Screening behaviours, demographics, and stage at diagnosis in the publicly funded Ontario Breast Screening Program.

PURPOSE: The Ontario Breast Screening Program (OBSP) offers free screening mammograms every 2 years, to women aged 50-74. Study objectives were to determine demographic characteristics associated with the adherence to OBSP and if women screened in the OBSP have a lower stage at diagnosis than non-screened eligible women. METHODS: We used the Ontario cancer registry (OCR) to identify 48,927 women, aged 51-74 years, diagnosed with breast cancer between 2010 and 2017. These women were assigned as having undergone adherent screening (N = 26,108), non-adherent screening (N = 6546) or not-screened (N = 16,273) in the OBSP. We used multinomial logistic regression to investigate the demographic characteristics associated with screening behaviour, as well as the association between screening status and stage at diagnosis. RESULTS: Among women with breast cancer, those living in rural areas (versus the largest urban areas) had a lower odds of not being screened (odds ratio [OR] 0.73, 95% confidence interval [CI] 0.68, 0.78). Women in low-income (versus high-income) communities were more likely not to be screened (OR 1.42, 95% CI 1.33, 1.51). When stratified, the association between income and screening status only held in urban areas. Non-screened women were more likely to be diagnosed with stage II (OR 1.91, 95% CI 1.82, 2.01), III (OR 2.96, 95% CI 2.76, 3.17), or IV (OR 8.96, 95% CI 7.94, 10.12) disease compared to stage I and were less likely to be diagnosed with ductal carcinoma in situ (DCIS) (OR 0.91, 95% CI 0.84-0.98). CONCLUSIONS: This study suggests that targeting OBSP recruitment efforts to lower income urban communities could increase screening rates. OBSP adherent women were more likely to be diagnosed with earlier stage disease, supporting the value of this initiative and those like it.

Development and validation of a multivariable prediction model for major adverse cardiovascular events after early stage breast cancer: a population-based cohort study.

AIMS: Develop a score to predict the risk of major adverse cardiovascular events (MACE) after early stage breast cancer (EBC) to facilitate personalized decision-making about potentially cardiotoxic treatments and interventions to reduce cardiovascular risk. METHODS AND RESULTS: Using administrative databases, we assembled a cohort of women diagnosed with EBC in Ontario between 2003 and 2014, with follow-up through 2015. Two-thirds of the cohort were used for risk score derivation; the remainder were reserved for its validation. The outcome was a composite of hospitalizations for acute myocardial infarction, unstable angina, transient ischaemic attack, stroke, peripheral vascular disease, heart failure (HF), or cardiovascular death. We developed the score by regressing MACE incidence against candidate predictors in the derivation sample using a Fine-Gray model. Discrimination was assessed in the validation sample using Wolber's c-index for prognostic models with competing risks, while calibration was assessed by comparing predicted and observed MACE incidence. The risk score was derived in 60 294 women and validated in 29 810 women. Age, hypertension, diabetes, ischaemic heart disease, atrial fibrillation, HF, cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and chronic kidney disease were significantly associated with MACE incidence and incorporated into the score. Ten-year MACE incidence was >40-fold higher for patients in the highest score decile compared to the lowest. The c-index was 81.9% (95% confidence interval 80.9-82.9%) at 5 years and 79.8% (78.8-80.8%) at 10 years in the validation cohort, with good agreement between predicted and observed MACE incidence. CONCLUSION: Cardiovascular prognosis after EBC can be estimated using patients' pre-treatment characteristics.

Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework.

Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.

Benzodiazepine drug use and adverse respiratory outcomes among older adults with COPD.

Our purpose was to evaluate the association of new benzodiazepine use relative to non-use with adverse clinical respiratory outcomes among older adults with chronic obstructive pulmonary disease (COPD). This was a retrospective population-based cohort study of Ontario, Canada, residents between 2003 and 2010. A validated algorithm was applied to health administrative data to identify adults aged 66 years and older with COPD. Relative risks (RRs) of several clinically important respiratory outcomes were examined within 30 days of incident benzodiazepine use compared with non-use, applying propensity score matching. New benzodiazepine users were at significantly higher risk for outpatient respiratory exacerbations (RR 1.45, 95% CI 1.36-1.54) and emergency room visits for COPD or pneumonia (RR 1.92, 95% CI 1.69-2.18) compared to non-users. Risk of hospitalisation for COPD or pneumonia was also increased in benzodiazepine users, but was nonsignificant (RR 1.09, 95% CI 1.00-1.20). There were no significant differences in intensive care unit admissions between the two groups and all-cause mortality was slightly lower among new versus non-users. Benzodiazepines were associated with increased risk for several serious adverse respiratory outcomes among older adults with COPD. The findings suggest that decisions to use benzodiazepines in older patients with COPD need to consider potential adverse respiratory outcomes.

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada.

OBJECTIVES: We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings. METHODS: We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates. RESULTS: Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable. CONCLUSIONS: We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Effects of impairment in activities of daily living on predicting mortality following hip fracture surgery in studies using administrative healthcare databases.

BACKGROUND: Impairment in activities of daily living (ADL) is an important predictor of outcomes although many administrative databases lack information on ADL function. We evaluated the impact of ADL function on predicting postoperative mortality among older adults with hip fractures in Ontario, Canada. METHODS: Sociodemographic and medical correlates of ADL impairment were first identified in a population of older adults with hip fractures who had ADL information available prior to hip fracture. A logistic regression model was developed to predict 360-day postoperative mortality and the predictive ability of this model were compared when ADL impairment was included or omitted from the model. RESULTS: The study sample (N = 1,329) had a mean age of 85.2 years, were 72.8% female and the majority resided in long-term care (78.5%). Overall, 36.4% of individuals died within 360 days of surgery. After controlling for age, sex, medical comorbidity and medical conditions correlated with ADL impairment, addition of ADL measures improved the logistic regression model for predicting 360 day mortality (AIC = 1706.9 vs. 1695.0; c -statistic = 0.65 vs 0.67; difference in - 2 log likelihood ratios: χ(2) = 16.9, p = 0.002). CONCLUSIONS: Direct measures of ADL impairment provides additional prognostic information on mortality for older adults with hip fractures even after controlling for medical comorbidity. Observational studies using administrative databases without measures of ADLs may be potentially prone to confounding and bias and case-mix adjustment for hip fracture outcomes should include ADL measures where these are available.

Risk of perioperative blood transfusions and postoperative complications associated with serotonergic antidepressants in older adults undergoing hip fracture surgery.

Serotonergic antidepressants (SAds) are associated with bleeding-related adverse events. An increased risk of bleeding with SAds may have important implications in surgical settings. Our study evaluates the risk of red blood cell (RBC) transfusions and postoperative complications associated with SAds among older adults undergoing hip fracture surgery. We conducted a retrospective cohort study of individuals 66 years or older who underwent hip fracture surgery in Ontario, Canada. The risk of RBC transfusion among current users of SAds and nonserotonergic antidepressants (NSAds) was compared with recent former SAd users. Secondary outcomes included measures of postoperative morbidity and mortality. Subgroup analyses were undertaken in groups who were coprescribed other medications known to effect bleeding. Multivariable logistic regression was utilized to determine the odds ratios (ORs) for antidepressants and postoperative outcomes. A total 11,384 individuals were included in the study sample. Current SAd users had an increased risk of RBC transfusion compared with recent former users of SAds (OR, 1.28; 95% confidence interval, 1.14-1.43) as did current NSAd users (OR, 1.17; 95% confidence interval, 1.03-1.33). The risk of RBC transfusion with SAds or NSAds was further increased among individuals receiving antiplatelet agents. However, postoperative morbidity and mortality were not increased among either group of antidepressant users. In conclusion, SAds are associated with an increased risk of RBC transfusions, although this does not appear to result in major postoperative complications. Clinicians should be aware of this increased risk, although routine discontinuation of antidepressants before surgery is likely unwarranted in most cases.

Antipsychotics and mortality in Parkinsonism.

BACKGROUND: : The use of antipsychotic medications is associated with an increased risk of death in older adults with dementia. The risk of death in patients with preexisting parkinsonism who receive antipsychotic drugs is not known. METHODS: : Using a nested case-control design, we examined the risk of death within 30 days of newly starting antipsychotic medications among people with Parkinsonism aged 70 years and older in Ontario, Canada. Data were obtained from Ontario's healthcare administrative databases. RESULTS: : Among 5,391 individuals with parkinsonism who died during the study period (2002-2008) and a matched comparison group of 25,937 who were still alive, individuals exposed to atypical antipsychotic drugs had a higher risk of death (unadjusted odds ratio [OR] = 2.8, 95% CI: 2.1-3.8, adjusted OR: 2.0, 95% CI: 1.4-2.7). Results were similar for quetiapine use compared with no antipsychotic use (unadjusted OR: 2.5, 95% CI: 1.6-4.0, adjusted OR = 1.8, 95% CI: 1.1-3.0). Typical antipsychotics were associated with an increased odds of death compared with atypical antipsychotics (unadjusted OR = 2.4, 95% CI 1.1-5.2, adjusted OR = 2.4, 95% CI: 1.1-5.7). CONCLUSIONS: : Individuals with parkinsonism who are newly prescribed antipsychotic medications have a higher risk of death within 30 days than those who do not start these medications. Although it is not possible to establish causality, the results suggest an increased risk. It is important to be vigilant for accompanying serious medical conditions that may increase mortality in individuals requiring treatment with antipsychotics and to consider alternative approaches to treating psychosis, agitation, and aggression in this population.

Comparing the cohort design and the nested case-control design in the presence of both time-invariant and time-dependent treatment and competing risks: bias and precision.

PURPOSE: Observational studies using electronic administrative healthcare databases are often used to estimate the effects of treatments and exposures. Traditionally, a cohort design has been used to estimate these effects, but increasingly, studies are using a nested case-control (NCC) design. The relative statistical efficiency of these two designs has not been examined in detail. METHODS: We used Monte Carlo simulations to compare these two designs in terms of the bias and precision of effect estimates. We examined three different settings: (A) treatment occurred at baseline, and there was a single outcome of interest; (B) treatment was time varying, and there was a single outcome; and C treatment occurred at baseline, and there was a secondary event that competed with the primary event of interest. Comparisons were made of percentage bias, length of 95% confidence interval, and mean squared error (MSE) as a combined measure of bias and precision. RESULTS: In Setting A, bias was similar between designs, but the cohort design was more precise and had a lower MSE in all scenarios. In Settings B and C, the cohort design was more precise and had a lower MSE in all scenarios. In both Settings B and C, the NCC design tended to result in estimates with greater bias compared with the cohort design. CONCLUSIONS: We conclude that in a range of settings and scenarios, the cohort design is superior in terms of precision and MSE. Copyright © 2012 John Wiley & Sons, Ltd.

Serious events in older Ontario residents receiving bowel preparations for outpatient colonoscopy with various comorbidity profiles: a descriptive, population-based study.

BACKGROUND: Polyethylene glycol-based bowel preparations (PEGBPs) and sodium picosulfate (NaPS) are commonly used for bowel cleansing before colonoscopy. Little is known about adverse events associated with these preparations, particularly in older patients or patients with medical comorbidities. OBJECTIVE: To characterize the incidence of serious events following outpatient colonoscopy in patients using PEGBPs or NaPS. METHODS: The present population-based retrospective cohort study examined data from Ontario health care databases between April 1, 2005 and December 31, 2007, including patients >=66 years of age who received either PEGBP or NaPS for an outpatient colonoscopy. Patients with cardiac or renal disease, long-term care residents or patients receiving concurrent diuretic therapy were identified as high risk for adverse events. The primary outcome was a serious event (SE) defined as a composite of nonelective hospitalization, emergency department visit or death within seven days of the colonoscopy. RESULTS: Of the 50,660 outpatients >=66 years of age who underwent a colonoscopy, SEs were observed in 675 (2.4%) and 543 (2.4%) patients in the PEGBP and NaPS groups, respectively. Among high-risk patients (n=30,168), SEs occurred in 481 (2.8%) and 367 (2.8%) of patients receiving PEGBP and NaPS, respectively. CONCLUSIONS: The SE rate within seven days of outpatient colonoscopy was 24 per 1000 procedures, and among high-risk patients was 28 per 1000 procedures. The rates were similar for PEGBP and NaPS. Clinicians should be aware of the risks associated with colonoscopy in older patients with comorbidities.

Family physicians providing regular care to residents in Ontario long-term care homes: characteristics and practice patterns.

OBJECTIVE: To describe the characteristics and practice patterns of family physicians who regularly treat long-term care (LTC) residents in order to inform quality improvement strategies. DESIGN: Cross-sectional study involving a 2005 province-wide census of LTC residents' charts linked to additional health care administrative databases. SETTING: All LTC homes in Ontario. PARTICIPANTS: Residents aged 66 years and older (n = 50375) and the family physicians (n = 1190) most responsible for their care. MAIN OUTCOME MEASURES: Distribution of LTC residents across family physicians, and physician demographic characteristics and practice patterns. RESULTS: The distribution of residents across physicians was highly skewed (median 27 residents, mean 42.5 residents). The care of 90.4% of residents was accounted for by 628 (52.8%) identified physicians. Family physicians practising in LTC facilities were more likely to be older (mean age 52.4 years vs 48.2 years, P < .001) and male (82.4% vs 61.5%, P < .001) than other family physicians. Urban physicians who provided care to LTC residents had bigger LTC practices than rural LTC physicians did (median 50 residents vs median 12 residents). CONCLUSION: About 600 family physicians are responsible for the regular care of more than 90% of LTC residents in Ontario and quality improvement efforts could be aimed at this relatively small group of physicians. Half of the urban physicians who practise in LTC homes are responsible for 50 or more LTC residents. This might represent a key part of their overall practice.

Impact of the COVID-19 Pandemic on Diabetes Care for Adults With Type 2 Diabetes in Ontario, Canada.

OBJECTIVES: The COVID-19 pandemic and related public health prevention measures have led to a disruption of the delivery of routine care and may have had an impact on the quality of diabetes care. Our aim in this study was to evaluate the extent to which structure, process and outcome quality measures in diabetes care changed in the first 6 months of the pandemic compared with previous periods. METHODS: A before-and-after observational study of all community-living Ontario residents >20 years of age and living with diabetes. The patients were divided into 3 cohorts: a pandemic cohort, alive March to September 2020 (n=1,393,404); reference cohort 1, alive March to September 2019 (n=1,415,490); and reference cohort 2, alive September 2019 to February 2020 (n=1,444,000). Outcome measures were in-person/virtual visits to general practitioners and specialists, eye examinations, glycated hemoglobin (A1C) and low-density lipoprotein (LDL) testing, filled prescriptions, and admissions to emergency departments (EDs) and hospitals for acute and chronic diabetes complications. RESULTS: The probability of an in-person visit to a GP decreasing by 47% (95% confidence interval [CI], 47% to 47%) in the pandemic period compared with both previous periods. The probability of having an eye exam was lower by 43% (95% CI, 44% to 43%), an A1C test by 28% (95% CI, 29% to 28%) and an LDL test by 31% (95% CI, 31% to 31%) in the pandemic period compared with the same 6-month period the year before. There were very small decreases in drug prescriptions and decreases of 18% and 16% in ED and hospital visits for complications. CONCLUSIONS: We observed disruptions to both structure and processes measures of diabetes care in Ontario during the first wave of the pandemic.

Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a general adult population cohort in Ontario, Canada.

BACKGROUND: Administrative healthcare databases are increasingly used for health services and comparative effectiveness research. When comparing outcomes between different treatments, interventions, or exposures, the ability to adjust for differences in the risk of the outcome occurring between treatment groups is important. Similarly, when conducting healthcare provider profiling, adequate risk-adjustment is necessary for conclusions about provider performance to be valid. There are limited validated methods for risk adjustment in ambulatory populations using administrative healthcare databases. OBJECTIVES: To examine the ability of the Johns Hopkins' Aggregated Diagnosis Groups (ADGs) to predict mortality in a general ambulatory population cohort. RESEARCH DESIGN: Retrospective cohort constructed using population-based administrative data. SUBJECTS: All 10,498,413 residents of Ontario, Canada between the ages of 20 and 100 years who were alive on their birthday in 2007. Subjects were randomly divided into derivation and validation samples. MEASURES: Death within 1 year of the subject's birthday in 2007. RESULTS: A logistic regression model consisting of age, sex, and indicator variables for 28 of the 32 ADG categories had excellent discrimination: the c-statistic (equivalent to the area under the receiver operating characteristic curve) was 0.917 in both derivation and validation samples. Furthermore, the model showed very good calibration. In comparison, the use of the Charlson comorbidity index or the Elixhauser comorbidities resulted in a minor decrease in discrimination compared with the use of the ADGs. CONCLUSIONS: Logistic regression models using age, sex, and the John Hopkins ADGs were able to accurately predict 1-year mortality in a general ambulatory population of subjects.

Confounders and intermediaries in case-control study designs: a strategy for distinguishing between the two when measured using the same variable.

PURPOSE: An intermediary falls within the exposure-outcome pathway and is distinct from a confounder. In case-control studies, it may be difficult to discern between the two when both are measured by the same variable. Using data from a study on the effects of antipsychotic initiation on risk of death among older adults, where hospital use is both a confounder and intermediary, we illustrate the bias introduced when this distinction is overlooked and propose a modified exposure classification strategy to mitigate this. METHODS: We identified 5391 cases and 25,937 controls. Three analyses were completed: traditional analytic adjustment including hospital use (full), traditional analytic adjustment excluding hospital use (reduced) and exposure classification incorporating hospital use prior to antipsychotic initiation (extended). RESULTS: The unadjusted odds ratio (OR) was 2.8 (95% confidence interval (CI) 2.1-3.8). Full and reduced analytic adjustment resulted in ORs of 0.8 (95% CI 0.6-1.2) and 1.4 (95% CI 1.0-1.9), respectively. The extended exposure classification strategy produced an OR of 1.4 (95% CI 0.9-2.1) among those without hospital use prior to antipsychotic initiation. CONCLUSIONS: Full analytic adjustment resulted in a biased estimate of effect. The extended exposure analysis differentiated between hospital use that occurred prior (confounder) and subsequent (intermediary) to antipsychotic initiation. This strategy may overcome the limitations of analytic adjustment alone.

Influence of the competing risk of death on estimates of disease recurrence in trials of adjuvant endocrine therapy for early-stage breast cancer: A secondary analysis of MA.27, MA.17 and MA.17R.

BACKGROUND: Many women diagnosed with early-stage hormone-sensitive breast cancer die of causes other than their breast cancer. These competing risks can create challenges in analysing and clearly communicating data on risk of breast cancer recurrence or death. Here, we quantify the impact of competing risks on estimates of disease recurrence and benefit from therapy. PATIENTS AND METHODS: Using data from the MA.27, MA.17 and MA.17R trials of adjuvant endocrine therapy in early breast cancer, we compared Kaplan-Meier (KM) and competing risk methods for disease-free survival (DFS) and distant recurrence-free survival (DRFS). Each trial was analysed separately. In KM analyses, participants were censored at the time of non-breast cancer death. Competing risk analyses comprised cumulative incidence functions in which non-breast cancer death was a competing risk. RESULTS: Non-breast cancer deaths were observed more often in older participants, in those with lower risk of breast cancer and after longer follow-up. Compared with conventional analyses, estimates of the proportion of participants with DFS or DRFS events were lower in competing risk analyses, with this difference increasing over the course of follow-up. The absolute treatment benefit was similar or modestly lower in competing risk analyses. CONCLUSION: Compared with KM methods, competing risk analyses result in lower estimates of DFS and DRFS events and similar or modestly lower absolute benefit from experimental endocrine therapy. Over a long time horizon, competing risk methods may be preferable to KM methods when estimating future risk of recurrence in early-stage hormone-sensitive breast cancer. CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov; NCT00003140, NCT00754845, NCT00066573.

Development and validation of a predictive algorithm for risk of dementia in the community setting.

BACKGROUND: Most dementia algorithms are unsuitable for population-level assessment and planning as they are designed for use in the clinical setting. A predictive risk algorithm to estimate 5-year dementia risk in the community setting was developed. METHODS: The Dementia Population Risk Tool (DemPoRT) was derived using Ontario respondents to the Canadian Community Health Survey (survey years 2001 to 2012). Five-year incidence of physician-diagnosed dementia was ascertained by individual linkage to administrative healthcare databases and using a validated case ascertainment definition with follow-up to March 2017. Sex-specific proportional hazards regression models considering competing risk of death were developed using self-reported risk factors including information on socio-demographic characteristics, general and chronic health conditions, health behaviours and physical function. RESULTS: Among 75 460 respondents included in the combined derivation and validation cohorts, there were 8448 cases of incident dementia in 348 677 person-years of follow-up (5-year cumulative incidence, men: 0.044, 95% CI: 0.042 to 0.047; women: 0.057, 95% CI: 0.055 to 0.060). The final full models each include 90 df (65 main effects and 25 interactions) and 28 predictors (8 continuous). The DemPoRT algorithm is discriminating (C-statistic in validation data: men 0.83 (95% CI: 0.81 to 0.85); women 0.83 (95% CI: 0.81 to 0.85)) and well-calibrated in a wide range of subgroups including behavioural risk exposure categories, socio-demographic groups and by diabetes and hypertension status. CONCLUSIONS: This algorithm will support the development and evaluation of population-level dementia prevention strategies, support decision-making for population health and can be used by individuals or their clinicians for individual risk assessment.

Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates.

BACKGROUND: The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level. METHODS AND RESULTS: We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, -0.42; P=0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion). CONCLUSIONS: Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.

The relationship between variations in antipsychotic prescribing across nursing homes and short-term mortality: quality of care implications.

BACKGROUND: High rates of antipsychotic drug prescribing in nursing homes can signal poor quality processes, but also raise concerns about drug safety due to the mortality risk of this therapy. Determining the extent to which variations in antipsychotic use are a symptom of facility-level quality problems as compared with a drug safety issue is important for selecting the correct interventions to effect change. OBJECTIVE: To determine whether nursing homes with higher rates of antipsychotic dispensing had higher rates of short-term mortality among their residents. METHODS: This population-based study examined 60,105 older adults newly admitted to nursing homes in Ontario between April 1, 2000 and March 31, 2004. Using adjusted Cox proportional hazard models, we explored the relationship between facility-level dispensing rates and mortality, controlling for resident characteristics. Facilities were grouped into quintiles according to mean antipsychotic rate. All-cause mortality at 30 and 120 days after admission was stratified by recent hospital discharge and analyzed by quintile. RESULTS: Average antipsychotic dispensing ranged from 11.6% in the lowest quintile to 30.0% in the highest. Among residents with no recent hospitalization, all-cause mortality at 30 days was 2.5% in the lowest compared with 3.3% in the highest quintile (adjusted hazard ratio: 1.28, confidence interval: 1.06-1.56) and at 120 days was 9.3% compared with 11.7% (adjusted hazard ratio: 1.25, confidence interval: 1.13-1.39). CONCLUSION: Residents were at increased risk of death simply by being admitted to a facility with a higher intensity of antipsychotic drug use, despite similar clinical characteristics at admission.

Association between tamsulosin and serious ophthalmic adverse events in older men following cataract surgery.

CONTEXT: Both benign prostatic hyperplasia (BPH) and cataract formation are common in older men. The alpha-adrenergic receptor blocker tamsulosin is frequently prescribed to treat BPH, and research suggests this drug may increase the intraoperative difficulty of cataract surgery. No studies have documented whether use of tamsulosin or other alpha-blocker drug therapies affect the risk of serious postoperative adverse events. OBJECTIVE: To assess the risk of adverse events following cataract surgery in older men prescribed tamsulosin or other alpha-blocking drugs used to treat BPH. DESIGN, SETTING, AND PATIENTS: Nested case-control analysis of a population-based retrospective cohort study using linked health care databases from Ontario, Canada. We included all men aged 66 years or older who had cataract surgery between 2002 and 2007 (N = 96 128). MAIN OUTCOME MEASURES: A composite of procedures signifying retinal detachment, lost lens or lens fragment, or endophthalmitis occurring within 14 days after cataract surgery. The risk of these adverse events was compared between men treated with tamsulosin or other alpha-blockers and men with no exposure to these medications in the year prior to cataract surgery. We separately examined the association of drug exposure that was either recent (within the 14 days before surgery) or previous (15-365 days before surgery). RESULTS: Overall, 3550 patients (3.7%) in the cohort had recent exposure to tamsulosin and 7426 patients (7.7%) had recent exposure to other alpha-blockers. Two hundred eighty-four patients (0.3%) had an adverse event. We randomly matched 280 of the cases to 1102 controls according to their age, surgeon, and year of surgery. Adverse events were significantly more common among patients with recent tamsulosin exposure (7.5% vs 2.7%; adjusted odds ratio [OR], 2.33; 95% confidence interval [CI], 1.22-4.43) but were not associated with recent exposure to other alpha-blockers (7.5% vs 8.0%; adjusted OR, 0.91; 95% CI, 0.54-1.54) or to previous exposure to either tamsulosin (< or = 1.8% vs 1%; adjusted OR, 0.94; 95% CI, 0.27-3.34) or other alpha-blockers (2.9% vs 2.1%; adjusted OR, 1.08; 95% CI, 0.47-2.48). This corresponds to an estimated number needed to harm (NNH) of 255 (95% CI, 99-1666). CONCLUSIONS: Exposure to tamsulosin within 14 days of cataract surgery was significantly associated with serious postoperative ophthalmic adverse events. There were no significant associations with exposure to other alpha-blocker medications used to treat BPH.