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1.
Urology ; 2021 Feb 13.
Artigo em Inglês | MEDLINE | ID: mdl-33592224

RESUMO

OBJECTIVES: To compare toxicity and all-cause mortality for mCRPC patients receiving first line oral systemic therapy prescribed by medical oncologists and urologists. METHODS: Population-based retrospective cohort study of chemotherapy-naïve men aged ≥66 years treated for mCRPC with first-line abiraterone or enzalutamide based on administrative health data (Ontario, Canada, 2012-2017). Primary outcomes were hospitalizations/ER visits for any cause or treatment-related toxicity during first-line mCRPC treatment. Secondary outcome was all-cause mortality. We calculated hazard ratios (HRs) comparing outcomes for different medical specialties using multivariable Cox proportional hazards models. RESULTS: Among 3405 mCRPC patients, 2407 (70.7%) received abiraterone and 998 (29.3%) received enzalutamide. 1786 (52.5%) patients visited the ER or were hospitalized. Men treated by medical oncologists had an increased risk of hospitalization/ER visits (HR1.16, 95%CI 1.03-1.31; P = .02), toxicity-related visits (HR1.34, 95%CI 1.08-1.69; P = .01), and mortality (HR1.16, 95%CI 1.02-1.33; P = .02) compared to urologists. Limited information was available, beyond PSA adjustment and prior treatment, on patient disease burden. CONCLUSION: We observed fewer hospital visits overall and for treatment-related toxicity for mCRPC patients who were prescribed first line abiraterone or enzalutamide by urologists compared to medical oncologists. These differences may result from higher prostate cancer disease burden in patients managed by medical oncologists, and/or other unmeasured differences in patient management between specialties.

2.
Clin Infect Dis ; 2021 Feb 17.
Artigo em Inglês | MEDLINE | ID: mdl-33595621

RESUMO

BACKGROUND: The role of antibiotics in preventing urinary tract infection (UTI) in older adults is unknown. We sought to quantify the benefits and risks of antibiotic prophylaxis among older adults. METHODS: We conducted a matched cohort study comparing older adults (≥66 years) receiving antibiotic prophylaxis, defined as antibiotic treatment for at least 30 days starting within 30 days of a positive culture, to patients with positive urine cultures that received antibiotic treatment but did not receive prophylaxis. We matched each prophylaxis recipient to 10 non-recipients based on organism, number of positive cultures, and propensity score. Outcomes included 1) emergency department (ED) visit or hospitalization for UTI, sepsis, or bloodstream infection within 1 year; 2) acquisition of antibiotic resistance in urinary tract pathogens; 3) antibiotic-related complications. RESULTS: Overall 4.7% (151/3,190) of UTI prophylaxis patients and 3.6% (n=1,092/30,542) controls required an ED visit or hospitalization for UTI, sepsis, or bloodstream infection (Hazard Ratio (HR) 1.33, 95%CI 1.12 to 1.57). Acquisition of antibiotic resistance to any urinary antibiotic (HR 1.31, 95%CI 1.18 to 1.44) and to the specific prophylaxis agent (HR 2.01, 95% CI 1.80 to 2.24) were higher in patients receiving prophylaxis. While the overall risk of antibiotic-related complications was similar between groups (HR 1.08, 95%CI 0.94 to 1.22) the risk of C. difficile and general medication adverse events was higher in prophylaxis recipients (HR 1.56, 95%CI 1.05 to 2.23; HR 1.62, 95%CI 1.11 to 2.29, respectively). CONCLUSIONS: Among older adults with UTI, the harms of long-term antibiotic prophylaxis may outweigh their benefits.

3.
Ann Surg Oncol ; 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33067747

RESUMO

BACKGROUND: Melanoma and the immune system are intimately related. However, the association of immunosuppressive medications (ISMs) with survival in melanoma is not well understood. The study evaluated this at a population level. METHODS: A cohort of patients with a diagnosis of invasive cutaneous melanoma (2007-2015) was identified from the Ontario Cancer Registry and linked to identify demographics, stage at diagnosis, prescription of immunosuppressive medications (both before and after diagnosis), and outcomes. The demographics of patients with and without prescriptions for ISM were compared. Patients eligible for Ontario's Drug Benefit Plan were included to ensure accurate prescription data. The primary outcome was overall survival. Cox Proportional Hazards Regression models identified factors associated with mortality, including use of ISM as a time-varying covariate. RESULTS: Of the 4954 patients with a diagnosis of cutaneous melanoma, 1601 had a prescription for ISM. The median age of the patients was 74 years. Overall, 58.4% of the patients were men (60.5% of those without ISM and 54% of those using ISM; p < 0.001). The use of oral immunosuppression was associated with an increased hazard of death (hazard ratio, 5.84; 95% confidence interval, 5.11-6.67; p < 0.0001) when control was used for age, disease stage at diagnosis, anatomic site, comorbidity, and treatment. Other factors associated with death were increasing age, male sex, increased disease stage, truncal location of primary melanoma, and inadequate treatment. In sensitivity analysis with steroid-only ISM use excluded, survival did not differ significantly (p = 0.355). CONCLUSIONS: The use of immunosuppressive steroids for melanoma is associated with worse overall survival. Use of steroids should be limited when possible.

4.
Artigo em Inglês | MEDLINE | ID: mdl-33059090

RESUMO

OBJECTIVE: Selective reporting of antibiotic susceptibility test results may help guide appropriate antibiotic prescribing, particularly for urinary tract infections. Our objective was to describe laboratory urine culture susceptibility reporting practices and to estimate their impact on antibiotic prescribing in outpatients. METHODS: We examined all positive urine cultures with Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis associated with an antibiotic prescription among outpatients over 65 years of age in Ontario, Canada from 2014 through 2017. We evaluated antibiotic prescribing in the empirical window (1-3 days before culture result) and in the directed window (0-5 days after culture result). Unadjusted and adjusted odds ratios were reported to estimate the association between reporting and prescribing. RESULTS: In total 113 780 eligible urine cultures from 48 laboratories were included in the study cohort. Susceptibility reporting practices were highly variable between laboratories, with a range across antibiotics from norfloxacin (n = 5/48, 10.4% reporting) to nitrofurantoin (n = 40/48, 83.3% reporting). Reporting antibiotic susceptibility was associated with increased odds of prescribing that antibiotic in the directed window (aOR 2.98, 95%CI 2.07-4.28). At the laboratory level, the proportion of urine cultures reporting specific antibiotic susceptibility results was also associated with an increase in prescribing of that antibiotic in the empirical window (adjusted OR 1.23, 95%CI 1.13-1.33, per 25% increase in reporting). CONCLUSIONS: Laboratory reporting of antibiotic susceptibility results for urine cultures is associated with empirical and directed prescribing of the reported antibiotics. Laboratories can play an important role in guiding appropriate antibiotic selection for urinary indications.

5.
Drugs Aging ; 37(11): 817-827, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32978758

RESUMO

BACKGROUND: In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use. OBJECTIVES: The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies. METHODS: We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry. RESULTS: Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation. CONCLUSIONS: Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.

6.
CMAJ ; 192(36): E1026-E1036, 2020 Sep 08.
Artigo em Inglês | MEDLINE | ID: mdl-32900763

RESUMO

BACKGROUND: Different primary care delivery models exist for mothers and their infants. We examined whether primary care system performance measures differed when mother-infant dyads received primary care from the same or different providers. METHODS: We conducted a population-based cohort study using Ontario health administrative data from 2004 to 2016. We included primiparous women and their singleton term infants and classified the primary care practitioners who provided the majority of care to the infant and the mother as concordant (same family physician for both; reference group), discordant (a different family physician for each) or pediatrician (pediatrician for the child, family physician for the mother). The primary outcome was nonobstetric maternal hospital admissions between 42 days and 2 years after delivery. RESULTS: Among 481 721 mother-child pairs, 239 033 (49.6%) received concordant care, 114 006 (23.7%) received discordant care, and 128 682 (26.7%) received pediatrician care. Mothers in the pediatrician group were older and had greater comorbidity. Relative to concordant care, maternal nonobstetric hospital admissions occurred similarly under discordant care (adjusted odds ratio [OR] 1.00, 95% confidence interval [CI] 0.96-1.04) and in the pediatrician group (adjusted OR 0.99, 95% CI 0.95-1.02). Maternal deaths were similar under discordant care (adjusted OR 1.00, 95% CI 0.62-1.63) but lower in the pediatrician group (adjusted OR 0.55, 95% CI 0.34-0.89). Maternal primary care visits were lower in both the discordant group (adjusted relative risk [RR] 0.68, 95% CI 0.68-0.69) and the pediatrician group (adjusted RR 0.75, 95% CI 0.75-0.76). Healthy children were more likely to miss the enhanced 18-month well-baby visit under discordant care (adjusted OR 1.06, 95% CI 1.03-1.09) but less likely to miss this visit under pediatrician care (adjusted OR 0.47, 95% CI 0.46-0.49). INTERPRETATION: Concordant care provided to a new mother and her infant by the same family physician was not associated with better primary care health system performance. The reason that pediatric primary care is associated with better maternal and child outcomes remains to be determined.

7.
J Pediatr ; 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32451126

RESUMO

OBJECTIVES: To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada. STUDY DESIGN: Population-based cohort study using linked administrative data of children (17-24 months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics. RESULTS: Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5 years in practice vs ≥21 years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening. CONCLUSIONS: In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

8.
Clin Infect Dis ; 2020 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-32069358

RESUMO

BACKGROUND: Antibiotic use is the strongest modifiable risk factor for the development of Clostridioides difficile infection, but prescribers lack quantitative information on comparative risks of specific antibiotic courses. Our objective was to estimate risks of C. difficile infection associated with receipt of specific antibiotic courses. METHODS: We conducted a longitudinal case-cohort analysis representing over 90% of Ontario nursing home residents, between 2012 and 2017. Our primary exposure was days of antibiotic receipt in the prior 90 days. Adjustment covariates included: age, sex, prior emergency department or acute care stay, Charlson comorbidity index, prior C. difficile infection, acid suppressant use, device use, and functional status. We examined incident C. difficile infection, including cases identified within the nursing home, and those identified during subsequent hospital admissions. Adjusted and unadjusted regression models were used to measure risk associated with 5 to 14-day courses of 18 different antibiotics. RESULTS: We identified 1,708 cases of C. difficile infection (1.27 per 100,000 resident-days). Longer antibiotic duration was associated with increased risk: 10 and 14-day courses incurred 12% (ARR [adjusted relative risk]=1.12, 95%CI: 1.09,1.14) and 27% (ARR=1.27, 95%CI: 1.21,1.30) more risk compared to 7-day courses. Among 7-day courses with similar indications: moxifloxacin resulted in 121% more risk than amoxicillin (ARR=2.21, 95%CI: 1.67,3.08), ciprofloxacin engendered 89% more risk than nitrofurantoin (ARR=1.89, 95%CI: 1.45,2.68), and clindamycin resulted in 112% (ARR=2.12, 95%CI: 1.32,3.78) more risk than cloxacillin. CONCLUSIONS: C. difficile infection risk increases with antibiotic duration, and there are wide disparities in risks associated with antibiotic courses used for similar indications.

9.
Can J Neurol Sci ; 47(2): 153-159, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31987059

RESUMO

BACKGROUND: Women are more likely to be admitted to nursing home after stroke than men. Differences in patient characteristics and outcomes by sex after institutionalization are less understood. We examined sex differences in the characteristics and care needs of patients admitted to nursing home following stroke and their subsequent survival. METHODS: We identified patients with stroke newly admitted to nursing home between April 2011 and March 2016 in Ontario, Canada, with follow-up until March 2018 using linked administrative data. We calculated prevalence ratios and 95% confidence intervals (CIs) for the primary outcomes of dependence for activities of daily living, cognitive impairment, frailty, health instability, and symptoms of depression or pain, comparing women to men. The secondary outcome was all-cause mortality. RESULTS: Among 4831 patients, 60.9% were women. Compared to men, women were older (median age [interquartile range, IQR]: 84 [78, 89] vs. 80 [71, 86]), more likely to be frail (prevalence ratio 1.14, 95% CI [1.08, 1.19]), have unstable health (1.45 [1.28, 1.66]), and experience symptoms of depression (1.25 [1.11, 1.40]) or pain (1.21 [1.13, 1.30]), and less likely to have aggressive behaviors (0.87 [0.80, 0.94]). Overall median survival was 2.9 years. In a propensity-score-matched cohort, women had lower mortality than men (hazard ratio 0.85, 95% CI [0.77, 0.94]), but in the age-stratified survival analysis, the survival advantage in women was limited to those aged 75 years and older. CONCLUSIONS: Despite lower subsequent mortality, women admitted to nursing home after stroke required more care than men. Pain and depression are two treatable symptoms that disproportionately affect women.

10.
Infect Control Hosp Epidemiol ; 41(2): 154-160, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31762432

RESUMO

OBJECTIVE: Interfacility patient movement plays an important role in the dissemination of antimicrobial-resistant organisms throughout healthcare systems. We evaluated how 3 alternative measures of interfacility patient sharing were associated with C. difficile infection incidence in Ontario acute-care facilities. DESIGN: The cohort included adult acute-care facility stays of ≥3 days between April 2003 and March 2016. We measured 3 facility-level metrics of patient sharing: general patient importation, incidence-weighted patient importation, and C. difficile case importation. Each of the 3 patient-sharing metrics were examined against the incidence of C. difficile infection in the facility per 1,000 stays, using Poisson regression models. RESULTS: The analyzed cohort included 6.70 million stays at risk of C. difficile infection across 120 facilities. Over the 13-year period, we included 62,189 new cases of healthcare-associated CDI (incidence, 9.3 per 1,000 stays). After adjustment for facility characteristics, general importation was not strongly associated with C. difficile infection incidence (risk ratio [RR] per doubling, 1.10; 95% confidence interval [CI], 0.97-1.24; proportional change in variance [PCV], -2.0%). Incidence-weighted (RR per doubling, 1.18; 95% CI, 1.06-1.30; PCV, -8.4%) and C. difficile case importation (RR per doubling, 1.43; 95% CI, 1.29-1.58; PCV, -30.1%) were strongly associated with C. difficile infection incidence. CONCLUSIONS: In this 13-year study of acute-care facilities in Ontario, interfacility variation in C. difficile infection incidence was associated with importation of patients from other high-incidence acute-care facilities or specifically of patients with a recent history of C. difficile infection. Regional infection control strategies should consider the potential impact of importation of patients at high risk of C. difficile shedding from outside facilities.

11.
Inflamm Bowel Dis ; 26(6): 898-906, 2020 05 12.
Artigo em Inglês | MEDLINE | ID: mdl-31560042

RESUMO

BACKGROUND: Abdominal imaging is important in managing inflammatory bowel disease (IBD). We characterized utilization of imaging and exposure to ionizing radiation. METHODS: We enumerated abdominal diagnostic imaging in a population-based cohort of IBD patients between 1994 and 2016. Trends in utilization of abdominal computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound were characterized. Cumulative doses of ionizing radiation were compared between IBD patients and non-IBD controls and between Crohn's disease (CD) and ulcerative colitis (UC) patients. Regression models were constructed to assess predictors of high ionizing radiation exposure. RESULTS: There were 72,933 incident cases of IBD. During the first 5 years of diagnosis, IBD patients were exposed to nearly 6-fold higher exposure to cumulative ionizing radiation attributable to abdominal imaging compared with non-IBD controls (18.6 mSv vs 2.9 mSv). Cumulative ionizing radiation exposure was higher in CD than UC (26.0 mSv vs 12.0 mSv; P < 0.001). Crohn's disease patients were more than twice as likely as UC patients to exceed 50 mSv (15.6% vs 6.2%; P < 0.001) and 100 mSV (5.0% vs 2.1%; P < 0.001). There was geographic variation in ionizing radiation exposure, and individuals of lower income were more likely to have high exposure. Utilization of abdominal MRI has increased substantially, peaking between 2007 and 2012 and increasing annually at 34%, which coincided with an annual 2% decline in the use of abdominal CT. CONCLUSIONS: Crohn's disease patients are at highest risk for high exposure to ionizing radiation, with a subgroup receiving potentially harmful levels. Increasing utilization and access to abdominal MRI may alleviate exposure.

12.
Clin Infect Dis ; 70(8): 1620-1627, 2020 Apr 10.
Artigo em Inglês | MEDLINE | ID: mdl-31197362

RESUMO

BACKGROUND: Rates of antibiotic use vary widely across nursing homes and cannot be explained by resident characteristics. Antibiotic prescribing for a presumed urinary tract infection is often preceded by inappropriate urine culturing. We examined nursing home urine-culturing practices and their association with antibiotic use. METHODS: We conducted a longitudinal, multilevel, retrospective cohort study based on quarterly nursing home assessments between April 2014 and January 2017 in 591 nursing homes and covering >90% of nursing home residents in Ontario, Canada. Nursing home urine culturing was measured as the proportion of residents with a urine culture in the prior 14 days. Outcomes included receipt of any systemic antibiotic and any urinary antibiotic (eg, nitrofurantoin, trimethoprim/sulfonamides, ciprofloxacin) in the 30 days after the assessment and Clostridiodes difficile infection in the 90 days after the assessment. Adjusted Poisson regression models accounted for 14 resident covariates. RESULTS: A total of 131 218 residents in 591 nursing homes were included; 7.9% of resident assessments had a urine culture in the prior 14 days; this proportion was highly variable across the 591 nursing homes (10th percentile = 3.4%, 90th percentile = 14.3%). Before and after adjusting for 14 resident characteristics, nursing home urine culturing predicted total antibiotic use (adjusted risk ratio [RR] per doubling of urine culturing, 1.21; 95% confidence interval [CI], 1.18-1.23), urinary antibiotic use (RR, 1.33; 95% CI, 1.28-1.38), and C. difficile infection (incidence rate ratio, 1.18; 95% CI, 1.07-1.31). CONCLUSIONS: Nursing homes have highly divergent urine culturing rates; this variability is associated with higher antibiotic use and rates of C. difficile infection.

13.
J Gen Intern Med ; 34(12): 2763-2771, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31576508

RESUMO

BACKGROUND: Prescribing patterns for episodic medications, such as antibiotics, might make useful surrogate measures of a physician's overall prescribing practice because use is common, and variation exists across prescribers. However, the extent to which a physician's current antibiotic prescribing practices are associated with the rate of prescription of other potentially harmful medications remains unknown. OBJECTIVE: To examine the association between a physician's rate of antibiotic prescribing and their prescribing rate of benzodiazepines, opioids and proton-pump inhibitors in older adults. DESIGN: Population-based cohort study in nursing homes in Ontario, Canada, which provides comprehensive clinical, behavioural and functional information on all patients. PARTICIPANTS: 1926 physicians who provided care among 128,979 physician-patient pairs in 2015. MAIN MEASURES: Likelihood of prescribing a benzodiazepine, opioid or proton-pump inhibitor between low-, average- and high-intensity antibiotic prescribers, adjusted for patient characteristics. KEY RESULTS: Compared with average-intensity antibiotic prescribers, high-intensity prescribers had an increased likelihood of prescribing a benzodiazepine (odds ratio 1.21 [95% CI, 1.11-1.32]), an opioid (odds ratio 1.28 [95% CI, 1.17-1.39]) or a proton-pump inhibitor (odds ratio 1.38 [95% CI, 1.27-1.51]]. High-intensity antibiotic prescribers were more likely to be high prescribers of all three medications (odds ratio 6.24 [95% CI, 2.90-13.39]) and also more likely to initiate all three medications, compared with average-intensity prescribers. CONCLUSIONS: The intensity of a physician's episodic antibiotic prescribing was significantly associated with the likelihood of new and continued prescribing of opioids, benzodiazepines and proton-pump inhibitors in nursing homes. Patterns of episodic prescribing may be a useful mechanism to target physician-level interventions to optimize general prescribing behaviors, instead of prescribing behaviors for single medications.


Assuntos
Analgésicos Opioides/administração & dosagem , Antibacterianos/administração & dosagem , Benzodiazepinas/administração & dosagem , Prescrições de Medicamentos , Casas de Saúde/tendências , Padrões de Prática Médica/tendências , Inibidores da Bomba de Prótons/administração & dosagem , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Assistência de Longa Duração/estatística & dados numéricos , Assistência de Longa Duração/tendências , Masculino , Casas de Saúde/estatística & dados numéricos , Ontário/epidemiologia , Vigilância da População , Padrões de Prática Médica/estatística & dados numéricos
14.
CMAJ Open ; 7(3): E582-E589, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31551235

RESUMO

BACKGROUND: Opioids are an important pain therapy, but their use may be associated with adverse events in frail and cognitively impaired long-term care residents. The objective of this study was to investigate trends in opioid prescribing among Ontario long-term care residents over time, given the paucity of data for this setting. METHODS: We used linked clinical and health administrative databases to conduct a population-based, repeated cross-sectional study of opioid use among Ontario long-term care residents between Apr. 1, 2009, and Mar. 31, 2017. We identified prevalent opioid use by drug type, dosage and coprescription with benzodiazepines, and within certain vulnerable subgroups. We used log-binomial regression to quantify the percent change between 2009/10 and 2016/17. RESULTS: Among an average of 76 147 long-term care residents per year, the prevalence of opioid use increased from 15.8% in 2009/10 to 19.6% in 2016/17 (p < 0.001). Over the study period, the use of hydromorphone increased by 233.2%, whereas the use of all other opioid agents decreased. The use of high-dose opioids (> 90 mg of morphine equivalents) and the coprescription of opioids with benzodiazepines decreased significantly, by 17.7% (p < 0.001) and 23.8% (p < 0.001), respectively. Increases in opioid prevalence were more notable among frail residents (37.6% v. 18.8% among nonfrail residents, p < 0.001) and those with dementia (38.6% v. 21.6% among those without dementia, p < 0.001). INTERPRETATION: Within Ontario long-term care, trends suggest a shift toward increased use of hydromorphone but reduced prevalence of use of other opioid agents and potentially inappropriate opioid prescribing. Further investigation is needed on the impact of these trends on resident outcomes.

15.
Gynecol Oncol ; 154(2): 338-344, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31171407

RESUMO

OBJECTIVE: Determine rates of radical minimally invasive surgery (MIS) for cervix cancer in Ontario, and whether these rates varied over time and by region. Assess whether changes in the use of MIS impacted length of hospital stay and readmissions. METHODS: Retrospective population-based cohort study of women undergoing radical surgery for cervical cancer between 2002 and 2015. Radical MIS versus laparotomy were compared. Trends in rate of MIS over time, length of hospital stay, and readmission within 30 days were determined. Multivariate logistic regression was used to determine factors associated with MIS approach. RESULTS: 805 women underwent radical abdominal surgery versus 538 radical minimally invasive surgery. Radical MIS increased over the study period, from 17.7% in 2002 to 61.5% in 2015. The most significant predictor of MIS approach was hospital site, with a 14-fold difference in sites with highest and lowest uptake of MIS. Mean length of hospital stay was significantly shorter after radical MIS compared to radical abdominal surgery (1.1 v. 4.2 days). Hospital readmission within 30 days was reduced over the study period for MIS but remained stable following abdominal surgery. CONCLUSIONS: Although rates of radical MIS increased in Ontario over the time period studied, this seems to have been driven by a few high volume centres. Cervical cancer is rare and it takes time to develop the skills to carry out the procedure effectively. Abandonment of minimally invasive radical hysterectomy may have a significant impact on surgical training and subsequent proficiency in the skills unique to this procedure.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Neoplasias do Colo do Útero/cirurgia , Adulto , Feminino , Humanos , Histerectomia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Ontário/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Neoplasias do Colo do Útero/epidemiologia
16.
JAMA Pediatr ; : e191439, 2019 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-31157877

RESUMO

Importance: Diagnostic imaging overuse in children evaluated in emergency departments (EDs) is a potential target for reducing low-value care. Variation in practice patterns across Canada and the United States stemming from organization of care, payment structures, and medicolegal environments may lead to differences in imaging overuse between countries. Objective: To compare overall and low-value use of diagnostic imaging across pediatric ED visits in Ontario, Canada, and the United States. Design, Setting, and Participants: This study used administrative health databases from 4 pediatric EDs in Ontario and 26 in the United States in calendar years 2006 through 2016. Individuals 18 years and younger who were discharged from the ED, including after visits for diagnoses in which imaging is not routinely recommended (eg, asthma, bronchiolitis, abdominal pain, constipation, concussion, febrile convulsion, seizure, and headache) were included. Data analysis occurred from April 2018 to October 2018. Exposures: Diagnostic imaging use. Main Outcome and Measures: Overall and condition-specific low-value imaging use. Three-day and 7-day rates of hospital admission and those admissions resulting in intensive care, surgery, or in-hospital mortality were assessed as balancing measures. Results: A total of 1 783 752 visits in Ontario and 21 807 332 visits in the United States were analyzed. Compared with visits in the United States, those in Canada had lower overall use of head computed tomography (Canada, 22 942 [1.3%] vs the United States, 753 270 [3.5%]; P < .001), abdomen computed tomography (5626 [0.3%] vs 211 018 [1.0%]; P < .001), chest radiographic imaging (208 843 [11.7%] vs 3 408 540 [15.6%]; P < .001), and abdominal radiographic imaging (77 147 [4.3%] vs 3 607 141 [16.5%]; P < .001). Low-value imaging use was lower in Canada than the United States for multiple indications, including abdominal radiographic images for constipation (absolute difference, 23.7% [95% CI, 23.2%-24.3%]) and abdominal pain (20.6% [95% CI, 20.3%-21.0%]) and head computed tomographic scans for concussion (22.9% [95% CI, 22.3%-23.4%]). Abdominal computed tomographic use for constipation and abdominal pain, although low overall, were approximately 10-fold higher in the United States (0.1% [95% CI, 0.1%-0.2%] vs 1.2% [95% CI, 1.2%-1.2%]) and abdominal pain (0.8% [95% CI, 0.7%-0.9%] vs 7.0% [95% CI, 6.9%-7.1%]). Rates of 3-day and 7-day post-ED adverse outcomes were similar. Conclusions and Relevance: Low-value imaging rates were lower in pediatric EDs in Ontario compared with the United States, particularly those involving ionizing radiation. Lower use of imaging in Canada was not associated with higher rates of adverse outcomes, suggesting that usage may be safely reduced in the United States.

17.
Ann Surg ; 269(6): 1192-1199, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31082920

RESUMO

OBJECTIVE: To estimate long-term mortality following major burn injury compared with matched controls. SUMMARY BACKGROUND DATA: The effect of sustaining a major burn injury on long-term life expectancy is poorly understood. METHODS: Using health administrative data, all adults who survived to discharge after major burn injury between 2003 and 2013 were matched to between 1 and 5 uninjured controls on age, sex, and the extent of both physical and psychological comorbidity. To account for socioeconomic factors such as residential instability and material deprivation, we also matched on marginalization index. The primary outcome was 5-year all-cause mortality, and all patients were followed until death or March 31, 2014. Cumulative mortality estimates were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to estimate the association of burn injury with mortality. RESULTS: In total, 1965 burn survivors of mean age 44 (standard deviation 17) years with median total body surface area burn of 15% [interquartile range (IQR) 5-15] were matched to 8671 controls and followed for a median 5 (IQR 2.5-8) years. Five-year mortality was significantly greater among burn survivors (11 vs 4%, P < 0.001). The hazard ratio was greatest during the first year (4.15, 95% CI 3.17-5.42), and declined each year thereafter, reaching 1.65 (95% CI 1.02-2.67) in the fifth year after discharge. Burn survivors had increased mortality related to trauma (mortality rate ratio, MRR 9.8, 95% CI 5-19) and mental illness (MRR 9.1, 95% CI 4-23). CONCLUSIONS: Burn survivors have a significantly higher rate of long-term mortality than matched controls, particularly related to trauma and mental illness. Burn follow-up should be focused on injury prevention, mental healthcare, and detection and treatment of new disease.


Assuntos
Queimaduras/mortalidade , Adulto , Queimaduras/complicações , Canadá , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Taxa de Sobrevida
18.
J Crohns Colitis ; 13(3): 330-336, 2019 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-30312376

RESUMO

BACKGROUND AND AIMS: The number of inflammatory bowel disease [IBD]-related visits to the emergency department [ED] is increasing in North America. This study evaluates the relationship between access to specialists and utilization of ED services. METHODS: We conducted a population-based study of all IBD patients in Ontario in 2014-2015 to measure utilization of non-emergency IBD care by specialists [NICS] and ED visits. After characterizing regional variation in access to gastroenterologists and region-wide implementation of NICS, we constructed regression models to determine whether they were predictors of individual utilization of NICS and ED services. RESULTS: The number of gastroenterologists per 1000 IBD patients varied geographically, ranging from 1.13 to 10.65, as did the region-wide proportion of patients who received NICS, ranging from 21% to 52%. Compared with those with low access to gastroenterologists, those living in areas with moderate (odds ratio [OR], 2.37; 95% confidence interval [CI]: 2.27-2.47) and high [OR, 1.83; 95% CI: 1.71-1.95] access were more likely to receive NICS. The risk of visits to the ED was lower among those residing in regions with moderate [OR, 0.78; 95% CI: 0.75-0.82] and high access [OR, 0.74; 95% CI: 0.69-0.80] to gastroenterologists and in regions where implementation of NICS was not low [OR, 0.78; 95% CI: 0.75-0.81]. CONCLUSIONS: Poor access to outpatient IBD specialist care contributes to IBD-related ED visits. Strategies to increase specialist access may reduce the utilization of emergency services.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Gastroenterologistas/provisão & distribução , Gastroenterologistas/estatística & dados numéricos , Gastroenterologia/estatística & dados numéricos , Acesso aos Serviços de Saúde , Doenças Inflamatórias Intestinais/terapia , Adulto , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Área Programática de Saúde/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ontário
19.
Am J Geriatr Psychiatry ; 26(12): 1244-1257, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30262407

RESUMO

BACKGROUND: Antipsychotic drugs are commonly used to treat psychosis in patients with Parkinson disease; however, individuals with parkinsonism are at risk for serious adverse effects with antipsychotic use. The choice of antipsychotic is critical. OBJECTIVE: To examine the frequency and pattern of antipsychotic prescribing to patients with Parkinson disease and parkinsonism over time. METHODS: Individuals with parkinsonism aged 66 or older in Ontario were studied in a retrospective cohort study from 2005-2013 and followed for prevalent and/or incident antipsychotic drug dispensing. RESULTS: In 2005, 15% of 22,837 individuals with prevalent parkinsonism were dispensed an antipsychotic drug. By 2013, the proportion was 11% of 34,262 individuals. Primary care physicians represented the vast majority of prescribers. Of individuals receiving antipsychotics in 2013, 20% were dispensed a typical antipsychotic drug. Among individuals with incident parkinsonism, living in a nursing home, older age, male sex, a greater number of comorbidities, and a prior diagnosis of dementia were significantly associated with an increased rate of receiving an antipsychotic during follow-up. Among those who received an antipsychotic, factors associated with typical antipsychotic exposure were absence of a prior diagnosis of dementia, higher Charlson comorbidity index, more concurrent medications, more recent year of first parkinsonism diagnosis and not having seen a neurologist, psychiatrist, or geriatrician. CONCLUSION: A substantial proportion of individuals with parkinsonism are exposed to antipsychotic drugs, including typical antipsychotics. Given the risks of these drugs to individuals with parkinsonism, education of prescribers, particularly primary care physicians, is needed.


Assuntos
Antipsicóticos/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Transtornos Parkinsonianos/tratamento farmacológico , Médicos de Atenção Primária/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Ontário , Doença de Parkinson/tratamento farmacológico , Estudos Retrospectivos
20.
BMC Geriatr ; 18(1): 211, 2018 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-30208884

RESUMO

BACKGROUND: The identification of contextual factors that modify associations between client frailty and their health and service use outcomes is essential for informed home health care and policy planning. Our objective was to examine variation in the associations between frailty and select 1-year health outcomes by caregiver distress and client sex among community-residing older care recipients. METHODS: We conducted a retrospective cohort study using linked population-based clinical and health administrative databases for all long-stay home care clients (n = 234,552) aged 66+ years assessed during April 2010-2013 in Ontario, Canada. Frailty was assessed using a previously validated 72-item frailty index (FI). Presence of caregiver distress was derived from clinical assessment items administered by trained home care assessors. Multivariable log-binomial regression models were used to examine variations in the associations between frailty and outcomes of interest (mortality, nursing home [NH] placement, all-cause and prolonged hospitalization) by caregiver distress, with further model stratification by client sex. RESULTS: Frailty prevalence varied little by sex (19.3% women, 19.9% men) despite significant sex-differences in clients' sociodemographic and health characteristics. In both sexes, frailty was significantly associated with all outcomes, particularly NH placement (RR = 3.84, 95%CI 3.75-3.93) and death (RR = 2.32, 95%CI 2.27-2.37), though risk ratios were greater for women. Caregiver distress was more common with increasing frailty and for male clients, and a significant independent predictor of NH placement and prolonged hospitalization in both sexes. The association between frailty and NH placement (but not other outcomes) varied by caregiver distress for both men and women (p < 0.001 interaction terms), showing a greater magnitude of association among clients without (vs. with) a distressed caregiver. CONCLUSIONS: As caregiver distress varies by client sex, represents a key driver of NH placement (even among relatively robust clients), and modifies the impact of other risk factors such as frailty, it should be routinely assessed. Further, sex-differences should be considered when developing and evaluating community-based services for older adults and their caregivers.


Assuntos
Cuidadores/psicologia , Idoso Fragilizado , Casas de Saúde , Estresse Psicológico/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Feminino , Avaliação Geriátrica , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Prevalência , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais
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