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

Study shows “healthy immigrant” effect in rates of major cardiovascular events in Ontario

Tu JV, Chu A, Rezai MR, Guo H, Maclagan LC, Austin PC, Booth GL, Manuel DG, Chiu M, Ko DT, Lee DS, Shah BR, Donovan LR, Sohail QZ, Alter DA. The incidence of major cardiovascular events in immigrants to Ontario, Canada: the CANHEART immigrant study. Circulation. 2015; Aug 31 [Epub ahead of print].

ISSUE

Many immigrants to Canada come from low- and middle-income countries that have the greatest absolute burden of cardiovascular deaths. Do significant differences in the incidence of cardiovascular events exist among immigrants of different ethnicities and how do traditional risk factors contribute to these differences?

STUDY

Identified 824,662 first-generation immigrants aged 30–74 from 8 ethnic groups and 201 countries of birth who immigrated to Ontario from 1985–2000 and compared this cohort to a reference group of 5.2 million long-term Ontario residents. Examined cardiovascular disease risk factors, including smoking, hypertension, diabetes and lipid levels, and the 10-year incidence rates of cardiovascular events, including acute myocardial infarction, revascularization, stroke and death.

KEY FINDINGS

The 10-year age-standardized incidence of cardiovascular events was 30% lower among immigrants compared with long-term residents, demonstrating a “healthy immigrant effect” where new immigrants are typically healthier overall than long-term residents. However, incidence rates varied widely across ethnic groups, with a four-fold difference from best to worst. East Asian immigrants (predominantly ethnic Chinese) had the lowest incidence of major cardiovascular events (2.4 in males and 1.1 in females per 1,000 person years); however, these rates worsened after 10 years in Canada. Immigrants from South Asia had the highest incidence rates overall (8.9 in males and 3.6 in females per 1,000 person years) along with immigrants born in Guyana, Iraq and Afghanistan. There was a strong association between overall prevalence of cardiac risk factors (smoking, hypertension and diabetes) and rates of cardiovascular events.

IMPLICATIONS

These findings provide new information that may assist clinicians and policy makers in developing culturally-tailored strategies for the early detection and prevention of cardiovascular diseases in immigrant populations. 
 
 

No increase in adverse outcomes for elective day surgery when doctor worked night before

Govindarajan A, Urbach DR, Kumar M, Li Q, Murray BJ, Juurlink D, Kennedy E, Gagliardi A, Sutradhar R, Baxter NN. Outcomes of daytime procedures performed by attending surgeons after night work. N Engl J Med. 2015; 373(9):845–53.

ISSUE

Acute sleep deprivation can impair mood, cognitive performance and psychomotor function. Do outcomes of elective procedures performed by physicians who are likely to be sleep deprived because of overnight clinical work differ from the outcomes of procedures performed by the same physicians on a day when they did not provide overnight care?

STUDY

Examined 38,978 patients representing all Ontarians who underwent 1 of 12 elective daytime procedures between January 2007 and December 2011. Patients were assigned to the postmidnight group if they underwent a daytime procedure performed by a physician who had worked in the preceding overnight hours (midnight to 7:00 AM). Patients in this group were matched to patients undergoing the same procedure by the same physician on a day when the physician had not worked after midnight. Outcomes examined included death, readmission, complications, length of stay and procedure duration.

KEY FINDINGS

Overall, the risks of adverse outcomes of elective daytime procedures were similar whether or not the physician had provided medical services the previous night. A negative outcome (death, readmission or complication) occurred in 22.2% of patients in the postmidnight group and 22.4% of those in the control group. Across both groups, the median length of stay was 3 days and the median procedure duration was 2.6 hours.

IMPLICATIONS

Calls for broad-based policy shifts in attending-surgeon duty hours and practices to address the effect of acute sleep deprivation may not be necessary at this time. However, the effect of profound sleep loss on procedure outcomes may warrant further study.
 
 

Study establishes risk of death during chronic opioid therapy, men at much higher risk than women

Kaplovitch E, Gomes T, Camacho X, Dhalla IA, Mamdani MM, Juurlink DN. Sex differences in dose escalation and overdose death during chronic opioid therapy: a population-based cohort study. PLoS One. 2015; 10(8):e0134550.

ISSUE

Over the past 20 years, the use of opioids for chronic noncancer pain has increased substantially, with patients often receiving doses far in excess of those originally suggested for treatment. What is the relationship between sex, dose escalation and overdose death among patients prescribed opioids for chronic noncancer pain?

STUDY

Identified 32,499 individuals aged 15–64 who began treatment with an opioid (oral codeine, morphine, oxycodone, hydromorphone or transdermal fentanyl) in Ontario between April 1997 and December 2010. Patients were followed from their first opioid prescription until discontinuation of therapy, death from any cause or the end of the study period, whichever occurred first. The primary outcome of interest was escalation to a daily opioid dose of more than 200 milligrams of morphine or equivalent. 

KEY FINDINGS

Among patients receiving chronic opioid therapy, 589 (1.8%) escalated to high-dose therapy (roughly 1 of every 45 men and 1 of every 70 women in the study). While on treatment, 59 patients (0.2%) died of opioid-related causes. Relative to women, men were almost 50% more likely to escalate to high-dose opioids and twice as likely to die from opioid-related causes. Opioid-related death occurred in 1 of every 350 men and 1 of every 850 women. Patients who escalated to high-dose therapy were nearly 24 times more likely to die than those who did not escalate their dose.

IMPLICATIONS

These findings underscore the importance of judicious opioid use, particularly in men as their doses begin to escalate. Physicians who prescribe opioid therapy should understand the risks and ensure that their patients also understand them.
 
 

Air pollution exposure leads to increased health service use by people with chronic illness

To T, Feldman L, Simatovic J, Gershon AS, Dell S, Su J, Foty R, Licskai C. Health risk of air pollution on people living with major chronic conditions: a Canadian population-based study. BMJ Open. 2015; 5(9):e009075.

ISSUE

Air pollution is being increasingly identified as a significant public health issue with measurable adverse effects across populations. What is the impact of poor air quality on short-term morbidity for individuals with chronic diseases?

STUDY

Included all individuals aged 0–99 years who resided in Ontario from 2003–2010 and were ever diagnosed with any of 11 chronic conditions: asthma, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, angina, acute myocardial infarction, ischemic heart disease, congestive heart failure, stroke, lung cancer and non-lung cancers. Identified total daily health service use (physician office visits, emergency department (ED) visits and hospitalizations) to measure acute health morbidities. Air pollution was measured using the Air Quality Health Index (AQHI), a composite measure of levels of nitrogen dioxide, fine particulate matter and ozone.

KEY FINDINGS

Increases in outpatient visits ranged from 1% to 5% for every unit increase in the 10-point AQHI scale, corresponding to an increase of about 15,000 outpatient visits on a day with poor air quality versus good air quality. The greatest increases in outpatient visits were among individuals with non-lung cancers and COPD; the greatest increases in hospitalization were among individuals with diabetes and COPD. The increase in the rate of same-day ED visits was relatively small. These impacts on health service use remained 2 days after peak AQHI levels. 

IMPLICATIONS

Air pollution exposure should be considered a risk factor for acute health morbidities among people with certain common chronic diseases. Timely AQHI air quality advisories with integrated risk reduction messages may lead to a reduction in associated health service use. 
 
 

Source region plays a role in type and intensity of mental health services accessed by immigrants

Durbin A, Moineddin R, Lin E, Steele LS, Glazier RH. Mental health service use by recent immigrants from different world regions and by non-immigrants in Ontario, Canada: a cross-sectional study. BMC Health Serv Res. 2015; 15:336.

ISSUE

Existing research on immigrants’ use of health and social services rarely considers the diversity of these populations. How does an immigrant’s source region influence his or her use of mental health services in the host country? 

STUDY

Identified 912,114 immigrants aged 18–105 from 9 world regions of origin and examined their rates of primary care and speciality services for non-psychotic mental health disorders during their first 5 years in Ontario within the study period 1993–2012. Three mental health service use outcomes were measured for immigrants and their age-matched long-term residents: visits to primary care physicians, visits to psychiatrists, and a composite of emergency department visits or hospital admissions.

KEY FINDINGS

Men and women from Western and Central Africa and Latin America and men from the Caribbean were more likely than long-term residents to visit primary care physicians for mental health disorders; men and women from Central and Eastern Europe and East Asia and the Pacific and women from South Asia were less likely to access primary mental health care. Immigrants from all regions accessed fewer specialty mental health services (psychiatry and hospital care) than long-term residents. 

IMPLICATIONS

These findings help combat stereotypes that newcomers overuse publicly funded services, including mental health services. Findings also underscore the importance of identifying underlying individual characteristics that affect service use, which may allow clinicians and policy makers to make services more responsive to newcomers. 
 
 
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