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

South Asian men and black women and men show greatest decline in heart health over past decade in Ontario

Chiu M, Maclagan LC, Tu JV, Shah BR. Temporal trends in cardiovascular disease risk factors among white, South Asian, Chinese and black groups in Ontario, Canada, 2001 to 2012: a population-based study. BMJ Open. 2015; 5(8):e007232.

ISSUE

Globally, the prevalence of most cardiovascular disease risk factors, including tobacco use, high-blood pressure, obesity and physical inactivity, has been increasing due in part to urbanization and more sedentary lifestyles. Many of these risk factors are also on the rise in Canada. Is the prevalence of cardiovascular disease risk factors changing differently over time for Canada’s major ethnic groups?

STUDY

Identified 219,276 Ontario residents who responded to various Canadian Community Health Surveys from 2001 to 2012. Survey data were examined for 2001–2004, 2005–2008 and 2009–2012 for four ethnic groups: white, black, Chinese and South Asian. Sociodemographic characteristics including age, sex and education level were examined, as were eight cardiovascular disease risk factors, including diabetes, obesity, current smoking, hypertension, inadequate leisure physical activity, inadequate nutrition, psychosocial stress and alcohol consumption. 

KEY FINDINGS

The prevalence of cardiovascular disease risk factors worsened the most for South Asian males, followed by black males and black females. The prevalence of diabetes increased from 6.7% to 15.2% among South Asian males and from 6.3% to 12.2% among black females. The prevalence of obesity increased over time across all ethnic groups, particularly among Chinese males (from 2.8% to 5.9%). In general, black females were the most likely to be obese, hypertensive and report high levels of psychosocial stress. White men had the highest rates of smoking, although smoking rates declined for most groups.

IMPLICATIONS

An awareness of ethnicity-specific trends provides an opportunity to identify high-risk groups and target prevention strategies more effectively.
 
 

Hunger in Ontario leads to poorer health, higher health costs

Tarasuk V, Cheng J, de Oliveira C, Dachner N, Gundersen C, Kurdyak P. Association between household food insecurity and annual health care costs. CMAJ. 2015; Aug 10 [Epub ahead of print].

ISSUE

In 2012, 12.6% of Canadian households experienced inadequate or insecure access to food due to financial constraints. The association between food insecurity and poor health status is well known. What is the association between household food insecurity status and annual health care costs in Ontario?

STUDY

Identified 67,033 Ontario residents aged 18–64 who participated in the Canadian Community Health Survey between 2005 and 2010. Assessed their household food insecurity in the 12 months before the survey interview using an 18-item scale and Health Canada’s coding method to define marginal, moderate and severe food insecurity. Used administrative health care data to determine participants’ direct health care costs over the same 12-month period. 

KEY FINDINGS

Household food insecurity was a robust predictor of health care utilization and costs. Total health care costs and average costs for inpatient hospital care, emergency department visits, physician services, same-day surgeries and prescription drugs covered by the Ontario Drug Benefit (ODB) Program rose systematically with increasing severity of food insecurity. Compared with total annual health care costs (including ODB prescriptions) in food-secure households, adjusted annual costs were 23% higher in households with marginal food insecurity, 49% higher in households with moderate food insecurity and 121% higher in households with severe food insecurity. 

IMPLICATIONS

Findings provide a unique picture of the burden of household food insecurity on Ontario’s health care system. Policy interventions at the provincial and federal level designed to reduce household food insecurity could offset considerable public expenditures in health care.
 
 

Pay-for-performance program shows modest improvement in ED wait times

Vermeulen M, Stukel TA, Boozary AS, Guttmann A, Schull MJ. The effect of pay for performance in the emergency department on patient waiting times and quality of care in Ontario, Canada: a difference-in-differences analysis. Ann Emerg Med. 2015; Jul 25 [Epub ahead of print].

ISSUE

The Ontario Ministry of Health and Long-Term Care launched the Emergency Department Wait Times Strategy in 2008 to address emergency department (ED) crowding and reduce length of hospital stay. Strategy initiatives have included public reporting of ED performance, province-wide benchmarks, a targeted process improvement program to improve patient flow, and the Pay for Results Program, which provides financial incentives to hospitals for improved performance on ED length-of-stay targets. What has been the effect of this pay-for-performance program on ED length of stay and have there been any unintended consequences?

STUDY

Identified over 5.5 million ED visits across 70 Ontario hospitals eligible for the pay-for-performance program from April 2007 to March 2011 and matched them with control sites across each of three waves of the program roll-out. The primary outcome of interest was 90th percentile ED length of stay, which was defined by the time from triage or registration (whichever was earlier) to the time the patient left the ED. ED quality-of-care measures, including 7- and 30-day mortality and 30-day readmission, were also examined.

KEY FINDINGS

Overall, there were modest improvements in ED wait times in the first year of the pay-for-performance program. ED-admitted patients had a significant reduction in adjusted 90th percentile length of stay in wave 1 (−225 minutes) and wave 2 (−133 minutes) of the program roll-out, but reductions in wait times were less pronounced for the majority of patients. Nonadmitted low-acuity patients had reductions in wave 1 (−24 minutes) and wave 3 (−19 minutes). There were no negative effects on quality of care.

IMPLICATIONS

Future research and policy design should consider the sustainability, incentive design and health care context that are all factors in driving the effectiveness of pay-for-performance schemes. 
 
 

Chickenpox immunization program has led to drop in physician and ED visits

Wormsbecker AE, Wang J, Rosella LC, Kwong JC, Seo CY, Crowcroft NS, Deeks SL. Twenty years of medically-attended pediatric varicella and herpes zoster in Ontario, Canada: a population-based study. PLoS One. 2015; 10(7):e0129483.

ISSUE

Varicella (chickenpox) is a common childhood illness with the potential for serious complications, even among healthy children. Ontario introduced a publicly funded varicella vaccination in 2004, and a booster shot was added in 2010 based on data suggesting two doses would reduce the number of breakthrough cases and prevent outbreaks. Has publicly funded immunization led to a reduction in medically-attended pediatric varicella and herpes zoster (shingles) in Ontario?

STUDY

Examined data on varicella and herpes zoster among those younger than 18 years in Ontario from 1992–2011. Identified 600,208 incident physician office visits, 55,472 emergency department (ED) visits and 2,701 incident hospitalizations over three time periods: pre-vaccine (1992–1998), vaccine privately available (1999–2003) and public vaccination program (2004–2011). 

KEY FINDINGS

Overall, the incidence of medically-attended varicella decreased during the study period, particularly after the introduction of the publicly funded program. Varicella-related physician office visits per 1,000 declined from 25.1 in 1994 to 3.2 in 2011. Annual declines in office visits were 7.7%, 9.1%, 8.4% and 8.4% per year among children aged less than 1 year, 1–4 years, 5–11 years and 12 years or older, respectively. Varicella-associated skin and soft tissue infections declined significantly among children younger than 12 years, and rates of ICU admissions decreased significantly for children younger than 1 year. A consistent impact on herpes zoster was not observed.

IMPLICATIONS

Reductions in the incidence of pediatric varicella suggest immunization program success in Ontario. Future analyses will be needed to assess the impact of the two-dose vaccine program, especially on varicella outbreaks, in order to better understand the relationship between childhood varicella immunization and herpes zoster.
 
 

Being diagnosed with diabetes late in life associated with higher risk of dementia

Haroon NN, Austin PC, Shah BR, Wu J, Gill SS, Booth GL. Risk of dementia in seniors with newly diagnosed diabetes: a population-based study. Diabetes Care. 2015; Jul 27 [Epub ahead of print].

ISSUE

Medical advances over the past two decades have resulted in longer life expectancy for people with chronic conditions, leading to the emergence of geriatric complications among older people with diabetes. A growing body of evidence supports an association between diabetes and dementia due to their shared common cardiovascular and metabolic risk factors. Is diabetes onset in late life a risk factor for dementia?

STUDY

Identified 225,045 Ontario residents aged 66 to 105 with newly diagnosed diabetes between April 1995 and March 2007, who were matched to 668,070 without. Both groups were followed until March 2012 for a new diagnosis of dementia. Baseline data examined included age, sex, income level, and history of hypertension, coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral vascular disease (PVD) or chronic kidney disease (CKD). 

KEY FINDINGS

During the study period, 169,114 new cases of dementia were diagnosed. Older adults with diabetes had a 16% higher risk of developing dementia than those without diabetes. This increased risk was independent of pre-existing CAD or CVD, hypertension and CKD — conditions thought to mediate the association between diabetes and dementia. The risk of dementia was greatest among those with previous CVD or PVD and those with more than one hospital visit for hypoglycemia. 

IMPLICATIONS

As life expectancy continues to improve for older populations with diabetes, health care systems will need to identify strategies that can effectively prevent dementia. 
 
 
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