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  INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES
MARCH 2015
 
At a Glance
  MONTHLY HIGHLIGHTS OF ICES RESEARCH FINDINGS FOR STAKEHOLDERS  
 

Family physicians and psychiatrists among the most common specialties caring for Ontarians with HIV

Kendall CE, Wong J, Taljaard M, Glazier RH, Hogg W, Younger J, Manuel DG. A cross-sectional, population-based study of HIV physicians and outpatient health care use by people with HIV in Ontario. BMC Health Serv Res. 2015; 15:63.

ISSUE

As a result of combination antiretroviral therapy, people with HIV in high-income countries are living longer and are likely to develop additional chronic conditions due to normal aging. Little is known about who is providing care to prevent and manage comorbidities among this population. Which physician specialities provide care most frequently to Ontarians with HIV, and what type of care are they providing?

STUDY

Examined office-based physician visits of 14,282 Ontario residents aged 18 or older with HIV between April 2009 and March 2012. Frequency and type of physician care were stratified into three categories: (1) care by physician speciality (family physicians, infectious disease specialists, internists and other specialists); (2) care based on physician caseload (low, medium or high, categorized as ≤5, 6-49 or ≥50 HIV patients per physician); and (3) care that was related or unrelated to HIV. 

KEY FINDINGS

Individuals with HIV made 406,411 outpatient visits, one-third of which (136,590) were for HIV care. Family physicians provided 217,850 of these visits (53.6% of all visits, 53.9% of HIV-related visits). Infectious disease specialists provided 12.5% of all visits and 32.7% of HIV visits. Internists provided 4.9% of all visits and 9.6% of HIV visits. Among other specialists, psychiatrists provided 12.5% of all visits and 9.6% of HIV visits. Family physicians caring for people with HIV were more often female, older, practicing in rural settings and seeing patients for non-HIV-related care. Only 2.1% of family physicians had high-volume HIV caseloads. Internists and infectious disease specialists caring for these patients were more likely to be male, younger and practicing in urban settings, and less likely to provide non-HIV visits.

IMPLICATIONS

Future research should examine how various specialties share care for Ontarians with HIV, particularly as the family physician workforce ages and fewer services are available. Findings also demonstrate the need for significant mental health resources for this population.
 
 

Combining neuraxial and general anesthesia leads to no reduction in medical complications following surgery

Nash DM, Mustafa RA, McArthur E, Wijeysundera DN, Paterson JM, Sharan S, Vinden C, Wald R, Welk B, Sessler DI, Devereaux PJ, Walsh M, Garg AX. Combined general and neuraxial anesthesia versus general anesthesia: a population-based cohort study. Can J Anaesth.  2015; 62(4):356–68.

ISSUE

Neuraxial (epidural or spinal) anesthesia is widely used for major surgery in combination with general anesthesia. The combination has shown advantages over general anesthesia alone, including better postoperative pain control and fewer postoperative respiratory issues; however, its impact on mortality and adverse outcomes is uncertain. Does combining general and neuraxial anesthesia reduce major medical complications of surgery compared with general anesthesia alone?

STUDY

Identified 12,379 patients undergoing 21 different elective procedures that were amenable to either combined anesthesia or to general anesthesia alone in 108 Ontario hospitals between June 2004 and December 2011. Four major medical complications were assessed together as a composite and individually in the 30 days following surgery: acute kidney injury, stroke, myocardial infarction and all-cause mortality.

KEY FINDINGS

Compared to general anesthesia alone, combined anesthesia was not associated with a reduced risk for the 4 medical complications either in composite or individually. For 7 of the 21 procedures, a longer length of hospital stay was associated with combined anesthesia compared to general anesthesia alone (7 days vs. 6 days).

IMPLICATIONS

Future research should isolate neuraxial anesthesia to attempt to understand why a reduction in the development of major medical complications was not found. Future studies should also examine the difference in hospital length of stay between patients with combined anesthesia and those with general anesthesia.
 
 

Risk of ischemic stroke highest during first 30 days of warfarin therapy

Tung JM, Mamdani MM, Juurlink DN, Paterson JM, Kapral MK, Gomes T. Rates of ischemic stroke during warfarin treatment for atrial fibrillation. Stroke. 2015; Feb 19 [Epub ahead of print].

ISSUE

Warfarin is a drug used to prevent ischemic stroke and systemic embolism in patients with atrial fibrillation. In addition to increased risk of major hemorrhage, recent evidence suggests there is a 71% increased risk of ischemic stroke in the first 30 days following initiation of warfarin therapy. What is the absolute risk of ischemic stroke throughout the course of warfarin therapy and is risk influenced by patient characteristics?

STUDY

Identified 148,446 patients aged 66 and older with atrial fibrillation who began warfarin therapy in Ontario between April 1997 and March 2010. Baseline characteristics including age, comorbidities and medication use were assessed, and each patient was followed up in 30-day intervals until the first of ischemic stroke, death, end of the 5-year follow-up period or end of the study period. To identify patient characteristics, all analyses were stratified by CHADS2 (congestive heart failure, hypertension, age 75 or older, diabetes, previous stroke) score.

KEY FINDINGS

The 30-day cumulative incidence of ischemic stroke among new users of warfarin was 0.5% (n=721), increasing to 2.0% (n=2,917) after 1 year, 2.7% (n=4,067) after 2 years, and 4.0% (n=6,006) after 5 years. The risk of ischemic stroke was highest during the first 30 days of treatment (6.0% per person-year) compared with the reminder of the 5-year follow-up (1.6% per person-year). This early elevated risk increased with previous stroke history and higher baseline CHADS2 score.

IMPLICATIONS

The rate of ischemic stroke is highest within the first 30 days after initiating warfarin. The increased thromboembolic risk despite treatment highlights the need for further research in this area.
 
 

ICES report examines the burden of mental illness and addictions on Ontario children and youth

MHASEF Research Team. The Mental Health of Children and Youth in Ontario: A Baseline Scorecard. Toronto, ON: Institute for Clinical Evaluative Sciences; 2015.

ISSUE

Mental health and addictions (MHA) services in Ontario have been assessed as fragmented and uncoordinated, with service provision limited by the low capacity of the health care system and determined largely by funding instead of actual need. Ontario’s Comprehensive Mental Health and Addictions Strategy represents an effort to address these criticisms and improve the system. 

STUDY

The baseline scorecard provides a snapshot of child and youth populations at risk, existing processes of MHA care and relevant MHA outcomes. The scorecard used two types of indicators: contextual (describing the state of child and youth MHA service provision) and performance (tracking MHA system performance and outcomes over time). The scorecard used the most current health administrative data, population-based survey data and school-level education data available to report on indicators from April 2002 to March 2012 across the province’s 14 Local Health Integration Networks.

KEY FINDINGS

Children and youth living in the lowest-income neighbourhoods had the highest rates of acute care MHA service use and the highest suicide rates; babies of mothers in this group had much higher rates of neonatal abstinence syndrome than other babies. Regions with greater need for MHA services also had fewer outpatient resources, longer wait times (particularly in rural areas) and the lowest rates of mental health visits, suggesting an association between socioeconomic status and access to physician MHA services. Targeted investments in services were associated with improved access to MHA care. Specifically, out-of-country treatment of eating disorders decreased significantly after the implementation of a systematic referral screening process in 2008, and rates of telepsychiatry increased after 2009, particularly in remote regions with a low per capita supply of psychiatrists.

IMPLICATIONS

The need for and access to MHA services vary greatly across Ontario. Mental health and public health practitioners need to work together to identify and enhance MHA promotion and intervention strategies across the province. Additionally, future performance measurement would be enhanced by widespread adoption of standardized assessment tools. New data partnerships with other child and youth agencies, the inclusion of further surveillance surveys and the addition of new indicators will strengthen the analytical capacity of Ontario’s Comprehensive Health and Addictions Strategy.
 
 

Repeated performance assessments improve predictions for cancer patient risk of death

Su J, Barbera L, Sutradhar R. Do repeated assessments of performance status improve predictions for risk of death among patients with cancer? A population-based cohort study. Palliat Med. 2015 Jan 29 [Epub ahead of print].

ISSUE

The Palliative Performance Scale (PPS) is a provider-reported, validated tool for assessing the performance status of cancer patients based on five functional dimensions: level of ambulation, activity level and evidence of disease, ability to perform self-care, ability to intake food orally, and level of consciousness. PPS data are usually collected at a single point in time, typically during cancer diagnosis. Do repeated PPS assessments of performance status improve the ability to predict for risk of death among cancer patients?

STUDY

Identified 15,487 patients who were diagnosed with cancer in Ontario on or after January 1, 2007, and had at least one PPS assessment during their follow-up period. Patients were followed until their date of death from cancer or March 31, 2011. A prediction model based on a PPS assessment at diagnosis was compared to a prediction model based on time-varying PPS assessments. Performance status was categorized as stable (a PPS score of 70–100), transitional (40–60) or end of life (10–30).

KEY FINDINGS

The study considered 53,503 PPS assessments. The median number of assessments per patient was 3 and the median time between assessments was 4.3 months. The utilization of repeated assessments was found to have better predictive ability of performance status (0.722) than using only the performance status assessment taken at diagnosis (0.697) by a difference of 2.5%.

IMPLICATIONS

The initiative implemented in Ontario to conduct a PPS assessment at each visit for every cancer patient has made longitudinal performance status data readily available. Researchers should be encouraged to use this data to increase the accuracy in predicting risk of death.
 
 
ICES is a not-for-profit research institute encompassing a community of research, data and clinical experts, and a secure and accessible array of Ontario's health-related data.
 
 
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