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  INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES
JULY/AUGUST 2013
 
At A Glance
  MONTHLY HIGHLIGHTS OF ICES RESEARCH FINDINGS FOR STAKEHOLDERS  
 

Diabetes-related mortality rates plummet in Canada and the UK since mid-1990s

Lind M, Garcia-Rodriguez LA, Booth GL, Cea-Soriano L, Shah BR, Ekeroth G, Lipscombe LL. Mortality trends in patients with and without diabetes in Ontario, Canada and the UK from 1996 to 2009: a population-based study. Diabetologia. 2013 Jun 22 [Epub ahead of print]. 

ISSUE

A 2011 review of studies investigating diabetes mortality suggested that having diabetes raised a person’s risk of death by 80% compared with the general population. However, several of the studies were published prior to 2000. What is the current excess risk of mortality in patients with diabetes and how has it changed over time?

STUDY

Compared annual age- and sex-adjusted mortality rates for approximately 13 million adults older than 20 years with and without diabetes in Ontario and the UK from January 1996 to December 2009.

KEY FINDINGS

From 1996 to 2009, the prevalence of diabetes rose from 5.4% to 11.4% in Ontario and from 3.2% to 5.9% in the UK. However, during the study period the excess risk of mortality from diabetes fell from 90% to 51% in Canada and from 114% to 65% in the UK. The fall was experienced across all age groups and for both men and women. In 2009, the excess risk of mortality among diabetic individuals aged 45 to 64 was double that of people without diabetes; the risk was slightly lower at 70–80% for 20- to 44-year-olds and 15–25% for those aged 65 and older.

IMPLICATIONS

The decline in the excess risk of mortality in individuals with diabetes may be due to more aggressive treatment of diabetes, as well as to improved screening that results in people with diabetes receiving treatment earlier.
 
 

Commonly coprescribed statins and antibiotics linked to muscle loss, kidney failure in seniors

Patel AM, Shariff S, Bailey DG, Juurlink DN, Gandhi S, Mamdani M, Gomes T, Fleet J, Hwang YJ, Garg AX. Statin toxicity from macrolide antibiotic coprescription: a population-based cohort study. Ann Intern Med. 2013; 158(12):869–76.

ISSUE

Some antibiotics increase the blood values of commonly prescribed statins by inhibiting the liver enzyme that metabolizes them. What is the risk for serious statin toxicity among older adults who are coprescribed an antibiotic?

STUDY

Identified 144,336 continuous statin users older than age 65 who were coprescribed clarithromycin (n=72,591), erythromycin (n=3,267) or azithromycin (n=68,478) in Ontario from June 2003 to December 2010.  Assessed hospital admissions for rhabdomyolysis (muscle fibre loss) and acute kidney injury as well as death within 30 days of antibiotic prescribing.

KEY FINDINGS

Atorvastatin was the most commonly prescribed statin (73%) followed by simvastatin (24%) and lovastatin (3%). Compared with azithromycin, coprescription of atorvastatin, simvastatin or lovastatin with clarithromycin or erythromycin was associated with an absolute increased risk of hospitalization of  0.02% for rhabdomyolysis, 1.26% for acute kidney injury and 0.25% for all-cause mortality.

IMPLICATIONS

Although the increase in risk is relatively small, given the frequency at which statins are prescribed and the high rate of coprescription, this preventable drug-drug interaction is clinically important. The results suggest that many deaths and hospitalizations due to acute kidney injury in Ontario may have been attributable to this interaction.
 
 

Low-income heart attack survivors less likely to engage in life-extending exercise

Alter DA, Franklin B, Ko DT, Austin PC, Lee DS, Oh PI, Stukel TA, Tu JV. Socioeconomic status, functional recovery, and long-term mortality among patients surviving acute myocardial infarction. PLoS One. 2013; 8(6):e65130.

ISSUE

Socioeconomic status (SES) has been shown to be an important determinant of survival after acute myocardial infarction (AMI).  What is the relationship between SES, functional capacity recovery and long-term survival after AMI?

STUDY

Identified 1,368 Ontario residents who survived at least one year after hospitalization for AMI between December 1999 and February 2003, and analyzed their SES and self-reported measures of physical health, along with other factors including ethnicity, clinical characteristics, processes of care following hospitalization and mental health. Patients were followed to December 31, 2010, to track mortality (mean 9.6 years).

KEY FINDINGS

Ten years post-AMI, nearly 35% of patients in the lowest income group had died, compared to 27% of the middle-income group and 15% of the highest earners. To a lesser extent the same pattern held true for educational status. Higher SES patients experienced significantly greater improvement in functional recovery (physical activity capacity) than their lower SES counterparts. Functional recovery was the strongest modifiable predictor of long-term mortality irrespective of SES, cardiac rehabilitation referral or access to physician specialists, and explained nearly 30% of the association between SES and long-term mortality after AMI.

IMPLICATIONS

These results support the need for innovative solutions to improve exercise and physical activity patterns among socioeconomically disadvantaged patients. Such solutions may involve workplace integration, tax incentives, community networks and investments in the built environment.
 
 

Trends and inequities persist after launch of colorectal cancer screening program

Honein-AbouHaidar GN, Baxter NN, Moineddin R, Urbach DR, Rabeneck L, Bierman AS. Trends and inequities in colorectal cancer screening participation in Ontario, Canada, 2005–2011. Cancer Epidemiol. 2013 May 20 [Epub ahead of print].

ISSUE

Participation in screening tests for colorectal cancer (CRC) has been generally low in Ontario, particularly among males, residents of rural areas and low-income individuals. To address this deficit, Colon Cancer Check, a province-wide screening program, was launched in 2008. What has been the effect of the program on CRC screening participation among eligible patients?

STUDY

Identified six annual cohorts of individuals aged 50 to 74 years and eligible for CRC screening in each fiscal year from 2005 to 2011. For the overall population, calculated age-standardized percentages for three outcome measures―Fecal Occult Blood Test (FOBT) participation, large bowel endoscopy participation, and being up-to-date with CRC screening tests―and then stratified by sex, age group, income quintile and urban/rural status.

KEY FINDINGS

From 2005 to 2011, FOBT participation increased from 7.6% to 14.8%, large bowel endoscopy participation from 3.4% to 5.7%, and being up-to-date with CRC screening from 27.2% to 41.3%. An immediate increase above the baseline annual increase in participation was noted following the program launch in 2008, but this was not sustained, and rates of annual increase returned to pre-program levels. Sociodemographic inequities in CRC participation persisted after the launch.

IMPLICATIONS

Continued efforts to increase CRC screening uptake in the general population are needed, as well as interventions to reduce inequities in screening participation among certain populations.
 
 

Four in five Ontario patients visiting an orthopedic surgeon do not receive surgery

Badley EM, Canizares M, Mackay C, Mahomed NN, Davis AM. Surgery or consultation: a population-based cohort study of use of orthopaedic surgeon services. PLoS One. 2013; 8(6):e65560.

ISSUE

Each year 22% of the population makes at least one doctor visit for musculoskeletal disorders; of these, one-third see specialists. What are the sociodemographic characteristics and health conditions of patients who do not get surgery following an ambulatory visit to an orthopedic surgeon?

STUDY

Identified patients making an initial office visit to orthopedic surgeons in Ontario between October 2004 and September 2005, excluding those who received surgery within two days of the first visit or who had surgery within the previous six months. Followed the remaining patients for orthopedic surgery in the subsequent 18 months, and assessed those who did not receive surgery by sex, age group, income quintile and diagnostic group.

KEY FINDINGS

Of the 477,945 patients in the cohort, 49% visited orthopedic surgeons for injury and 24% for arthritis. A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. Overall, 79.3% of patients did not receive surgery within 18 months of the initial visit. Low-income individuals were more likely to be non-surgical, as were women. Younger patients were significantly more likely to be non-surgical than those 65 years and older. For injury and other conditions, the odds of not getting surgery were significantly higher for women than men; for arthritis and bone and joint conditions, the opposite was true.

IMPLICATIONS

These findings contribute to the development of evidence-based strategies to streamline access to care for those who need surgery, and to develop interventions to meet the needs of those who do not.
 
 
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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