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  INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES
DECEMBER 2014
 
At a Glance
  MONTHLY HIGHLIGHTS OF ICES RESEARCH FINDINGS FOR STAKEHOLDERS  
 

Ontario regulatory interventions significantly reduce prescriptions for potentially misused drugs

Gomes T, Juurlink D, Yao Z, Camacho X, Paterson JM, Singh S, Dhalla I, Sproule B, Mamdani M. Impact of legislation and a prescription monitoring program on the prevalence of potentially inappropriate prescriptions for monitored drugs in Ontario: a time series analysis. CMAJ Open. 2014; 2(4):E256–61.

ISSUE

To counter the inappropriate prescribing of opioids, benzodiazepines and stimulants, the Narcotics Safety and Awareness Act (NSAA) and a centralized Narcotics Monitoring System (NMS) were implemented by the Ontario government in November 2011 and May 2012, respectively. The NSAA requires physicians to include their name and registration number on prescriptions for narcotics and other controlled substances. The NMS provides real-time data access to pharmacists regarding inappropriate drug-seeking behaviour. What has been the impact of these interventions on the rate of dispensing monitored drugs?

STUDY

Analyzed publicly funded prescriptions for opioids, benzodiazepines and stimulants dispensed monthly from January 2007 to May 2013 in Ontario. A prescription was deemed potentially inappropriate if it was dispensed within seven days of an earlier prescription of at least 30 tablets of a drug in the same class but originated from a different physician and pharmacy than the earlier prescription.

KEY FINDINGS

More than 70 million prescriptions for monitored drugs were dispensed during the 6.5-year study period; 885,465 of these were deemed to represent potential misuse. Before enactment of the NSAA, a monthly average of 1.8% of opioid prescriptions, 0.9% of stimulant prescriptions and 0.4% of benzodiazepine prescriptions were deemed potentially inappropriate. Upon implementation of the NSAA and NMS, the prevalence of potentially inappropriate opioid prescriptions decreased 40%. The prevalence of potentially inappropriate benzodiazepine and stimulant prescriptions fell by 50% and 57%, respectively. 

IMPLICATIONS

Regulatory interventions that could be applied to other jurisdictions and drugs of concern can promote appropriate prescribing. The value of the NMS could be enhanced by making it available to physicians and helping them to identify drug-seeking behaviour at the time of writing a prescription.
 
 

Women with bipolar disorder nearly twice as likely to deliver preterm babies

Mei-Dan E, Ray JG, Vigod SN. Perinatal outcomes among women with bipolar disorder: a population-based cohort study. Am J Obstet Gynecol. 2014 Oct 14 [Epub ahead of print].

ISSUE

It remains unclear whether risk for adverse pregnancy outcomes among women with bipolar disorder is specific to that illness or characteristic of severe mood disorders in general. What is the risk of adverse perinatal outcomes in pregnant women previously hospitalized for bipolar disorder? 

STUDY

Of all pregnant Ontario women aged 15 to 50 with an estimated conception date between April 1, 2002 and March 31, 2010, identified those previously hospitalized for bipolar disorder (1,859) or major depressive disorder (3,724). Compared each group to women without a documented mental illness (432,358) for the following: preterm birth before 37 weeks’ gestation; infants small for gestational age; and infants large for gestational age; as well as rates of stillbirth, congenital malformations, neonatal morbidity and readmission to hospital within 28 days.

KEY FINDINGS

Women with bipolar disorder were twice as likely to have preterm birth compared to women without a history of mental illness (11.4% vs. 6.2%). Babies born to women with bipolar disorder were more likely to be large for their gestational age, in contrast to babies born to women with depression who were more likely to be small for their gestational age. Babies born to women with bipolar disorder were more likely to have higher rates of congenital malformations and other complications and more likely to be readmitted to hospital within 28 days of discharge.

IMPLICATIONS

There is a need for monitoring fetal growth during pregnancy in this population. Interventions that improve maternal medical and mental health before and after pregnancy and that optimize social supports and lifestyle behaviours may help reduce the negative impact of bipolar disorder on perinatal outcomes.
 
 

Canadian-educated doctors more likely to screen patients for cancer

Lofters AK, Ng R, Lobb R. Primary care physician characteristics associated with cancer screening: a retrospective cohort study in Ontario, Canada. Cancer Med. 2014; Nov 27 [Epub ahead of print].

ISSUE

Primary care physicians can serve as both facilitators and impeders of cancer screening, particularly for underscreened groups such as immigrant patients. What characteristics of Canadian- and foreign-trained primary care physicians are associated with cancer screening for their patients?

STUDY

Identified 6,303 physicians in urban primary care practices in Ontario serving over 9 million patients who were alive as of December 31, 2010, either formally or virtually rostered and eligible for at least one of breast, cervical or colorectal cancer screening. 

KEY FINDINGS

Of the physicians, 40% were female, and 26% were foreign trained. Physicians who attended medical schools in the Caribbean/Latin America, the Middle East/North Africa, South Asia, and Western Europe were less likely to screen their patients than graduates of Canadian medical schools. South Asian patients with South Asian physicians were the most vulnerable to underscreening. Low-income patients were vulnerable to underscreening, although this impact was less important for immigrant patients.

IMPLICATIONS

Physician characteristics should be assessed when designing physician-targeted interventions and education campaigns. Future research should explore the reasons for these findings.
 
 

Survival rates improving for patients arriving at the emergency department after cardiac arrest

Wong MKY, Morrison LJ, Qiu F, Austin PC, Cheskes S, Dorian P, Scales DC, Tu JV, Verbeek PR, Wijeysundera HC, Ko DT. Trends in short- and long-term survival among out-of-hospital cardiac arrest patients alive at hospital arrival. Circulation. 2014; 130(21):1883–90.

ISSUE

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and poses a significant burden on the health care system. How have OHCA incidence and survival rates changed over time?

STUDY

Identified 34,291 patients older than 20 years who were transported to the emergency department (ED) of an acute care hospital in Ontario after OHCA between April 2002 and March 2012, and evaluated their 30-day and one-year survival from the day of ED arrival. Patients with life-threatening trauma and those who died prior to hospital arrival were excluded.

KEY FINDINGS

The overall age- and sex-standardized incidence of OHCA patients transported alive to the ED was 36 cases per 100,000 persons and did not significantly change over the study period. The prevalence of cardiac risk factors (diabetes, hypertension and dyslipidemia) increased significantly over time, whereas the rate of most previous cardiovascular conditions (myocardial infarction, heart failure and cerebrovascular disease) decreased significantly. Between 2002 and 2011, the survival rate at 30 days improved from 9.4% to 13.6% and at one year, from 7.7% to 11.8%. Survival improvement varied based on patient age; the youngest age group had the largest improvement with almost a doubling of survival, while the oldest age group experienced the smallest improvement.

IMPLICATIONS

Despite the encouraging finding that cardiac arrest patients reaching the hospital were more likely to survive, the majority of patients died prior to reaching the hospital. More effort is needed to improve their survival.
 
 

Kidney donors more likely to be diagnosed with gestational hypertension or preeclampsia

Garg AX, Nevis IF, McArthur E, Sontrop JM, Koval JJ, Lam NN, Hildebrande AM, Reese PP, Storsley L, Gill JS, Segev DL, Habbous S, Bugeja A, Knoll GA, Dipchand C, Monroy-Cuadros M, Lentine KL; the DONOR Network. Gestational hypertension and preeclampsia in living kidney donors. N Engl J Med. 2014; Nov 14. [Epub ahead of print].

ISSUE

Each year more than 27,000 persons worldwide become living kidney donors, the majority of them women. Do female donors have a higher risk of gestational hypertension or preeclampsia than nondonors?

STUDY

Identified 85 living women who donated a kidney in Ontario between July 1992 and April 2010 and had at least one pregnancy with a gestation of at least 20 weeks Matched each woman to six nondonors with similar levels of baseline health and at least one pregnancy carried to 20 weeks. Women were followed until death, emigration from the province or March 31, 2013. The presence of a hospital-based diagnosis of either gestational hypertension or preeclampsia and other maternal and fetal outcomes was determined.

KEY FINDINGS

Gestational hypertension or preeclampsia was more common among living kidney donors than among nondonors (11% vs. 5%). There were no significant differences between donors and nondonors with respect to rates of preterm birth (8% vs. 7%) or low birthweight (6% vs. 4%). There were no reports of maternal death, stillbirth or neonatal death among the donors.

IMPLICATIONS

Women considering living kidney donation should be made aware of its potential impact on future pregnancies.
 
 
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