Self-reported adherence to direct oral anticoagulants versus warfarin therapy in a specialized thrombosis service-a cross-sectional study of patients in a Canadian Health Region.

PURPOSE: Direct oral anticoagulants (DOACs) have a better safety and efficacy profile than warfarin and are currently recommended for stroke prevention in non-valvular atrial fibrillation (AF) and treatment of venous thromboembolism (VTE). Given that DOACs do not require regular laboratory monitoring compared to warfarin, patients' interactions with the health care system is reduced. Adequate adherence to DOACs is important and reported adherence to anticoagulation is unclear in clinical practice. This study aims to assess self-reported adherence to oral anticoagulants in a specialized Adult Outpatient Thrombosis Service (TS).  METHODS: This cross-sectional study included patients aged ≥ 18 years who were prescribed an oral anticoagulant and had attended at least one appointment with an Adult Outpatient Thrombosis Service (TS) between October 10, 2017, and May 31, 2019. Adherence to oral anticoagulant therapy was assessed using the 12-item validated Adherence to Refills and Medications Scale (ARMS) score. Logistic regression analyses were used to evaluate association between patient characteristics and medication adherence. Adherence rates in DOACs and warfarin were compared. RESULTS: Three hundred and ninety-nine patients completed and returned the survey. Of the 399 who completed the survey, 74% were prescribed DOACs and 26% received warfarin. Most of the patients (89.3%) were ≥ 50 years of age and half (57.3%) were male. About two-thirds (67%) had at least post-secondary education. The duration of anticoagulation use differed between patients on DOAC and warfarin; a greater proportion of those who had used anticoagulants for less than 1 year was on DOACs compared to warfarin (20.9% vs 4.9%, p = 0.001). For patients who had been on anticoagulation for > 5 years, the proportion of warfarin patients was greater than DOAC (57.8% vs 20.5%, p = 0.001). Self-reported adherence to oral anticoagulant therapy using the 12-item ARMS scale for warfarin and DOACs were 87.3% and 90.9%, respectively. Among the warfarin users, patient satisfaction with TS was associated with medication adherence (OR = 0.22; 95% CI: 0.05-0.89). CONCLUSIONS: Self-reported medication adherence was similar between warfarin and DOACs. Since suboptimal adherence is associated with poor clinical outcomes and increased costs, various stakeholders should emphasize the importance of medication adherence to oral anticoagulants at each patient encounter.

Patient satisfaction with quality of care of a multidisciplinary thrombosis service - a cross sectional survey.

BACKGROUND: In October 2017 we opened a multidisciplinary Adult Outpatient Thrombosis Service (Thrombosis Service) in a regional health authority servicing over 300 000 people. The Thrombosis Service is a comprehensive thrombosis and anticoagulation management program with unique, interrelated clinics providing a broad spectrum of care for this patient group. Evaluation of patient satisfaction with this new model of patient care is an important quality measurement. METHODS: We conducted a cross-sectional survey of patients who attended the Thrombosis Service between October 2017 and May 2019. We measured patient satisfaction with the seven-item Short Assessment of Patient Satisfaction (SAPS) which uses a 5 point scale (0-4) for responses. The continuous score range for SAPS is 0 to 28. Categorical responses for SAPS are defined as 0-10 very dissatisfied, 11-18 dissatisfied, 19-26 satisfied, and 27-28 very satisfied. We used linear regression analysis to examine the associations between patients' characteristics and their satisfaction with the Thrombosis Service. RESULTS: Of the 1058 surveys distributed, 563 were returned. The mean score for the SAPS was 22.1 (SD 4.1, range 8 to 28). For the categorical response, 85% were satisfied or very satisfied with the Thrombosis Service. The multivariate analysis showed patients with post-secondary education were more satisfied with the Thrombosis Service (ß-coefficient 1.6153, p = 0.024), and patients taking warfarin were less likely to be satisfied with the Thrombosis Service (ß-coefficient -1.5832, p = 0.0390). CONCLUSIONS: The majority of survey participants (85%) who attended an appointment in one of the Thrombosis Service clinics were satisfied or very satisfied with the care they received. This information may benefit other centres who are interested in developing a program to manage thrombosis and anticoagulation.

Socio-demographic factors related to binge drinking in Ontario.

BACKGROUND: Alcohol consumption has been linked to harmful health short and long-term outcomes. An analysis of socio-demographic factors related to binge drinking may help to identify groups at risk and provide primary health care providers an opportunity to assist members of those groups. In this study, we examined socio-demographic factors associated with binge drinking in Ontario, Canada. METHODS: This analysis used data from a cross-sectional survey of Ontario adults (ages 19 and older) for the 2015-2017 period. Bivariate and multivariate adjusted analyses examined the association between binge drinking and socio-demographic factors. These analyses were also stratified by sex. RESULTS: Increased alcohol binge drinking was associated with several socio-demographic factors including younger age groups, lower educational attainment, lower household income quintile, having immigrated to Canada within past 10 years, being male, reporting poorer mental health, being single, living in rural areas, and being unemployed. No differences were noted by households with or without children or by sexual orientation. Many of the factors associated with binge drinking remained significant when stratified by sex. DISCUSSION: These findings suggest that several socio-demographic factors are associated with binge drinking. These can be helpful indicators for decision makers responsible for programs and policies aimed at reducing alcohol binge drinking, and for primary care providers, who in a brief intervention can screen for binge drinking and support those individuals by connecting them with local resources to reduce their harmful alcohol consumption habits.

Preventing alcohol-related cancer: what if everyone drank within the guidelines?

OBJECTIVES: The purpose of this study was to estimate the proportion and number of cancer cases diagnosed in Ontario in 2012 that are attributable to alcohol consumption and to compare the impact of drinking within two sets of guidelines on alcohol-attributable cancer incidence. METHODS: We estimated the proportion of cancers in Ontario attributable to alcohol consumption by calculating population-attributable fractions (PAFs) for six cancer types using drinking prevalence from the 2000/2001 Canadian Community Health Survey and relative risks from a meta-analysis. Each PAF was multiplied by the number of incident cancers in 2012, allowing for a 12-year latency period, to calculate the number of alcohol-attributable cases. We also estimated the number of alcohol-attributable cases under two scenarios: (1) assuming consumption had not exceeded the levels recommended by the Low-Risk Alcohol Drinking Guidelines (LRADG) and (2) assuming consumption had not exceeded the recommended levels by the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) guidelines. RESULTS: One thousand two hundred ninety-five (95% confidence interval 1093-1499) new cases of cancer diagnosed in Ontario during 2012 are estimated to be attributed to alcohol consumption, representing approximately 1.7% (1.4-1.9%) of all new cancer cases. If no Ontario adults had exceeded the LRADG, an estimated 321 fewer cancer cases could have been diagnosed in 2012, whereas an estimated 482 fewer cancer cases could have been diagnosed if no Ontario adults had exceeded the stricter WCRF/AICR guidelines. CONCLUSION: Strategies to limit alcohol consumption to the levels recommended by drinking guidelines could potentially reduce the cancer burden in Ontario.

Association of insulin dosage with mortality or major adverse cardiovascular events: a retrospective cohort study.

BACKGROUND: Existing studies have shown conflicting evidence regarding the safety of exogenous insulin therapy in patients with type 2 diabetes. In particular, observational studies have reported an increased risk of death and cardiovascular disease among users of higher versus lower doses of insulin. We aimed to quantify the association between increasing dosage of insulin exposure and death and cardiovascular events, while taking into account time-dependent confounding and mediation that might have biased previous studies. METHODS: We did a cohort study using primary care records from the UK-based Clinical Practice Research Datalink (CPRD). New users of metformin monotherapy were identified in the period between Jan 1, 2001, and Dec 31, 2012. We then identified those in this group with a new prescription for insulin. Insulin exposure was categorised into groups according to the mean dose (units) per day within 180-day time segments throughout each patient's follow-up. Relative differences in mortality and major adverse cardiovascular events (non-fatal myocardial infarction, non-fatal stroke, cardiovascular-related mortality) were assessed using conventional multivariable Cox proportional hazards models. Marginal structural models were then applied to reduce bias introduced by the time-dependent confounders affected by previous treatment. FINDINGS: We identified 165 308 adults with type 2 diabetes in the CPRD database. After applying our exclusion criteria, 6072 (mean age 60 years [SD 12·5], 3281 [54%] men, mean HbA1c 8·5% [SD 1·75], and median follow-up 3·1 years [IQR 1·7-5·3) were new add-on insulin users and were included in the study cohort; 3599 were new add-on insulin users and were included in the subcohort linked to hospital records and death certificate information. Crude mortality rates were comparable between insulin dose groups; <25 units per day (46 per 1000 person-years), 25 to <50 units per day (39 per 1000 person-years), 50 to <75 units per day (27 per 1000 person-years), 75 to <100 units per day (34 per 1000 person-years), and at least 100 units per day (32 per 1000 person-years; p>0·05 for all; mean rate of 31 deaths per 1000 person-years [95% CI 29-33]). With adjustment for baseline covariates, mortality rates were higher for increasing insulin doses: less than 25 units per day [reference group]; 25 to <50 units per day, hazard ratio (HR) 1·41 [95% CI 1·12-1·78]; 50 to <75 units per day, 1·37 [1·04-1·80]; 75 to <100 units per day, 1·85 [1·35-2·53]; and at least 100 units per day, 2·16 [1·58-2·93]. After applying marginal structural models, insulin dose was not associated with mortality in any group (p>0·1 for all). INTERPRETATION: In conventional multivariable regression analysis, higher insulin doses are associated with increased mortality after adjustment for baseline covariates. However, this effect seems to be confounded by time-dependent factors such as insulin exposure, glycaemic control, bodyweight gain, and the occurrence of cardiovascular and hypoglycaemic events. This study provides reassurance of the overall safety of insulin use in the treatment of type 2 diabetes and contributes to our understanding of the contrasting conclusions from non-randomised and randomised studies regarding dose-dependent effects of insulin on cardiovascular events and mortality. FUNDING: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, and the Newfoundland and Labrador Research and Development Corporation.

Colorectal cancer incidence in the Aboriginal population of Ontario, 1998 to 2009.

BACKGROUND: Studies suggest that colorectal cancer incidence increased disproportionately among the Aboriginal population of Ontario relative to the general population. Using an ecological approach, this study examined colorectal cancer incidence for the 1998-to-2009 period among Aboriginal people living in Ontario. DATA AND METHODS: Based on their postal code when they were diagnosed, cases of colorectal cancer identified from the Ontario Cancer Registry were assigned to census geographic areas with high (33% or more) or low percentages of Aboriginal identity residents, using the Postal Code Conversion File Plus (PCCF+). To account for potential misclassification by the PCCF+, Indian reserves for which assignment through postal codes is likely to be accurate were identified. Age-standardized incidence rates and rate ratios were calculated to compare colorectal cancer incidence in high-Aboriginal identity areas or on Indian reserves with incidence in low-Aboriginal identity areas. RESULTS: Colorectal cancer incidence was significantly higher for residents of high- versus low-Aboriginal identity areas in Ontario (rate ratio for men = 1.44, 95% CI = 1.26-1.63; rate ratio for women = 1.42, 95% CI = 1.23-1.63), a disparity that persisted by age group. When the Aboriginal sample was limited to residents of Indian reserves, the difference was statistically significant only for men and for people aged 50 to 74. INTERPRETATION: The incidence of colorectal cancer differs across areas of Ontario with high and low percentages of Aboriginal identity residents.

Cervical cancer incidence in ontario women: differing sociodemographic gradients by morphologic type (adenocarcinoma versus squamous cell).

OBJECTIVE: Identify patterns in cervical cancer incidence in Ontario according to neighborhood sociodemographic characteristics over time and by morphologic type. METHODS: Incident cases of cervical cancer diagnosed from 1991 to 2009 were obtained from the Ontario Cancer Registry. Population data and data on neighborhood sociodemographic characteristics were obtained from the Canadian Census. Age-standardized incidence rates (ASIR) and rate ratios (RRs) with 95% confidence intervals (CIs) were calculated for each sociodemographic characteristic, stratified by morphologic type (squamous cell carcinoma and adenocarcinoma) and time period of diagnosis. RESULTS: Incidence was 51% higher in the poorest neighborhoods compared with the richest (RR, 1.51; 95% CI, 1.42-1.61) and 7% higher in rural areas compared with urban (RR, 1.07; 95% CI, 1.01-1.13). Incidence of squamous cell carcinoma was significantly higher in the poorest neighborhoods compared with the richest (RR, 1.74; 95% CI, 1.61-1.88), a trend observed for all time periods, and in rural areas compared with urban (RR, 1.10; 95% CI, 1.02-1.18). For adenocarcinoma, ASIRs in the earlier time period (1991-1998) were higher in the poorest neighborhoods compared with richest (RR, 1.26; 95% CI, 1.01-1.57), whereas for the more recent time period (1999-2009), ASIRs were lower for women living in the poorest neighborhoods compared with the richest (RR, 0.82; 95% CI, 0.68-0.99). CONCLUSIONS: This study identified significantly higher incidence of cervical cancer in low-income neighborhoods in Ontario. The association was especially pronounced for squamous cell carcinoma and varied by time period for adenocarcinoma. Improvements to screening and prevention efforts against oncogenic human papillomavirus strains would increase the detection of cervical cancer, adenocarcinoma especially, and may further reduce cervical cancer incidence.

Interventions performed by community pharmacists in one Canadian province: a cross-sectional study.

PURPOSE: Interventions made by pharmacists to resolve issues when filling a prescription ensure the quality, safety, and efficacy of medication therapy for patients. The purpose of this study was to provide a current estimate of the number and types of interventions performed by community pharmacists during processing of prescriptions. This baseline data will provide insight into the factors influencing current practice and areas where pharmacists can redefine and expand their role. PATIENTS AND METHODS: A cross-sectional study of community pharmacist interventions was completed. Participants included third-year pharmacy students and their pharmacist preceptor as a data collection team. The team identified all interventions on prescriptions during the hours worked together over a 7-day consecutive period. Full ethics approval was obtained. RESULTS: Nine student-pharmacist pairs submitted data from nine pharmacies in rural (n = 3) and urban (n = 6) centers. A total of 125 interventions were documented for 106 patients, with a mean intervention rate of 2.8%. The patients were 48% male, were mostly ≥18 years of age (94%), and 86% had either public or private insurance. Over three-quarters of the interventions (77%) were on new prescriptions. The top four types of problems requiring intervention were related to prescription insurance coverage (18%), drug product not available (16%), dosage too low (16%), and missing prescription information (15%). The prescriber was contacted for 69% of the interventions. Seventy-two percent of prescriptions were changed and by the end of the data collection period, 89% of the problems were resolved. CONCLUSION: Community pharmacists are impacting the care of patients by identifying and resolving problems with prescriptions. Many of the issues identified in this study were related to correcting administrative or technical issues, potentially limiting the time pharmacists can spend on patient-focused activities.

Use of evidence-based therapy at discharge for patients with acute myocardial infarction: retrospective audit of medical records.

BACKGROUND: Various guidelines are available outlining optimal therapy for patients with acute myocardial infarction. Canadian institutions providing care for such patients have been encouraged to evaluate their care processes using specific indicators. OBJECTIVE: To determine the proportion of patients with acute myocardial infarction discharged from a single health authority for whom acetylsalicylic acid (ASA), adrenergic ß-receptor antagonists (ß-blockers), angiotensin-converting enzyme (ACE) inhibitors, or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) had been prescribed. METHODS: Patients treated over a 12-month period (April 1, 2004, to March 31, 2005) for whom the most responsible diagnosis was acute myocardial infarction were eligible for inclusion in this review. Retrieved data included diagnosis, demographic information, comorbidities, and medications at the time of admission and discharge. Rates of discharge prescribing for the 4 drug classes were calculated for all patients and for "ideal" patients (those without documented contraindications). Rates were compared with published benchmark values. RESULTS: Medical records for a total of 346 eligible patients were reviewed. Mean age was 65.3 years (standard deviation 13.4 years), and 226 (65.3%) of the patients were male. The coded diagnosis was ST-elevation myocardial infarction for 91 patients (26.3%), non-ST-elevation myocardial infarction for 164 (47.4%), and myocardial infarction not specified for 91 (26.3%). For "ideal" patients, the prescribing rates were 99.0% (308 of 311 patients) for ASA, 96.3% (310 of 322 patients) for ß-blockers, 90.4% (264 of 292 patients) for ACE inhibitors, and 88.8% (278 of 313 patients) for statins. CONCLUSIONS: Rates of prescribing of ASA, ß-blockers, ACE inhibitors, and statins for "ideal" patients discharged after treatment for acute myocardial infarction exceeded the published Canadian benchmark rates (≥ 90% for ASA, ≥ 85% for ß-blockers and ACE inhibitors, ≥ 70% for statins).