Quality of palliative and end-of-life care: a quantitative study of temporal trends and differences according to illness trajectories in Quebec (Canada).

BACKGROUND: Our aim was to assess temporal trends and compare quality indicators related to Palliative and End-of-Life Care (PEoLC) experienced by people dying of cancer (trajectory I), organ-failure (Trajectory II), and frailty/dementia (trajectory III) in Quebec (Canada) between 2002 and 2016. METHODS: This descriptive population-based study focused on the last month of life of decedents who, based on the principal cause of death, would have been likely to benefit from palliative care. Five PEoLC indicators were assessed: home deaths (1), deaths in acute care beds with no PEoLC services (2), at least one Emergency Room (ER) visit in the last 14 days of life (3), ER visits on the day of death (4) and at least one Intensive Care Unit (ICU) admission in the last month of life (5). Data were obtained from Quebec's Integrated Chronic Disease Surveillance System (QICDSS). RESULTS: The annual percentage of home deaths increased slightly between 2002 and 2016 in Quebec, rising from 7.7 to 9.1%, while the percentage of death during a hospitalization in acute care without palliative care decreased from 39.6% in 2002 to 21.4% in 2016. Patients with organ failure were more likely to visit the ER on the day of death (20.9%) than patients dying of cancer and dementia/frailty with percentages of 12.0% and 6.4% respectively. Similar discrepancies were observed for ICU visits in the last month and ER visits in the last 14 days. CONCLUSION: PEoLC indicators showed more aggressiveness of care for patients with organ failure and highlight the need for more equitable access to quality PEoLC between malignant and non-malignant illness trajectories. These results underline the challenges of providing timely and optimal PEoLC.

Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation.

OBJECTIVES: Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year. STUDY DESIGN AND SETTING: We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting. RESULTS: A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously. CONCLUSION: We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.

Change in intention and hesitancy regarding COVID-19 vaccines in a cohort of adults in Quebec during the pandemic.

Although COVID-19 vaccine uptake was high in Quebec for the primary series, vaccine acceptance decreased for the subsequent booster doses. This article presents the evolution of vaccine intention, self-reported vaccination behaviors, and vaccine hesitancy over 2 years. A series of cross-sectional surveys were conducted in Quebec between March 2020 and March 2023, with a representative sample of 3,330 adults recruited biweekly via a Web panel. Panelists could have answered multiple times over the course of the project. A cohort of respondents was created to assess how attitudes and behaviors about COVID-19 vaccines evolved. Descriptive statistics and multivariate logistic regressions were performed. Among the 1,914 individuals with no or low intention of getting vaccinated in Fall 2021 (Period 1), 1,476 (77%) reported having received at least two doses in the Winter 2023 (Period 2). Not believing in conspiracy theory (OR = 2.08, 95% CI: 1.65-2.64), being worried about catching COVID-19 (OR = 2.12, 95% CI: 1.65-2.73) and not living in a rural area (ORs of other areas are 2.27, 95% CI: 1.58-3.28; 1.66, 95% CI: 1.23-2.26; 1.82 95% CI: 1.23-2.73) were the three main factors associated with being vaccinated at Period 2. Among the 11,117 individuals not hesitant at Period 1, 1,335 (12%) became hesitant at Period 2. The three main factors significantly associated with becoming vaccine hesitant were the adherence to conspiracy theories (OR = 2.28, 95% CI: 1.95-2.66), being a female (OR = 1.67, 95% CI: 1.48-1.90) and being younger than 65 years old (the ORs for 18-34, 35-49, and 50-64 compared with 65 and over are 2.82, 95% CI: 2.32-3.44; 2.39, 95% CI: 2.00-2.86 and 1.82, 95% CI: 1.55-2.15 respectively). As the pandemic is over, monitoring the evolution of vaccine attitudes and uptake will be important.

The Qanuilirpitaa? 2017 Nunavik Health Survey: design, methods, and lessons learned.

OBJECTIVE: To depict the design, methods, sociodemographic characteristics of the population, and lessons learned during the Qanuilirpitaa? 2017 Nunavik Inuit Health Survey, the third major health survey to be conducted among youth and adults residing in Nunavik (Northern Quebec, Canada). METHODS: Qanuilirpitaa? 2017 is a cross-sectional survey that served to update information regarding various aspects of physical health, mental health, and general well-being of Nunavimmiut. The survey was guided by the ethics principles of Ownership, Control, Access, and Possession (OCAP®) ( https://fnigc.ca/ocap ). Questionnaires and clinical tests were administered to residents from the 14 coastal communities onboard the Canadian Coast Guard Ship Amundsen during late summer and early fall 2017. As part of the community component of the survey, qualitative interviews were performed with key respondents, and services and resources supporting health and well-being in the 14 communities were inventoried and characterized. RESULTS: A total of 1326 Nunavimmiut aged 16 and over participated in the survey. Despite difficulties encountered with the recruitment of participants, co-interpretation sessions with Inuit partners revealed that the survey had succeeded in capturing cultural, socio-economic, and lifestyle characteristics of Nunavimmiut. In all, 20 thematic reports have been published covering various aspects of health and well-being of Nunavimmiut. Regional and local reports pertaining to the community component were produced. More in-depth analyses have ensued, and results are presented in articles published in this CJPH supplement issue. CONCLUSION: Information from this survey is being used to update health services and programs in the region and for the development of health policies and public health interventions to tackle key health-related issues faced by Nunavimmiut. Drawing lessons from challenges and successes encountered in Qanuilirpitaa? 2017, this survey paved the way to the upcoming Inuit-led Qanuippitaa? National Inuit Health Survey to be conducted every 5 years throughout Inuit Nunangat.

RéSUMé: OBJECTIF: Décrire la conception, les méthodes, les caractéristiques sociodémographiques de la population et les leçons tirées de l'Enquête sur la santé des Inuits du Nunavik Qanuilirpitaa? 2017, la troisième grande enquête de santé menée auprès de jeunes et d'adultes résidant au Nunavik (Nord du Québec, Canada). MéTHODES: Qanuilirpitaa? 2017 est une enquête transversale qui a permis la mise à jour des informations concernant divers aspects de la santé physique, de la santé mentale et du bien-être général des Nunavimmiut. L'enquête a été guidée par les principes de propriété, de contrôle, d'accès et de possession (OCAP®) ( https://fnigc.ca/ocap ). Des questionnaires et des tests cliniques ont été administrés à des résidents des 14 communautés côtières, à bord du navire Amundsen de la Garde côtière canadienne, à la fin de l'été et au début de l'automne 2017. Des entrevues qualitatives ont également été réalisées avec des répondants clé dans le cadre de la composante communautaire. RéSULTATS: Au total, 1 326 Nunavimmiut âgés de 16 ans et plus ont été recrutés. Malgré les difficultés rencontrées lors du recrutement des participants, les rencontres de co-interprétation ont permis de vérifier que l'enquête avait réussi à capturer les caractéristiques culturelles, socioéconomiques et les habitudes de vie de la population. Au total, 20 rapports thématiques ont été publiés, lesquels couvrent différents aspects de la santé et du bien-être des Nunavimmiut. Un rapport régional et des rapports locaux liés à la composante communautaire ont également été produits. Des analyses plus approfondies ont également été réalisées, dont les résultats sont présentés dans les articles publiés dans ce numéro supplémentaire de la Revue canadienne de santé publique. CONCLUSION: Les informations issues de cette enquête sont utilisées pour la mise à jour des services de santé dans la région et pour le développement de politiques de santé et d'interventions de santé publique, ayant pour cibles les principaux défis auxquels les Nunavimmiut sont confrontés. Grâce aux leçons apprises lors de sa réalisation, cette enquête a pavé la voie aux prochaines enquêtes Qanuippitaa ? qui seront menées tous les 5 ans dans tout l'Inuit Nunangat.

School-based vaccination program against HPV and Hepatitis B: A longitudinal analysis of vaccine coverage between 2015 and 2021 in Quebec.

BACKGROUND: HPV vaccination prevents cancers, including 90% of cervical cancer. Since 2008, a school-based HPV vaccination program has been implemented in Quebec, but vaccine coverage is suboptimal. The COVID-19 pandemic disrupted school-based vaccination programs. This study aimed to assess variation in HPV vaccination coverage in the school-based program between 2015 and 2022 in Quebec and to identify sociodemographic characteristics associated with non-vaccination. METHODS: HPV vaccine coverage data were extracted from the Quebec Immunization Registry for students in Grade 4 and matched to the 2016 Canadian census sociodemographic data. Descriptive analysis was conducted to explore individual-level vaccine coverage according to sociodemographic data. A Generalized Estimating Equations model assessed the independent association between non-vaccination and students' sociodemographic characteristics. RESULTS: HPV vaccine coverage (at least one dose) was 84% in 2018-2019 and 85% in 2019-2020. A decrease was observed during the pandemic. In 2020-2021, the HPV vaccine coverage (at least one dose) was 52% (at the end of the school year) and rose to 84% with intense catch-up activities. In 2021-2022, the coverage was slightly lower than before the pandemic (81%). Factors in the dissemination area were statistically significantly associated with non-vaccination: material (p-value = 0.0001) and social deprivation index (p-value = 0.0048), the proportion of immigration (p-value < 0.0001), and the language spoken at home (English (p-value = 0.0318), other than French or English (p-value = 0.0001). CONCLUSION: School-based vaccination programs offer equitable access to vaccination, and our analysis showed that some groups have consistently lower vaccine acceptance and uptake. Strategies to improve HPV vaccine coverage should target children living in areas with a higher proportion of immigrants, non-French speakers, and people from underprivileged backgrounds. Although it is too early to assess the full impact of COVID-19 on school-based programs in Quebec, it remains important to ensure that catch-up strategies are implemented for missed doses.

Marginal structural models with latent class growth analysis of treatment trajectories: Statins for primary prevention among older adults.

Latent class growth analysis is increasingly proposed as a solution to summarize the observed longitudinal treatment into a few distinct groups. When latent class growth analysis is combined with standard approaches like Cox proportional hazards models, confounding bias is not properly addressed because of time-varying covariates that have a double role of confounders and mediators. We propose to use latent class growth analysis to classify individuals into a few latent classes based on their medication adherence pattern, then choose a working marginal structural model that relates the outcome to these groups. The parameter of interest is defined as a projection of the true marginal structural model onto the chosen working model. Simulation studies are used to illustrate our approach and compare it with unadjusted, baseline covariates adjusted, time-varying covariates adjusted, and inverse probability of trajectory groups weighted adjusted models. Our proposed approach yielded estimators with little or no bias and appropriate coverage of confidence intervals in these simulations. We applied our latent class growth analysis and marginal structural model approach to a database comprising information on 52,790 individuals from the province of Quebec, Canada, aged more than 65 and who were statin initiators to estimate the effect of statin-usage trajectories on a first cardiovascular event.

Evolution in Trends of Primary Lower-Extremity Amputations Associated With Diabetes or Peripheral Artery Disease From 2006 to 2019.

BACKGROUND: Given the importance in prevention of lower extremity amputations (LEAs) associated with diabetes or peripheral artery disease (PAD), we sought to document the trends of primary LEA in Québec, Canada, from years 2006 to 2019. METHODS: Using the Québec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of primary LEA associated with diabetes and PAD among adults ≥ 40 years (99% confidence intervals [CI]), and all-cause 1-year mortality proportion trends following a primary LEA (95% CI), stratified by minor or major as the highest level of LEA during the same hospital stay and age groups. Trends were assessed using multivariate regression models. RESULTS: In 2019, the crude rate of primary LEA was 116.0 per 100,000 (n = 825) with 93.7 and 21.9 per 100,000 of minor (n = 665) and major (n = 160) LEA, respectively. A tendency of decrease by 8% (-15.0 to 0.4%) of age-standardized incidence of primary LEA was observed between 2006 and 2019, while the absolute number of primary LEA increased from 610 to 825 cases. Minor LEA increased by 14.2% (3.7 to 25.9%) and major LEA decreased by 49.5% (-57.1 to -40.5%). Incidence trends remained stable among the 40 to 64 years, and declined by 14.6% and 20.1% for the 65 to 79 and ≥ 80 years of age groups, respectively. Major LEA decreased in all age groups, whereas minor LEA increased by 26.2% among the patients 40 to 64 years of age only. Age-standardized 1-year mortality decreased by 35.1% (95% CI, -43.4 to -25.7%) between 2006 and 2019, with a crude 1-year mortality of 11.3% in 2019. CONCLUSIONS: The reduction of major LEA and 1-year mortality are encouraging, although increased minor LEA, especially in younger age groups, emphasizes the importance to improve preventive care further.

Temporal trends of aortic stenosis and comorbid chronic kidney disease in the province of Quebec, Canada.

OBJECTIVE: To investigate temporal trends of chronic kidney disease (CKD) among patients with incident aortic stenosis (AS) and to compare these trends with that of a matched control population. METHODS: Using the Quebec Integrated Chronic Disease Surveillance System, we performed a population-based nested case-control study including 108 780 patients newly hospitalised with AS and 543 900 age-matched, sex-matched and fiscal year-matched patients without AS from 2000 to 2016 in Quebec (Canada). Three subgroups were considered. Dialysis subgroup had at least two outpatient billing codes of dialysis. The predialysis subgroup had at least one hospital or two billing diagnostic codes of CKD. The remaining individuals were included in the non-CKD subgroup. We estimated overall and sex-specific standardised annual proportions of CKD subgroups through direct standardisation using the 2016-2017 age structure of the incident AS cohort. The trends overtime were estimated through fitting robust Poisson regression models. Age-specific distribution of AS and control population were assessed for each subgroup. RESULTS: From 2000 to 2016, age-standardised proportions of patients with AS with dialysis and predialysis increased by 41% (99% CI 12.0% to 78.1%) and by 45% (99% CI 39.1% to 51.6%), respectively. Inversely, age-standardised proportions of dialysis and pre-dialysis among non-AS patients decreased by 63% (99% CI 55.8% to 68.7%) and by 32% (99% CI 29.9% to 34.6%), respectively, during the same study period. In patients with and without AS, age-standardised annual proportions of males in predialysis were significantly higher than females in most of the study period. Patients with AS on dialysis and predialysis were younger than their respective controls (dialysis: 29.6% vs 45.1% had ≥80 years, predialysis: 60.8% vs 72.7% had ≥80 years). CONCLUSIONS: Over time, the proportion of patients with CKD increased significantly and remained consistently higher in incident AS individuals compared with controls. Our results highlight the need to investigate whether interventions targeting CKD risk factors may influence AS incidence in the future.

Evolution of the burden of aortic stenosis by sex in the province of Quebec between 2006 and 2018.

OBJECTIVES: To evaluate the evolution of the burden of aortic stenosis (AS) by sex in the province of Quebec from 2006-2007 to 2018-2019 and compare the percentage of mortality between people who underwent aortic valve intervention and those who did not. METHODS: Persons aged ≥20 years were identified from the Quebec Integrated Chronic Disease Surveillance System using International Classification of Diseases and intervention codes in the hospital files. RESULTS: In 2018, the crude prevalence and incidence of AS were 0.89% (99% CI 0.89 to 0.90) (n=59 025) and 1.39 per 1000 (1.35 to 1.43) (n=9105), respectively. Age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018 from 0.67% (0.66 to 0.68) to 0.75% (0.74 to 0.76) and from 0.91 per 1000 (0.88 to 0.95) to 1.20 per 1000 (1.17 to 1.23), respectively. Among incident AS, the age-standardised percentage of valve interventions increased from 11.7% (10.9 to 12.6) to 14.5% (13.9 to 15.3). This increase was only observed in men. The 30-day mortality was stable among patients with incident AS treated conservatively, from 6.9% (6.5 to 7.4) to 7.3% (6.9 to 7.6), and decreased from 7.6% (6.1 to 9.3) to 3.8% (3.1 to 4.7) among operated patients with incident AS. This decrease was only observed in women. However, from 2010, the age-adjusted mortality among prevalent AS tended to be higher in women. CONCLUSIONS: In the province of Quebec, age-standardised prevalence and incidence of AS diagnosis increased between 2006 and 2018. Among incident AS, there was an increase in valve intervention in men and a decrease in 30-day mortality in women who underwent valve intervention. Overall and age-standardised mortality remained higher in women.

Epidemiology associated with the exposure to Toxoplasma gondii in Nunavik's Inuit population using the 2017 Qanuilirpitaa cross-sectional health survey.

Foci of high seroprevalence against Toxoplasma gondii are observed in Nunavik, the Inuit land of Northern Quebec (Canada). Considering the rare occurrence of felids in the region, exposure is suspected to be driven by water- and food-borne transmission routes. Hypotheses were that drinking untreated water from natural sources and eating country food mostly raw increased the risk of exposure to the parasite. Data from 1,300 Inuit participants of the 2017 Nunavik Health Survey were included in three weighted robust Poisson regression models. The effect of three types of exposure variables: (1) water treatment (yes/no) and if country food was mostly eaten raw (yes/no); (2) main source of drinking water (bottled/municipal/natural) and frequency of country food consumption (continuous) and (3) drinking water risk (low/intermediate/high) and frequency of a raw country food consumption (continuous), on the presence of Toxoplasma antibodies were estimated. Models were adjusted for age, sex and ecological region, with multiple sensitivity analyses being performed. Toxoplasma gondii seroprevalences were consistently correlated with age quadratically, sex (prevalence ratio = PRwoman/man ranged from 1.18 to 1.22), ecological region (PRHudsonBay/HudsonStrait ranged from 2.18 to 2.41; PRHudsonBay/UngavaBay ranged from 1.52 to 1.59) and consuming bivalve mollusc/urchin (PR varied from 1.02 to 1.21) across all three models. Each increase of two consumptions per month of beluga (PR ranged from 1.01 to 1.03), seal liver (PR ranged from 1.01 to 1.02) and goose (PR ranged from 1.01 to 1.02) were also associated with seropositivity, albeit more clearly in models 2 and 3, while drinking water mainly from natural (PR of 1.47) or municipal (PR = 1.42) sources compared to bottled water, was correlated with seroprevalence, although results were compatible with the null. Our results suggest that both the oocyst- (mollusc/urchin, drinking water) and cyst-borne (walrus, seal liver and goose) transmission pathways could be present in Nunavik.

COVID-19 vaccination attitudes and intention among Quebecers during the first and second waves of the pandemic: findings from repeated cross-sectional surveys.

The availability of safe and effective vaccines is a major breakthrough in controlling the COVID-19 pandemic. However, the success of the COVID-19 vaccination campaign relies on high uptake by the public. We monitored Quebecers' attitudes and intention toward COVID-19 vaccination during the first and second waves of the pandemic. Since March 2020, online surveys are conducted every week in Quebec (Canada) to assess Quebecers' adherence to recommended public health measures (3,300 respondents are surveyed every week through an online panel; respondents are not invited to answer the survey for 21 days after responding). Ten items measured respondents' attitudes and intentions regarding COVID-19 vaccination. Logistic regression models were used to identify determinants of intention to be vaccinated against COVID-19. Intention to be vaccinated against COVID-19 ranged from 76%-66% between the first and second waves. The proportion of undecided adults remained stable (12%). Being a man; being 60 years of age and over; having a university education level; having or living with someone with chronic medical conditions and increased risk perceptions of COVID-19 were the strongest predictors of COVID-19 vaccine acceptance in multivariate analysis. During data collection, COVID-19 vaccine supply was very limited. It was reassuring to note that intention to be vaccinated is the highest among older age groups that are prioritized to be vaccinated first. As more doses and vaccines will be available it will be important to enhance vaccine acceptance and uptake, especially among adults younger than 60 years of age and Quebecers with lower risk perceptions of COVID-19.

Covid-19 vaccine acceptance, hesitancy, and refusal among Canadian healthcare workers: A multicenter survey.

BACKGROUND: Determinants of COVID-19 vaccine acceptance among healthcare workers (HCW) remains poorly understood. We assessed HCWs' willingness to be vaccinated and reasons underlying hesitancy. METHODS: Cross-sectional survey across 17 healthcare institutions. HCWs eligible for vaccination (Pfizer-BioNTech mRNA) in December 2020 were invited to receive immunization. Multivariate logistic regression was performed to identify predictors of acceptance. Reasons for refusal among those who never intended to be vaccinated (ie, firm refusers) and those who preferred delaying vaccination (ie, vaccine hesitants) were assessed. RESULTS: Among 2,761 respondents (72% female, average age, 44), 2,233 (80.9%) accepted the vaccine. Physicians, environmental services workers and healthcare managers were more likely to accept vaccination compared to nurses. Male sex, age over 50, rehabilitation center workers, and occupational COVID-19 exposure were independently associated with vaccine acceptance by multivariate analysis. Factors for refusal included vaccine novelty, wanting others to receive it first, and insufficient time for decision-making. Among those who declined, 74% reported they may accept future vaccination. Vaccine firm refusers were more likely than vaccine hesitants to distrust pharmaceutical companies and to prefer developing a natural immunity by getting COVID-19. CONCLUSIONS: Vaccine hesitancy exists among HCWs. Our findings provide useful information to plan future interventions and improve acceptance.

The association between removing and reintroducing man-made jumps in terrain parks and severe alpine skiing and snowboarding injuries.

OBJECTIVES: To explore the effect of removing and reintroducing man-made jumps in terrain parks (TPs), on the proportion of severe injuries among alpine skiers and snowboarders in Québec, Canada. DESIGN: Quasi-experimental study. METHODS: Injuries were identified via injury report forms completed by ski patrollers during seasons 2000-2001 to 2016-2017 in Québec ski areas. Severe injuries were defined based on the type of injury or ambulance evacuation. Logistic regression analysis was used to provide adjusted odds ratios (AOR) for the comparison of the time periods before jump removal (PRE) and after jump reintroduction (POST) with the jump removal interval (INT). RESULTS: Compared with INT, the proportion of severe injuries in PRE was not significantly different (AOR: 1.05; 95% CI: 0.85-1.30), but was higher in POST (AOR: 1.76; 95% CI: 1.24-2.51) for ski areas with jump removal. In ski areas without jump removal, there was no change in PRE (AOR: 0.96; 95% CI: 0.87-1.07) and increased odds of severe injuries in POST (AOR: 1.20; 95% CI: 1.07-1.35). A supplementary analysis suggested that removing jumps from TPs has contributed significantly to a reduction in the proportion of severe injuries. This protective effect appears to decline over time. CONCLUSIONS: These results do not suggest that removing jumps from TPs as an effective long-term injury prevention strategy in skiing and snowboarding. Collecting data on exposure could improve our understanding of how removing, introducing or reintroducing man-made jumps in TPs is associated with the risk of minor and severe injuries in TPs and on regular trails.

Dental Caries Experience in Elementary School Students in Quebec: Surveillance Study Using ICDAS II.

OBJECTIVES: The main objective of a 2012-2013 clinical study on the oral health of Quebec elementary school students was to assess the oral health status of Grade 2 and Grade 6 students. We assessed various stages of caries and created caries indicators for primary and permanent dentitions combined. METHODS: Oral health examination of 2875 Grade 2 students and 2788 Grade 6 students, enrolled in public and private, French- and English-language schools, was carried out at schools. The examinations were performed by 16 trained and calibrated dentists using International Caries Detection and Assessment System (ICDAS) II criteria. A 3-level sampling design ensured that the study was representative for the province of Quebec. RESULTS: Mean indexes for decayed, missing, filled primary teeth (dmft) and secondary teeth (DMFT) or surfaces (dmfs and DMFS) for all stages of caries were as follows. Grade 2 students: dmft 3.96, DMFT 1.88, dmft + DMFT 5.84, dmfs 8.33, DMFS 2.96 and dmfs + DMFS 11.28. Grade 6 students: dmft 1.94, DMFT 4.98, dmft + DMFT 5.98, dmfs 4.04, DMFS 7.86 and dmfs + DMFS 9.96. Most students (90% for Grade 2 and 92% for Grade 6) had a dmfs + DMFS > 0. CONCLUSION: Tooth decay remains a public health problem in Quebec. The findings testify to the importance of reinforcing preventive measures to better control dental caries among youth. It is advantageous to use ICDAS II in the context of oral health surveillance at a population level and to present the results as a combination of primary and permanent dentitions.

Public Health Outcomes May Differ After Switching from Brand-Name to Generic Angiotensin II Receptor Blockers.

BACKGROUND: It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death. STUDY DESIGN: This was a retrospective cohort study. METHODS: This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified). RESULTS: In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76-78 years, 59-66% were female, 90-92% had hypertension, and 13-15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99-1.14) for ER consultation, 1.26 (1.14-1.39) for hospitalization, and 1.01 (0.61-1.67) for death. The corresponding rates for candesartan were 1.00 (0.95-1.05), 0.96 (0.89-1.03), and 0.57 (0.37-0.88), respectively. CONCLUSIONS: We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings.

Adoption of municipal bylaw legislating mandatory helmet use for cyclists under the age of 18: impact on cycling and helmet use. / Adoption d'un règlement municipal pour obliger les moins de 18 ans à porter un casque à vélo : effet sur la pratique du vélo et le port du casque.

INTRODUCTION: Bicycle helmet use is recognized as an effective way to prevent head injuries in cyclists. A number of countries have introduced legislation to make helmets mandatory, but many object to this type of measure for fear that it could discourage people, particularly teenagers, from cycling. In 2011, the City of Sherbrooke adopted a bylaw requiring minors to wear a bicycle helmet. The objective of this study was to assess the impact of this bylaw on cycling and bicycle helmet use. METHODS: The impact of the bylaw was measured by comparing the evolution of bicycle helmet use among youth aged 12 to 17 years in the Sherbrooke area (n = 248) and in three control regions (n = 767), through the use of logistic regression analyses. RESULTS: Cycling rates remained stable in the Sherbrooke area (going from 49.9% to 53.8%) but decreased in the control regions (going from 59.1% to 46.3%). This difference in evolution shows that cycling rates increased in the Sherbrooke area after the adoption of the bylaw, compared to the control regions (odds ratio [OR] of the interaction term: 2.32; 95% confidence interval [CI]: 1.01-5.35). With respect to helmet use, a non-statistically significant upward trend was observed in the Sherbrooke area (going from 43.5% to 60.6%). This figure remained stable in the control regions (going from 41.5% to 41.9%). No significant difference was observed in the evolution of helmet use between the two groups (OR of the interaction term of 2.70; 95% CI: 0.67-10.83). CONCLUSION: After the bylaw was adopted, bicycle use among youth aged 12 to 17 years in the Sherbrooke area remained stable and helmet used increased, though not significantly.

Did Generic Clopidogrel Commercialization Affect Trends of ER Consultations and Hospitalizations in the Population Treated with Clopidogrel?

BACKGROUND: Clopidogrel has been widely used to prevent atherothrombotic events. Since 2011, pharmacists have offered their patients the opportunity to switch to generic clopidogrel, an economic alternative. Whether bioequivalence of generic cardiovascular drugs translates into clinical equivalence at a population level remains unclear and needs to be further documented. OBJECTIVE: We aimed to evaluate the impact of generic clopidogrel commercialization on adverse events (AEs): hospitalizations or emergency room (ER) consultations. METHODS: This is an interrupted time series analysis using the Quebec Integrated Chronic Disease Surveillance System. We included all patients ≥ 66 years old who were users of the brand-name clopidogrel or a generic version (n = 6) 24 months before and up to 12 months after generics commercialization. Rates of AEs were computed, and periods before and after generics commercialization were analyzed by segmented regression models along with exploratory analyses (generic vs. brand name). Sensitivity analyses were also performed using stratification of the time series by (1) sex, (2) the number of prevalent cardiovascular comorbidities, and (3) socioeconomic status. RESULTS: Time series were constituted of 89,525 clopidogrel users (mean age 78 years, 45% women, 71% ischemic heart disease, 34% stroke). For all users, there was a mean rate of 157 AEs per 1000 user-months, stable trend before (-0.1% [95% confidence interval -0.3 to 0.1] and after (0.0% [- 0.5 to 0.6]) generics commercialization. In exploratory analyses, once generic clopidogrel versions were commercialized, rates of AEs were 19.2% (95% CI 11.7-26.7) higher for generic versus brand-name users. This difference persisted up to 1 year. Sensitivity analyses yielded similar results. CONCLUSIONS: The population treated with clopidogrel had similar rates of hospitalizations or ER consultations before and after generics commercialization. However, differences in rates of hospitalizations or ER consultations between generic and brand-name clopidogrel users may represent a drug safety signal which remains to be validated. Using a different study design, permitting adjustment for potential confounders, could be useful in this regard.

Trends in Hospital Visits for Generic and Brand-Name Warfarin Users in Québec, Canada: A Population-Based Time Series Analysis.

BACKGROUND: Federal standards authorize the commercialization of generic medicines after bioequivalence versus the brand-name originator has been demonstrated. For drugs with narrow therapeutic indexes, such as warfarin, the accepted difference in bioavailability is ≤ 10%. No systematic pharmacovigilance studies are conducted once generics become available. OBJECTIVE: We aimed to assess the impact of the arrival of generic warfarin on hospital visit trends (hospital admissions or emergency room consultations) in warfarin users. METHODS: This was an observational interrupted time series analysis (2 January 1996 to 1 January 2016). Using the Québec Integrated Chronic Disease Surveillance System, we included all patients who were aged ≥ 66 years, publicly covered and using brand-name or generic warfarin (N = 280,158). We estimated rates of hospital visits in 6-month periods, 5 years before and up to 15 years after the arrival of generic warfarin. Periods before and after were compared using segmented regression models for all users along with exploratory (generic vs. brand name)/subgroup analyses (cardiovascular comorbidities and socioeconomic status). RESULTS: Generic warfarin arrived on the market on 2 January 2001. Over the 20-year period of the study, the mean rate of hospital visits was 113 for 100 brand-name or generic users per 6-month period and was similar before and after the arrival of the generics. Up to 15 years after the arrival of the generics, the rates of hospital visits were 10% higher for generic than for brand-name users, which was confirmed by subgroup analyses. CONCLUSIONS: Overall, we observed no impact on hospital visits after the arrival of generic warfarin in all the population treated with any type of warfarin. However, a higher crude rate of hospital visits among generic users than brand-name users remains to be validated using a different methodology and specific outcomes.

Population-level trends in the distribution of body mass index in Canada, 2000-2014.

OBJECTIVE: Research studying population-level body mass index (BMI) trends document increases in mean or prevalence of overweight/obese but less consideration has been given to describing the changing distribution of BMI. The objective of this research was to perform a detailed analysis of changes in the BMI distribution in Canada. METHODS: Using data from the CCHS (2000-2014), we analyzed distributional parameters of BMI for 492,886 adults aged 25-64 years. We further stratified these analyses for women and men, education level, and region of residence. RESULTS: Mean BMI has increased for most subgroups of the Canadian population. Mean BMI values were higher for men, while standard deviation (SD) of the BMI distribution was systematically higher in women. Increases in mean BMI were accompanied with increases in SD of BMI across cycles. Across survey cycles, the 95th percentile increased more than 10 times more rapidly compared to the 5th percentile, showing a very unequal change between extreme values in the BMI distribution over time. There was a relationship between SD with BMI, but these relations were generally not different between educational categories and regions. This suggests that the growing inter-individual inequalities (i.e., dispersion) in BMI were not solely attributable to socioeconomic and demographic factors. CONCLUSIONS: This study supports the hypothesis that the simultaneous increases in mean BMI and SD of the BMI distribution are occurring, and suggests the need to move beyond the mean-centric paradigm when studying a complex public health phenomenon such as population change in BMI.