Early specialist care for diabetes: who benefits most? A propensity score-matched cohort study.

AIMS: To examine whether early endocrinologist care reduces the risk of cardiovascular complications among newly diagnosed patients with diabetes of differing complexity. METHODS: We conducted a population-based propensity score-matched cohort study using provincial health data from Ontario, Canada. Adults (≥ 30 years) diagnosed with diabetes between 1 April 1998 and 31 March 2006 who received endocrinologist care in the first year of diagnosis were matched to a comparison group receiving primary care alone (N = 79 020) based on propensity scores and medical complexity (assigned using information on chronic conditions). Individuals were followed for 3- and 5-year outcomes, including non-fatal acute myocardial infarction or coronary heart disease death (primary endpoint), major cardiovascular events (acute myocardial infarction, stroke) or all-cause death, amputation and end-stage renal disease. RESULTS: Among medically complex patients, early endocrinologist care was associated with a lower 3-year incidence of the primary endpoint (hazard ratio 0.89, 95% CI 0.78-1.01) and major cardiovascular events or all-cause death (hazard ratio 0.91, 95% CI 0.85-0.97). These effects persisted after accounting for a higher incidence of end-stage renal disease on follow-up and were greatest in those with ≥ 3 visits to an endocrinologist (primary endpoint: hazard ratio 0.69, 95% CI 0.56-0.86 and 0.61, 95% CI 0.45-0.82, for unadjusted and end-stage renal disease adjusted analyses, respectively). In contrast, no benefit was observed in the non-medically complex subgroup. Overall effects were similar at 5 years. CONCLUSIONS: Early endocrinologist care is associated with a lower incidence of cardiovascular events and death among newly diagnosed patients with diabetes who have comorbid medical conditions.

Impact of socio-economic status on breast cancer screening in women with diabetes: a population-based study.

AIMS: There is evidence to suggest that mammography rates are decreased in women with diabetes and in women of lower socio-economic status. Given the strong association between low socio-economic status and diabetes, we explored the extent to which differences in socio-economic status explain lower mammography rates in women with diabetes. METHODS: A population-based retrospective cohort study in Ontario, Canada, of women aged 50 to 69 years with diabetes between 1999 and 2010 age matched 1:2 to women without diabetes. Main outcome measure is the likelihood of at least one screening mammogram in women with diabetes within a 36-month period, starting as of either 1 January 1999, their 50th birthday, or 2 years after diabetes diagnosis--whichever came last. Outcomes were compared with those in women without diabetes during the same period as their matched counterparts, adjusting for socio-economic status based on neighbourhood income and other demographic and clinical variables. RESULTS: Of 504,288 women studied (188,759 with diabetes, 315,529 with no diabetes), 63.8% had a screening mammogram. Women with diabetes were significantly less likely to have a mammogram after adjustment for socio-economic status and other factors (odds ratio 0.79, 95% CI 0.78-0.80). Diabetes was associated with lower mammogram use even in women from the highest socio-economic status quintile (odds ratio 0.79, 95% CI 0.75-0.83). CONCLUSIONS: The presence of diabetes was an independent barrier to breast cancer screening, which was not explained by differences in socio-economic status. Interventions that target patient, provider, and health system factors are needed to improve cancer screening in this population.

The impact of exercise consultation on activity levels and metabolic markers in obese adolescents: a pilot study.

Objective. To assess the impact of exercise consultation on physical activity (PA) levels, anthropometric measures, and metabolic markers in obese adolescents. Methods. Obese adolescents (14-18 years) were randomized to either an exercise consultation (intervention group) or to review "Canada's Physical Activity Guide for Youth" (control group). Outcomes, including accelerometry, anthropometrics, blood pressure, stage of exercise behavior change, fasting glucose, insulin, and lipids, were measured at baseline and 3 months later. Results. Thirty adolescents (mean BMI = 36.1 kg/m(2); SD = 6.9) completed the study. At follow-up, the intervention group had significantly greater PA compared with controls (P < .05). Similarly, the intervention group weighed an average 2.6 kg less than the control group (P < .05), with a mean BMI z-score of 2.15 compared to 2.21 for controls (P = .054). No other differences were noted. Conclusion. Exercise consultation may be a simple approach to increase PA levels, reduce weight, and lower BMI in obese adolescents.

Use of vascular risk-modifying medications for diabetic patients differs between physician specialties.

AIMS: Although heart disease and stroke are the underlying causes of death in most people with diabetes, vascular risk modification targets are frequently not met. This study examined whether vascular risk-modifying medication utilization for diabetic patients differed among physician specialties. METHODS: A population-based study using administrative data from 105 715 people aged >/= 65 years with newly diagnosed diabetes in Ontario between 1994 and 2001. The receipt of antihypertensive and lipid-lowering drugs was compared between patients who had regular care from endocrinologists, internists/geriatricians and family physicians. Hierarchical logistic regression adjusted for patient-level differences, physician-level differences and patient clustering within physicians. RESULTS: Only two-thirds of patients received antihypertensive drugs and about one-quarter received lipid-lowering drugs. Compared with patients of family physicians, the adjusted odds ratios for antihypertensive drug use were 1.27 [95% confidence interval (CI) 1.16, 1.38] for patients of internists/geriatricians and 1.03 (95% CI 0.94, 1.12) for patients of endocrinologists. For lipid-lowering drugs, the odds ratios were 1.20 (95% CI 1.11, 1.30) for patients of internists/geriatricians and 1.58 (95% CI 1.42, 1.76) for patients of endocrinologists. CONCLUSIONS: Despite recommendations to use vascular risk-modifying medication for most older people with diabetes, many patients were not receiving these medications. Medication utilization differed between physician specialties, with family physicians having the lowest rates of use. Notably, although blood pressure control has the greatest evidence of benefit and is cost-saving, endocrinologists did not use antihypertensive drugs more often than family physicians after adjustment for other differences.

Problems for clinical judgement: 4. Surviving in the report card era.

Health care report cards involve comparisons of health care systems, hospitals or clinicians on performance measures. They are going to be an important feature of medical care in Canada in the new millennium as patients demand more information about their medical care. Although many clinicians are aware of this growing trend, they may not be prepared for all of its implications. In this article, we provide some historical background on health care report cards and describe a number of strategies to help clinicians survive and thrive in the report card era. We offer a number of tips ranging from knowing your outcomes first to proactively getting involved in developing report cards.

Problems for clinical judgement: 3. Thinking clearly in an emergency.

The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Over-reliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into effective action and better patient outcomes.

Proton pump inhibitors. Compliance with a mandated step-up program.

OBJECTIVE: To assess compliance with a step-up approach to proton pump inhibitor (PPI) therapy before implementation of a new provincial policy to promote histamine-type 2 receptor antagonist (H2RA) use before PPI therapy. DESIGN: Population-based, retrospective, open cohort study using prescribing and medical procedure data from January 1, 1995, to April 30, 1999. SETTING: Health administration databases for the universal health care system in Ontario. PARTICIPANTS: Approximately 1.4 million residents of Ontario older than 65 years. MAIN OUTCOME MEASURES: Proportion of patients who received a trial of H2RA therapy or gastrointestinal diagnostic testing 12 months before starting PPI therapy in 1996. RESULTS: Among the 25,870 patients who met study criteria in 1996, about 63% had received H2RAs 12 months before starting PPI therapy and 73% had had a trial of H2RAs or gastrointestinal diagnostic testing. Repeat analysis for January through April 1999, following the new policy implementation, showed that about 72% of patients had had a trial of H2RAs within 12 months of starting PPI therapy. CONCLUSION: A modest gain (9%) in compliance with using H2RA therapy within 12 months before starting PPI therapy was seen following introduction of the step-up intervention. In future, costs and benefits of potential interventions should be carefully considered before implementing new policies.

Problems for clinical judgement: 1. Eliciting an insightful history of present illness.

This article presents the results of a review of studies of psychology that describe how ordinary human reasoning may lead patients to provide an unreliable history of present illness. Patients make errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension of a question changes depending on ambiguities in the language used and conversational norms. Recall fails through the forgetting of relevant information and through automatic shortcuts to memory. Evaluation can be mistaken because of shifting social comparisons and faulty personal beliefs. Expression is influenced by moods and ignoble failures. We suggest that an awareness of how people report current symptoms and events is an important clinical skill that can be enhanced by knowledge of selected studies in psychology. These insights might help clinicians avoid mistakes when eliciting a patient's history of present illness.

Problems for clinical judgement: 2. Obtaining a reliable past medical history.

Ordinary human reasoning may lead patients to provide an unreliable history of past experiences because of errors in comprehension, recall, evaluation and expression. Comprehension of a question may change depending on the definition of periods of time and prior questions. Recall fails through the loss of relevant information, the fabrication of misinformation and distracting cues. Evaluations may be mistaken because of the "halo effect" and a reluctance to change personal beliefs. Expression is influenced by social culture and the environment. These errors can also occur when patients report a history of present illness, but they tend to be more prominent with experiences that are more remote. An awareness of these specific human fallibilities might help clinicians avoid some errors when eliciting a patient's past medical history.

Progressive trends in the prevalence of benzodiazepine prescribing in older people in Ontario, Canada.

OBJECTIVES: The extensive use of benzodiazepines has been a concern of healthcare providers and policy makers in Canada and around the world. The purpose of this study was to examine temporal trends in benzodiazepine prescriptions dispensed in older people from 1993-1998. DESIGN: Retrospective population-based cross-sectional study using administrative databases. SETTING: Ontario, Canada. PARTICIPANTS: The over 1 million residents of Ontario age 65 and older covered by the provincial universal drug benefit program. MEASUREMENTS: The main outcome measures were the prevalence, overall and with respect to age and gender, of benzodiazepine prescriptions dispensed and the ratio of the number of people to whom short- versus long-acting benzodiazepine prescriptions were dispensed in each study year. The annual rates of switching to other psychotropic agents were examined for those patients that discontinued filling benzodiazepine prescriptions. RESULTS: The annual prevalence of benzodiazepine prescriptions dispensed decreased consistently over time (25.1% in 1993 to 22.5% in 1998; P < .001). Benzodiazepine dispensing prevalence increased with increasing age (approximately 20% of those age 65 to 69 to approximately 30% of those age > or =85; P < .001) and more females than males received the medication (relative risk = 1.50, 95% confidence interval = 1.49-1.51). The ratio of short- to long-acting benzodiazepine prescriptions filled increased over time (3.6 in 1993 to 5.8 in 1998; P < .001), in line with guideline recommendations. Rates of switching to antidepressants increased over time (8.5% in 1993 to 10.2% in 1998; P < .001), whereas switching to barbiturates was consistently low (0.12%; P = .403). CONCLUSION: The prevalence of benzodiazepine therapy for older people in Ontario has steadily declined between 1993 and 1998. There is a trend of dispensing relatively more short-acting than long-acting benzodiazepines and of replacing benzodiazepines with antidepressants in older people without a remarkable increase in barbiturate consumption. These findings suggest that, without undue regulation, physicians are making progress in the prescribing of benzodiazepine therapy on the basis of current knowledge available.

Increasing rates of ischemic heart disease in the native population of Ontario, Canada.

BACKGROUND: The prevalence of ischemic heart disease (IHD) has been declining in North America since the 1960s. Over this time, Native populations, which have traditionally had low rates of IHD, have undergone striking lifestyle changes that may have had health consequences. In this context, IHD trends in the Native communities of Ontario, Canada, were evaluated. OBJECTIVE: To assess trends in admission rates for IHD in the Native population of Ontario compared with the general population of Ontario. METHODS: A comprehensive administrative database of all hospital admissions in Ontario 1981 to 1997, was used. Age- and sex-adjusted rates of hospital admissions with IHD-related diagnostic or procedure codes were determined in all residents of Ontario communities that had regular census participation and at least 95% of their population claiming Native origins (N=16,874 in 1991). Comparison was made with all residents of the surrounding northern Ontario region (N=822,450) and of the whole province (N = 10,084,885). RESULTS: In 1981, the rate of IHD admissions was similar in all groups, at 99 to 124 per 10,000 persons. By 1997, it decreased to 82 per 10,000 in the province (slope, -1.09; 95% confidence interval, -1.26 to -0.91), with a similar trend in northern Ontario. However, in the Native communities, it increased to 155 per 10,000 (slope, 5.6; 95% confidence interval, 3.8-7.5). A similar trend was seen for acute myocardial infarction admissions, a more precisely coded subset of IHD. Spurious causes of increasing rates were ruled out. CONCLUSIONS: Hospitalizations for IHD have doubled in the Native population despite declining rates in the general population. These findings document an alarming trend in Native health and support the need for further research and targeted intervention.

Confidential prescriber feedback and education to improve antibiotic use in primary care: a controlled trial.

BACKGROUND: Antibiotics are a medication class for which inappropriate prescribing is frequently described. We sought to assess the effectiveness of a mailed intervention combining confidential prescribing feedback with targeted educational bulletins in increasing the use of less expensive, first-line antibiotics by practising physicians. METHODS: The participants were 251 randomly selected primary care physicians from southern Ontario who consented to participate (135 in the feedback group and 116 in the control group). Prescribing data were obtained from the claims database of the Ontario Drug Benefit program, which covers all Ontarians over age 65 years for drugs selected from a minimally restrictive formulary. Confidentially prepared profiles of antibiotic prescriptions coupled with guidelines-based educational bulletins were mailed to the intervention group every 2 months for 6 months. The control group received no intervention until after completion of the study. The main outcome measures were change from baseline in physician's median antibiotic cost and proportion of episodes of care in which a prespecified first-line antibiotic was used first. RESULTS: The median prescription cost of about $11 remained constant in the feedback group but rose in the control group (change of $0.05 v. $3.37, p < 0.002). First-line drug use increased in the feedback group but decreased in the control group (change of 2.6% v. -1.7%, p < 0.01). In a mailed survey of 100 feedback recipients (response rate 76%), 82% indicated that they would participate readily in another, similar program. INTERPRETATION: A simple program of confidential feedback and educational materials blunted cost increases, increased the use of first-line antibiotics and was highly acceptable to Ontario primary care physicians.

Monetary and nonmonetary costs to patients attending an ambulatory dermatology clinic.

BACKGROUND: Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs. OBJECTIVE: To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic. METHODS: Consecutive new patients in a 6-week period completed a self-administered questionnaire. RESULTS: Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs. CONCLUSION: Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.

Case selection and appropriateness of coronary angiography and coronary artery bypass graft surgery in British Columbia and Ontario.

OBJECTIVES: To compare the types of patients selected for coronary angiography (CA) and coronary artery bypass graft (CABG) surgery, and the appropriateness of the procedures performed on these patients in a random sample of cases in British Columbia and Ontario. DESIGN: Retrospective randomized medical record review. SETTING: All hospitals performing CA and/or CABG in British Columbia and Ontario in fiscal year 1989/90. PATIENTS: For CA, 395 randomly selected patients in Ontario and 139 randomly selected patients in British Columbia; for CABG, 431 randomly selected patients in Ontario and 125 randomly selected patients in British Columbia. MAIN OUTCOME MEASURES: Case selection was measured in terms of the demographic and clinical characteristics of patients undergoing the procedures. Appropriateness was measured by comparing the clinical characteristics of patients undergoing the procedures with explicit criteria established by a panel of Canadian physicians. The yield from CA was measured as the proportion of patients who were found to have insignificant anatomical disease. RESULTS: Analysis of patients selected for CA showed that sample patients from Ontario were less likely than those from British Columbia to be female (25% versus 37%, respectively, P = 0.012) and less likely to have undergone a previous revascularization (12% versus 24%, respectively, P = 0.005). The distribution of main indications for CA differed between the two provinces (P = 0.002), with Ontario patients more likely to have chronic stable angina (45% versus 24%) and less likely to have unstable angina (16% versus 26%). For CABG, sample patients from Ontario were less likely to be 65 years of age or older (32% versus 45%, P = 0.016) and more likely to have an ejection fraction less than 35% (14% versus 5%, P = 0.006). The distribution of the main indications for CABG differed (P < 0.001), with Ontario patients more likely to have chronic stable angina (68% versus 38%) and less likely to have unstable angina (20% versus 43%). There was no statistically significant difference in CA cases rated as inappropriate (8.4% in Ontario versus 10.8% in British Columbia, P = 0.396) or CABG cases rated as inappropriate (3.9% in Ontario versus 2.4% in British Columbia, P = 0.393). There were no statistically significant differences in the proportion of CA that yielded insignificant anatomical disease (17.5% in Ontario versus 18.4% in British Columbia, P = 0.355). CONCLUSIONS: There were differences between Ontario and British Columbia in the demographic and clinical characteristics of patients selected for CA and CABG. This may indicate differences in the referral process in the two provinces. Despite these differences the rates of inappropriate procedures and the yield from CA were similar.

Are the marginal returns of coronary artery surgery smaller in high-rate areas? The Steering Committee of the Provincial Adult Cardiac Care Network of Ontario.

BACKGROUND: Population-based rates of surgery vary within and between health-care systems, causing concern that case selection is less appropriate in high-rate areas. This inverse relationship has not been shown with appropriateness criteria generated by expert panels. We applied a trials-based measure of the potential survival benefit of coronary artery bypass graft surgery (CABG) to patients in a provincial registry, to determine the relationship between survival gains and rates of CABG. METHODS: We did a population-based retrospective review of linked registry and administrative datasets. 5058 patients in the linked datasets underwent isolated CABG in Ontario between April 1, 1992, and March 31, 1993. Potential survival benefit of surgery was scored with an algorithm derived from a published overview of trials comparing CABG to medical treatment, analysed by county and by referral regions. FINDINGS: Overall, case selection was appropriate whether assessed clinically (96.3% had either severe disease as judged on the coronary arteries affected or moderate to severe angina) or on the basis of survival benefit scores (94.0% predicted to obtain moderate or high benefit). There was significant variation in benefit scores across referral regions (p < 0.001). Benefit scores correlated inversely with county surgical rate (r = -0.49, p < 0.005) and the proportion of low-benefit cases increased with rates (r = 0.50, p < 0.005). Referral regions served by high-rate surgical centres had lower mean benefit scores. INTERPRETATION: Most patients undergoing CABG in Ontario are in the high-survival benefit category. Surgery is defensible for patients with low survival benefit on the grounds of symptom relief, but the proportion of cases with low benefit rises with higher local rates of surgery. The inverse relationship between surgery rates and appropriateness of case selection may be better understood as diminishing marginal returns for specific outcomes with rising local use of procedures.

Noninvasive assessment of cardiac function during exercise in patients with CHF or COPD: measurement of aortic bloodflow indices by continuous wave Doppler.

OBJECTIVE: To test whether continuous-wave Doppler measurements of aortic bloodflow indices would reliably distinguish patients with congestive heart failure (CHF) from those with chronic obstructive pulmonary disease (COPD) and a similar degree of exertional dyspnea. DESIGN. Parallel group comparison. SETTING: University teaching hospital. PARTICIPANTS: Eighteen out-patients with clinically distinct syndromes of CHF or COPD but of similar age and functional limitation. INTERVENTION: Participants were observed during graded treadmill exercise. The following indices were obtained: heart rate, systolic blood pressure (SBP), earlobe oxygen saturation, and continuous-wave Doppler measurements of aortic bloodflow from the suprasternal notch. MAIN RESULTS: Exercise duration (mean +/- SE): COPD 14.2 +/- 1.2 mins, CHF 14.0 +/- 1.2 mins, not significant. Maximum results during exercise: heart rate, CHF 143 +/- 7 beats/min, COPD 149 +/- 5 beats/min, not significant; peak velocity, CHF 0.60 +/- 0.04 m/s, COPD 0.92 +/- 0.07 m/s, P < 0.005; peak acceleration, CHF 17 +/- 1 m/s2, COPD 37 +/- 3 m/s2, P < 0.001; SBP: CHF 152 +/- 8 mmHg, COPD 207 +/- 5 mmHg, P < 0.001; minimum oxygen saturation: CHF 92 +/- 1%, COPD 88 +/- 2%, not significant. CONCLUSIONS: Aortic bloodflow indices can be measured during exercise in patients with exertional dyspnea due to CHF or COPD and, in CHF, these indices are significantly reduced compared with individuals with COPD measured at similar levels of exercise. These data suggest that measurement of aortic bloodflow indices may have a role as an adjunct to routine tests in the diagnosis of patients with dyspnea. Further studies are indicated in patients with clinical features of both COPD and CHF in whom the etiology of dyspnea is uncertain.