Emergency Department Visits During Pregnancy.

STUDY OBJECTIVE: Pregnant women often seek care in an emergency department (ED). We sought to describe the frequency, characteristics, and factors associated with increased ED visits during pregnancy. METHODS: We conducted a retrospective cohort study using administrative health data of all pregnancies resulting in a live birth at 20 or more weeks of gestation in Alberta, Canada, from 2011 to 2017. The primary outcome was the occurrence of any ED visit during pregnancy. The secondary outcomes were ED visit characteristics and discharge disposition. We calculated rate ratios (RRs) and 95% confidence intervals (CIs) for associations between sociodemographic and clinical factors and increased ED visits during pregnancy using random-effect negative binomial regression adjusting for multiple pregnancies per person during the study period. RESULTS: We included 255,929 pregnancies from 193,965 women. Of all the pregnancy episodes followed, 37.3% (95% CI 37.1 to 37.5) had at least 1 ED visit, resulting in a total of 226,811 ED visits and an overall ED visit rate of 94.0 visits per 100 pregnancies (95% CI 93.6 to 94.3). Most visits were nonobstetric (46.4%) and resulted in ED discharge (85.3%). Increased ED visits were associated with living in remote (RR 6.9; 95 %CI 6.7 to 7.1) or rural (RR 3.4; 95% CI 3.4 to 3.5) areas, younger age (RR 1.9; 95% CI 1.8 to 2.0), intensive prenatal care (RR 1.5; 95% CI 1.5 to 1.5), major/moderate health conditions (RR 1.6; 95% CI 1.6 to 1.6), mental health conditions (RR 1.6; 95% CI 1.5 to 1.6), and high antepartum risk score (RR 1.1; 95% CI 1.1 to 1.1). CONCLUSION: Approximately 1 in 3 women in our sample visited the ED during pregnancy. A higher number of visits occurred in those with rural/remote residence, younger maternal age, and concomitant health conditions.

Emergency Department Visits During the Postpartum Period: A Canadian Cohort Study.

STUDY OBJECTIVE: Challenges in transitioning from obstetric to primary care in the postpartum period may increase emergency department (ED) visits. This study described the frequency, characteristics, and predictors of maternal ED visits in the postpartum period. METHODS: Retrospective cohort study of all live-birth pregnancies occurring in Alberta (Canada) between 2011 and 2017. Individual-level health and ED utilization data was linked across 5 population health databases. We calculated age-standardized ED visit rates in the postpartum period and used negative binomial regression models to assess the outcome of any ED visit in the postpartum period associated with relevant sociodemographic and clinical factors. Results were reported using rate ratios (RRs) and 95% confidence intervals (95% CIs). RESULTS: Data on 255,929 pregnancies from 193,965 individuals were analyzed. During the study period, 44.7% of pregnancies had 1 or more ED visits; 29.7% of visits occurred within 6 weeks after delivery. Increased postpartum ED visits were associated with living in remote (RR, 2.8; 95% CI, 2.6 to 2.9) or rural areas (RR, 2.3; 95% CI, 2.3 to 2.4), age less than 20 years (RR, 2.5; 95% CI, 2.4 to 2.6), mental (RR, 1.6; 95% CI, 1.6 to 1.7) and major/moderate health conditions (RR, 1.5; 95% CI, 1.5 to 1.6), multiparity 4 or more (RR, 2.0; 95% CI, 1.9 to 2.1), cesarean delivery (RR, 1.4; 95% CI, 1.4 to 1.4), and intensive prenatal care (RR, 1.4; 95% CI, 1.4 to 1.5). CONCLUSION: Almost one third of ED visits in the postpartum occurred within 6 weeks immediately after delivery. Potential gaps in equitable access and quality of prenatal care should be bridged by appropriate transitions to primary care in the postpartum period.

Frequent emergency department use and mortality in patients with substance and opioid use in Alberta: A population-based retrospective cohort study.

OBJECTIVES: In the current opioid epidemic, identifying high-risk patients among those with substance and opioid use may prevent deaths. The objective of this study was to determine whether frequent emergency department (ED) use and degree of frequent use are associated with mortality among ED patients with substance and opioid use. METHODS: This cohort study used linked population-based ED (National Ambulatory Care Reporting System) and mortality data from Alberta. All adults ≥ 18 years with substance or opioid use-related visits based on diagnostic codes from April 1, 2012, to March 31, 2013, were included (n = 16,389). Frequent use was defined by ≥ 5 visits in the previous year. Outcomes were unadjusted and adjusted (for age, sex, income) mortality within 90 days (primary), and 30 days, 365 days, and 2 years (secondary). To examine degree, frequent use was subcategorized into 5-10, 11-15, 16-20, and > 20 visits. RESULTS: Frequent users were older, lower income, and made lower acuity visits than non-frequent users. Frequent users with substance use had higher mortality at 365 days (hazard ratio [HR] 1.36 [1.04, 1.77]) and 2 years (HR 1.32 [1.04, 1.67]), but not at 90 or 30 days. Mortality did not differ for frequent users with opioid use overall. By degree, patients with substance use and > 20 visits/year and with opioid use and 16-20 visits/year demonstrated a higher 365-day and 2-year mortality. CONCLUSIONS: Among patients with substance use, frequent ED use and extremely frequent use (> 20 visits/year) were associated with long-term but not short-term mortality. These findings suggest a role for targeted screening and preventive intervention.

OBJECTIF: Dans le contexte actuel de l'épidémie de surdoses d'opioïdes, la détection des patients à risque élevé parmi ceux qui font usage d'opioïdes ou d'autres substances psychoactives peut avoir, pour effet, la prévention de la mort. L'étude visait donc à déterminer si les consultations fréquentes au service des urgences (SU) et le degré de fréquence étaient associés à la mortalité chez les patients faisant usage d'opioïdes ou d'autres substances psychoactives, traités au SU. MÉTHODE: Il s'agit d'une étude de cohortes fondée sur la population et reposant sur des bases de données liées en ce qui concerne les consultations au SU (Système national d'information sur les soins ambulatoires) et la mortalité, en Alberta. Ont été inclus dans l'étude tous les adultes ≥ 18 ans ayant consulté pour des troubles liés à l'usage d'opioïdes ou d'autres substances psychoactives, d'après les codes de diagnostic inscrits du 1er avril 2012 au 31 mars 2013 (n = 16 389). On entendait par « visites fréquentes ¼ ≥ 5 consultations (cons.) au cours de l'année précédente. Les résultats recherchés consistaient en la mortalité brute et la mortalité rajustée selon l'âge, le sexe et les revenus au cours des 90 jours suivants (critère d'évaluation principal) ainsi qu'au bout de 30 jours, de 365 jours et de 2 ans (critères d'évaluation secondaires). Quant au degré de fréquence, le nombre de visites a été subdivisé en tranches de 5-10, 11-15, 16-20 et > 20 consultations. RÉSULTATS: Les usagers fréquents étaient des personnes plus âgées, ayant des revenus plus faibles et consultant pour des troubles moins graves que les usagers non fréquents. Parmi les usagers fréquents, ceux qui utilisaient des substances psychoactives connaissaient une mortalité plus élevée au bout de 365 jours (rapport des risques instantanés [RRI] : 1,36 [1,04­1,77]) et de 2 ans (RRI : 1,32 [1,04­1,67]), mais pas au bout de 90 jours ou de 30 jours. Par contre, il n'y avait pas de différence de mortalité chez les usagers fréquents utilisant des opioïdes, dans l'ensemble. Enfin, la mortalité calculée en fonction du degré de fréquence chez les patients faisant usage de substances psychoactives et comptant > 20 cons./année ainsi que chez ceux faisant usage d'opioïdes et comptant 16-20 cons./année était plus élevée au bout de 365 jours et de 2 ans. CONCLUSION: Une fréquence élevée et extrêmement élevée de consultations (> 20/année) au SU chez les patients faisant usage de substances psychoactives a été associée à la mortalité à long terme mais pas à court terme. Les résultats laissent donc croire à la pertinence d'un dépistage ciblé et d'interventions préventives.

Past and Future Burden of Inflammatory Bowel Diseases Based on Modeling of Population-Based Data.

BACKGROUND & AIMS: Inflammatory bowel diseases (IBDs) exist worldwide, with high prevalence in North America. IBD is complex and costly, and its increasing prevalence places a greater stress on health care systems. We aimed to determine the past current, and future prevalences of IBD in Canada. METHODS: We performed a retrospective cohort study using population-based health administrative data from Alberta (2002-2015), British Columbia (1997-2014), Manitoba (1990-2013), Nova Scotia (1996-2009), Ontario (1999-2014), Quebec (2001-2008), and Saskatchewan (1998-2016). Autoregressive integrated moving average regression was applied, and prevalence, with 95% prediction intervals (PIs), was forecasted to 2030. Average annual percentage change, with 95% confidence intervals, was assessed with log binomial regression. RESULTS: In 2018, the prevalence of IBD in Canada was estimated at 725 per 100,000 (95% PI 716-735) and annual average percent change was estimated at 2.86% (95% confidence interval 2.80%-2.92%). The prevalence in 2030 was forecasted to be 981 per 100,000 (95% PI 963-999): 159 per 100,000 (95% PI 133-185) in children, 1118 per 100,000 (95% PI 1069-1168) in adults, and 1370 per 100,000 (95% PI 1312-1429) in the elderly. In 2018, 267,983 Canadians (95% PI 264,579-271,387) were estimated to be living with IBD, which was forecasted to increase to 402,853 (95% PI 395,466-410,240) by 2030. CONCLUSION: Forecasting prevalence will allow health policy makers to develop policy that is necessary to address the challenges faced by health systems in providing high-quality and cost-effective care.

Epidemiologic trends in substance and opioid misuse-related emergency department visits in Alberta: a cross-sectional time-series analysis.

OBJECTIVES: Substance and opioid misuse are growing public health concerns. This study's objectives were to evaluate trends in substance and opioid misuse-related emergency department (ED) visits in Alberta, Canada. METHODS: This is a cross-sectional time-series analysis utilizing National Ambulatory Care Reporting System ED data from Alberta, Canada. All substance and opioid misuse-related visits made by adults (≥ 18 years) from 2010/11 to 2014/15 were analyzed. Acuity was measured by the Canadian Triage and Acuity Scale (CTAS). Relevant visits were identified by ICD-10 diagnostic coding. Substance and opioid visits over 60 months were compared to all ED visits per 100,000 adult population using regression analysis, while controlling for temporal and seasonal variation. Trends among age and sex subgroups were also evaluated. RESULTS: From 2010/11 to 2014/15, substance and opioid misuse-related visits increased by 38.0% and 57.3% to 1119 and 118 visits per 100,000 population, respectively. Annual growth rates for substance and opioid visits were 4.4% higher (95% CI: 2.2, 6.7) and 10.6% higher (95% CI: 6.8, 14.6) than all ED visits. The 18-29 year-old category experienced the highest annual growth rate of all age groups, and the annual opioid visit growth rate was 5.6% higher among males than females. Compared to all visits, substance misuse-related visits arrived more frequently by ambulance, were higher acuity, and were hospitalized more often. CONCLUSION: Substance and opioid misuse-related ED visits increased significantly from 2010 to 2015, especially among younger patients. Future research should elaborate causes and evaluate interventions to curb the growth of this issue.

Presentations for hypoglycemia associated with diabetes mellitus to emergency departments in a Canadian province: A database and epidemiological analysis.

AIMS: The prevalence of diabetes mellitus was reportedly 9% in 2014, making it one of the most common global chronic conditions. Hypoglycemia is an important complication of diabetes treatment. The objective of this study was to quantify and characterize hypoglycemia presentations associated with type 1 or 2 diabetes made to emergency departments (EDs) by adults in a Canadian province. METHODS: A retrospective cohort study was conducted using reliable administrative data from Alberta for a five-year period (2010/11-2014/15). Records of interest were those with an ICD-10-CA diagnosis of diabetes-associated hypoglycemia (e.g., E10.63). A descriptive analysis was conducted. RESULTS: Data extraction yielded 7835 presentations by 5884 patients. The majority (56.2%) of presentations were made by males, median patient age was 62, and 60.5% had type 2 diabetes. These episodes constituted 0.08% of presentations to Alberta EDs. The annual rate of presentations decreased by 11.8% during the five-year period. Most presentations (63.4%) involved transportation to ED via ambulance. Median length-of-stay was four hours. For 27.5% of presentations, an X-ray was obtained. Most hypoglycemic episodes (65.2%) were considered to be moderate, while 34.3% were considered to be severe. CONCLUSIONS: Diabetes-associated hypoglycemia presentations to Alberta EDs are more commonly made by patients with type 2 diabetes, who are more likely to be transported via ambulance and also admitted. Each year, approximately one percent of Albertans with diabetes presented with a hypoglycemia episode; however, knowledge of the variation across regions can guide a strategy for improved care.

The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: principal results.

BACKGROUND: In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist that contribute to substantial health impairments. A supportive, educational, self-management intervention (with in-person and web-based versions) for patients wait-listed for bariatric care has already been implemented in Northern and Central Alberta, Canada, but its effectiveness is unknown. The objective of this trial is to evaluate the clinical and economic outcomes of two self-management programs of varying intensity that are currently in use. METHODS: We conducted a pragmatic, prospective, parallel-arm, randomized controlled trial of 651 wait-listed patients from two regional bariatric programs. Patients were randomized to (1) an in-person, group-based intervention (13 sessions; n = 215) or (2) a web-based intervention (13 modules; n = 225) or (3) control group (printed educational materials; n = 211). After randomization, subjects had 3 months to review the content assigned to them (the intervention period) prior to bariatric clinic entry. The primary outcome was the proportion of patients achieving 5% weight loss at 9 months. Intention-to-treat two-way comparisons were performed and adjusted for baseline age, sex, site and body mass index. RESULTS: At baseline, mean age was 40.4 ± 9.8 years, mean weight was 134.7 ± 25.2 kg, mean body mass index was 47.7 ± 7.0 kg/m2 and 83% of participants were female. A total of 463 patients (71%) completed 9 months follow-up. At least 5% weight loss was achieved by 24.2% of those in the in-person strategy, 24.9% for the web-based strategy and 21.3% for controls (adjusted p value = 0.26 for in-person vs. controls, 0.28 for web-based vs. controls, 0.96 for in-person vs. web-based). Absolute and relative (% of baseline) mean weight reductions were 3.7 ± 7.1 kg (2.7 ± 5.4%) for in-person strategy, 2.8 ± 6.7 kg (2.0 ± 4.8%) for web-based and 2.9 ± 8.8 kg (1.9 ± 5.9%) for controls (p > 0.05 for all comparisons). No between-group differences were apparent for any clinical or humanistic secondary outcomes. Total annual costs in Canadian dollars were estimated at $477,000.00 for the in-person strategy, $9456.78 for the web-based strategy and $2270.31 for provision of printed materials. DISCUSSION: Two different self-management interventions were no more effective and were more costly than providing printed education materials to severely obese patients. Our findings underscore the need to develop more potent interventions and the importance of comprehensively evaluating self-management strategies before widespread implementation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01860131 . Registered 17 May 2013.

Working With Parents to Prevent Childhood Obesity: Protocol for a Primary Care-Based eHealth Study.

BACKGROUND: Parents play a central role in preventing childhood obesity. There is a need for innovative, scalable, and evidence-based interventions designed to enhance parents' motivation to support and sustain healthy lifestyle behaviors in their children, which can facilitate obesity prevention. OBJECTIVE: (1) Develop an online screening, brief intervention, and referral to treatment (SBIRT) eHealth tool to enhance parents' concern for, and motivation to, support children's healthy lifestyle behaviors, (2) refine the SBIRT eHealth tool by assessing end-user acceptability, satisfaction, and usability through focus groups, and (3) determine feasibility and preliminary effectiveness of the refined SBIRT eHealth tool through a randomized controlled trial. METHODS: This is a three-phase, multi-method study that includes SBIRT eHealth tool development (Phase I), refinement (Phase II), and testing (Phase III). Phase I: Theoretical underpinnings of the SBIRT tool, entitled the Resource Information Program for Parents on Lifestyle and Education (RIPPLE), will be informed by concepts applied within existing interventions, and content will be based on literature regarding healthy lifestyle behaviors in children. The SBIRT platform will be developed in partnership between our research team and a third-party intervention development company. Phase II: Focus groups with parents, as well as health care professionals, researchers, and trainees in pediatrics (n=30), will explore intervention-related perceptions and preferences. Qualitative data from the focus groups will inform refinements to the aesthetics, content, structure, and function of the SBIRT. Phase III: Parents (n=200) of children-boys and girls, 5 to 17 years old-will be recruited from a primary care pediatric clinic while they await their children's clinical appointment. Parents will be randomly assigned to one of five groups-four intervention groups and one control group-as they complete the SBIRT. The randomization function is built into the tool. Parents will complete the eHealth SBIRT using a tablet that will be connected to the Internet. Subsequently, parents will be contacted via email at 1-month follow-up to assess (1) change in concern for, and motivation to, support children's dietary and physical activity behaviors (primary outcome), and (2) use of online resources and referrals to health services for obesity prevention (secondary outcome). RESULTS: This research was successfully funded and received ethics approval. Development of the SBIRT started in summer 2012, and we expect all study-related activities to be completed by fall 2016. CONCLUSIONS: The proposed research is timely and applies a novel, technology-based application designed to enhance parents concern for, and motivation to, support children's healthy lifestyle behaviors and encourage use of online resources and community services for childhood obesity prevention. Overall, this research builds on a foundation of evidence supporting the application of SBIRTs to encourage or "nudge" individuals to make healthy lifestyle choices. Findings from Phase III of this project will directly inform a cluster randomized controlled trial to study the effectiveness of our intervention across multiple primary care-based settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02330588; http://clinicaltrials.gov/ct2/show/NCT02330588 (Archived by WebCite at http://www.webcitation.org/6WyUOeRlr).

The evaluating self-management and educational support in severely obese patients awaiting multidisciplinary bariatric care (EVOLUTION) trial: rationale and design.

BACKGROUND: In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist and contribute to substantial health impairments.A supportive, educational intervention (with in-person and web-based versions) designed to enhance the self-management skills of patients wait-listed for multidisciplinary bariatric medical and surgical care has been variably implemented across Alberta, Canada. However, its effectiveness has not been evaluated. Our objectives were: 1. To determine if this program improves clinical and humanistic outcomes and is cost-effective compared to a control intervention; and 2. To compare the effectiveness and cost-effectiveness of in-person group-based versus web-based care. We hypothesize that both the web-based and in-person programs will reduce body weight and improve outcomes compared to the control group. Furthermore, we hypothesize that the in-person version will be more effective but more costly than the web-based version. METHODS/DESIGN: This pragmatic, prospective controlled trial will enrol 660 wait-listed subjects (220 per study arm) from regional bariatric programs in Alberta and randomly assign them to: 1. an in-person, group-based intervention (9 modules delivered over 10 sessions); 2. a web-based intervention (13 modules); and 3. controls who will receive mailed literature. Subjects will have three months to review the content assigned to them (the intervention period) after which they will immediately enter the weight management clinic. Data will be collected at baseline and every 3 months for 9 months (study end), including: 1. Clinical [5% weight loss responders (primary outcome), absolute and % weight losses, changes in obesity-related comorbidities]; 2. Humanistic (health related quality of life, patient satisfaction, depression, and self-efficacy); and 3. Economic (incremental costs and utilities and cost per change in BMI assessed from the third party health care payor perspective) outcomes. Covariate-adjusted baseline-to-nine-month change-scores will be compared between groups for each outcome using linear regression for continuous outcomes and logistic regression for dichotomous ones. DISCUSSION: Our findings will determine whether this intervention is effective and cost-effective compared to controls and if online or in-person care delivery is preferred. This information will be useful for clinicians, health-service providers and policy makers and should be generalizable to similar publically-funded bariatric care programs. TRIAL REGISTRATION: Trial Identifier: NCT01860131.

Inter- and intratester reliability of anthropometric assessment of limb circumference in labrador retrievers.

OBJECTIVE: To report a standardized method of, and determine inter- and intratester reliability for, anthropometric assessment of limb circumference in dogs. STUDY DESIGN: Prospective blinded study. ANIMALS: Labrador Retrievers (n = 20). METHOD: Unsedated dogs were manually restrained in lateral recumbency and triplicate measurements of limb circumference at the level of the proximal antebrachium, mid brachium, proximal crus, and mid-thigh were made using the Gulick II tape measure in the morning and afternoon of the same day. Observers were blinded to measurements made during each occasion and those made by co-observers. Estimates of inter- and intratester reliability were made for first and mean measurements using intra-class correlation coefficients (ICC). RESULTS: Measurements of the proximal antebrachium were made with moderate to fair intratester reliability by all observers with ICC's ranging from 0.68-0.78 (1st measurement) and 0.67-0.78 (mean measurement), and moderate to fair intertester reliability with ICC's of 0.66-0.68 (1st measurement) and 0.70-0.72 (mean measurement). Measurements of the brachium, crus, and thigh typically had poor inter- and intratester reliability, ICC < 0.5. CONCLUSION: Using the described method of muscle measurement in Labrador Retrievers only measurement of the proximal antebrachium was reliable; a single (1st) measurement was as reliable as using the mean of triplicate measurements.

Living alone, patient sex and mortality after acute myocardial infarction.

BACKGROUND: Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear. OBJECTIVE: To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex. DESIGN: Historical cohort study. PARTICIPANTS/SETTING: All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998-1999 fiscal year. MEASUREMENTS: Patients' sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001. RESULTS: Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1-3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7-2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5-1.5). CONCLUSIONS: Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.

Factors associated with depression in patients referred to headache specialists.

OBJECTIVE: To evaluate the relationship between selected demographic characteristics and clinical features in patients with headache and depression. METHODS: We studied demographic and clinical data collected at the time of consultation for 712 new patients with headache referred to five headache specialty clinics in Canada. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The Beck Depression Inventory (BDI-II) was used to identify the presence of depression. Multivariable logistic regression analysis was employed to evaluate associations between age, gender, employment status, marital status, diagnosis, headache days per month, medication overuse, headache impact (HIT-6), and headache disability (MIDAS) and the presence of depression as measured by the BDI-II. RESULTS: Among the sample of patients with headache, 27% (n = 189) had moderate to severe depression. Factors independently associated with depression included age less than 50 years, being unemployed, being on disability pension or welfare, being widowed, separated, or divorced, a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder, and showing severe headache impact as measured by the HIT-6, or severe disability as measured by the MIDAS. CONCLUSIONS: In patients with headache referred for specialist consultation, depression is strongly associated with being on disability or welfare, unemployment, age under 50 years, showing severe headache impact on the Headache Impact Test-6, and receiving a diagnosis of transformed migraine. The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics.

Demographics and clinical features of patients referred to headache specialists.

OBJECTIVE: To examine demographic characteristics and clinical features of headache patients referred to neurologists specializing in headache in Canada. METHODS: Demographic and clinical data were collected at the time of consultation for 865 new headache patients referred to five headache-specialty clinics in Canada. The Headache Impact Test (HIT-6) and Migraine Disability Questionnaire (MIDAS) were used to measure headache impact and disability. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. RESULTS: The average age of the patients was 40 years and the majority were female (78%). Most were employed either full time (49%) or part time (13%). The majority of patients were diagnosed with either migraine or tension-type headache (78%). Over a third of patients experienced headache every day, and half had experienced a headache in the previous month which was of severe intensity. Most (80%) scored in the "very severe" category of the HIT-6 and over half (55%) were severely disabled as measured by the MIDAS. CONCLUSION: Patients referred to headache specialists in Canada are severely disabled by their headache disorders. These patients are in the most productive phase of their lives in terms of age and employment. It is important to provide the best available treatment to headache patients in order to minimize the disability and impact of their headache disorders.

Pain free efficacy of sumatriptan in the early treatment of migraine.

BACKGROUND: There is evidence that headache response rates may be higher if triptans are used early when a migraine attack is still mild, as compared to when it is treated after pain has reached moderate or severe intensity. METHODS: In this randomized, double blind, placebo controlled, parallel group clinical trial, 361 patients took either placebo, sumatriptan 50 mg, or sumatriptan 100 mg in a single attack study. The primary outcome measure was pain-free status at two hours. RESULTS: In the intention to treat group, two hour pain free rates were 16%, 40%, and 50% in the placebo group, sumatriptan 50 mg group, and the sumatriptan 100 mg group respectively (p < 0.001, active treatment groups vs. placebo). CONCLUSIONS: Both sumatriptan 50 mg and 100 mg were significantly superior to placebo for the pain-free end point at two hours. The pain-free response rates in this trial where sumatriptan was taken while the headache was still mild were generally higher than in older clinical trials where headache was treated after reaching a moderate or severe intensity.

Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador.

OBJECTIVES: To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the St John's region. METHODS: Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery and women's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the St John's region, and separately for hospitals in the rest of the province. RESULTS: There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronary artery bypass grafting (CABG) morbid event rate improved, although access to CABG was not optimal. CONCLUSIONS: Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

The influence of breast self-examination on subsequent mammography participation.

OBJECTIVES: We evaluated whether breast self-examination (BSE) influences subsequent mammography participation. METHODS: We evaluated associations between BSE and subsequent mammography participation, adjusting for baseline screening behaviors and sociodemographic, health, and lifestyle characteristics, among women aged 40 years and older using data from the longitudinal Canadian National Population Health Survey. RESULTS: Regular performance of BSE at baseline was not associated with receipt of a recent mammogram at follow-up among all women (adjusted odds ratio [OR]=1.01; 95% confidence interval [CI]= 0.75, 1.35) or with mammography uptake among the subgroup of women reporting never use at baseline (adjusted OR=0.78; 95% CI=0.50, 1.22). CONCLUSIONS: The lack of association between performance of BSE and subsequent mammography participation suggests that not recommending BSE is unlikely to influence mammography participation.

Antibiotic utilisation in community practices: guideline concurrence and prescription necessity.

PURPOSE: To evaluate the indications, concurrence with prescribing guidelines and potential necessity for antibiotic (AB) prescriptions written in community practice. METHODS: We reviewed the charts of all patients with infection-related illnesses seen by family physicians during two random days of regular practice between 1 Oct 1997 and 30 Jan 1998. Guideline concurrence of AB prescribing was assessed using regional AB prescribing guidelines. Likelihood of AB indication for respiratory tract infections was assessed using published clinical practice guidelines for determination of likely viral versus bacterial etiology. RESULTS: Of 4218 visits captured, 949 (22%) were for newly acquired infections. Sixty four percent (n=604) of consultations for newly acquired infections resulted in an AB prescription. Based on the doctors' diagnoses, 61% of AB prescriptions were concurrent with prescribing guidelines, 10% were for the wrong drug, 20% were not indicated and in 10% of cases a lower line AB was available. For respiratory tract infections, 12% of these infections were likely bacterial, whereas the physicians determined that 56% were bacterial. CONCLUSIONS: A large proportion of ABs administered in community practices were not in concurrence with community AB prescribing guidelines. Improvements can be made in AB choice and in decisions about likely viral etiology for respiratory tract infections.

Absence of sex differences in pharmacotherapy for acute myocardial infarction.

BACKGROUND: Previous studies have indicated that sex differences may exist in the pharmacological management of acute myocardial infarction (AMI), with female patients being treated less aggressively. OBJECTIVES: To determine if previously reported sex differences in AMI medication use were also evident among all AMI patients treated at hospitals in an urban Canadian city. METHODS: All patients who had a primary discharge diagnosis of AMI from all three adult care hospitals in Calgary, Alberta, in the 1998/1999 fiscal year were identified from hospital administrative records (n=914). A standardized, detailed chart review was conducted. Information collected from the medical charts included sociodemographic and clinical characteristics, comorbid conditions, and cardiovascular medication use during hospitalization and at discharge. RESULTS: Similar proportions of female and male patients were treated with thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, nitrate, heparin, diuretics and digoxin. Among patients aged 75 years and over, a smaller proportion of female patients received acetylsalicylic acid in hospital than did male patients (87% versus 95%; P=0.026). Multivariable logistic regression analysis revealed that, after correction for age, use of other anticoagulants/antiplatelets and death within 24 h of admission, sex was no longer an independent predictor for receipt of acetylsalicylic acid in hospital. Medications prescribed at discharge were similar between male and female patients. CONCLUSION: The results from this Canadian chart review study, derived from detailed clinical data, indicate that the pattern of pharmacological treatment of female and male AMI patients during hospitalization and at discharge was very similar. No sex differences were evident in the treatment of AMI among patients treated in an urban Canadian centre.