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  INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES

OCTOBER 2013

 
At a Glance
  MONTHLY HIGHLIGHTS OF ICES RESEARCH FINDINGS FOR STAKEHOLDERS  
 

Half of uterine cancer patients in Ontario wait longer than recommended six weeks for surgery

O'Leary E, Elit L, Pond G, Seow H. The wait time creep: changes in the surgical wait time for women with uterine cancer in Ontario, Canada, during 2000–2009. Gynecol Oncol. 2013; 131(1):151–7.

ISSUE

A report published at the onset of the Ontario Wait Time Strategy in 2005 documented lengthy waits for hysterectomies, with 75% of surgeries occurring at 11.3 weeks, significantly longer than the proposed recommendation of a wait within 6 weeks of uterine cancer diagnosis. To what extent have surgery wait times for women with uterine cancer changed in Ontario since 2000? What indicators predict longer surgery wait times?

STUDY

Measured the wait time from diagnosis to hysterectomy of 9,330 uterine cancer patients in Ontario between April 2000 and March 2009. Several demographic and health system factors were examined for their effect on wait times.

KEY FINDINGS

Wait times for surgery increased steadily from a median of 34 to 55 days between 2000 and 2006, followed by a plateau until 2009 during which patients waited a median of 53 to 55 days. Nearly half of all patients received surgery in less than 6 weeks after diagnosis, which is less than the target of 90%. Predictors of a wait time greater than 6 weeks included older age, region of residence, lower income, later year of diagnosis, non-sarcoma histology group, surgery by a gynecologic oncologist or having surgery in a teaching hospital.

IMPLICATIONS

Regular reporting of cancer wait times by specific disease site would help to identify progress in reducing wait times as well as opportunities for improvement.
 
 

Better selection criteria needed for patients with stable angina who undergo angiograms

Levitt K, Guo H, Wijeysundera HC, Ko DT, Natarajan MK, Feindel CM, Kingsbury K, Cohen EA, Tu JV. Predictors of normal coronary arteries at coronary angiography. Am Heart J. 2013; 166(4):694–700.

ISSUE

While some proportion of coronary angiograms are expected to be normal, it is important that this proportion be minimized, given the invasive nature of angiograms and the associated risk and significant cost. What are the clinical predictors of normal angiograms? How do rates of normal angiograms compare among hospitals?

STUDY

Analyzed 2,718 patients undergoing their first cardiac catheterization for an indication of stable angina between April 2006 and March 2007 at one of 17 cardiac centres in Ontario. Determined predictors of normal angiograms (those with no coronary stenosis) and compared rates of patients with normal catheterizations across centres.

KEY FINDINGS

Overall, 41.9% of patients with stable angina had a normal catheterization. Female gender, absence of traditional cardiac risk factors and lack of typical angina symptoms were associated with a higher frequency of normal results among stable patients. The rate of normal angiograms varied from 18.4% to 76.9% across hospitals and was more common in community hospitals than in academic settings (47.1% vs. 35.4%).

IMPLICATIONS

These findings highlight the need to elicit better histories of patient symptoms and develop better non-invasive methods (novel biomarkers, newer imaging techniques) to identify those patients more likely to have abnormal angiograms. The wide variation in the frequency of normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection.
 
 

Cancer and chronic disease screening lowest in disadvantaged neighbourhoods

Borkhoff CM, Saskin R, Rabeneck L, Baxter NN, Liu Y, Tinmouth J, Paszat LF. Disparities in receipt of screening tests for cancer, diabetes and high cholesterol in Ontario, Canada: a population-based study using area-based methods. Can J Public Health. 2013; 104(4):e284–90.

ISSUE

Few studies have compared socioeconomic disparities in screening tests for cancer with other chronic diseases. Does the uptake of these various tests differ by neighbourhood-level socioeconomic and recent immigrant status in Ontario?

STUDY

Conducted a population-based analysis of approximately 7.7 million Ontario residents identified as screen-eligible in 2009. Their neighbourhoods were stratified by income quintile and proportion of recent immigrants (within previous 10 years). Prevalence of screening for colorectal, cervical and breast cancer, diabetes and high cholesterol were calculated for men and women.

KEY FINDINGS

Screening for cancer, diabetes and high cholesterol were all lower among men and women living in neighbourhoods with a low average income and/or a high proportion of recent immigrants. Among women living in high-immigration neighbourhoods, those in low-income neighbourhoods were significantly less likely than women in more affluent neighbourhoods to undergo screening for colorectal cancer (48.6% vs. 60.2%), cervical cancer (52.0% vs. 61.0%) and breast cancer (45.7% vs. 57.6%). Among men living in high-immigration neighbourhoods, those in low-income neighbourhoods were significantly less likely than their counterparts in higher-income neighbourhoods to undergo screening for colorectal cancer (40.6% vs. 52.9%). Screening rates for diabetes and high cholesterol were higher overall, and disparities in receipt of screening were not as great as for cancer.

IMPLICATIONS

An integrated chronic disease screening strategy that leverages higher diabetes and cholesterol screening participation rates may increase screening for cancer and other chronic diseases in never- and underscreened populations.
 
 

Risk of dying one year after hospitalization in Ontario fell sharply between 1994 and 2009

van Walraven C. Trends in 1-year  survival of people admitted to hospital in Ontario, 1994–2009. CMAJ. 2013 Sep 30 [Epub ahead of print].

ISSUE

Hospital care consumes a large proportion of health care resources. To help gauge its performance, it is important to measure trends in outcomes of hospitalized patients. What is the long-term survival of patients admitted to Ontario hospitals?

STUDY

Identified all adults aged 20 and older admitted to Ontario acute care hospitals in 1994, 1999, 2004 and 2009 and determined mortality from any cause within one year following their admission date.

KEY FINDINGS

Compared to those from 1994, hospitalized people in 2009 were significantly more likely to die within one year (9.2% vs. 11.6%). However, patients in 2009 were significantly older, had more comorbidities and were more likely to have been transported to hospital by ambulance. After adjusting for these patient factors and improved survival in the general population, patients hospitalized in 2009 were 22% less likely to die compared to the 1994 cohort.

IMPLICATIONS

Further research needs to be done on hospital admissions and mortality, as the reasons for the improved survival cannot be determined from this study.
 
 

Drug prescribing significantly influenced by clinical evidence and policy changes

Hashim S, Gomes T, Juurlink D, Hellings C, Mamdani M. The rise and fall of the thiazolidinediones: impact of clinical evidence publication and formulary change on the prescription incidence of thiazolidinediones. J Popul Ther Clin Pharmacol. 2013; 20(3):e238–42. 

ISSUE

Drug prescribing is influenced by a number of factors including clinical research supporting their effectiveness and safety, cost, drug policy and marketing. The thiazolidinedione (TZD) drugs rosiglitazone and pioglitazone are used in the treatment of type 2 diabetes. What has been the impact of cardiovascular safety concerns and public drug formulary restrictions on their use?

STUDY

Analyzed health care claims of more than 1.6 million older Ontario residents from January 2000 to September 2010 to examine the impact of two events on the rate of initiation of TZDs among those aged 66 and older: (1) the 2007 publication of a prominent meta-analysis suggesting cardiovascular harm for rosiglitazone, and (2) the introduction of prescribing restrictions for TZDs on the public drug formulary in June 2009.

KEY FINDINGS

Rosiglitazone prescribing declined 92% in the first 3 months following publication of the meta-analysis that raised safety concerns. Similarly, pioglitazone prescribing declined 72% from just prior to the publication of the meta-analysis to just prior to the implementation of formulary restrictions in the second quarter of 2009. Following the implementation of formulary restrictions, the rate of incident prescriptions for rosiglitazone fell 85% between the first and third quarters of 2009. The rate of prescriptions dispensed for pioglitazone fell 80% in that period.

IMPLICATIONS

Both the publication of clinical evidence and changes to drug policy can significantly influence the use of TZDs. The effects of both of these may be more pronounced if viable treatment alternatives exist.
 
 
ICES is an independent, non-profit organization that conducts research on a broad range of topical issues to enhance the effectiveness of health care for Ontarians.
 
 
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