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

Too many unnecessary tests performed before low-risk surgical procedures in Ontario

Kirkham KR, Wijeysundera DN, Pendrith C, Ng R, Tu JV, Laupacis A, Schull MJ, Levinson W, Bhatia RS. Preoperative testing before low-risk surgical procedures. CMAJ. 2015; June 1 [Epub ahead of print].

ISSUE

Studies have shown that routine testing in patients undergoing low-risk surgery does not improve outcomes and may lead to further unnecessary testing, surgical delays, increased patient anxiety and increased cost. What is the rate of preoperative testing prior to hospital-based, low-risk surgical procedures in Ontario?

STUDY

Identified more than 1.5 million patients aged 18 and older who underwent more than 2.2 million low-risk procedures, including endoscopy, ophthalmologic surgery, knee arthroscopy and hernia repair, from April 2008 to March 2013 at 137 institutions in 14 health regions in Ontario. Patient- and institution-level characteristics were identified for electrocardiography (ECG), transthoracic echocardiography, cardiac stress testing and chest radiography within 60 days prior to the procedure.

KEY FINDINGS

ECG and chest radiography were conducted before 31% and 10.8% of low-risk procedures, respectively, and echocardiography and stress testing were conducted before 2.9% and 2.1%, respectively. There was significant variation across institutions (the frequency of preoperative ECG ranged from 3.4‒88.8%) and across age groups (ECGs were conducted 18.3 times more often among people aged 66‒75 than those aged 18‒25).

IMPLICATIONS

Further research is required to determine the underlying causes of regional and institutional variation in preoperative testing and to develop plans to reduce these costly, low-value services.
 
 

Some immigrants and refugees at higher risk of psychotic disorders compared to the general Ontario population

Anderson KK, Cheng J, Susser E, McKenzie KJ, Kurdyak P. Incidence of psychotic disorders among first-generation immigrants and refugees in Ontario. CMAJ. 2015; May 11 [Epub ahead of print].

ISSUE

Ontario is home to the largest number of migrants in Canada, with first-generation migrants constituting nearly 30% of the population. Studies have suggested that migrant groups are at an increased risk of psychotic disorders, with their risk level varying by country of origin. Relative to the general population, what is the incidence of schizophrenia and schizoaffective disorders among first-generation immigrants and refugees to Ontario?

STUDY

Identified more than 4.2 million people aged 14‒40 living in Ontario as of April 1, 1999, and followed them for 10 years. Of these, 9.8% (n=418,433) were first-generation migrants, and of the migrant group, 22.7% (n=95,148) had refugee status. Hospital admission and physician billing data were linked to Citizenship and Immigration Canada data, and examined for one of the following to determine an incident case: a primary discharge diagnosis of schizophrenia from a hospital, or at least two Ontario Hospital Insurance Plan billing claims or emergency department visits for schizophrenia or schizoaffective disorder in a 12-month period. 

KEY FINDINGS

The incidence rate of psychotic disorders among the general population in the cohort was 55.6 per 100,000 person-years; the rate was similar among immigrants at 51.7 per 100,000 person-years, but higher among refugees at 72.8 per 100,000 person-years. The degree and direction of risk varied by refugee status and country of birth. Immigrants from the Caribbean and Bermuda, as well as refugees from East Africa and South Asia, had a 1.5‒2.0 times higher risk of psychotic disorders compared to the general population of Ontario. Migrants living in the province’s highest income areas were at lowest risk for psychotic disorders.

IMPLICATIONS

Migrant status, and particularly refugee status, should be considered as an important risk factor for psychotic disorders in Ontario. Further research should identify the protective factors in migrant groups with low risk of psychotic disorders, in order to inform the design of programs to support high-risk groups.
 
 

Carrying a boy increases a pregnant woman’s risk of developing gestational diabetes

Retnakaran R, Shah BR. Fetal sex and the natural history of maternal risk of diabetes during and after pregnancy. J Clin Endocrinol Metab. 2015; May 20 [Epub ahead of print].

ISSUE

Gestational diabetes mellitus (GDM) arises in women who have a defect in the pancreatic b-cell function such that they are unable to secrete sufficient insulin to make up for the insulin resistance of the latter half of pregnancy, resulting in antepartum hyperglycemia. Study results have recently shown that carrying a male fetus is associated with poorer maternal b-cell function in pregnancy and an increased risk of GDM. Does fetal sex influence the natural history of maternal risk of diabetes after delivery?

STUDY

Identified 642,987 Ontario women aged 15‒49 with a singleton live-birth first pregnancy between April 2000 and March 2010. All women were followed until March 2013 for the development of diabetes outside of pregnancy, or a censoring event (e.g., another pregnancy or death). 

KEY FINDINGS

There were 329,707 women who delivered a boy and 313,987 who delivered a girl. Carrying a boy yielded a higher risk of GDM in the first pregnancy. Specifically, women having a boy were 3% more likely to develop GDM than women having a girl. Women who had GDM in their first pregnancy (n=23,302) had a 7% higher risk of developing Type 2 diabetes before a second pregnancy, if their first baby was a girl. 

IMPLICATIONS

Fetal sex is a previously unrecognized factor associated with the natural history of maternal diabetic risk after delivery. Looking at the sex of a baby may help to predict its mother’s risk for future diseases. 
 
 

Patients prescribed warfarin in the ED have higher frequency of long-term use than those prescribed the drug by a primary care provider

Atzema CL, Austin PC, Chong AS, Dorian P, Jackevicius CA. The long-term use of warfarin among atrial fibrillation patients discharged from an emergency department with a warfarin prescription. Ann Emerg Med. 2015; May 8 [Epub ahead of print].

ISSUE

Atrial fibrillation (AF) is associated with a five-fold increased risk of stroke. Patients at significant risk for AF should be treated with anticoagulants, such as warfarin. Currently, there is no evidence to support the initiation of anticoagulation by the emergency department (ED) physician over referring the patient to his or her primary care provider for provision of such therapy. However, a prescription provided by an ED physician may be interpreted as being of very high importance compared to a prescription from a primary care physician weeks after the AF is identified. Does providing a warfarin prescription in the ED to eligible patients result in higher rates of use of the medication after ED discharge, compared with eligible patients who were not offered a prescription in the ED?

STUDY

Identified 3,510 patients aged 20 and older with a primary diagnosis of AF seen in 24 Ontario EDs between April 2008 and March 2009. After excluding patients admitted to hospital, patients already on warfarin, patients younger than 65, and patients with a low risk for stroke or a high risk for bleeding complications, 137 met the inclusion criteria for the study. The frequency of warfarin use at six months and one year after discharge from the ED was compared for patients who were given a prescription for warfarin before they left the ED and those who were prescribed the drug subsequently by a primary care physician. 

KEY FINDINGS

Thirty-three patients (24.1%) were given a warfarin prescription before discharge from the ED. At six months, 25 of the 33 patients were still receiving warfarin, compared with 34 of the 104 patients who were not given a prescription in the ED; at one year, 75.8% vs. 35.6% were receiving warfarin, respectively. 

IMPLICATIONS

This study demonstrates that patients place importance on prescriptions provided in the emergency setting and confirms that decisions made in the ED affect longitudinal care. By prescribing anticoagulant therapy in the ED, physicians have the opportunity to improve stroke prophylaxis in patients with AF.
 
 

Balance of primary care and specialist physician services required for HIV patients

Kendall CE, Taljaard M, Younger J, Hogg W, Glazier RH, Manuel DG. A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario. BMJ Open. 2015; 5(5):e007428.

ISSUE

There is evidence that HIV specialists and those providers with more HIV experience provide higher quality of care to HIV patients, but that some care needed for people with HIV falls outside the scope and comfort of many HIV specialists. As a result, HIV patients, like many patients with other chronic diseases, have their care shared between primary care providers and specialist physicians. To what extent do different patterns of care address the needs of people with HIV?

STUDY

Identified 13,480 Ontario residents aged 18 and older with HIV who were assigned to one of five patterns of care: exclusively primary care, family physician‒dominant co-management, specialist physician‒dominant co-management, exclusively specialist care, or low-engagement care (patient not assigned to a regular family physician and had no specialist physician providing HIV care). The patients were followed from April 2009 to March 2012 and examined for several indicators, including cancer screening outcomes (mammography, cervical screening, colorectal screening), health services delivery outcomes (emergency visits, hospital admissions) and any HIV-specific outcome (receipt of antiretroviral therapy). 

KEY FINDINGS

How care was provided to HIV patients influenced the quality of care delivered. Models of care in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care. Models with two providers (both a family physician and HIV specialist) had the highest emergency department visit rates. Odds of hospitalization and HIV-specific hospitalization were lower among patients who saw exclusively family physicians. Models in which HIV care was provided predominantly by family physicians were less likely to receive prescriptions for antiretroviral therapy.

IMPLICATIONS

This study suggests, on a population level, the need for both specialist and primary care expertise to cover the broad range of health care needs of complex populations like people with HIV. Further research is required to understand how best to integrate specialist and primary care. 
 
 
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