New ICES atlas examines head and neck cancer surgery in Ontario

Eskander A, Irish JC, Urbach DR, Goldstein DP. Head and Neck Cancer Surgery in Ontario, 2003‒2010: An ICES Atlas. Toronto, ON: Institute for Clinical Evaluative Sciences; 2015.

Head and neck cancers represent a significant burden because of their impact on a patient’s ability to breathe, speak and swallow. There has been a major shift in the regionalization of head and neck cancer surgery to nine large-volume centres across six cities in Ontario, but the impact of regionalization on patient treatment and outcomes is unknown. How many patients are developing head and neck cancers in Ontario and are there demographic or regional variations in treatment rates?

Identified 6,470 patients in Ontario who were newly diagnosed with one of three cancers (oral cavity, larynx/hypopharynx, salivary gland) between January 2003 and December 2010. Examined procedures and health resources used by patients in a specific 2-year time period, from 12 months before diagnosis to 12 months after. Also examined patient sociodemographic data including age group, sex, neighbourhood income level, community size, and region (Local Health Integration Network, or LHIN) of residence and of treatment.

During the study period, there was a marked decrease in the incidence of larynx/hypopharynx cancer, a moderate rise in the incidence of salivary gland cancers and a significant rise in the incidence of oral cavity cancers. The incidence of head and neck cancers increased with advanced age, particularly among those aged 65 or older. Variations in the diagnostic workup, treatment approach, use of adjunctive procedures and number of consultations for patients existed even among high-volume regional head and neck cancer treatment centres.

As the Ontario population ages, there may be an increasing demand for health care services to treat head and neck cancers. The growing number of survivors will lead to increased health care system costs over time. Further research is required to understand differences in access to specialist care and head and neck cancer treatment patterns across the LHINs.

Physician-diagnosed migraine associated with increased risk of deliberate self-harm

Colman I, Kingsbury M, Sareen J, Bolton J, van Walraven C. Migraine headache and risk of self-harm and suicide: a population-based study in Ontario, Canada. Headache. 2015; Oct 31 [Epub ahead of print].

Migraine headache is a common and recurring source of intense pain and has been linked to several psychiatric disorders including major depression and anxiety. A growing body of evidence also associates migraine with thoughts of suicide, self-harming and suicide attempts, but to date only one study focusing on US veterans has examined this potential link. What is the association between physician-diagnosed migraine, deliberate self-harm and suicide mortality?

Identified 101,114 Ontarians aged 12 and older who participated in the Canadian Community Health Survey in 2003, 2005 or 2007. Survey respondents were able to self-report a physician diagnosis of migraine headache. Examined follow-up time until first presentation to the emergency department for deliberate self-harm or until death by suicide.

Physician diagnosis of migraine was reported by 11.2% of survey respondents (11,314 people). Emergency department visits for self-harm during the follow-up period were almost 50% more likely among those with diagnosed migraine compared to those without (76.4 vs 35.7 per 100,000 person-years). Death by suicide was rare with only 55 suicides in the follow-up period. Risk of suicide was similar for both those with and without a history of migraines. 

Given the danger of intentional self-harm and the strong associations observed in this study between migraine headache and self-harm, health care professionals should consider monitoring suicidal risk in individuals with migraines.

Less than half of eligible Ontarians get all recommended screening tests for cancer, diabetes and heart disease

Fernandes KA, Sutradhar R, Borkhoff CM, Baxter N, Lofters A, Rabeneck L, Tinmouth J, Paszat L, Ontario Cancer Screening Research Network. Small-area variation in screening for cancer, glucose and cholesterol in Ontario: a cross-sectional study. CMAJ Open. 2015; 3(4):E1-9.

Despite primary care reforms and incentives, the uptake of screening tests for cervical, breast and colon cancers and elevated levels of cholesterol and glucose remains low in Ontario. What is the rate of screening participation at the small-area level and what are the factors contributing to these rates?

Identified over 6.6 million Ontarians (3.8 million women and 2.8 million men) who were age-eligible for the five screening tests in 2011. Used postal codes to allocate this population to 18,950 “small areas” based on census dissemination areas of fewer than 1,000 people. Calculated rates for each test among the small areas overall and stratified by demographic, socioeconomic and primary care descriptors.

On average, approximately 30% of women had completed all five screening tests for which they were eligible. Men fared slightly better at approximately 40%, but this may be explained by the fact that men only require three of the five tests. Screening rates (whether for individual tests or all five tests combined) were progressively lower in areas with lower rates of high school completion, lower income levels and less individual attachment to a primary care physician.

These findings will assist health policy planners, primary care teams and local service agencies to better target neighbourhood interventions in order to reach populations that are less likely to get screened, with the goal of improving early diagnosis and patient outcomes. 

Study of pregnancy complications finds refugee women in Ontario have higher rates of HIV

Wanigaratne S, Cole DC, Bassil K, Hyman I, Moineddin R, Urquia ML. Contribution of HIV to maternal morbidity among refugee women in Canada. Am J Public Health. 2015; 105(12):2449-56.

Severe maternal morbidity (SMM)—where a woman nearly dies but survives a complication during pregnancy, childbirth or within 42 days of termination of pregnancy—has become an increasingly important indicator to assess both the maternal health of populations and the quality of obstetric care. How do SMM rates (including HIV rates) among refugee women compare to nonrefugee immigrant and nonimmigrant women? 

Linked 1,154,421 Ontario hospital deliveries between April 2002 and March 2011 to immigration records from 1985 to 2010. Identified incidence of SMM—any woman with 1 or more of 45 different diagnoses or procedures related to specific diseases (e.g., HIV), interventions (e.g., blood transfusion) or organ dysfunctions (e.g., hepatic failure) reported during hospital admission for labour or delivery. Determined SMM incidence according to immigration periods, which were characterized by lifting restrictions for all HIV-positive immigrants (in 1991) and refugees who may place “excessive demand” on government services (in 2002).

Between 2002 and 2011, refugees had a higher risk of SMM than did immigrants and nonimmigrants (17.1, 12.1 and 12.4 per 1,000 deliveries, respectively). Among SMM subtypes, refugees had a much higher risk of HIV than did immigrants and nonimmigrants; rates were 8 times higher among refugees than immigrants and 17 times higher among refugees than Canadian-born women. SMM disparities were greatest after the 2002 policy came into effect. After exclusion of HIV cases, SMM disparities disappeared. Refugee women with HIV/AIDS did not suffer from complications any more than other women with HIV/AIDS.

Findings suggest that refugee women do not place an increased demand on the health care system during childbirth. Future research should examine refugee women with less severe pregnancy complications to provide more insight into whether additional support is needed for refugee mothers.

Rural seniors underuse preventive diagnostic services for acute myocardial infarction

Cohen D, Manuel DG, Sanmartin C. Do rural patients in Canada underutilize preventive care for myocardial infarction? J Rural Health. 2015; Oct 30 [Epub ahead of print].

Residents of rural areas experience lower utilization rates of preventive health care services compared to the urban population. How do Ontario’s urban and rural populations differ in their use of primary and secondary preventive diagnostic services for acute myocardial infarction (AMI)?

Identified 30,491 Ontarians aged 40–105 who were admitted to hospital with a primary diagnosis of AMI between April 2010 and March 2012 and no other AMI hospitalizations for up to 20 years before the index event. Patients were identified as either rural or urban based on their postal code. A rural area was defined as any area outside of an urban centre with a population of less than 1,000. Patients were coded as senior if they were 65 or older during the 2-year preventive care period; all other patients were coded middle-aged. The primary and secondary preventive care services used by patients in the 2 years prior to their AMI were examined.

For primary preventive care services, 64.4% of all patients received lipid testing and 72.5% received glucose testing. For secondary preventive care services, 15.9% received stress testing, 67.8% received electrocardiogram and 28.5% received echocardiogram. Compared to middle-aged patients, seniors received more of every type of preventive service. The odds of receiving primary preventive screening were lower by between 48% and 64% for rural patients compared to the odds of their urban counterparts. For secondary preventive care, the odds of receiving services were lower by between 18% and 28% for rural patients compared to urban patients.

These findings point to the need to focus on improvements in rural primary care in order to meaningfully address healthy aging policy and to achieve equitable health status for rural and urban populations.