion to excess weight and $10.0 ($7.8 to $12.0) billion to physical inactivity. A 1% relative annual reduction in each of the three RFs would result in an $8.5 billion annual reduction in economic burden by 2031. CONCLUSION: A modest annual 1% relative reduction in the RFs of tobacco smoking, excess weight and physical inactivity can have a substantial health and economic impact over time at the population level.

Adherence to clinical practice guidelines in the management of children, youth, and young adults with type 1 diabetes--a prospective population cohort study.

OBJECTIVE: To describe adherence to clinical practice guidelines for the treatment of childhood type 1 diabetes and identify associated patient and system level factors. STUDY DESIGN: This prospective cohort study used population-based administrative data to describe individuals aged 1-24 years who had been diagnosed with type 1 diabetes at <20 years of age (1472 unique individuals and 5883 person-years over a 7-year period) living in British Columbia, Canada. The outcome measure was proportion 'at goal,' which was defined as having optimal adherence (3 diabetes-related physician visits/year, 3 hemoglobin A1c (HbA1c) tests/year, 1 glucagon prescription dispensed/year, and appropriate screening for diabetes-related comorbidity [ie, hypothyroidism] and complications [ie, retinopathy and nephropathy]), or good adherence to guidelines (2 diabetes-related physician visits/year, 2 HbA1c tests/year, and appropriate screening for diabetes-related comorbidity and complications). Statistical methods included descriptive statistics and logistic regression modeling. RESULTS: Fifty-four percent person-years had poor adherence to guidelines (<2 diabetes-related physician visits and HbA1c tests/year) and 7.4% had optimal adherence. The proportion of person-years at goal was higher in females vs males (41.0% vs 37.6%; P = .007). Individuals 4-years post-diagnosis of diabetes were 78% less likely to be at goal compared with the year of diagnosis (P < .0001). CONCLUSIONS: The treatment of pediatric type 1 diabetes likely does not meet national and international standards. Future studies should explore facilitators and barriers to adherence to guidelines among health care providers, patients, and families, and whether adherence to guidelines is associated with glycemic control.

Cost avoidance associated with optimal stroke care in Canada.

BACKGROUND AND PURPOSE: Evidence-based stroke care has been shown to improve patient outcomes and may reduce health system costs. Cost savings, however, are poorly quantified. This study assesses 4 aspects of stroke management (rapid assessment and treatment services, thrombolytic therapy, organized stroke units, and early home-supported discharge) and estimates the potential for cost avoidance in Canada if these services were provided in a comprehensive fashion. METHODS: Several independent data sources, including the Canadian Institute of Health Information Discharge Abstract Database, the 2008-2009 National Stroke Audit, and the Acute Cerebrovascular Syndrome Registry in the province of British Columbia, were used to assess the current status of stroke care in Canada. Evidence from the literature was used to estimate the effect of providing optimal stroke care on rates of acute care hospitalization, length of stay in hospital, discharge disposition (including death), changes in quality of life, and costs avoided. RESULTS: Comprehensive and optimal stroke care in Canada would decrease the number of annual hospital episodes by 1062 (3.3%), the number of acute care days by 166 000 (25.9%), and the number of residential care days by 573 000 (12.8%). The number of deaths in the hospital would be reduced by 1061 (14.9%). Total avoidance of costs was estimated at $682 million annually ($307.4 million in direct costs, $374.3 million in indirect costs). CONCLUSIONS: The costs of stroke care in Canada can be substantially reduced, at the same time as improving patient outcomes, with the greater use of known effective treatment modalities.

Validation of classification algorithms for childhood diabetes identified from administrative data.

OBJECTIVE: Type 1 diabetes is the most common form of diabetes among children; however, the proportion of cases of childhood type 2 diabetes is increasing. In Canada, the National Diabetes Surveillance System (NDSS) uses administrative health data to describe trends in the epidemiology of diabetes, but does not specify diabetes type. The objective of this study was to validate algorithms to classify diabetes type in children <20 yr identified using the NDSS methodology. PATIENTS AND METHODS: We applied the NDSS case definition to children living in British Columbia between 1 April 1996 and 31 March 2007. Through an iterative process, four potential classification algorithms were developed based on demographic characteristics and drug-utilization patterns. Each algorithm was then validated against a gold standard clinical database. RESULTS: Algorithms based primarily on an age rule (i.e., age <10 at diagnosis categorized type 1 diabetes) were most sensitive in the identification of type 1 diabetes; algorithms with restrictions on drug utilization (i.e., no prescriptions for insulin ± glucose monitoring strips categorized type 2 diabetes) were most sensitive for identifying type 2 diabetes. One algorithm was identified as having the optimal balance of sensitivity (Sn) and specificity (Sp) for the identification of both type 1 (Sn: 98.6%; Sp: 78.2%; PPV: 97.8%) and type 2 diabetes (Sn: 83.2%; Sp: 97.5%; PPV: 73.7%). CONCLUSIONS: Demographic characteristics in combination with drug-utilization patterns can be used to differentiate diabetes type among cases of pediatric diabetes identified within administrative health databases. Validation of similar algorithms in other regions is warranted.

Burden of malignancy after a primary skin cancer: recurrence, multiple skin cancers and second primary cancers.

The current paper summarizes relevant recent research on the high risk of recurrence, multiple skin cancers and second primary cancers in the growing number of people with a history of skin cancer; the ultimate purpose is to better assess the burden of malignancy following skin cancer. A number of challenges exist in identifying and tracking both melanoma and non-melanoma skin cancer (NMSC) cases. Most jurisdictions do not routinely track NMSC cases and, even if they do, it is customary to only include the first diagnosis. There are variable rules for counting multiple melanoma cancers, and recurrences are not considered for either major type of skin cancer. Applying insights from recent studies of this issue to Canadian cancer statistics would increase reported diagnoses of NMSC by about 26% and melanoma by 10% in this country. This approach to a fuller assessment of the burden of skin cancers has been called a "diagnosis-based incidence approach" as compared with a "patient-based incidence approach". A further issue that is not usually taken into account when assessing the burden of skin cancers is the 20% to 30% elevated risk of noncutaneous second primary cancers following a primary skin tumour. In summary, individuals with skin cancer are subject to a high risk of recurrence, multiple skin cancers and second primary cancers. This burden should be a special concern in the large and growing pool of individuals with a history of skin cancer, as well as among prevention planners.