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  INSTITUTE FOR CLINICAL EVALUATIVE SCIENCES
MARCH 2016
 
At a Glance
  MONTHLY HIGHLIGHTS OF ICES RESEARCH FINDINGS FOR STAKEHOLDERS  
 

Suicide risk threefold higher after concussion; rates highest following weekend concussions

Fralick M, Thiruchelvam D, Tien HC, Redelmeier DA. Risk of suicide after a concussion. CMAJ. 2016; Feb 8 [Epub ahead of print].

ISSUE

Concussion is the most common brain injury in young people. The incidence of depression after concussion can be high; traumatic brain injury in the military has been associated with subsequent suicide, but less is known about outcomes after a concussion in the community. Is concussion associated with an increased long-term risk of suicide and, if so, can the day of the concussion (weekday vs. weekend) be used to identify patients at further increased risk?

STUDY

Identified 235,110 Ontario patients with a diagnosis of concussion between April 1992 and March 2012, excluding severe cases that resulted in hospitalization (such cases tend to reflect severe brain injury – a known risk factor for suicide). The primary outcome of interest was the long-term risk of suicide after a weekend concussion (midnight Friday to midnight Sunday) or a weekday concussion (remaining days and nights).

KEY FINDINGS

A total of 667 subsequent suicides occurred over an average follow-up period of 9.3 years, equivalent to 31 deaths per 100,000 patients annually or three times the population norm. Weekend concussions were associated with a one-third further increased risk of suicide compared with weekday concussions. The average interval between concussion and suicide was six years.

IMPLICATIONS

Understanding how a history of concussion raises the risk of suicide and supporting patients with better screening, treatment and follow-up may be important steps in preventing these avoidable deaths.
 
 

Lower income Ontario seniors less likely to access newly approved blood thinner

Sholzberg M, Gomes T, Juurlink DN, Yao Z, Mamdani MM, Laupacis A. The influence of socioeconomic status on selection of anticoagulation for atrial fibrillation. PLoS One. 2016; 11(2):e0149142. 

ISSUE

For decades, patients with nonvalvular atrial fibrillation (NVAF) were prescribed warfarin. In October 2010, Health Canada approved dabigatran as an alternative to warfarin with fewer negative side effects. However, dabigatran is approximately 20 times more expensive than warfarin in Ontario and until April 2012, it was not covered under the public drug program. Are older Ontarians who switched from warfarin to dabigatran before it was publicly funded more likely to live in wealthier neighbourhoods compared to those who remained on warfarin and, if so, did this socioeconomic difference persist once dabigatran was added to the provincial drug formulary?

STUDY

Identified 34,797 Ontarians aged 66 and older with NVAF, including 3,183 patients who switched from warfarin to dabigatran after it was approved for use but prior to its inclusion in the public drug program (“switchers”), and 31,614 patients with ongoing warfarin use during the same period (“non-switchers”). Socioeconomic status was identified through neighbourhood income quintile. A secondary analysis separated the “non-switchers” group into those who initially remained on warfarin but transitioned to dabigatran in the six months following its public funding, and those who continued to use warfarin exclusively.

KEY FINDINGS

Higher socioeconomic status was associated with switching to dabigatran in the interval between its approval for use and its inclusion in the public drug program. Warfarin patients living in the highest income neighbourhoods were 50% more likely to switch to dabigatran than those living in the lowest. There was no association between income level and switching to dabigatran after the drug became available at no cost to the patient.

IMPLICATIONS

These findings can likely be generalized to other new and cost-effective drugs that are slow to be added to provincial public drug plans. Findings also support the need to update public drug plans in a timely manner based upon high-quality evidence about cost effectiveness, to ensure that income is not a barrier to access.
 
 

Emergency visits by Ontario youth for mental health and addictions increased by 32% over six years

Gandhi S, Chiu M, Lam K, Cairney JC, Guttmann A, Kurdyak P. Mental health service use among children and youth in Ontario: population-based trends over time. Can J Psychiatry. 2016; 61(2):119–24.

ISSUE

Most mental health conditions have an onset between childhood and early adulthood, highlighting the importance of access and early intervention. US studies have shown that mental health accounts for a significant portion of acute care use among children and youth, but less is known about the proportion of health care use attributable to mental health care among children and youth in Canada. What have been the trends in psychiatric emergency department (ED) visits, hospitalizations and outpatient physician visits among children and youth in Ontario?

STUDY

Identified all Ontario residents aged 10 to 24 years and examined all mental health- and addictions-related ED visits, hospitalizations and outpatient visits between 2006 and 2011. 

KEY FINDINGS

Overall, the rate of ED visits increased from 14.6 to 19.3 per 1,000 people, representing a 32.5% relative growth during the study period. Anxiety disorders, the most common reason for ED visits, rose by 2.2 per 1,000 people, accounting for 47% of the total increase in mental health–related ED visits. While hospitalizations were rare, the relative increase for this service was 53.7% (from 2.9 to 4.5 per 1,000 people). Office-based physician visits increased 15.8%, with family physicians providing the most outpatient visits, followed by psychiatrists and pediatricians.

IMPLICATIONS

These findings provide health planners with the evidence they need to better coordinate child and youth mental health care across Ontario. Future research should examine whether these observed trends reflect challenges with access to outpatient care, a growing burden of mental illness and addictions in the child and youth population, or a rise in the acuity of mental illness and addictions presentations.
 
 

Even moderate changes in air temperature can lead to increase in deaths

Chen H, Wang J, Li Q, Yagouti A, Lavigne E, Foty R, Burnett RT, Villeneuve PJ, Cakmak S, Copes R. Assessment of the effect of cold and hot temperatures on mortality in Ontario, Canada: a population-based study. CMAJ Open. 2016; 4(1):E48–58.

ISSUE

High air temperature is associated with death; however, heat-related risk of death has not been quantified systematically in Ontario, and even less is known about cold-related risk in this population. To what extent do cold and hot temperatures affect mortality in Ontario?

STUDY

Identified 352,818 Ontario residents who died from non-accidental causes between January 1996 and December 2010. Analyzed the relationship between daily temperature fluctuation and deaths from non-accidental and selected causes in cold (December to February) and warm (June to August) seasons, respectively.

KEY FINDINGS

In warm seasons, each 5°C increase in daily average temperature was associated with a 2.5% increase in non-accidental deaths, and in cold seasons, each 5°C decrease in daily temperature was associated with a 3.0% increase in non-accidental deaths. These changes were estimated to correlate with about four more non-accidental deaths per day in summer and about seven more non-accidental deaths per day in winter. Cold-related effects were more strongly linked to cardiovascular-related deaths, especially in people under 65 years of age, while heat increased the number of respiratory-related deaths.

IMPLICATIONS

These findings add evidence to previous observations that both cold and heat may be associated with mortality and indicate that greater public health attention to cold-related mortality is required. Further research to better understand high-risk subgroups, including the homeless and people with inadequately heated housing, may help target effective preventive measures.
 
 

Significant rise in gallbladder disease surgery among children in 20-year period

Murphy PB, Vogt KN, Winick-Ng J, McClure JA, Welk B, Jones SA. The increasing incidence of gallbladder disease in children: a 20-year perspective. J Pediatr Surg. 2016; Feb 12 [Epub ahead of print].

ISSUE

Gallstone disease in children was once thought to be rare, but it appears that over the past few decades, cholecystectomy (surgical removal of gallbladder) rates in children may have increased. The increase is likely multi-factorial; in the US, it may be due in part to an increasing practice of removing the gallbladder for biliary dyskinesia (a motility disorder), and to an increase in the incidence of obesity-related gallstone disease. Has the incidence of pediatric cholecystectomy changed in Ontario?

STUDY

Identified 6,040 cholecystectomies conducted in Ontario on patients younger than 18 years of age between April 1993 and March 2012. The population was stratified into five four-year periods for analysis: 1993-96, 1997-00, 2001-04, 2005-08 and 2009-12. The primary outcome was incidence of cholecystectomy over the time period studied. Secondary outcomes of interest included location of surgery, surgical approach and patient characteristics.

KEY FINDINGS

Between 1993-96 and 2009-12, the incidence of cholecystectomy surgery per 100,000 person-years increased from 8.8% to 13.0%. The majority of cholecystectomies were performed on females (79.6%), and most patients were between the ages of 13 and 17 (82.0%). Most surgeries (75.1%) were performed in non-teaching hospitals (vs. teaching hospitals), although this decreased from 76.5% to 71.2% over the study period. The use of laparoscopy increased from 86.9% to 95.2%, and the number of operations performed as day surgery increased from 0% to 57.0%.

IMPLICATIONS

These findings suggest that pediatricians and surgeons should be on the lookout for gallstone disease, especially in overweight, adolescent females. Future research should examine the role geography plays in cholecystectomy incidence, particularly with respect to access to unhealthy food choices.
 
 
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