Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival.

BACKGROUND: There has been minimal research on the influence of delays for cancer treatments on patient outcomes. We measured the influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. METHODS: We used the linked Surveillance, Epidemiology and End Results (SEER)-Medicare databases (1993-1996) to identify patients who underwent nonemergent colon cancer surgery. We assessed 2 time intervals: surgeon consult to hospital admission for surgery and first diagnostic test for colon cancer to hospital admission. Follow-up data were available to the end of 2003. We selected the time intervals to create patient groups with clinical relevance and they did not extend past 120 days. RESULTS: We identified 7989 patients who underwent nonemergent colon cancer surgery. Median delays from surgeon consult to admission and from first diagnostic test to admission were 7 and 17 days, respectively. The odds of operative mortality were similar if the consult-to-admission interval was 22 days or more versus 1-7 days (odds ratio [OR] 1.0, 95% confidence interval [CI] 0.6-1.8, p = 0.91) or if the test-to-admission interval was 43 days or more versus 1-14 days (OR 0.8, 95% CI 0.4-1.5, p = 0.51), respectively. For these same respective interval comparisons, disease-specific survival was not influenced by the consult-to-admission wait (hazard ratio [HR] 1.0, 95% CI 0.9-1.2, p = 0.91) or the test-to-admission wait (HR 1.0, 95% CI 0.8-1.1, p = 0.63). The risk of death was slightly greater if the consult-to-admission interval was 22 or more days versus 1-7 days (HR 1.1, 95% CI 1.0-1.2, p = 0.013) and if the test-to-admission interval was 43 days or more versus 1-14 days (HR 1.2, 95% CI 1.1-1.3, p = 0.003). CONCLUSION: It is unlikely that delays to nonemergent colon cancer surgery longer than 3 weeks from initial surgical consult or longer than 6 weeks from first diagnostic test negatively impact operative mortality, disease-specific survival or overall survival.

Impact of a Graduated Approach on Opioid Initiation and Loss of Earnings Following Workplace Injury: A Time Series Analysis.

OBJECTIVE: The aim of this study was to explore the impact of the Ontario Workplace Safety and Insurance Board's (WSIB's) graduated approach to opioid management on opioid prescribing and disability claim duration. METHODS: We studied patterns of opioid use and disability claim duration among Ontarians who received benefits through the WSIB between 2002 and 2013. We used interventional time series analysis to assess the impact of the WSIB graduated formulary on these trends. RESULTS: After the introduction of the graduated formulary, initiation of short- and long-acting opioids fell significantly (P < 0.0001). We also observed a shift toward the use of short-acting opioids alone (P < 0.0001). Although disability claim duration declined, this could not be ascribed to the intervention (P = 0.18). CONCLUSION: A graduated opioid formulary may be an effective tool for providers to promote more appropriate opioid prescribing.

Pre-Post Evaluation of an Integrated Return to Work Planning Program in Workers' Compensation Assessment Clinics.

OBJECTIVE: The aim of this study was to assess the impact of a new workers' compensation medical assessment model on loss of earnings (LOE) benefits duration. METHODS: A medical assessment model was introduced incorporating return to work planning and inclusion of the worker's treating physician. Impact of the program on LOE benefit duration was assessed using a quasi-experimental pre-post study design. Cox PH multivariable regression was adjusted for age, gender, injury severity, time to referral, and industry. RESULTS: The study population comprised 3146 workers: 1794 assessed pre-intervention and 1574 assessed after introduction of the new model. There was a significant reduction in LOE benefit duration for workers assessed in the new model (hazard ratio 1.33, 95% confidence interval 1.23-1.43). CONCLUSIONS: The probability of being off LOE benefits for workers assessed in the new program was 33% greater than for workers assessed in the prior program.

Comparison of methods to identify outliers observed in health services small area variation studies.

Small area variation analysis (SAV) is an established methodology in health services and epidemiological research. The goal is to demonstrate that rates differ across areas, and to explain these differences by differences in physician practice styles or patient characteristics. While the SAV statistics provide an overall variation estimate, they do not provide a statistical means to identify significant outliers. We compared the chi-square (chi2) test with three approaches in determining significant outliers in SAV. We used data from the Canadian Institute for Health Information (CIHI) for Ontario residents discharged between 1989 and 1991. Coronary artery bypass surgery, hysterectomy and hip replacement data were used to compare four statistics in determining outliers: the chi2 test, Swift's approximate bootstrap confidence interval (ABC), Carriere's T2 (T2) with simultaneous confidence intervals (SCI), and Gentleman's normalized scores (GNS). Both the ABC and SCI correct the skewness of the distribution of the adjusted rates. With large data, confidence intervals calculated by the normal or the ABC methods are indistinguishable. The T2 can be applied to also nonbinary events. For binary events, it is asymptotically the same as the chi2. The GNS ranks the rates, but the distribution of these ranks does not differ significantly from that of the adjusted rates. We concluded that when using large data with binary events, there is little advantage in using the ABC, SCI or GNS over the commonly known chi2. The chi2 remains a useful tool in small area variation analysis to 'screen' or flag potential differences beyond chance alone.

Influence of hospital characteristics on operative death and survival of patients after major cancer surgery in Ontario.

BACKGROUND: There is a lack of information from Canadian hospitals on the role of hospital characteristics such as procedure volume and teaching status on the survival of patients who undergo major cancer resection. Therefore, we chose to study these relationships using data from patients treated in Ontario hospitals. METHODS: We used the Ontario Cancer Registry from calendar years 1990-2000 to obtain data on patients who underwent surgery for breast, colon, lung or esophageal cancer or who underwent major liver surgery related to a cancer diagnosis between 1990 and 1995 in order to assess the influence of volume of procedures and teaching status of hospitals on in-hospital death rate and long-term survival. For each disease site and before observing patient outcomes data, volume cut-off points were selected to create volume groups with similar numbers of patients. Teaching hospitals were those directly affiliated with a medical school. Logistic regression and proportional hazards models were used to consider the clustering of data at the hospital level and to assess operative death and long-term survival. We also used 4 measures to gauge the degree of procedure regionalization across the province including (1) the number of hospitals performing a procedure; (2) the percentage of patients treated in teaching hospitals; (3) the percentage of rural patients treated in higher volume procedure hospitals; and (4) median distances travelled by patients to receive care. RESULTS: The number of patients in our cohorts who underwent resection of the breast, colon, lung, esophagus or liver was 14 346, 8398, 2698, 629 and 362, respectively. Surgery in a high-volume versus a low-volume hospital did not have a statistically significant influence on the odds of operative death for patients who underwent colon, liver, lung or esophageal cancer resection. The risk of long-term death was increased in low-volume versus high-volume hospitals for patients who underwent resection of the breast (hazard ratio [HR] 1.2, 95% confidence interval [95% CI] 1.0-1.4, p < 0.05), lung (HR 1.3, 95% CI 1.1-1.6, p < 0.01) and liver (HR 1.7, 95% CI 1.0-2.7, p = 0.04). There were no significant differences in the odds of operative (in-hospital) death or risk of long-term death among patients treated in teaching compared with nonteaching hospitals. There was more regionalization of liver, lung and esophageal operations versus breast and colon operations. CONCLUSIONS: Increased hospital procedure volume correlated with improved longterm survival for patients in Ontario who underwent some, but not all, cancer resections, whereas hospital teaching status had no significant impact on patient outcomes. Across the province, further regionalization of care may help improve the quality of some cancer procedures.

Using administrative databases to measure waiting times for patients undergoing major cancer surgery in Ontario, 1993-2000.

PURPOSE: To determine how long patients in Ontario waited for major breast, colorectal, lung or prostate cancer surgery in the years 1993-2000. METHODS: "Surgical waiting time" was defined as the interval from date of preoperative surgeon consult to date of hospital admission for surgery. We created patient cohorts by linking appropriate diagnosis and procedure codes from Canadian Institutes of Health Information data. Scrambled unique surgeon identifiers were obtained from Ontario Health Insurance Plan data. Changes in median surgical waiting times were assessed with univariate time-trend analyses and multilevel models. Models were controlled for year of surgery and other patient (age, gender, comorbid conditions, income level, area of residence) and hospital level characteristics (teaching status, procedure volume status). RESULTS: Compared with 1993, median surgical waiting times in the year 2000 increased 36% for patients with breast cancer (to 19 d), 46% with colorectal (to 19 d), 36% with lung (to 34 d) and 4% with prostate cancer (to 83 d). Multilevel models confirmed significant increases in waiting times for all procedures. There were no concerning or consistent differences in waiting times among the categories of hospitals and patients examined. DISCUSSION: There were significant increases in surgical waiting times among patients undergoing breast, colorectal, lung or prostate cancer surgery in Ontario over years 1993-2000. Administrative databases can be used to efficiently measure such waits.

Burden of parkinsonism: a population-based study.

Parkinson's disease (PD) is associated with a significant burden of illness and cost to society, which has been difficult to quantify. Our objective was to use linked administrative databases from the population of Ontario, Canada, to assess the prevalence of parkinsonism, physician- and drug-related costs, and hospital utilization for parkinsonian patients compared with age/sex matched controls. An inception cohort of parkinsonian cases from 1993/1994 was age and sex matched (1:2) to controls and followed for 6 years. Patients were identified by the diagnostic code for PD, the use of specific PD drugs, or a combination. The parkinsonian case cohort (15,304) was matched to (30,608) controls that did not have parkinsonism. The age-adjusted prevalence rates were 3.63 for men and for 3.24 women per 1,000 (increased by 5.4% for men and 9.8% for women). Physician costs were 1.4 times more, there were 1.44 times more hospital admissions, admissions were on average 1.19 times longer, and drug costs were 3.0 times more for parkinsonian cases. We conclude that the substantially higher physician and drug costs as well as hospitalization rates compared with controls clearly suggest that parkinsonism is associated with large direct costs to society.

Parkinsonism in Ontario: comorbidity associated with hospitalization in a large cohort.

To study comorbidity in patients with Parkinsonism (PKM), relative hospitalization rates from 1994 to 1999 for 15,304 cases were compared with 30,608 controls. After correction for differential survival, the rates were higher for cases compared to controls for aspiration pneumonia (6.34; 95% confidence interval [CI], 5.23, 7.93), affective psychosis (2.71; 95% CI, 2.13, 3.32), hip fractures (2.56; 95% CI, 2.35, 2.76), other urinary tract disorders including infections (2.5; 95% CI, 2.17, 2.86), septicemia (2.39; 95% CI, 2.02, 2.85) and fluid and electrolyte disorders (2.27; 95% CI, 1.93,2.66). The rates for cardiac, cerebrovascular, and peripheral vascular disease were similar. Preventive measures and aggressive management of these conditions as outpatients may reduce the rates of hospitalization and improve the morbidity and mortality of PKM.