Rates of thyroid cancer diagnosis vary four-fold across Ontario’s health planning regions

Hall SF, Irish J, Groome P, Griffiths R. Access, excess, and overdiagnosis: the case for thyroid cancer. Cancer Med. 2014 Jan 10 [Epub ahead of print].

Previous studies have reported an increasing incidence of thyroid cancer, particularly among women. To what extent do rates of discretionary diagnostic testing and measures of health and access to care relate to rates of thyroid cancer diagnosis in Ontario’s health planning regions?

Identified 12,959 patients over 18 years of age who had a surgical treatment for thyroid cancer between January 1999 and December 2008 and who resided in one of Ontario’s 14 Local Health Integration Networks (LHINs). For each LHIN, data were obtained on demographics, general health and access to health care for the population, as well as availability of diagnostic equipment and operating rooms.

There was a 112% increase in the number of new cases of thyroid cancer over the nine years (from 893 to 1,890). Eighty percent of patients were female. Across LHINs, annual thyroid cancer diagnosis rates ranged from 5.2 to 21.6 cases per 100,000 population. LHINs with the highest use of discretionary medical tests (including diagnostic ultrasound of the pelvis, abdomen and neck), the highest population densities and the highest levels of education had the highest rates of thyroid cancer diagnosis.

The overdiagnosis of asymptomatic thyroid cancer may be leading to unnecessary medical care.

Adults with chronic kidney disease at increased risk for bone fracture

Naylor KL, McArthur E, Leslie WD, Fraser LA, Jamal SA, Cadarette SM, Pouget JG, Lok CE, Hodsman AB, Adachi JD, Garg AX. The three-year incidence of fracture in chronic kidney disease. Kidney Int. 2014 Jan 15 [Epub ahead of print].

Bone fractures are an important outcome in adults with chronic kidney disease. Knowing a person’s fracture risk according to their kidney function, age and sex may influence clinical management and decision-making.

Identified 679,114 Ontarians aged 40 and older between April 2002 and March 2009 whose kidney function, or estimated glomerular filtration rate (eGFR), had been measured. Stratified them by their eGFR (60+ [which represents normal kidney function], 45–59, 30–44, 15–29 or under 15 ml/min per 1.73 m²), age group (40–65 and over 65) and sex. Individuals were followed for three years for evidence of a fracture.

For both sexes and both age groups, the three-year cumulative incidence of fracture significantly increased in a graded manner with decreasing eGFR. Among women over age 65, the cumulative incidence of fracture across the five eGFR groups was 4.3%, 5.8%, 6.5%, 7.8% and 9.6%, respectively. Corresponding estimates for men over age 65 were 1.6%, 2.0%, 2.7%, 3.8% and 5.0%, respectively.

Physicians can use these fracture estimates to help guide patient treatment decisions and illustrate fracture risk to patients. The estimates may also inform sample size requirements for future fracture prevention trials.

Lower surgeon volumes linked to greater risk of postsurgery hospitalization in patients with Crohn’s disease

Nguyen GC, Steinhart AH. The impact of surgeon volume on postoperative outcomes after surgery for Crohn's disease. Inflamm Bowel Dis. 2014; 20(2):301–6.

Higher volume hospitals have been associated with better postoperative outcomes for patients with inflammatory bowel disease. What is the contribution of surgeon volume to postoperative outcomes among patients with Crohn’s disease?

Identified 2,482 patients with Crohn’s disease who underwent a first related surgery in Ontario between April 1996 and March 2009. Assessed the association between surgeon volume (in quartiles), hospital volume (in quintiles), patient characteristics (age, sex, income, rural residence, comorbidity) and postoperative outcomes (in-hospital mortality, re-hospitalization within three months and after three months).

In-hospital mortality was 4.4% and did not vary significantly by surgeon volume. Individuals in the lowest income quintile experienced a mortality rate that was three times higher than those in the highest income quintile. After adjustment for important confounders, patients of the lowest-volume surgeons were at increased risk for late rehospitalization.

Lower surgeon volumes were associated with increased risk for late hospitalizations after surgery. Further study is warranted to clarify if this is a consequence of suboptimal surgical proficiency or infrastructure factors that may contribute to inadequate postoperative management of Crohn’s disease.

Heart rate at hospital discharge a predictor of mortality in patients with chronic heart failure

Habal MV, Liu PP, Austin PC, Ross HJ, Newton GE, Wang X, Tu JV, Lee DS. Association of heart rate at hospital discharge with mortality and hospitalizations in patients with heart failure. Circ Heart Fail. 2014; 7(1):12–20.

Blood pressure at hospital discharge is a significant predictor of mortality among patients with heart failure. What effect does heart rate at hospital discharge have on a heart failure patient’s risk of death or rehospitalization?

Identified 9,097 patients aged 18 and older who were discharged from Ontario hospitals with a diagnosis of heart failure between 1999 and 2001 and between 2004 and 2005, and examined the effect of discharge heart rate on risk of rehospitalization and mortality at 30 days and one year.

The distribution of patients by discharge heart rate was 1,333 with 40–60 beats per minute (bpm), 2,170 with 61–70 bmp, 2,631 with 71–80 bmp, 1,700 with 81–90 bmp and 1,263 with greater than 90 bmp. A positive association was found between increasing heart rate at discharge and all-cause mortality. Discharge heart rates of more than 90 bpm were associated with increased odds of 30-day and one-year all-cause mortality and cardiovascular mortality, as well as greater risks of readmission for heart failure and cardiovascular disease within 30 days of initial hospital discharge.

These findings highlight the importance of heart rate as a potentially modifiable risk factor in patients with heart failure. Further research is warranted to determine whether interventions to lower heart rate can prevent early mortality after hospitalization for heart failure, and what the therapeutic targets should be.

Women with schizophrenia at higher risk for pre-term birth and pregnancy complications

Vigod SN, Kurdyak PA, Dennis CL, Gruneir A, Newman A, Seeman MV, Rochon PA, Anderson GM, Grigoriadis S, Ray JG. Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study. BJOG. 2014 Jan 21 [Epub ahead of print].

More women with schizophrenia are becoming pregnant. How do maternal and neonatal health outcomes among women with schizophrenia compare to those of women without the disease?

Identified 1,391 Ontario women aged 15 to 49 and diagnosed with schizophrenia who gave birth to a live or stillborn infant between April 2002 and March 2011. Compared their risk for adverse pregnancy outcomes to a reference group of 432,358 women with no history of a mental disorder in the five years preceding conception.

Women with schizophrenia had higher rates of pre-existing diabetes mellitus (3.9% vs. 1.2%), chronic hypertension (3.7% vs. 1.9%) and thromboembolic disease (1.7% vs. 0.5%) than unaffected women. Women with schizophrenia were more likely to experience septic shock, require a caesarean section, be transferred to an intensive care unit and be readmitted to hospital. They also had more than five times the risk of death in the year after giving birth. Infants born to women with schizophrenia were at increased risk of preterm birth and neonatal morbidity and tended to be abnormally small or large in weight compared to infants of unaffected mothers.

These findings may inform the development of interventions to reduce the identified health risks among pregnant women with schizophrenia.