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

Regular physician visits improve uptake of mammograms as women age

Sutradhar R, Gu S, Glazier RH, Paszat LF. The association between visiting a primary care provider and uptake of periodic mammograms as women get older. J Med Screen. 2015 Sep 9 [Epub ahead of print].

ISSUE

Cancer screening guidelines recommend that women aged 50 to 74 receive a mammogram every two to three years. Despite these guidelines and the introduction of the Ontario Breast Screening Program in the early 1990s, many eligible women still do not get screened. Previous studies have shown that having a primary care provider (PCP) is instrumental for breast cancer screening. Do PCP visits continue to enhance screening uptake as women age?

STUDY

Identified nearly 2.4 million women aged 50 to 79 between 2001 and 2010 who were cancer-free and eligible for the Ontario Health Insurance Plan. Used billing records to examine the association between periodic mammograms, patient age and the rate of PCP visits in the previous two years. 

KEY FINDINGS

Among women under 65, those who had visited a PCP in the previous two years were 1.7 times more likely to have had a mammogram than women who had not visited a PCP, with the likelihood increasing to 2.4 times among women 65 and older.

IMPLICATIONS

These findings demonstrate the importance of regular visits to PCPs in ensuring the uptake of periodic mammograms, particularly as women age. Future analyses can use this study as a guide for examining the links between PCPs and other types of screening, including cervical and colorectal cancer screening.
 
 

Increased risk of suicide after bariatric surgery indicates need for patient screening

Bhatti JA, Nathens AB, Thiruchelvam D, Grantcharov T, Goldstein BI, Redelmeier DA. Self-harm emergencies after bariatric surgery: a population-based cohort study. JAMA Surg. 2015 Oct 7 [Epub ahead of print].

ISSUE

Mental health problems, including substance misuse, depression and eating disorders, are prevalent among morbidly obese patients undergoing bariatric surgery. While mental health problems can compromise the success of the surgery, it is unclear if they are mitigated or aggravated by the procedure. Does bariatric surgery make existing mental health issues better or worse?

STUDY

Identified 8,815 Ontario adults who underwent bariatric surgery between April 2006 and March 2011. Examined self-harm emergencies resulting from physical trauma or medication, alcohol or toxic chemical overdose in the three years before and after surgery. Income, age and urban/rural residence status were also examined. 

KEY FINDINGS

The risk of self-harm emergencies increased by approximately 54% after bariatric surgery, compared to the same patients before surgery. Significantly increased risk was seen among those aged 35 or older, those with lower income status and those living in rural areas. 

IMPLICATIONS

These findings emphasize the importance of screening for mental health problems prior to surgery, as well as close monitoring in the period thereafter, particularly for patients in high-risk groups.
 
 

One in 30 Ontario women require vaginal mesh revision or removal surgery after treatment for stress urinary incontinence

Welk B, Al-Hothi H, Winick-Ng J. Removal or revision of vaginal mesh used for the treatment of stress urinary incontinence. JAMA Surg. 2015 Sep 9 [Epub ahead of print].

ISSUE

Synthetic mesh slings are the most common surgical treatment for female stress urinary incontinence (SUI), but the US Food and Drug Administration has released warnings questioning their safety. What is the incidence of mesh removal or revision among women with SUI?

STUDY

Identified 59,887 women who underwent mesh-based procedures for SUI in Ontario between April 2002 and December 2012. Examined the yearly volume of such procedures performed by treating surgeons. The primary outcome of interest was a composite of surgical procedures related to removal or revision of mesh slings owing to erosion, fistula, pain or urinary retention.

KEY FINDINGS

One of every 30 women required mesh revision or removal. The cumulative incidence rate of complications increased from 1.17 at one year to 3.29 at 10 years. Patients of low-volume surgeons had a 37% higher relative risk for mesh removal or revision compared with patients treated by high-volume surgeons. The addition of a mesh sling if the initial one failed was common but increased the risk of eventual mesh removal or revision by almost five-fold.

IMPLICATIONS

Surgeons should achieve expertise in their chosen procedure to achieve optimal patient outcomes. Patients should be counseled that serious complications can occur with mesh-based SUI procedures, and the safety of this practice should be studied further.
 
 

Residents of for-profit long-term care homes have higher hospitalization and mortality rates than residents of not-for-profit facilities

Tanuseputro P, Chalifoux M, Bennett C, Gruneir A, Bronskill SE, Walker P, Manuel D. Hospitalization and mortality rates in long-term care facilities: does for-profit status matter? J Am Med Dir Assoc. 2015; 16(10):874–83.

ISSUE

More than half of the long-term care (LTC) facilities in Canada are operated on a for-profit basis. The effect of the facilities’ proprietary status on quality of care has been studied with mixed results. Does a LTC facility’s funding model have an effect on the hospitalization and mortality rates of its residents?

STUDY

Identified all first-time admissions to for-profit and not-for profit LTC facilities between January 2010 and March 2012. Resident outcomes were calculated at 3, 6 and 12 months after admission, and residents followed until discharge, death or for 365 days, whichever came first. For each resident, determined time to first hospitalization and time to death.

KEY FINDINGS

Compared with their not-for-profit counterparts, for-profit LTC facilities had 18.4%, 16.7% and 12.3% greater mortality rates per 1,000 person-years and 38.2%, 35.9% and 29.2% greater hospitalization rates at 3, 6 and 12 months post-LTC admission, respectively. 

IMPLICATIONS

The differences in outcomes among residents in for-profit and not-for-profit LTC homes suggest disparities in patient care. Further research is needed to understand the reasons behind these differences. 
 
 

Women with intellectual and developmental disabilities have more labour inductions and caesarean sections

Brown HK, Kirkham YA, Cobigo V, Lunsky Y, Vigod SN. Labour and delivery interventions in women with intellectual and developmental disabilities: a population-based cohort study. J Epidemiol Community Health. 2015 Oct 8 [Epub ahead of print].

ISSUE

Among pregnant women, particularly those in developed countries, rates of labour and delivery interventions are increasing. Are women with intellectual and developmental disabilities (IDD) more likely than other women to undergo a labour and delivery intervention, and do certain pre-pregnancy health conditions or pregnancy complications explain the higher frequency of these interventions?

STUDY

Identified 3,932 deliveries to women with IDD and 382,774 to women without IDD in Ontario between 2002 and 2011. Labour and delivery interventions examined included induction, caesarean section and operative vaginal births (i.e., forceps use or vacuum extraction). Examined pre-pregnancy health conditions including pre-existing diabetes, chronic hypertension, herpes or HIV, and psychiatric disorders and pregnancy complications (maternal, placental or fetal). 

KEY FINDINGS

Compared to other women, those with IDD were more likely to experience induced labour (24.6% vs 21.5%) and caesarean sections (28.0% vs 27.3%) but not operative vaginal deliveries (9.6% vs 10.3%). Women with IDD were also more likely than other women to have one or more pre-pregnancy health conditions (55.9% vs 30.2%) and maternal (4.0% vs 2.5%), placental (7.1% vs 5.2%) or fetal (18.7% vs 12.6%) complications. 

IMPLICATIONS

Improvements in the surveillance and modification of pre-pregnancy risk factors could reduce the likelihood of labour and delivery interventions among the IDD population. Health care providers should be aware that instructions during labour and delivery, particularly surrounding informed consent for interventions, should be accessible to women with IDD.
 
 
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